Caietul de Rezumate

Organizator – Societatea Română de Chirurgie Toracică 1994

Presedinte Congresului - Prof. Dr. Ioan Cordoș

Comitet de organizare:

Dr. Ciprian Bolca

Dr. Cezar Motaș

Dr. Radu Matache

Dr. Radu Brânzea

Dr. Mihai Dumitrescu

Dr. Andrei Bobocea

Dr. Olga Dănăilă

Dr. Adrian Istrate

Dr. Adrian Iordache

Comitet științific

Prof. Dr. Adrian Aldea

Prof. Dr. Alexandru Boțianu

Prof. Dr. Ioan Cordoș

Prof. Dr. Teodor Horvat

Prof. Dr. Alexandru Nicodin

Prof. Dr. Zeno Popovici

Dr. Cristina Grigorescu

Dr. Dan Nicolau

Dr. Claudiu Nistor

Dr. Cristian Paleru

Nu ne lăsăm pradă...

Nu ne lăsăm pradă unei stări sociale fără precedent şi încercăm să dăm un bun exemplu,

exemplul unor oameni de bună credinţă a căror scop declarat sau nu (nu trîmbiţat!) este acela

de a-şi pune viaţa în slujba vindecării sau alinării suferinţei semenilor lor.

Nu ne lăsăm pradă neajunsurilor de tot felul şi purcedem la organizarea Celei de-a 9

Conferinţe Naţionale de Chirurgie Toracică cu participare internaţională, la jumătatea lunii

octombrie a acestui an într-un splendid peisaj montan, în vremea în care lumina molatecă a

toamnei va aurii crestele Bucegilor şi ale Pietrei Craiului. Întâlnirea cu bucurie a

participanţilor va avea loc în după amiaza zilei de joi, 13 octombrie, iar despărţirea, cu regret,

la mijlocul zilei de sâmbătă 15 octombrie. Dar ca să nu vă supunem la grea încercare

răbdarea, va anunţăm locul Conferinţei ca fiind noul hotel montan de la Cheile Grădiştei, la

circa patru sute de metri mai sus de acela în care s-a desfăşurat Cea de-a 7-a Conferinţă din

2009.

Fără îndoială alături de noi vor fi şi prieteni apropiaţi din lumea chirurgiei toracice mondiale

care ne vor împărtăşi din experienţa lor. Tema conferinţei se va axa mai mult pe tehnici

chirurgicale novatoare sau mai puţin uzuale precum şi pe promovarea Ghidului de diagnostic

şi tratament al cancerului bronho-pulmonar. Sigur spiritul nostru ştiinţific va fi mult mai bogat

în urma acestor conferinţe şi lucrări şi ca de obicei vom aprecia cum se cuvine şi programul

social.

Nu ne lăsăm pradă uneltirilor acelora care încearcă să vâre dihonia în nu foarte numeroasa

noastră societate şi invităm la Conferinţa noastră pe toţi truditorii cu suflet curat, pe toţi aceia

care luptă necondiţionat pentru bine pacientului: chirurgi toracici, anestezişti, pneumologi,

bronhologi, exploraţionişti de toate felurile, anatomo-patologi, toţi care ar putea să ne aducă o

cât de mică noutate în activitatea noastră fără preget. Invităm în mod special colegii

pneumologi care, după spusele profesorului G. Massard, au o mare responsabilitate în

alegerea chirurgului care să le opereze pacientul.

Dorim o cât mai mare participare a membrilor Societăţii nostre deoarece este an de alegeri, an

în care, în mod cu totul democratic şi deschis, vechea conducere va face un bilanţ al celor doi

ani trecuţi predând ştafeta noii conduceri pentru a consolida ceea ce s-a realizat, ceas de bilanţ

şi...critici. Fireşte, în spirit colegial.

Nu ne lăsăm pradă altor preocupări tentante şi ne notăm în calendar perioada 13-15 octombrie

când vă aşteptăm cu nerăbdare la Cheile Grădiştei pentru o întâlnire între învingători...

Preşedintele Societăţii Române de Chirurgie Toracică (care-şi asumă întreaga răspundere

pentru cele scrise mai sus):

Prof. Dr. Ioan Cordoş

THURSDAY, OCTOBER 13, 2011

16.00 – General assembly of the Romanian Society of Thoracic Surgery 1994

18.30 - 19.30 – Opening ceremony

19.30 – Welcome reception

FRIDAY, OCTOBER 14, 2011

09.00 – 11.00 - Conferences - Session I

Chairmen: Eric Frechette; Cristian Paleru

9.00 – 9.30

Teodor Horvat

Extramucosal myotomy of upper esophageal sphincter

9.30 – 10.00

Lex Maat

Lung transplantation: surgical issues, organization and logistic problems

10.00 – 10.30

Ioan Cordoș

Tracheobronchial stenosis – challenging cases

10.30 – 11.00

Rick Paul

TNM 7: What went wrong? Which way forward?

11.00 – 11.30 – Coffee break

11.30 – 13.30 - Conferences - Session II

Chairmen: Rick Paul; Lex Maat

11.30 – 12.00

Mariano Garcia Yuste

Results of standard pulmonary resection vs. conservatory (sublobar & bronchoplastic)

pulmonary resection in the treatment of carcinoid tumours

12.00 – 12.30

Eric Frechette

VATS lobectomy as treatment of NSCLC.

12.30 – 13.00

Dragan Subotic

Lung resection in COPD patients: where is the lower limit?

13.00 – 13.30

José Belda-Sanchis

Is thoracoscopic surgery justified to treat lung metastases?

13.30 – 15.30 – Lunch break

15.30 – 17.30 - Presentations - Session I

Chairmen: Mariano Garcia Yuste, Teodor Horvat

15.30 – 15.40

Bleeding from an adrenal metastasis as an atypical clinical onset of a stage iv lung cancer

Boţianu Petre Vlah-Horea1, Boțianu Alexandru-Mihail

1, Porav Daniel

2, Boţianu Ana-Maria

Voichiţa3

1-Clinica Chirurgie IV UMF Târgu-Mureş

2-Clinica Urologie UMF Târgu-Mureș

3-Clinica Medicală IV UMF Târgu-Mureș

15.40 – 15.50

Uniportal thoracoscopy for pleural effusions

Natalia Motaş, Cezar Motaş, Mihnea Davidescu, Ovidiu Rus, Elena Moise, Andreea Ştefan,

David Achim, Teodor Horvat

Thoracic Surgery Clinic, “Alexandru.Trestioreanu” National Institute of Oncology, Bucharest

15.50 – 16.00

Mediastinal ectopic parathyroid adenoma – case report

A.C.Nicodin1, O.N.Burlacu

1, Codruta Lazureanu

2, Mihaela Vlad

3

1 Thoracic Surgery Department, City Hospital Timisoara

2 Anatompathology Department , City Hospital Timisoara

3 Endocrinology Department, County Hospital Timisoara

16.00 – 16.10

Sleeve resection with full pulmonary preservation for posttraumatic main bronchial stenosis

Radu Matache, Ciprian Bolca, Andrei Cristian Bobocea, Olga Danaila, Ion Jentimir, Ioan

Cordos

1st Clinical Department of Thoracic Surgery, “Marius Nasta” National Institute of

Pneumology, Bucharest

16.10 – 16.20

A complex surgical system for solid sternal reconstruction: thoratex mesh, stratos system and

kryptonite bone cement

*Claudiu Nistor, *Adrian Ciuche, *Daniel Pantile, **Teodor Horvat

* Emergency University Military Central Hospital “Dr. Carol Davila”, Bucharest

** Institute of Oncology "Prof. Dr. Alexandru Trestioreanu”, Bucharest

16.20 – 16.30

The importance of histopathological factors in setting the long term prognosis for non-small

cell lung cancer

Suciu B.1, Bud V.

1, Copotoiu C.

1, Brânzaniuc Klara

2, Copotoiu Ruxandra

3, Fodor D.

1,

Butiurca V.4

Surgical Clinic no. 1, Mureș County Emergency Hospital

Anatomy Department, University of Medicine and Pharmacy, Tg.Mureș

ICU Clinic, Mureș County Emergency Hospital

Student, University of Medicine and Pharmacy, Tg.Mureș

16.30 – 16.40

Cervical video-assisted mediastinoscopic approach of the left main bronchus - a series of six

cases

Cristian Paleru¹, Olga Danaila¹, Ciprian Bolca¹, Radu Matache¹, Mihai Dumitrescu¹, Adrian

Istrate¹, Ruxandra Ulmeanu², Ioan Cordos¹

“Marius Nasta” National Institute of Pneumology, Bucharest, Romania

1 - Thoracic Surgery Department

2 - Bronchoscopy Department

16.40 – 16.50

Extra-musculo-periosteal plombage thoracoplasty with balls – still working after 46 years

Boțianu Petre Vlah-Horea, Boțianu Alexandru-Mihail

Discipline Surgery 4, University of Medicine and Pharmacy from Targu-Mures

16.50 – 17.00

Thoracic parietal hemangioma

Cezar Motaş, Ovidiu Rus, David Achim, Teodor Horvat


17.00 – 17.10

Unusual case of leyomiofibromatosis with multiple locations – the truth beyond the

appearances – case report

Adrian Istrate, Cristian Paleru, Mihai Dumitrescu, Ioan Cordos



17.10 – 17.20

Videothoracoscopic thimectomy in nonthymomatous patients with myasthenia gravis

Cristina Grigorescu*, Trufa Denis*, Iosep Gabriel**

*Clinic of Thoracic Surgery. University of Medicine “Gr.T.Popa” Iasi

** ICU , Hospital of Pneumology Iasi

17.20 – 17.30

Hydatid cyst of anterior mediastinum

Cezar Motaş, Natalia Motaş, Mihnea Davidescu, Elena Moise, Ovidiu Rus, Daniel Banciu,



Gala dinner – 20.00

SATURDAY, OCTOBER 15, 2011

08.30 – 11.00 - Conferences - Session III

Chairmen: José Belda-Sanchis, Alexandru Boțianu

8.30 – 9.00

Irina Strâmbu

The accuracy of imprint cytology for rapid intra operative diagnosis in lung cancer

9.00 – 9.30

Cristina Grigorescu

Neuroendocrine tumors of the lung

9.30 – 10.00

Lex Maat

Surgery in malignant pleural mesothelioma: sense or nonsense

10.00 – 10.30

Cristian Paleru

Mediastinal approach of postpneumonectomy left bronchial stump fistula

10.30 – 11.00

Alexandru Nicodin

European thoracic surgery database

11.00 – 11.30 – Coffee break

11.30 – 13.00 - Presentations – Session II

Chairmen: Dragan Subotic, Ioan Cordoș

11.30 – 11.40

Emergency pulmonary resections - pulmonary tumor torn in pleura

Ovidiu Rus, Natalia Motaş, Elena Moise, Teodor Horvat


11.40 – 11.50

Management of intrathoracic esophageal ruptures – a single center’s experience

C.P.Tunea, V.T.Voiculescu, O.N.Burlacu, G.V.Cozma, I.Miron, I.A.Petrache, M.Butas, A.C.

Nicodin

Thoracic Surgery Department, Municipal Hospital, Timisoara

11.50 – 12.00

Surgical management of tracheal invasion by thyroid carcinoma – single center experience

Andrei Cristian Bobocea, Ciprian Bolca, Olga Danaila, Ioan Cordos



12.00 – 12.10

Classical technique versus nuss in the treatment of failed surgery for pectus excavatum

G.V.Cozma, I.A.Petrache, O.N.Burlacu, A.C.Nicodin


12.10 – 12.20

Our experience in the anterior surgical approach of c7-t1 spine

*Adrian Ciuche, *Claudiu Nistor, *Marian Mitrica, **Teodor Horvat

*Emergency University Military Central Hospital “Dr. Carol Davila”, Bucharest


12.20 – 12.30

Postesophagectomy benign gastric tube to tracheobronchial tree fistulas. Presentation of two

cases, literature review, classification and treatment protocol

Bolca Ciprian*, Eric Frechette**

*1st Clinical Department of Thoracic Surgery, “Marius Nasta” National Institute of


** Thoracic Surgery Department, Institut Universitaire de Cardiologie et de Pneumologie de

Quebec (IUCPQ), Quebec City, Canada

12.30 – 12.40

Serial resection for double tracheal stenosis post oro-tracheal intubation

Codin Saon, Liliana Caracuda, Felix Dobritoiu, Ioan Cordos, Genoveva Cadar, Emilia Crisan



12.40 – 12.50

Our experience in the surgery of the chest wall tumors

A.C.Nicodin, I.Miron, O.Sirbu, G.V.Cozma, O.N.Burlacu, I.A.Petrache, A.C.Nicola,

C.Mogoi.


12.50 – 13.00

Ectopic thymomas with lateral – paracardiac development

Boțianu Alexandru-Mihail, Boțianu Petre Vlah-Horea, Urcan Marius, Chiujdea Dragoș,

Lucaciu Oana, Hogea Timur, Batog Olivia, Păvăloiu Valerian


Poster session

1. Rare mediastinal masses: bronchogenic cyst and castleman's disease

Andrei Cristian Bobocea, Radu Matache, Ion Jentimir, Ioan Cordos



2. Pericardial drainage in malignant effusions - early results

Cezar Motaş, Natalia Motaş, Mihnea Davidescu, Ovidiu Rus, Elena Moise, Andreea Ştefan,



3. Triple tracheo-bronchial lesion post-mediastinoscopy and ebus

Natalia Motaş, Cezar Motaş, Ovidiu Rus, Teodor Horvat


4. Malignant pleural pseudomesothelioma

Mihnea Davidescu, Elena Moise, Ovidiu Rus, Teodor Horvat


5. Bullous dystrophy of the middle lobe

Corina Bluoss, David Achim, Elena Moise, Teodor Horvat


6. Ianusian aspect of tyroid pathology

Elena Moise, Cezar Motas, Ovidiu Rus, Teodor Horvat


7. Giant pleural tumor – case report

Radu Matache, Andrei Cristian Bobocea, Ioan Cordos



8. The role of the geroulanos procedure in the treatment of lung hydatic cyst today

G.V.Cozma, O.N.Burlacu, V.T.Voiculescu, C.P.Tunea, I.Miron, I.A.Petrache, M.Butas, A.C.

Nicodin


9. Role of muscle flaps in the treatment of unresectable abscesses

Boțianu Petre Vlah-Horea, Boțianu Alexandru-Mihail, Gliga Mirela, Ionică Sebastian,

Chiujdea Dragoș, Lucaciu Oana, Hogea Timur, Batog Olivia


10. Reversal of the flow in the thoracic drainage system – rare postoperative accident

Boțianu Alexandru-Mihail, Boțianu Petre Vlah-Horea, Lucaciu Oana, Chiujdea Dragoș


13.00 – 13.30

„Traian Oancea” award, for the best presentation during the conference

Closing remarks

JOI, 13 OCTOMBRIE 2011

16.00 - Adunarea Generala a Membrilor Societatii Romane de Chirurgie Toracica 1994

18.30 - 19.30 - Ceremonia de deschidere

19.30 - Cocktail-ul de deschidere

VINERI, 14 OCTOMBRIE 2011

09.00 – 11.00 - Conferințe - Sesiunea I

Moderatori: Eric Frechette; Cristian Paleru

9.00 – 9.30

Teodor Horvat

Miotomia extramucoasă a sfincterului esofagian superior

9.30 – 10.00

Lex Maat

Lung transplantation: surgical issues, organization and logistic problems

10.00 – 10.30

Ioan Cordoș

Stenozele traheo-bronşice – cazuri dificile

10.30 – 11.00

Rick Paul


11.00 – 11.30 – Pauză de cafea

11.30 – 13.30 - Conferințe - Sesiunea II

Moderatori: Rick Paul; Lex Maat

11.30 – 12.00




12.00 – 12.30

Eric Frechette


12.30 – 13.00

Dragan Subotic


13.00 – 13.30

José Belda-Sanchis


13.30 – 15.30 – Pauză de prânz

15.30 – 17.30 - Lucrări - Sesiunea I

Moderatori: Mariano Garcia Yuste, Teodor Horvat

15.30 – 15.40

Hemoragia din metastază suprarenaliană – modalitate atipică de debut clinic al unui cancer

pulmonar stadiul IV


1, Porav Daniel


Voichiţa3

1-Clinica Chirurgie IV UMF Târgu-Mureş, România

2-Clinica Urologie UMF Târgu-Mureș, România

3-Clinica Medicală IV UMF Târgu-Mureș, România

15.40 – 15.50

Toracoscopia uniportală în pleurezii



Clinica de Chirurgie Toracică, Institutul Oncologic „Prof. Dr. Alexandru Trestioreanu”

Bucureşti

15.50 – 16.00

Adenom paratiroidian ectopic cu localizare mediastinala – prezentare de caz



2, Mihaela Vlad

3

1 Clinica de Chirurgie Toracica, Spitalul Municipal Timisoara

2 Departamentul de Anatomie patologica, Spitalul Municipal Timisoara

3 Clinica de Endocrinologie, Spitalul Judetean Timisoara

16.00 – 16.10

Rezectie-bronhoanastomoza de bronsie primitiva cu prezervare pulmonara totala pentru

stenoza posttraumatica


Cordos

Clinica 1 Chirurgie Toracică, Institutul Național de Pneumologie “Marius Nasta”, București

16.10 – 16.20

Sistem chirurgical complex pentru reconstrucţia solidă sternală: plasă thoratex, lamă stratos

şi ciment kryptonite


* Spitalul Universitar de Urgenţă Militar Central “Dr. Carol Davila”, Bucureşti

** Institutul Oncologic "Prof. Dr. Alexandru Trestioreanu”, Bucureşti

16.20 – 16.30

Importanța factorilor histopatologici în stabilirea prognosticului pacienților operați pentru

cancer pulmonar fără celule mici

Suciu B.1, Bud V.1, Copotoiu C.1, Brânzaniuc Klara2, Copotoiu Ruxandra3, Fodor D.1,

Butiurca V.4

Clinica Chirurgie I, Spitalul Clinic Județean de Urgență Mureș

Disciplina de Anatomie, Universitatea de Medicină și Farmacie Tg. Mureș

Clinica ATI, Spitalul Clinic Județean de Urgență Mureș

Student, Universitatea de Medicină și Farmacie Tg. Mureș

16.30 – 16.40

Abordul cervical videomediastinoscopic al bronşiei primitive stângi - o serie de 6 cazuri



Institutul National de Pneumologie “Marius Nasta”, Bucuresti

1 – Clinica I Chirurgie Toracica

2 – Departamentul Bronhologie

16.40 – 16.50

Plombaj extra-musculo-periostal cu bile funcțional după 46 de ani


Disciplina Chirurgie 4, Universitatea de Medicină și Farmacie din Târgu-Mureș, România

16.50 – 17.00

Hemangiom parietal toracic



Bucureşti

17.00 – 17.10

Leiomiofibromatoza cu multiple localizari – adevarul dincolo de aparente – prezentare de caz



17.10 – 17.20

Timectomia videotoracoscopica in hiperplazia timica cu miastenie gravis


*Clinica de Chirurgie Toracica Iasi, UMF “Gr.T.Popa” Iasi

** Sectia de ATI, Spital clinic de Pneumoftiziologie Iasi

17.20 – 17.30

Chistul hidatic al mediastinului anterior




Bucureşti

Gala dinner – 20.00

SÂMBĂTĂ, 15 OCTOMBRIE 2011

08.30 – 11.00 - Conferințe - Sesiunea III

Moderatori: José Belda-Sanchis, Alexandru Boțianu

8.30 – 9.00

Irina Strâmbu

Valoarea amprentei tumorale in diagnosticul rapid intraoperator in cancerul pulmonar

9.00 – 9.30

Cristina Grigorescu


9.30 – 10.00

Lex Maat


10.00 – 10.30

Cristian Paleru

Abordul mediastinal al fistulei de bont bronsic postpneumonectomie stanga

10.30 – 11.00

Alexandru Nicodin


11.00 – 11.30 – Pauză de cafea

11.30 – 13.00 - Lucrări – Sesiunea II

Moderatori: Dragan Subotic, Ioan Cordoș

11.30 – 11.40

Rezectii pulmonare in urgenta - tumora pulmonara rupta in pleura



Bucureşti

11.40 – 11.50

Managementul rupturilor esofagiene intratoracice – experienta unui singur centru


Nicodin

Clinica de Chirurgie Toracică, Spitalul Municipal, Timișoara

11.50 – 12.00

Managementul chirurgical al carcinomului tiroidian cu invazie traheala - experienta unui

singur centru



12.00 – 12.10

Sternocondroplastia clasica versus tehnica nuss in pectus excavatum recidivat



12.10 – 12.20

Experienţa noastră în abordul chirurgical anterior al vertebrelor c7-t1

*Adrian Ciuche, *Claudiu Nistor, *Marian Mitrică, **Teodor Horvat

*Spitalul Universitar de Urgenţă Militar Central “Dr. Carol Davila”, Bucureşti


12.20 – 12.30

Fistula benignă postesofagectomie între tubul gastric și arborele traheobronșic: prezentare a

două cazuri, studiu literaturii, clasificare și protocol terapeutic


*Clinica 1 Chirurgie Toracică, Institutul Național de Pneumologie “Marius Nasta”, București

**Clinica de Chirurgie Toracică, Institutul Universitar de Cardiologie și Pneumologie

(IUCPQ), Quebec, Canada

12.30 – 12.40

Rezectie etajata, seriata, pentru dubla stenoza traheala severa post intubatie oro-traheala

Codin Saon, Liliana Caracuda, Felix Dobritoiu, Ioan Cordos


12.40 – 12.50

Experienta noastra in chirurgia tumorilor parietale toracice


C.Mogoi.


12.50 – 13.00

Timoamele ectopice cu dezvoltare laterală - paracardiacă



Disciplina Chirurgie 4, Universitatea de Medicină și Farmacie din Târgu-Mureș, România

Sesiunea postere

1. Tumori mediastinale rare: chist bronhogenetic si boala castleman mediastinala



2. Drenajul pericardic în revărsatele maligne – rezultate precoce




Bucureşti

3. Triplă leziune traheo-bronşică post-mediastinoscopie şi ebus


Clinica de Chirurgie Toracică, Institutul Oncologic Bucureşti

4. Pseudomezoteliom pleural malign



Bucureşti

5. Distrofia buloasă de lob mediu



Bucureşti

6. Aspect ianusian de patologie tiroidiană



Bucureşti

7. Tumora fibroasa solitara pleurala giganta – prezentare de caz



8. Rolul actual al procedeului geroulanos in tratamentul chirurgical al chistului hidatic

pulmonar


Nicodin


9. Rolul lambourilor musculare în tratamentul abceselor pulmonare nerezecabile



Disciplina Chirurgie 4, Universitatea de Medicină și Farmacie din Târgu-Mureș

10. Inversarea fluxului în sistemul de drenaj toracic – accident postoperator rar



13.00 – 13.30

Decernarea premiului „Traian Oancea” pentru cea mai bună prezentare în cadrul

sesiunilor de lucrări

Închiderea conferinței

ABSTRACTS

CONFERENCES

Miotomia extramucoasă a sfincterului esofagian superior

Teodor Horvat


Se prezintă un subiect mai puţin cunoscut în literatura medicală din România –

miotomia extramucoasă a sfincterului esofagian superior.

Sunt trecute în revistă date de anatomie chirurgicală şi aspecte de fiziologie şi fiziopatologie

ale sfincterului esofagian superior. Sunt aduse în discuţie maladiile care pot afecta

funcţionarea normală a complexului faringe-sfincter-esofag cervical, care în principal pot fi

boli neurologice centrale şi/sau periferice, afecţiuni musculare congenitale sau câştigate,

maladii intrinseci ale muşchiului cricofaringian etc.

Se prezintă indicaţiile şi contraindicaţiile chirurgicale ale miotomiei extramucoase faringo-

crico-esofagiene, date de tehnică chirurgicală, operaţii asociate, complicaţii postoperatorii.

Rezultate postoperatorii şi re-miotomii extramucoase sunt trecute în revistă.

Extramucosal myotomy of upper esophageal sphincter

Teodor Horvat

Thoracic Surgery Clinic, Institute of Oncology, Bucharest

A less known subject in romanian medical literature is presented – extramucosal myotomy of

the upper esophageal sphincter.

This paper presents surgical anatomy data, physiologic and physiopathologic aspects of the

upper esophageal sphincter. The maladies which affect the normal function of the pharinx-

sphincter-esophagus are also presented, meaning neurological diseases (central and/or

peripheral), muscular diseases (congenital or aquired), intrinsec conditions of cricopharyngeal

muscle etc.

Surgical indications and contraindications of the pharingo-crico-esophageal extramucosal

myotomy are presented and also surgical techniques, associated procedures and postoperatory

complications. Postoperatory results and extramucosal re-myotomy are reviewed.

Lungtransplantation: surgical issues

APWM (Lex) Maat

Thoraxcenter, Erasmus MC, Rotterdam, Netherlands

In this presentation, both aspects of the donor operation and the implantation will be

discussed.

Since most donation procedures are multi-organ procedures, operation starts with a midline

sterno-laparotomy which is usually made by the abdominal team. On arrival of the lung

donation team a broncoscopy is performed in the OR and the lungs are visually inspected and

palpated by the donor surgeon. When the lung(s) are accepted for donation, the implant team

is called to proceed with the acceptor operation. The main pulmonary artery is canulated to

deliver antegrade pulmoplegia and the left atrial appendage is opened to allow for drainage.

After pulmoplegia, the lungs are harvested èn bloc and on a side table retrograde pulmoplegia

is given into the pulmonary veins to wash out any clots.

The lungs are then packed in 3 sterile plastic bags and stored in a cooler box on melting ice.

In the near future we expect that continuous perfusion and ventilation of donor lungs will

become standard practice in order to minimize ischemia time.

During the donation procedure, the implantation team has already started with the acceptor

operation. For bilateral lungtransplantation we position the patient on a special v-shaped

pillow with both arms in a low position to make a clam shell incision. For unilateral

lungtransplantation we use a standard postero-lateral thoracotomy. Extirpation of the

diseased lungs can be extremely difficult due to severe adhesions and hilar lymphadenopathy.

When a patient can not tolerate single lung ventilation, extra corporeal circulation is needed.

The technique of implantation is described with special attention for the bronchial

anastomosis and several tips and tricks are discussed for the anastomosis of the pulmonary

veins.

Lungtransplantation: organization and logistic problems

APWM (Lex) Maat


Organ donation procedures can be performed in the setting of a heart beating procedure or a

non heartbeating procedure. In heartbeating procedures the donor is braindead and the

procedure can be planned and performed in an semi-elective setting. In a heartbeating donor,

often the heart is also donated. Cardiac surgeon and lung surgeon have to work carefull

together in order to harvest both organs in an optimal way for implantation. In non

heartbeating donation the donor has severe braindamage and can not survive but the donor is

non brain dead. With the explant teams ready in the OR, ventilation is stopped; after

ventilation stop the EKG has to be flat within 1 hour. After cardiac arrest, there is a 5 minute

no touch time and then the donor is rushed to the OR. A midline sternotomy/laparotomy is

performed, clamping of descending aorta, perfusion of abdominal organs and lungs and after

perfusion organ harvest. In these procedures, the heart is not donated but is extirpated in order

to allow for easy access to both lungs. When in non-heartbeating donation the heart does not

stop in the hour after ventilation stop, the procedure is cancelled and the patient will not

donate any organs.

Lung donation is in most cases part a multi organ donation. It means different teams from

different hospitals have to be taken to the donor hospital and meet together in the OR. To

organize this is often very challenging. Most of these teams have never met before, never

worked together and often speak different languages and this can lead to problems.

From an experience of more then 25 years with heart- and lungtransplantion, we present

several unexpected and difficult situations we and other teams came accross.

Stenozele traheo-bronşice – cazuri dificile

Ioan Cordoş


Soluţionarea chirurgicală a stenozelor traheo-bronşice a reprezentat întotdeauna o provocare

pentru chirurgul toracic. Hermes Grillo a sesizat dificultatea intervenţiilor chirurgicale care

vizau extremităţile conductului aerian principal: joncţiunea laringo-traheală şi carina.

Majoritatea stenozelor traheo-bronşice pot fi rezolvate chirurgical respectând principiile

operatorii enunţate în tratatele de specialitate: diagnostic precis, intervenţie minuţioasă,

folosirea manevrelor de relaxare traheală, evitarea devascularizării capetelor de anastomozat,

buna colaborare a pacientului în perioada postoperatorie imediată.

Marile excepţii pot beneficia de metode mult mai sofisticate de plastie traheală cu grefoane

musculocutanate cu pedicul vascular, transplant de trahee conservată şi populată cu celule

proprii, grefă traheală din segment aortic sau în cel mai nefericit caz – stentarea conductului

aerian.

Între aceste două „extreme” se situează cazurile dificile, mai puţin pomenite sau detaliate în

tratate şi articole de specialite, situaţii operatorii care trebuie soluţionate ad hoc. Ele pot fi

dificile din mai multe puncte de vedere: al diagnosticului, al topografiei, al intervenţiei

chirurgicale ca atare şi al evoluţiei postoperatorii.

Stenozele traheobronşice pot fi de natură benignă sau malignă, primitive sau secundare.

Ca leziuni benigne am considerat cazuri dificile: reintervenţiile de rezecţie traheală pentru

restenozare sau chiar ruptură a anastomozei care a depăşit momentul critic, vital, prin

canularea capătului distal, capătul proximal „vindecându-se” prin obstrucţie completă (patru

cazuri) şi stenoza postraumatică a bronşiei primitive stângi (două cazuri). Un alt caz de

stenoză benignă a apărut la o pacientă laringectomizată cu traheostomă terminală definitivă.

Ca leziuni maligne primitive discutăm un caz de carcinom adenoid chistic situat la joncţiunea

dintre treimea medie şi inferioară a traheei mult extins ăn afara conductului aerian.

Leziunile maligne secundare cele extinse de la tiroidă (trei cazuri) şi o determinare secundară

de Mycosis fungoides.

Cu totul excepţionale au fost două situaţii de confuzie diagnostică care au condus la o

intervenţie de rezecţie traheo-bronho-pulmonară (lobectomie superioară) cu reconstrucţia

arborelui traheobronşic. Din fericire evoluţia postoperatorie a fost simplă.

Am dorit să prezentăm câteva cazuri particulare ca precedent pentru viitoarele cazuri

„dificile” intenţionând să sugerăm anumite soluţii care nouă ni s-au părut pertinente şi

fezabile, dovada fiind făcută de rezultatele bune imediate şi la distanţă a majorităţii pacienţilor

operaţi.

Tracheobronchial stenosis – challenging cases

Ioan Cordoş



The subject of tracheobronchial stenosis has always been a challenging one for thoracic

surgeons. Hermes Grillo was among the first to notice the challenges of surgical procedures

involving the extremities of the main respiratory duct: the laryngotracheal junction and the

carina.

Most cases of tracheobronchial stenosis can be solved by simply following the guidelines

mentioned in the medical literature: establishing a precise diagnosis, performing a carefully

planned procedure, applying tracheal relaxation inducing methods, avoiding the disruption of

blood supply to the ends chosen for anastomosis, and making sure the patient respects the

recovery program following surgery.

The most difficult cases can benefit from (1) sophisticated plastic and reconstructive surgery

procedures in which richly vascularized musculocutaneous flaps are used, (2) transplants with

tracheal tissue grown from the patient’s own stem cells, (3) tracheal graft from the aortic

segment, and with less extent – (4) tracheal stents.

In between these categories, we find the challenging cases, less mentioned in the medical

literature and studies, cases in which ad hoc solutions must be found. The challenges lie in (1)

establishing a correct diagnosis, (2) determining the topography of the region, (3) anticipating

and managing postoperative events and in (4) the surgical act itself.

Tracheobronchial stenoses are of benign or malignant origin, the latter being either primary or

secondary.

Among the cases listed in the „benign” section, we consider the following to be the most

challenging: resection for recurrent stenosis or even rupture, following a late anastomosis in

which the proximal end healed by complete obstruction (four cases) or post-traumatic

stenosis of the primitive left bronchia occured (two cases). Another case of benign stenosis

was encountered in a patient with permanent terminal tracheostomy following a total

laryngectomy.

From the „primary malignant” section, we wish to mention a case of adenoid cystic carcinoma

(ACC) at the junction of the second and third segments of the trachea, which had extended to

the tissue surrounding the trachea.

From the „secondary malignant” section, the cases worth mentioning are those involving the

thyroid (three cases) and a metastasis with Mycosis fungoides (granuloma fungoides).

In two unusual cases, diagnostic confusion led to a tracheobronchial pulmonary resection

(upper pulmonary lobe resection) followed by tracheobronchial reconstructive surgery.

Despite the post-operative risks, the recovery period was uneventful.

In this presentation we wished to draw attention to some particular cases which could serve as

a stepping stone to other „challenging cases” and at the same time offer solutions which we

consider to be relevant and viable, given the good long term results we obtained in most of the

patients we operated on.


M.A. Paul

VU University Medical Center, Amsterdam, Netherlands

The NSCLC staging system defines specific stages of the disease, which makes it possible to

compare treatment strategies and, to a certain extent, define prognosis. The TNM system has

been greatly successful and all over the world doctors now have a “ common language” .

Until recently the system was based on a rather limited number of, mainly surgical, cases

from North American data-bases. Unresectable tumors were classified T4, even if they were

small and could be treated well by an other modality(radiotherapy). Very large tumors,

confined to a lobe, were classified T2, because they were easily resectable.

A good classification system does not only predict respectability but also prognosis.

Prognosis is correlated with anatomical extension, but not exclusively. Biological factors also

play a major role and much research is carried out to unravel these mysteries. So far without

much result

The new edition of the TNM system has greatly expanded our knowledge. It is based on a

large data set, over 80.000 cases, from all over the world, and also includes cases with best

palliative care.

However, because the system has to be applicable to every country in the world it is still

based on anatomical criteria. “Tumour behavior” has still to come.

Two things have to be kept in mind when using the 7th

edition. First of all there is an

increasing number of subsets, which automatically occurs when one has a large number of

data. But in surgical practice this can be confusing. Second, the groups were not defined by “

resectability” but by prognosis. Which means that tumor types are grouped together, which

may be very different. For example, stage IIIA contains patients with T4N0, but also patients

with N2 disease. The 7th

TNM edition did not look into treatment, these data were considered

not reliable enough.

But surgeons need criteria for treatment. Prognosis and treatment approaches are not the

same and both are not static. Better imaging may lead to stage migration and better treatments

lead to a better prognosis.

Therefore we need biological criteria. Recently it was proposed to classify tumors according

to their clinical presentation (1). The growth pattern may very well reflect the biological

behavior

Four types of growth pattern have been postulated: 1) Direct local invasion, 2) Spread to

lymphnodes, 3) additional foci in the lung, and 4) (early)distant metastases. This emphasis on

clinical presentation can be used beside the new TNM system and may help the surgeon in

making treatment decisions. And help him in the discussion with non-surgical to prevent

undertreatment in some patients.

Literature:

1. Anatomy, biology and Concepts, pertaining to Lung Cancer Stage Classification.

Detterbeck FC, Tanoue LT, Boffa DJ.

JTO 2009; 4: 437 -443.




Professor of Surgery

Head of the Thoracic Surgery Department

University Clinic Hospital. Valladolid, Spain

The aim of this presentation is to answer different questions to determine the repercussion of

the surgical procedure in the prognosis of the lung carcinoid tumours.

From 1980 to 2008 we gained our experience in 1082 patients treated surgically. Among these

patients 923 (85.3%) had a lung carcinoid tumor; 796 (73.6%) were patients with typical

carcinoid (TC) and 127 (11.7%) with atypical carcinoid (AC). At the beginning, 389 of these

patients were collected retrospectively (345 TC; 44 AC) and from 1999 the other 535 (451

TC; 84 AC) were studied prospectively. Mediastinal sampling or nodal mediastinal dissection

were systematically performed in the prospective group. All the patients were pathologically

codified following the standards of the 2009 TNM lung cancer staging.

Surgical procedures performed in both typical versus atypical carcinoids were: standard

resections 598 (75%) /106 (83,4%) (lobectomy 427/71, bilobectomy 88/13 and

pneumonectomy 83/22), 114 sublobar procedures (14,3%)/15 (11,8%) and 84 bronchoplastic

procedures (11%)/6 (4,7%), respectively.

In patients with TC, 22 of 796 (2.8%) presented metastases. Additionally, 10 (1.3%)

presented local recurrence -3 of them associated with distant metastases- and another 7 only

local recurrence. The characteristics of the different factors for patients with and without

metastases were as follows: Demographics: male, 63.6% and 44.4% (p=0.074), mean age

43.3±17.3 and 49.03±16.1 years (p=0.651), size of primary tumour 33.4±19.15 and 24.9±13.5

mms (p=0.031), respectively.

When considering patients with AC, 27 of 127 patients (21.3%) presented metastases 5 of

which were associated to local recurrence. Additionally, 4 patients presented isolated local

recurrence. The behaviour of the factors analyzed as concerns TC with and without

metastases in these tumours was the following: Demographics: male, 63.9% and 52%

(p=0.310), mean age 60.1±8.6 and 52.9±17.8 years (p=0.000), size of primary tumour

35.6±17.3 and 31.4±15.7 mms (p=0.627), respectively.

According to 2009 TNM stage classification the results in percentage of T, N, and M factors

and tumour stage in both the TC and AC patients group are described in Table Ia.

Comparisons for the described parameters between patients with or without metastases are

defined in Table I.

Table I. A)TNM 2009 Classification. B) Comparisons for the described parameters between

patients with or without metastases.

A

Typical

Carcinoid

Atypical carcinoid

All

patients

With

metastases

% All

patients

With

metastases

%

T1a 248 7 2.8 20 2 10.0

T1b 105 2 1.9 16 3 18.8

T2a 375 7 1.8 66 17 25.8

T2b 31 2 6.4 11 1 9.1

T3 28 3 10.7 9 1 11.1

T4 9 1 11.1 5 3 12

N0 734 16 2.1 84 14 16.7

N1 40 5 12.5 18 5 27.8

N2 22 1 4.5 24 8 33.4

N3 0 0 0 1 0 0

M0 791 21 2.6 121 22 18.2

M1a 1 0 0 0 0 0

M1b 4 1 25 6 5 83.4

Ia 326 6 1.9 29 3 10.3

Ib 344 5 1.4 40 5 12.5

IIa 62 6 9.7 19 5 26.3

IIb 29 2 6.9 6 1 16.7

IIIa 30 2 6.7 24 7 21.2

IIIb 0 0 0 3 1 33.3

IV 5 1 20 6 5 83.3

B Typical Carcinoids Atypical Carcinoids

T factor 0.036 0.136

N Factor 0.000 0.275

M factor 0.018 0.000

Stage 0.000 0.004

The influence of surgical procedure and nodal involvement in the presence of metastases and

overall survival was analyzed considering central vs. peripheral location in these tumours.

(Table II)

Table II

P

Central

Location

Standard

resection

Bronchoplastic

resection

Others Metastases Overall

survival

Local

recurrence

Typical

carcinoid

N0 400 77 24 0.691 0.129 0.004

N+ 37 4 - 0.386 0.709 0.202

Atypical

carcinoid

N0 39 2 - 0.585 0.723 -

N+ 27 3 - 0.481 0.145 0.893

Peripheral

location

Standard

resection

Sublobar

resection

Typical

carcinoid

N0 142 89 3 0.975 0.447 0.375

N+ 19 1 - 0.773 0.900 0.950

Atypical

carcinoid

N0 30 13 - 0.45 0.599 0.018

N+ 11 2 - 0.763 0.727 0.345

Conclusion

Our results allow us to conclude the conditions in which the conservative resection of

parenchyma in carcinoid tumours is advisable. In central typical carcinoid the use of lung-

sparing bronchoplastic techniques demands the intraoperative pathologic verification of the

existence of an adequate surgical margin ≥ 5mm by frozen section avoiding local recurrence.

In peripheral atypical carcinoids the increase in the local recurrence probability after a limited

resection makes it not advisable.

References

1. Travis WD, Rush W, Flieder DB, Falk R, Fleming M, Gal A, et al. Survival analysis

of 200 pulmonary neuroendocrine tumors with clarification of criteria for atypical

carcinoid and its separation from typical carcinoid. Am J Surg Pathol 1998; 22:934-

44.

2. Stamatis G, Freitag L, Greschuchna D. Limited and radical resection for tracheal and

bronchopulmonary carcinoid tumour. Report on 227 cases. Eur J Cardiothorac Surg

1990; 4: 527-532.

3. Thomas CH F, Tazelaar HD, Jett JR. Typical and atypical pulmonary carcinoids.

Outcome in patients presenting with regional limph node involvement.Chest 2001;

119:1143–1150.

4. Filosso PL, Rena O, Donati G, Casadio C, Ruffini E, Papalia E, Oliaro A, Maggi G.

Bronchial carcinoid tumors: surgical management and long-term outcome. J Thorac

Cardiovasc Surg 2002; 123: 303-309.

5. Cardillo G, Sera F, Di Martino M, Graziano P, Giunti R, Carbone L, Facciolo F,

Martelli M. Bronchial carcinoid tumors: nodal status and long-term survival after

resection. Ann Thorac Surg 2004; 77: 1781-1785.

6. Asamura H, Kameya T, Matsuno Y, et al. Neuroendocrine neoplasms of the lung: a

prognostic spectrum. J Clin Oncol 2006; 24:70–76.

7. García-Yuste M, Matilla JM, Cueto A, Rodríguez Paniagua JM, et al. Typical and

atypical carcinoid: analysis of the experience of the Spanish multicenter study of

neuroendocrine tumors of the lung. Eur J Cardiothorac Surg 2007;31:192-197.

8. Rea F, Rizzardi G, Zuin A, et al.Outcome and surgical strategy in bronchial carcinoid

tumors:single institution experience with 252 patients. Eur J Cardiothorac Surg

2007:31:186-191.

9. García-Yuste M, Matilla JM, Gonzalez-Aragoneses F. Neuroendocrine lung tumors.

Current Opinión Oncology 2008; 20:148–154.

10. Bertino EM, Confer PD, Colonna JE, Ross P, Otterson GA. Pulmonary

neuroendocrine. Carcinoid tumors. Cancer 2009; 1: 4434-4441.

11. Davini F, Gonfiotti A, Comin C, Caldarella A, Mannini F, Janni A. Typical and

atypical carcinoid tumors: 20-year experience with 89 patients. J Cardiovasc Surg

2009; 50: 807-811.

12. Detterbeck FC. Management of carcinoid tumors. Ann Thorac Surg 2010; 89: 998-

1005.


Eric Frechette

Thoracic Surgery Department, Institut Universitaire de Cardiologie et de Pneumologie de


Since the first reports of VATS lobectomy in the 1990’s, the technique as gone through

different refinements, has gained wide world-wide acceptance, and is now considered by

many as a standard of care in the treatment for stage I NSCLC. When compared to open

lobectomy, the technique has been reported to have the same oncological results and many

benefits in term of postoperative pain, perioperative outcomes, length of stay, biological

impact and costs in a North-American setting. Although there is variability in the technique

between surgeons, the procedure is safe, can be easily learned, and is performed every year in

a growing proportion of cases. Lymph-node sampling or dissection can (and should) be

included. Locally advanced tumors have been resected through VATS with concomitant

chest-wall resection, pneumonectomy, or sleeve resection, but the benefit of performing

theses more extensive resections remains unclear. In many countries, the cost of the additional

staplers necessary to perform the technique may limit its development, but alternative

solutions exist. The knowledge of some simple intraoperative details and concepts will help

surgical teams to switch from open to VATS lobectomy. So although multiinstitutional trial of

open versus VATS lobectomy will probably never take place, the best available evidence

strongly suggests that VATS lobectomy is the treatment of choice for stage I NSCLC.


Dragan Subotic

Clinic for thoracic surgery, Clinical center of Serbia, Belgrade

Currently, the preoperative lung function assessment is focused to the prediction of

postoperative ventilatory function and to the estimate of cardiorespiratory reserve. It is now

established that predicted postoperative FEV1 (ppoFEV1) is accurate in predicting FEV1 3-

6 months after surgery, but in the same time it is likely to overestimate the FEV1 in the initial

post-operative days, when, in fact, most complications occur. It was recently demonstrated

that, on the first post-operative day after lobectomy, for example, the measured FEV1 may be

30% lower than predicted.

The smaller postoperative loss in FEV1 in COPD vs. non-COPD patients has been reported

with increasing frequency, but without clear suggestion of the lower limit. Results of several

reports showing that the lung function can be better preserved after upper lobectomy in COPD

patients, can be counterweighted by recent findings that the observed postoperative loss in

FEV1 may exceed the predicted loss after upper

lobectomies in COPD patients. It means that

COPD strongly influences FEV1 at both the early and late terms after upper lobectomy, so that

the exact way of it's influence to the early postoperative lung function preservation still has

not been fully elucidated.

In patients undergoing pneumonectomy, the ppoFEV1 can underestimate the actual poFEV1

by an average of 500 ml. The smaller loss in FEV1 and greater decrease of hyperinflation

after pneumonectomy in COPD vs. non-COPD patients means that prediction of the

postoperative lung function in candidates for pneumonectomy with limited lung function, can

be done in a similar way than in COPD patients undergoing a lobectomy: COPD patients are

likely to do a little bit better postoperatively than predicted. Furthermore, it was convincingly

demonstrated that, in patients with preserved phrenic nerve and normal diaphragm motion, the

postoperative FEV1 was significantly better than in patients with either immobile diaphragm

or with paradoxical diaphragm motion.

Having in mind that many COPD patients have also the increased cardiac risk, the current

review addresses several points that influence the preoperative selection in this challenging

patient population.


José Belda-Sanchis

Hospital Universitari Mutua de Terrassa, Barcelona, Spain

The advent of new and specific technology in earliest 90s leaded to an increase in interest in

videoassisted thoracoscopy surgery (VATS) as a diagnostic and therapeutic tool in all fields

of the thoracic surgery. At that time, many surgeons changed the traditional open approach to

pulmonary resection of colorectal metastases for less invasive thoracoscopic techniques. Still

now, there are many areas of controversy concerning the capability of VATS in detecting and

removing all the lung metastases.

For the moment, there are not randomized controlled trials comparing VATS to the open

approach for the curative pulmonary metastasectomy. In 1999 the CALGB planned a

prospective randomized trial comparing the treatment of pulmonary metastases by VATS vs

open surgery but the study was closed early due to the slow accrual (1). There are two

systematic reviews of published series which evaluate the current status of the surgical

treatment of colorectal lung metastases (2,3). Many others studies specifically review the

results of pulmonary metastasectomy by means of open and VATS approach in terms of

safety and long term survival.

Many case series and cohort studies have pointed out the main controversial aspects regarding

thoracoscopic pulmonary metastasectomy.

1st. Does VATS approach allow the identification and resection of pulmonary metastases

equal than open approach? VATS metastasectomy is based on the preoperative images, in

the ability (or inability) to adequately explore the entire lung using the thoracoscope, in the

palpation with the surgeon’s finger of the most external part of the lung or in the marking of

the pulmonary node with a spiral type harpoon. Validity of the old and new CT scans is

questionable for guiding pulmonary resection of pulmonary metastases with a sensitivity

ranging from 75% to 82% (4). Non-detected pulmonary metastases on preoperative CT scan

or FDG PET scan but discovered during bimanual palpation at thoracotomy range from 15%

to 42% (5,6,7,8). According these results, an open approach allows for more complete

resection of malignant metastases. At the moment, the clinical relevance in terms of prognosis

and survival of the disagreement between the number of preoperative detected nodules and

pathologically confirmed metastases is unknown.

2nd

What is the meaning of “complete resection” of lung metastases? It is well known that

a complete resection is an independent prognostic factor of survival after pulmonary

metastasectomy for colorectal cancer (2,9, 10). Nevertheless, the term “incomplete resection”

is used in the majority of studies for describing an unresectable disease due to the local

extension (the disease involves vital structures, mediastinal lymph nodes or the patient can not

afford the magnitude of the resection). Probably this meaning is not equivalent to

“radiologically undetectable” nodules that could remain into the lung after a VATS resection.

There is not evidence that such undetectable non-resected nodules confer a worse prognosis.

Such small nodules undetected at the time of the thoracoscopy will grow and they will be

diagnosed as new metastases. Many studies have shown that repeated metastasectomy is

associated to a 5-years survival equal than first metastasectomy (11,12,13,14).

3rd

VATS for selected patients? As Dr. Cerfolio state in their study published in the

European Journal of Cardio-thoracic Surgery in 2009, the optimal surgical approach to

pulmonary metastases may be patient-dependent rather than surgeon-dependent. There are

few studies of case series which addressed to this topic (15,16,17,18). In these studies, the

selective use of VATS metastasectomy is associated with a long term outcome (5 years

survival, disease free survival) that is comparable with that after resection by thoracotomy.

These authors recommend a VATS resection for patients with small nodules, fewer nodules or

single pulmonary metastases and lesions located in the outer third of the lung (15-20).

1. Kohman LJ. Cancer and Leukemia Group B Surgery Committee. Clin Cancer Res

2006; 12 (11 suppl):3622s-7.

2. Pfannschidt J, Dienemann H, Hoffmann. Surgical resection of pulmonary metastases

from colorectal cancer: A systematic review of published series. Ann Thorac Surg

2007;84:324-38.

3. Yano T, Shoji F, Maehara Y. Surg Today 2009;39:91-7.

4. Margaritora S, Porziella V, D’Andrilli A, Cesario A, Galetta D, Macis G, et al.

Pulmonary metastases: can accurate radiological evaluation avoid thoracotomic

approach? Eur J Cardiothorac Surg 2002;21:1111–4

5. McCormack PM, ATS 1993. Accuracy of lung imaging in metastases with

implications for the role of thoracoscopy. Estudio retrospectivo.

6. McCormack PM, Bains MS, Begg CB, Burt ME, Downey RJ, Panicek DM, et al. Role

of video-assisted thoracic surgery in the treatment of pulmonary metastases: Results of

a prospective trial. Ann Thorac Surg 1996;62:213–6.

7. Ludwig C, Cerinza J, Passlick B, Stoelben E. Comparison of the number of pre-,

intra- and postoperative lung metastases. Eur J Cardio-thorac Surg 2008;32:470-72.

8. Cerfolio RJ, McCarty T, Bryant A. Non-imaged pulmonary nodules discovered during

thoracotomy for metastasectomy by lung palpation. Eur J Cardio-thorac Surg

2009;35:786-91.

9. The International Registry of Lung Metastases. Long-term results of lung

metastasectomy: Prognostic analyses based on 5206 cases. J Thorac Cardiovasc Surg

1997;113:37–49.

10. Watanabe K, Nagai K, Kobayashi A, Sugito M, Saito N. Factors influencing survival

after complete resection of pulmonary metastases from colorectal cancer. Br J Surg

2009;96:1058-65.

11. Saito Y, Omiya H, Kohno K, Kobayashi T, Itoi K, Teramachi M, et al. Pulmonary

metastasectomy for 165 patients with colorectal carcinoma: a prognostic assessment. J

Thorac Cardiovasc Surg 2002;124:1007–13.

12. Pfannschmidt J, Muley T, Hoffmann H, Dienemann H. Prognostic factors and survival

after complete resection of pulmonary metastases from colorectal carcinoma:

Experiences in 167 patients. J Thorac Cardiovasc Surg 2003;126:732-9.

13. Ogata Y, Matano K, Hayashi A, Takamori S, Miwa K, Sasatomi T, et al. Repeat

pulmonary resection for isolated recurrent lung metastases yields results comparable

to those after fi rst pulmonary resection in colorectal cancer. World J Surg

2005;29:363–8.

14. Welter S, Jacobs J, Krbek T, Krebs B, Stamatis G. Long-term survival after repeated

resection of pulmonary metastases from colorectal cancer. Ann Thorac Surg

2007;84:203–10.

15. Rotolo N, De Monte L, Imperatori A, Dominioni L. Pulmonary resections of single

metastases from colorectal cancer. Surgical Oncology 2007;16:S141-S144.

16. Nakajima J, Murakawa T, Fukami T, Takamoto S: Is thoracoscopic surgery justified to

treat pulmonary metastasis from colorectal cancer? Interact Cardiovasc Thorac Surg

2008, 7:212-216. discussion 216–217.

17. Carballo M, Maish MS, Jaroszewski DE, Carmack E Holmes CE. Video-assisted

thoracic surgery (VATS) as a safe alternative for the resection of pulmonary

metastases: a retrospective cohort study. Journal of Cardiothoracic Surgery 2009;

4:13.

18. Mutsaerts EL, Zoetmulder FA, Meijer S, Baas P, Hart AA, Rutgers EJ. Long-term

survival of thoracoscopic metastasectomy vs metastasectomy by thoracotomy in

patients with a solitary pulmonary lesion. Eur J Surg Oncol 2002;28:864–868.

19. Lin JC, Wiechmann RJ, Szwerc MF, Hazelrigg SR, Ferson PF, Naunheim KS et al.

Diagnostic and therapeutic video-assisted thoracic surgery resection of pulmonary

metastases. Surgery 1999;126 (4):636-41.

20. Nakas A, Klimatsidas MN, Entwisle J, Martin-Ucar AE, Waller DA. Video-assisted

versus open pulmonary metastasectomy: the surgeon’s finger or the radiologist’s eye?

Eur J Cardio-thorac Surg 2009; 36: 469-474.

Aportul amprentei tumorale în diagnosticul cancerului pulmonar primitiv şi metastatic

Irina Strambu

Pneumology Department, “Marius Nasta” National Institute of Pneumology, Bucharest

Amprenta tumoralã reprezintã o alternativã simplã, rapidã şi cu cost scãzut la secţiunile din

material îngheţat pentru stabilirea intraoperatorie a diagnosticului histologic de cancer

pulmonar. Cu toate acestea, existã puţine studii care sã evalueze valoarea amprentei tumorale

şi ganglionare.

În acest studiu prospectiv am evaluat concordanţa diagnosticã între malignitatea identificată

prin amprenta citologică a tumorii şi cea prin examen histopatologic la parafinã cu scopul de a

stabili valoarea amprentei tisulare ca metodã rapidã de diagnostic histologic în cancerul

pulmonar. Ca obiectiv secundar, studiul şi-a propus să analizeze acurateţea identificării tipului

histologic prin metoda amprentei.

Au fost analizate 107 produse prelevate intraoperator în serviciul de chirurgie toracică, din

care s-a realizat amprenta pe lamă, fixată, colorată şi examinată imediat, ca şi includerea la

parafină şi examen histopatologic. X produse au fost excluse, Y examinate, dn care Z maligne

şi W benigne la examenul histopatologic.

Am calculat o sensibilitate a amprentei de 97,4%. Aceasta înseamna că testul confirmă boala

la majoritatea bolnavilor. Specificitatea a fost însă de doar 65%, cu o proporţie importantă de

fals pozitivi (7 cazuri din 20).

Rezultatele confirmă utilitatea acestei metode ca adjuvant sau alternativă la procedeul

extemporaneu cu secţiuni îngheţate, în evaluarea patologică a leziunilor neoplazice pulmonare

sau mediastinale, fiind însă necesare studii suplimentare pe cazuri benigne şi selecţia mai

riguroasă a cazurilor Metoda prezintă multe avantaje: este un procedeu simplu, mai ieftin şi

mai rapid decât secţiunile înghetate, dar pentru interpretare necesită un citolog cu experienţă.


Cristina Grigorescu

Clinic of Thoracic Surgery, University of Medicine “Gr.T.Popa” Iasi

Neuroendocrine tumors of the lung represent a broad spectrum of morphologic types that

share specific morphologic, immunohistochemical, ultrastructural, and molecular

characteristics. The classification of neuroendocrine lung tumors has changed over the last

decades and currently four categories are distinguished: typical carcinoid tumor, atypical

carcinoid tumor, large cell neuroendocrine carcinoma and small cell carcinoma. Because of

differences in clinical behavior, therapy, and prognosis, a reliable histological diagnosis, as

well as clinical and pathological staging system are essential for an appropriate medical

proceedings. The most effective treatment of bronchial carcinoids and large cell

neuroendocrine carcinoma in an early stage is complete surgical resection, whereas

chemotherapy remains the primary treatment for small cell carcinoma.Increased knowledge

about pulmonary neuroendocrine tumors biology and the genetic characteristics, imply that

carcinoid tumors appear to have a different etiology and pathogenesis than large cell

neuroendocrine and small cell carcinoma. In practice, it could be easiest to conceptualize this

group of pulmonary tumors as a spectrum of malignancy ranging from the low grade typical

carcinoid to the highly malignant large cell neuroendocrine and small cell carcinoma. Typical

carcinoid tumors associated with a fairly benign behavior should be classified as low-grade

neuroendocrine tumor/carcinoma (G1) and atypical carcinoid tumors as intermediate-grade

tumor/carcinoma (G2). Whereas, large cell neuroendocrine and small cell carcinoma should

be grouped together under the designation of high-grade neuroendocrine tumor/carcinoma

(G3).No medical therapy exists for the primary treatment of neuroendocrine tumor of the

lung. Chemotherapeutic agents and radiation therapy have been used in the treatment of

metastatic disease but have met with virtually no success. A response rate of 30-35% has been

reported using a combination of 5-fluorouracil and streptozotocin. Symptomatic relief of

carcinoid syndrome from metastatic disease has been achieved by administration of

octreotide.


APWM (Lex) Maat


Malignant pleural mesothelioma is a cancer rising from the mesothelial cells in the visceral

and parietal pleura. In The Netherlands between 400 and 500 patients die tearly due to

mesothelioma.

There is a close relationship between exposure to asbestos and development of mesothelioma.

Untill the introduction of Pemetrexed, there was a general therapeutic nihilism amongst most

physicians dealing with mesothelioma patients. The last 10 years however, many paper have

been published on surgery in malignant pleural mesothelioma, claiming that surgery in the

setting of multi-modality treatment is the treatment of choise. Till the summer of 2011

however, there have not been performed randomized controlled studies on surgery in

mesothelioma. The proponents of surgery in mesothelioma have been severely criticised on

their opinions and this led to heated discussions both in journals and during scientific

meetings. It is very well possible that success claimed by surgeons can be attributed to patient

selection, timing of diagnosis and natural behaviour of the disease. The different operations

(pleuro-pneumonectomy and pleurectomy-decortication) will be explained. The contents of

the criticism will be discussed. We will also shed light on the problems we encountered in

our own Rotterdam MPM study and will discuss the MARS study and finally will talk about

possible future ways.

Mediastinal approach of postpneumonectomy left bronchial stump fistula

Cristian Paleru



Left main bronchial stump fistula remains a severe complication of left pneumonectomy.

Mediastinal approach methods use a noncontaminated operatory field with an almost normal

anatomy. Classical method of transsternal transpericardial approach, developed in the 60’s is

nowadays in competition with minimally invasive surgery, especially with transcervical

approach, first described by Azorin in 1996.

Both these methods are being used in our department; this presentation tries to show when

should we use one or the other, advantages and limitations of each of those two techniques.

When possible, transcervical approach gained ground for reasons of reduction of the operating

time and hospital stay and reduction of mortality and morbidity related to transsternal

approach.


Alexandru Nicodin, Iris Miron, Ioan Petrache

Clinica de Chirurgie Toracica Timisoara

Introducere:

Datorita patologiei chirurgicale toracice, in special a cancerului bronho-pulmonar, care

ramane in continuare o piatra grea de incercare atat pentru pacienti cat si pentru medici,

incercarea de a intelege aceasta patologie a facut ca nevoia de a efectua studii pe loturi mari

de pacienti sa fie din ce in ce mai mare. Societatea Europeana de Chirurgie Toracica pune la

dispozitia noastra o modalitate usoara in vederea realizarii acestui deziderat.

Scop:

Lucrarea de fata isi propune sa familiarizeze chirurgul toracic cu baza de date europeana

propusa de ESTS (ESTS Registry) in incercarea de a contribui activ in dezvoltarea acestui

proiect pentru care colaboreaza in prezent alte 190 de tari si societatea similara din Statele

Unite (STS) si sa prezinte experienta Clinicii de Chirurgie Toracica din Timisoara in ceea ce

priveste folosirea acestei aplicatii, care, in conditiile in care sunt inscrise cat mai multe unitati

romanesti, poate servi pe post de baza de date nationala (o baza nationala de date realizata

independent costa foarte mult si necesita resurse pe care nu le avem).

De asemenea baza de date ESTS reprezinta calea catre accederea clinicilor de chirurgie

toracica in randul clinicilor cu acreditare europeana prin Programul European de Calitate

Institutionala.

Concluzii:

Baza de date europeana reprezinta nu numai o modalitate gratuita si facila in centralizarea

datelor pentru interventiile chirurgicale toracice si atingerea scopului realizarii de studii pe

loturi mari de pacienti, dar si o modalitate de autoevaluare a performantei clinicilor de

chirurgie toracica in vederea obtinerii certificarii in cadrul Programului European de Calitate

Institutionala.


Alexandru Nicodin, Iris Miron, Ioan Petrache


Introduction:

Due to the surgical pathology of the thorax, especially lung cancer, that poses still big

problems both for the patient and for the doctor, the attempt to understand this pathology lead

to the increasing need to develop studies on a larger number of patients. The European

Thoracic Surgery Society allows us easy access in achieving this goal.

Purpose:

This presentation’s purpose is to familiarize the thoracic surgeon with the ESTS database

(ESTS Registry) in the attempt to actively contribute to the development of this project for

which other 190 countries collaborate today, along with the similar American society(STS)

and to present our experience of using this application, which can be used as a national

thoracic surgery database if there are o lot of clinics in Romania that contribute, taking into

account that an independent national database would cost too much and would require

resources out of our reach.

Also, the ESTS database is the way to achieve European accreditation through the European

Institutional Quality certification program.

Conclusions:

The european database represents not only a free and fast way to centralize the data from the

surgical procedures in order to achieve studies on large number of patients, but also a way for

the auto-evaluation of performance of the thoracic surgery departments, especially in they

apply for the European Institutional Quality certification program.

ORAL PRESENTATIONS

BLEEDING FROM AN ADRENAL METASTASIS AS AN ATYPICAL CLINICAL

ONSET OF A STAGE IV LUNG CANCER


1, Porav Daniel


Voichiţa3




Introduction. We present a particular clinical onset of a lung cancer.

Material and method. We report a 46 years old male, with a history of 2 episodes of acute

pancreatitis and a laparoscopic cholecystectomy, whose actual disease started sudden with

intense pain in the left lumbar area. The patient presented to the Urology Clinic where the

diagnostic of renal colic was excluded (no pielo-caliceal dilatations) and the patient was

referred to the general surgery emergency department with the suspicion of acute abdomen.

Ultrasound showed a left adrenal mass and emergeny CT scan showed a 6 cm diameter

suppurated right pulmonary tumor and a left adrenal mass with a 7 cm diameter and

periglandular hemorrhagic infiltration, with no other secondary lesions. For pain control we

used opioides, followed by placement of an epidural catheter. We started with the thoracic

lesion, performing a non-anatomic resection of segment 6 Fowler, and after 10 days we

performed a left adrenalectomy through a left subcostal incision.

Results. The Immediate postoperative course was favourable, with complete resolution of the

lumbar pain after the left adrenalectomy. Pathologic examination showed in both specimens

adenoscuamous pulmonary carcinoma, the adrenal mass being a metastasis with diffuse

intraglandular bleeding. At 21 months after surgery, the patient has no abdominal or thoracic

complaints and has no signs of tumoral recurrence.

Conclusions. The case is interesting due to the sudden and atypical clinical onset of the lung

cancer due to the bleeding from the adrenal metastasis, due to the pain management problems

and the presence of secondary pulmonary suppuration which required to start the surgical

approach with the thoracic lesion.

UNIPORTAL THORACOSCOPY FOR PLEURAL EFFUSIONS




Introduction: Uniportal VATS has demonstrated a large application in the diagnosis and

treatment of different intrathoracic conditions.

Material and method: Between January 2010 and June 2011 (18 months) we performed 56

uniportal thoracic endoscopies for pleural effusions, representing 78.8% of all thoracoscopic

procedures (no minithoracotomy). There were 34 female and 22 male with mean age of

61.33±11.38 years.

A 5-mm, 0-degree thoracoscope was used. Double-lumen intubation and separrated-lung

ventilation was used in 29 cases, single-lumen intubation was preffered in 25 cases and

spontaneous ventilation with local and intravenous analgesia was appropriate in 2 selected

cases.

Results: Pleural biopsies were performed in all cases; when possible, intraoperatory talc

poudrage was added. A malignant diagnosis was made in 46 cases and chronical

inflammation in 10 cases. In 6 cases of unknown previous malignancy a pleural neoplasy was

diagnosed.

Conclusion: Uniportal thoracoscopy is a safe and effective diagnostic and therapeutical

procedure in pleural effusions. Double-lumen intubation anesthesia is reccomended but for

pleural biopsy and chemical pleurodhesis a single-lumen intubation can be safely used.

MEDIASTINAL ECTOPIC PARATHYROID ADENOMA – CASE REPORT



2, Mihaela Vlad

3

1 Thoracic Surgery Department, City Hospital Timisoara

2 Anatompathology Department , City Hospital Timisoara

3 Endocrinology Department, County Hospital Timisoara

Introduction.

Incidence of ectopic parathyroid glands in individuals is approximately 6%, the most common

location being the thymic capsule or the superior mediastinum.

Case.

We present the case of 21-years-old female with a recent history of osteoclastoma affecting

the maxillary bone and the mandible, together with increased values of the parathyroid

hormone (over 20 times the normal value), total calcium and alkaline phosphatase and

decreased serum phosphorus. A cervico-mediastinal MRI was performed with the disclosure

of a well delimited 5/5.5/2 cm tumoral mass in the antero-superior part of the mediastinum, as

well as multiple cystic bone tumors affecting the maxillary bone, mandible, clavicle, humeral

head and scapula - osteitis fibrosa cystica in context of the primary hyperparathyroidism.

In September 2010 thymectomy was performed through a right antero-lateral thoracotomy.

Intraoperatively we found a hemorhagic superior and anterior mediastinal mass, very adherent

to the ascending aorta. During the dissection of the tumor a lot of blood loss was encounterred

with the enlargement of the tumor. In order to removed the mass, we used human fibrinoid

haemostatic agents, as a tactical approach. Two chest drains were inserted.

Results.

At the site of the thymic capsullae a nodule was identified, formed mainly by parathyroidian

cells, without any sign of malignacy. The final anatomo-pathological result was ectopic

parathyroidian adenoma. Posoperative the evolution of tha patient was favorable, with the

decrease of serum values of PTH from 1392.4 pg/ml peroperatory down to 4 pg/ml the next

day. The patient received further tratment in the Endocrinolgy Clinic for re-establishing the

ionic and hormanal equilibrium.

Conclusion.

After surgical removal of the mediastinal mass, imagistically suspected and

histopathologically confirmed as ectopic parathyroid tissue, the syndrome of primary

hyperparathyroidism was resolved.

SLEEVE RESECTION WITH FULL PULMONARY PRESERVATION FOR

POSTTRAUMATIC MAIN BRONCHIAL STENOSIS


Cordos



Introduction

Tracheobronchial disruption is one of the most severe injuries caused by blunt chest trauma.

A high index of clinical suspicion and accurate interpretation of radiological findings are

necessary for prompt surgical intervention.

Cases report

We present five patients operated in our department with main bronchial stenosis after blunt

chest trauma. All patients are young males and were diagnosed with pneumothorax and

discrete pneumomediastinum. They all received chest drains for the affected hemithorax.

In four cases radiologic aspect was complete lung atelectasis, persistent pneumothorax and

bronchoscopy revealed main bronchial stenosis. In one case, main bronchus rupture was

diagnosed at admission and stenosis was later confirmed as pneumonia evolved under

antibiotherapy.

After thoracotomy lung parenchyma seemed normal and we resected only the stricture in all

patients. Control bronchoscopy reveals main bronchus widely patent with untraceable suture

line.

Discussion

Blunt tracheobronchial trauma is usually lethal, more than 75% of patients dying before

hospital admission.

Traumatic main bronchus rupture is an effect of chest wall compression generating traction

forces as lungs are fixed at carinal level, but mobile in the pleural cavity, and sudden increase

in intraluminal pressure.

Sleeve resection of the stenosed segment is the treatment of choice, restores full lung function

and gives best long-term results.

Management of delayed presentations is challenging. Surgical intervention even many years

after initial trauma gives excellent results.

Conclusion

Rupture of main bronchus is a rare complication of blunt chest trauma. Flexible bronchoscopy

is recommended for all patients with chest trauma and pneumothorax or pneumomediastinum

for early diagnosis of tracheobronchial injuries.

Posttraumatic bronchial stenosis can present months, even years after the initial incident. Late

presentation doesn’t impair the postsurgical evolution as subjacent lung parenchyma is

frequently in good shape despite long-time atelectasis. Conservative sleeve resection with

end-to-end anastomosis is the key of successful in these cases.

A COMPLEX SURGICAL SYSTEM FOR SOLID STERNAL RECONSTRUCTION:

THORATEX MESH, STRATOS SYSTEM AND KRYPTONITE BONE CEMENT


* Emergency University Military Central Hospital “Dr. Carol Davila”, Bucharest


Introduction: The paper presents 2 cases admitted in the thoracic surgery department with

malignant sternal tumors: a 49 years old female with manubrial secondary tumor (tubulo-

papilary adenocarcinoma) after a right breast cancer (right Halsted mastectomy with pre and

postoperative chemo and radiotherapy) and a 45 years old male with a primary

chondrosarcoma of the sternal body.

The authors reveal the modality of sternal resection and reconstruction in approaching of

these cases through very illustrative preoperative, intraoperative and postoperative images.

Material and method: In both cases, after radical resection of the tumors, the rigid

reinforcement of the sternum was achieved with thoratex mesh reinforced with STRATOS

system and Kryptonite bone cement. The soft reconstruction was made with widely mobilized

pectoralis major muscle flaps (humeralis, sterno-costal and clavicular insertions transected)

shifted to the midline for loose closure.

Results: The complete removal of the tumors and very good chest wall stability was achieved

in both cases. In the second case, the kryptonite bone cement mixed with healthy

osteochondral fragments is useful both for the rigid sternal reconstruction and for creation of a

neosternum (porous structure was favorable for osseointegration and bone regeneration).

Conclusions: Large sternal defects after resection for malignant sternal tumors are safely

reconstructed with this complex surgical system combined with pectoral major muscular

flaps.

THE IMPORTANCE OF HISTOPATHOLOGICAL FACTORS IN SETTING THE LONG

TERM PROGNOSIS FOR NON-SMALL CELL LUNG CANCER

Suciu B.1, Bud V.

1, Copotoiu C.



3, Fodor D.

1,

Butiurca V.4

Surgical Clinic no. 1, Mureș County Emergency Hospital

Anatomy Department, University of Medicine and Pharmacy, Tg.Mureș

ICU Clinic, Mureș County Emergency Hospital

Student, University of Medicine and Pharmacy, Tg.Mureș

Introduction

In the last decades, the rate of pulmonary cancer has risen alarmingly. Pulmonary cancer

represents the main cause of death in women and in men in the United States of America,

100.000 new cases being registered annually in men and 50000 new cases in women. The

purpose of our study is to evaluate the importance of histopatological factors in the long term

outcome of patients operated for lung cancer.

Material and methods

In order to write the present paper, we realized a retrospective observational study on a period

of 6 years. We used the casuistry of the Surgical Clinic No.1,Mureș County Emergency

Hospital. We studied all the patients’ papers who were admitted in Surgical Clinic No.1 from

the 1st of January 2005 till 31 December 2010. Further, we based our research on 197 patients

that were admitted in Surgical Clinic No.1 for bronchopulmonary tumors.

Results

We studied 197 patients admitted with malignant bronchopulmonary pathology in Surgical

Clinic No.1, Mureș County Emergency Hospital from 01.01.2006 till 31.12.2010. We tried to

study was the importance of the T descriptor (tumor) from the TNM staging for establishing

the long term prognostic. The value of p was 0.1676 so we didn’t obtain any value of

statistical importance. We also took into consideration the value of N from the TNM staging

as a prediction factor for long term survival in the patients that underwent surgical

intervention for pulmonary cancer. The p parameter was 0.0152 so we can say that we

obtained a direct connection between the stages of adenopathy and long term survival rate

Conclusions

Long time survival rate of the patients depends on the histological type of the tumor. Long

term survival prediction rate is better if the patients are over 60 years, compared with the

patients that are under 60 years. The N descriptor can be considered an important prediction

factor, while the T descriptor’s value is useless. The existence of N’s descriptor in more

stages of the TNM complex shows the limits of it and encourages for further improvements.

Key words : lung, cancer, prognosis, descriptor

CERVICAL VIDEO-ASSISTED MEDIASTINOSCOPIC APPROACH OF THE LEFT

MAIN BRONCHUS - A SERIES OF SIX CASES



1 - 1st Clinical Department of Thoracic Surgery, “Marius Nasta” National Institute of


2 - Bronchoscopy Department, “Marius Nasta” National Institute of Pneumology, Bucharest

Introduction

Bronchial stump fistula (BSF) after pneumonectomy remains a feared complication. Only 8

cases involving cervical video-assisted mediastinoscopy for closure of the bronchial stump

fistula (BSF) following pneumonectomy were reported worldwide.

Materials and Methods

The authors present a series of 6 patients who underwent cervical video-assisted

mediastinoscopy for closure of the left main bronchus (LMB) between December 2009 and

July 2011. Mean age was 44.2 years (2 females and 4 males). 2 patients underwent the

procedure for closure of the postpneumonectomy BSF and 4 prior to pneumonectomy in

tuberculous destroyed lung. The follow up ranged from 7 weeks to 20 months.

Results

Mean operating time was 85 minutes. Mediastinal drainage was performed in 1 case. Only

one stapling failure was recorded. The patients were discharged on the 3rd day following

surgery. No relapses during the follow-up period. 1 patient died 7 weeks after surgery as a

consequence of a cardiac event.

Conclusions

Cervical video-assisted mediastinoscopy is a viable alternative to thoracothomy and trans-

sternal approach of the left main bronchus. Its main indications are postpneumonectomy BSF,

airway sealing and bronchial resection in patients with permanent damaged lungs. This

procedure especially addresses the LMB because of the anatomical considerations. A high

level of expertise in mediastinoscopy and special surgical instruments are required. In order to

assure the success of the procedure the cases must be carefully selected, one of the main

conditions being a bronchial stump of at least 1.5cm in length.

EXTRA-MUSCULO-PERIOSTEAL PLOMBAGE THORACOPLASTY WITH BALLS –

STILL WORKING AFTER 46 YEARS



Introduction. Plombage thoracoplasty was extremely popular in the 1940-50's due to it'

simplicity and esthetic advantage; it was abandoned due to some specific complications and to

the good results achieved after the introduction of modern tuberculostatic treatment.

Material and method. We report an 81-years old patient who underwent at the age of 35 years

(46 years ago) an extramusculo-periosteal plambage with balls for a fibro-cavitary left upper

lobe tuberculosis.

Results. The patient had an excellent postoperative evolution, with negative cultures for

Mycobacterium tuberculosis, no respiratory symptoms and a complete social reinsertion

(general practitioner until the age of 70 years); he was admitted to our unit for an entero-

mesenteric infarction and died on postoperative day 8 (after segmentary enterectomy) due to a

myocardial infarction.

Conclusions. The case is interesting due to the imagistic aspects and the excellent evolution

after a procedure with which the actual generation of surgeons is not familiar. The actual

recrudescence of tuberculosis may bring into attention procedures that were considered

abandoned at a certain time.

THORACIC PARIETAL HEMANGIOMA



Introduction

Thoracic parietal angioma is a very rare condition. The positive and differential diagnosis is

difficult and the surgical resection can be technical challenging.

Material and method

A 56 years old male patient is admitted with a left posterior chest wall tumor developped

along 1 year period. The tumor is well delimited, developped along the inferior 2/3 of the

paravertebral muscles. CT-scan compleetly described the tumor and MRI pointed-out it’s rich

vascularisation.

Results

Intraoperatory description is an angiomatous mass, approx.20cm long, located under the

superficial sheat of left paravertebral muscles. The complete resection of the tumor is

performed toghether with muscular fibers adherent to it. The histologic result is cavernous

angioma. Postoperatory recovery is uneventfull.

Conclusions

The rare angiomatous tumors have to be considerred in any case of thoracic parietal tumor.

UNUSUAL CASE OF LEYOMIOFIBROMATOSIS WITH MULTIPLE LOCATIONS –

THE TRUTH BEYOND THE APPEARANCES – CASE REPORT




Introduction: Leyomiofibromatosis constitutes an unusual cause of respiratory and/or

digestive disturbances, her main localization being genital.

Material and methods: We present a puzzling case of a 22 years woman with multiple

localization of leyomiofibromas, which few symptoms (recurrent respiratory infections, slow

weight loss, dry cough, recent dysphagia to solids) remains undiagnosed and untreated for a

long period. Previous surgery (bilateral cataract, thyreoglossal cyst) have become important in

the process of elaborating an accurate diagnostic.

Results: Following the investigations, the patient was submitted to surgery (extended

resection of an posterior mediastinal tumor, which includes the esophagus, the esophageal

sphincter and the stomach fundus, and moving the liver, the right lung and the inferior vena

cava; biopsy of the bronchial and tracheal nodules; replacement with gastric tube of the

esophagus) trough thoracic-abdominal-cervical approach. In the 10th

postoperative day, it

develops a cervical anastomotic fistula, which under conservative treatment is solved. The

pathology results confirm leyomiofibromatosis. The follow-up at 30 days indicates no signs of

relapse.

Conclusion: Our case report may provide important insight into a rare, but significant

pathology with multiple implications, which undiagnosed leads to a high associated

morbidity. This case requires further investigations who may elucidate the etiology and the

possible association with an other pathologic entity.

VIDEOTHORACOSCOPIC THIMECTOMY IN NONTHYMOMATOUS PATIENTS

WITH MYASTHENIA GRAVIS


*Clinic of Thoracic Surgery. University of Medicine “Gr.T.Popa” Iasi

** ICU , Hospital of Pneumology Iasi

Myasthenia gravis(MG) is an autoimmune disease in which autoantibodies to different

antigens of the neuromuscular junction cause the typical weakness and fatigability.

Thymectomy is recommended as an option for nonthymomatous patients with generalized

MG, in particular those with acetylcholine antibodies and younger than 60 years, to increase

the likelihood of remission or improvement.

In last decade, variations in videothoracoscopic techniques have been developed, with

unilateral or bilateral acces to the mediastinum.

In our experience with 19 patients between 2008-2011, the use of thoracoscopic thymectomy

in nonthymomatous MG was comparable to that the classical transsternal approach; complete

stable remission was 95% at 2 years of follow-up.

Compared with transsternal surgery videothoracoscopic thymectomy is associated with less

morbidity and negligible esthetic sequelae.

HYDATID CYST OF ANTERIOR MEDIASTINUM




Introduction

Echinococcosis is endemic in Romania. Hydatid cyst can develop in any segment or organ,

but the most frequent locations are liver and lung. Mediastinal hydatid lesions are extremly

rare and a only a few cases exists in the medical literature.

Material and method

The objective is to evaluate clinical, imagistical and surgical aspects of this rare lesion.

Between 1994 and 2011 there were 3 patients diagnosed and surgical trated for hydatid cyst of

mediastinum. The patients were 2 men and 1 woman with ages of 20, 37 and 52 years. All

hydatid cysts were located in anterior mediastinum, all were solitary lesions, no other hydatid

dereminations.

Results

In 1 case the positive diagnosis was made preoperatory, in the other 2 the diagnosis was

intraoperatory. The approach was through thoracotomy: right axillary, right anterolateral and

left axillary. One cyst was complicate (non-viable tymyc hydatid cyst) and 2 chysts were

viable – there were inactivated with alcohol, evacuated and followed by pericystectomy. first

case was treated by ideal cystrctomy.

There was 1 postoperatory complication: gaseous cerebral embolism remitted after medical

treatment.

Conclusions

Although very rare, anterior mediastinal hydatid cysts must be considered in every patient

with anterior mediastinal mass. Complete surgical excision is the treatment of choice because

provides complete cure.

EMERGENCY PULMONARY RESECTIONS - PULMONARY TUMOR TORN IN

PLEURA



Introduction

The parafluide density tumors are often a problem of therapeutic management. Late

presentation of a patient to the doctor may generate complications, such as rupture of the

tumor content into the pleural space.

Method

The case of 52 years old patient, admited for chest pain and minimum haemoptysis for

approximately 2 months, is presented.

Chest CT scan, performed before admission, shows a bulky tumor, round-oval (10 / 5,5 / 4

cm), with parafluid structure, relatively homogeneous, well defined, in lower lob of right

lung without other associated pathological lesions.

The patient condition is deteriorating after admission with main symptoms such as increased

chest pain and dyspneea. CT exam confirms fluids accumulated in the pleural space.

Results

The right thing in this case was decided to be an emergency surgery. We have discovered

during the intervention liquid in the pleural cavity, about 1000ml, and also a relatively well-

demarcated tumor with a 5 cm diameter, with a hard consistency, presenting on mediastinal

face of the right lung a fistula that had a tumoral content with purulent aspect. It was

performed a right lower lobectomy with lymphadenectomy and pleuro-pulmonary Williams

decortication.

Cystic formation proved to be a mesenchymal tumor with large areas of necrosis, and after the

IHC tests, the diagnosis of synovial sarcoma was put.

Conclusions

This case draws attention to a rare, possible evolution, in lung tumors.

MANAGEMENT OF INTRATHORACIC ESOPHAGEAL RUPTURES – A SINGLE

CENTER’S EXPERIENCE


Nicodin


Introduction:

We are presenting our experience in the management of esophageal ruptures, emphasizing

various etiology and the attempt of a single and aggresive treatment.

Materials and Methods:

We studied the esophageal perforations treated between 2002 and 2011 in our Thoracic

Surgery Clinic; there were 10 cases (2 women and 8 men, ages between 29 and 69 years);

there were 5 foreign bodies, 1 postsurgical procedure, 1 stented neoplasm, 3 Boerhave

syndrome; 1 followed conservatory treatment, 4 first intention suture and 5 pleural drain and

alimentary tract derivation; the interval between the perforation and treatment was between 12

hours and 4 days; we used alimentary tract derivation only for the stenosis(postcaustic and

neoplasic).

Results:

There was only 1 death (stented esophageal neoplasm); the hospitalisation was between 17

and 35 days(Boerhave Syndrome); the case that was treated conservatory (cervico-

mediastinitis anfter swallowing of a fish bone)was cured without any sequels; serial surgical

procedures were done only for the Boerhave syndrome.

Conclusions:

The diagnosis was based on clinics; contrast substance ingestion confirmed only the

topography of the lesion; first intention suture is the safer method for the treatment no matter

the time span from the perforation; pleural drain and alimentary tract derivation are only for

final cases.

SURGICAL MANAGEMENT OF TRACHEAL INVASION BY THYROID CARCINOMA

– SINGLE CENTER EXPERIENCE




Introduction

Well-differentiated thyroid cancer usually progresses slowly and rarely invades other tissues.

Airway invasion by thyroid carcinoma is an uncommon but important clinical problem.

The surgical management of airway invasion is controversial. There are studies suggesting

that tangential shave excision might be adequate, despite a marked risk of local recurrence.

Circumferential sleeve resection of the trachea is safe and lowers this risk.

Materials and methods

We performed thyroidectomy and tracheal resection in 7 patients between January 2007 and

December 2010. All patients were admitted in emergency with severe dyspnea. The

bronchoscopic examination was very important to assess the exact involvement of the trachea

and the CT scan was performed in order to eliminate the distant spread of malignancy.

We performed en-bloc resection of the thyroid gland with 3 to 5 tracheal rings and in one case

with the anterior part of the cricoid cartilage. Local limphadenectomy was performed in all

cases.

Results

There were 3 nondifferentiated thyroid carcinomas (NDTC) and 4 well differentiated thyroid

carcinomas (WDTC). There was no postoperative mortality. In one case (NDTC) we

encountered an anastomotic fistula which required a definitive tracheostomy. The survival

was 6, 9 and 14 month for the patients with NDTC, one case with WDTC lived for 13 months,

the other three patients are alive and with no sign of local or distant disease at 9, 16 and 25

month after surgery.

Conclusions

There is still doubt whether a shave excision that may leave microscopic disease at the site, or

a complete resection that includes removal of a portion of these structures is the better

approach.

Tracheal resection and reconstruction for thyroid carcinomas with airway invasion might

provide long-lasting palliation and might even be curative in a significant number of patients

suffering from this disease.

CLASSICAL TECHNIQUE VERSUS NUSS IN THE TREATMENT OF FAILED

SURGERY FOR PECTUS EXCAVATUM



Introduction:

The aparition of minimal invasive pectus repair (Nuss) allowed the succesful replacement of

the classical technique(Ravitch) for a certain cathegory of the patients. There are situations

when the Nuss technique can be used even after the use of the classical technique. Our day to

day practice we encountered also reversed situations when the minimal invasive is not optimal

and we were forced to use the classical technique for the resolving of the rebound of pectus.

Matherial and methods:

Our experience totals a number of 37 cases on a ten year period(2001 – 2011), from which 19

were resolved through minimally invasive technique and the rest thorough classical technique.

Unfortunately we encountered cases with recurrence of the diformity. We present two cases

operated in our service with pectus excavatum. A female patient operated through Ravitch

procedure when she was 5 years old that was admitted after 15 years and resolved by Nuss

correction. The other patient, a young man operated two years ago by using minamal invasive

procedure was readmitted in our department with the rebound of pectus after the Lorentz

blade migrated. He was resolved by Ravitch technique.

Results:

In both situations the reintervention using complementary procedure was succesfully

accomplished, the sternal defect was optimally resolved.

Conclusions:

Although there are controversies in the choosing of the repair procedure, wether we talk about

Nuss or classical technique, in the cases with recurrent pectus excavatum after Nuss the

correction is done better by classical procedure, and in the recurrency after classical technique

Nuss can be the right solution

OUR EXPERIENCE IN THE ANTERIOR SURGICAL APPROACH OF C7-T1 SPINE

*Adrian Ciuche, *Claudiu Nistor, *Marian Mitrica, **Teodor Horvat

*Emergency University Military Central Hospital “Dr. Carol Davila”, Bucharest


Introduction: The paper presents three cases of traumatic injury with compression fracture of

C7-T1 spine. The authors reveal the surgical modality of approaching of these cases through

illustrative preoperative, intraoperative and postoperative images.

Material and method: Cervicothoracic CT scan and RM reveals the existence of compression

fracture T1 spine in the first case and C7 in the second and in the third case. In all cases, the

corporeal fragments of spine caused compression of the cervicothoracic spinal cord. The

surgery procedure was removing T1 versus C7 vertebral body and discectomy above and

below the involved vertebra. Vertebral reconstruction was performed with autogenous iliac

bone graft (anteriorly fixation using locking plate) in the first and third case and using titan

implant in the second one. Anterior surgical exposure of C7-T1 spine was performed through

a combined right oblique neck and upper sternotomy incision.

Results: Decompression of the spinal cord has been achieved in all cases through the

complete removal of the herniated corporeal fragments. In the third case we performed a

reintervention through the same anterior approach for the plate extraction (poor fixation and

migration to the spinal roots). Postoperative clinical results were satisfactory with

ameliorating the sensitive function and preserving the motor function.

Conclusions: Anterior surgical procedures of C7-T1 spine has represented a milestone both

for the neurosurgeon (difficult resection and reconstruction beyond great mediastinal vessels),

and for thoracic surgeon (cervicothoracic dissection with mobilization of the right thyroidian

lobe without laryngeal nerve injury and protecting innominate artery).

POSTESOPHAGECTOMY BENIGN GASTRIC TUBE TO TRACHEOBRONCHIAL

TREE FISTULAS. PRESENTATION OF TWO CASES, LITERATURE REVIEW,

CLASSIFICATION AND TREATMENT PROTOCOL


*1st Clinical Department of Thoracic Surgery, “Marius Nasta” National Institute of


** Thoracic Surgery Department, Institut Universitaire de Cardiologie et de Pneumologie de


Background

Benign fistula formation between the airway and the gastric tube after esophageal resection is

a very rare and potentially fatal complication requiring immediate management. As the

literature consists mainly in case reports, there is no agreement on the treatment for this rare

condition.

Material and methods

We present two cases of such fistulas succesfully treated in our department. The management

was different for these two cases, as was the clinical appearance and predisposing factors.

One case was treated by means of imediate surgery and the other by conservative mesures.

Texbooks and published articles offer limitead information on this subject. A Medline search

allowed us to identify 42 reported cases in the literarure. After studing all these published

reports we tried to establish a clasification and a protocol treatment of this dreadful

complication.

Results

Closure of gastric tube to main airway fistula was succesfully achieved in both our patients.

By studing all reported cases, we observed a pattern in ethiological and favoring factors, time

of appearance and management, which allowed us to propose a simple clasification and a

treatment protocol.

Conclusions

A benign fistula between the neoesophagus and main airway is an uncommon and difficult to

treat complication. Symptomatology, size and site of the fistula and and the period of time

after initial surgery will dictate the management in order to restore the patients airway and

reestablish a contient digestive tract and swallowing ability, thus providing efective treatment

for this debilitating condition.

SERIAL RESECTION FOR DOUBLE TRACHEAL STENOSIS POST ORO-TRACHEAL

INTUBATION




This report presents the case of a female patient aged 26, diagnosed with double

postintubation tracheal stenosis (neck and lower chest), following a car crash resulting in

severe cranio-thoracic politrauma.

Surgery consisted in two sleeve tracheal resections performed in two stages. The second

resection was performed one month after the first surgical intervention.

Evolution was favorable after surgery. Bronchoscopic controls performed one month, 6

months, and one year after the last intervention, showed that the tracheal lumen caliber

remains unchanged.

OUR EXPERIENCE IN THE SURGERY OF THE CHEST WALL TUMORS


C.Mogoi.


Introduction:

The tumoral pathology of the chest wall is extremely interesting and wide, and still today it

rises a great amount of problems related to the diagnosis and surgical treatement. That is why

the purpose of this article is to share our department’s experience confronting this type of

pathology.

Material and method:

We analysed a series of 154 patients that underwent surgery in our department in ap 10 years

period(2001 – 2011), with ages between 21 and 74 years old. 43 of the patients had benign

pathology, the rest of 111 had primary, secondary or contiguous malignancies of the chest

wall. The surgical procedures applied were chest wall resection followed by reconstruction

with several types of synthetic materials such as Thoratex mesh, „Spider Web” suture or the

use of methylmetacrylate in 25.4% of the cases and chest wall resection without stabilisation.

In 74.6% of the patients. The mean hospital stay was 8 days.

Results:

In all the cases the perioperative mortality and morbidity was zero. The immediate

postoperative outcome off the patients was good in 150 cases, 3 cases developed wound

seroma that was managed with conservative treatment and one patient underwent a second

surgery with muscular flap after stabilisation with methylmetacrylate.

Conclusions:

The tumoral pathology of the chest wall still raises a series of problems of surgical treatment,

some cases are indeed a chalange for the surgeon, but the continuous developement of the

surgical techniques and of the meterials for reconstruction along with the developement of

experienced surgical teams lead to obtaining optimal results without complications that

require further surgical attention.

ECTOPIC THYMOMAS WITH LATERAL – PARACARDIAC DEVELOPMENT




Introduction.Thymomas with atypical development remain a challenge, both as diagnostic and

treatment.

Material and method. During the last 15 years we had 4 cases referred to our unit with the

diagnosis of mediastinal / pulmonary tumor, in whom the preoperative imagistics showed

mediastinal tumors with lateral – paracardiac development. Intraoperative we found tumors in

closed contact with the diaphragm, developed posterior to the phrenic nerve. In all the cases

we performed complete excision of the tumors using a lateral approach (postero-lateral

thoracotomy – 2 cases, antero-lateral thoracotomy – 2 cases). Frozen-section examination was

unconcludent in all the cases, the diagnosis being established by the definitive pathologic

examination.

Results. The access on the lesion was excellent in all the cases. All the 4 patients had a good

immediate and late postoperative evolution. We encountered no recurrence (follow-up 6

months – 14 years).

Conclusions. In cases of intrathoracic tumors with paracardiac location the possibility of a

thymoma should be taken into consideration. The lateral approach offers a good exposure on

selected cases. We also emphasize the diagnostic difficulties in the conditions from our

country.

HEMORAGIA DIN METASTAZĂ SUPRARENALIANĂ – MODALITATE ATIPICĂ DE

DEBUT CLINIC AL UNUI CANCER PULMONAR STADIUL IV


1, Porav Daniel


Voichiţa3




Introducere. Prezentăm un debut clinic particular în cancerul pulmonar.

Material și metodă. Prezentăm cazul unui pacient de 46 de ani, având în antecedente 2

episoade de pancreatită acută și o colecistectomie laparoscopică, a cărui boală actuală a avut

un debut brusc cu dureri intense la nivelul lombei stângi. Pacientul s-a prezentat la Clinica de

Urologie unde s-a infirmat diagnosticul de colică renală (fără dilatații pielo-caliceale) și

pacientul a fost trimis pentru consult de chirurgie generală cu suspiciunea de abdomen acut

chirurgical. Ecografia a arătat o leziune în suprarenala stângă, iar examenul CT de urgență a

arătat o tumoră pulmonară dreaptă supurată de 6 cm diametru și o tumoră suprarenaliană

stângă de 7 cm cu infiltrat hemoragic periglandular, fără alte leziuni secundare. Pentru

controlul durerii am folosit opioide, urmate de plasarea unui cateter peridural. Am început cu

leziunea toracică, efectuând o rezecție atipică de segment 6 Fowler, urmată la 10 zile de

suprarenalectomie printr-o incizie subcostală stângă.

Rezultate. Evoluția postoperatorie imediată a fost favorabilă, cu dispariția completă a durerii

lombare după suprarenalectomie. Examenl histopatologic a arătat în ambele piese leziuni de

carcinom pulmonar adeno-scuamos, leziunea din suprarenală fiind o metastază cu hemoragie

intraglandulară difuză. La 21 de luni de la intervenția chirurgicală pacientul nu prezintă acuze

abdominale sau toracice și nici semne de recidivă tumorală.

Concluzii. Cazul este interesant datorită debutului clinic brusc și atipic al cancerului pulmonar

– secundar hemoragiei din metastaza suprarenaliană, problemelor de control a durerii și

prezenței supurației pulmonare care a impus abordarea tumorii pulmonare înaintea celei

suprarenaliene.

TORACOSCOPIA UNIPORTALĂ ÎN PLEUREZII




Bucureşti

Introducere: Toracoscopia uniportală este utilizată în diagnosticul şi tratamentul diferitelor

afecţiuni intratoracice.

Material şi metodă: Între ianuarie 2010 şi iunie 2011 (18 luni) am efectuat 56 toracoscopii

uniportale pentru pleurezii, reprezentând 78,8% din totalul procedurilor toracoscopice (fără

minitoracotomie). Pacienţii au fost 34 de femei şi 22 de bărbaţi, cu vârsta medie de

61.33±11.38 ani.

A fost utilizat un toracoscop de 5mm cu vedere la 0 grade. Intubaţia selectivă a fost folosită la

29 de pacienţi, cea neselectivă la 25 de cazuri iar în 2 cazuri selecţionate s-a folosit anestezie

locală potenţată intravenos.

Rezultate: S-au efectuat biopsii pleurale în toate cazurile; unde a fost posibil, s-a efrectuat

talcaj pleural intraoperator. Diagnosticul histologic a fost malign în 46 de cazuri iar la 10

pacienţi a fost de inflamaţie cronică. În 6 cazuri fără neoplazii cunoscute preoperator a fost

afirmat diagnosticul de cancer pleural (primar sau secundar).

Concluzii: Toracoscopia uniportală reprezintă o procedură de diagnostic şi tratament sigură şi

eficientă în pleurezii. Este de preferat intubaţia oro-traheală selectivă, însă pentru biopsii

pleurale şi pleurodeză chimică se poate utiliza în siguranţă şi intubaţia neselectivă.

ADENOM PARATIROIDIAN ECTOPIC CU LOCALIZARE MEDIASTINALA –

PREZENTARE DE CAZ



2, Mihaela Vlad

3

1 Clinica de Chirurgie Toracica, Spitalul Municipal Timisoara

2 Departamentul de Anatomie patologica, Spitalul Municipal Timisoara

3 Clinica de Endocrinologie, Spitalul Judetean Timisoara

Introducere:

Incidenta paratiroidei ectopice este de aproximativ 6%, cea mai intalnita localizare fiind

reprezentata de capsula timica din mediastinul superior.

Caz:

Prezentam cazul unei femei de 21 de ani cu un istoric recent de osteoclastom maxilar si

mandibular, asociat cu valori ridicate ale concentratiei parathormonului (peste 20 de ori

valoarea normala), corelata cu niveluri crescute ale calcemiei, fosfatazei alcaline, si scaderea

fosfatemiei serice. S-a efectuat un RMN cervico-mediastinal cu evidentierea unei formatiuni

de 5/5/2 cm la nivelul mediastinului anterosuperior precum si multiple tumori chistice osoase

afectand maxilarul, mandibula, clavicula, capul humeral si scapula – osteita fibroasa chistica

in contextul hiperparatiroidismului primar. In septembrie 2010 a fost efectuata timectomie

prin toracotomie anterolaterala dreapta. Intraoperator a fost decelata o formatiune tumorala

mediastinala extrem de sangeranda la disectie, intim aderenta la aorta ascendenta. Disectia a

fost dificila dat fiind faptul ca formatiunea era extrem de sangeranda, a fost nevoie de

folosirea de material hemostatic din fibrina umana pentru a controla hemoragia. Masa

tumorala a fost excizata in intregime. Drenajul pleural a fost asigurat de prezenta a 2 tuburi de

dren pleurale.

Rezultate:

La nivelul capsulei timice a fost identificat un nodul format in principal din celule

paratiroidiene, fara forme microcelulare de malignitate;. Diagnosticul histopatologic final a

fost de adenom paratiroidian ectopic. Postoperator evolutia pacientei a fost favorabila cu

prabusirea valorilor PTH de la 1392.4 pg/ml preoperator la 4 pg/ml a doua zi dupa operatie.

Pacienta a fost urmarita in clinica de endocrinologie pentru reechilibrare electrolitica si

hormonala.

Concluzii:

Dupa suprimarea chirurgicala a formatiunii tumorale mediastinale, suspicionata imagistic si

confirmata histopatologic ca fiind paratiroida ectopica, sindromul hiperparatiroidian primar a

fost remis.

REZECTIE-BRONHOANASTOMOZA DE BRONSIE PRIMITIVA CU PREZERVARE

PULMONARA TOTALA PENTRU STENOZA POSTTRAUMATICA


Cordos


Introducere

Rupturile traheo-bronsice sunt dintre cele mai grave consecinte ale traumatismelor toracice

inchise. Suspiciunea clinica si interpretarea imaginilor radiologice au prima importanta pentru

interventia chirurgicala.

Prezentare de cazuri

Cinci pacienti au fost operati in clinica noastra pentru stenoze posttraumatice de bronsie

primitiva. Toti pacientii erau barbati tineri diagnosticati cu pneumotorax total si

pneumomediastin redus. In fiecare caz a fost drenata cavitatea pleurala afectata.

In patru cazuri aspectul radiologic a fost de atelectazie pulmonara completa cu pneumotorax

persistent iar bronhoscopia a pus diagnosticul de stenoza de bronsie primitiva. Intr-un caz,

ruptura de bronsie primitiva a fost identificata la internare si stenoza este suspicionata datorita

unei pneumonii drepte in evolutie sub tratament antibiotic si este diagnosticata tot

bronhoscopic.

Dupa toracotomie parenchimul pulmonar pare normal si se practica doar rezectia zonei de

stenoza a primitivei cu bronhoanastomoza in toate cazurile. Bronhoscopia de control arata

primitiva libera cu sutura slab vizibila.

Discutii

Traumatismele traheo-bronsice sunt de regula letale, peste 75% dintre victime decedeaza pana

la momentul spitalizarii.

Ruptura bronsiei primitive in traumatismele toracice inchise reprezinta un efect cumulativ al

compresiei peretelui toracic, tractiunii aplicate asupra plamanilor, fixati la nivelul carenei, dar

liberi in cavitatea pleurala, cu cresterea brusca a presiunii intraluminale.

Rezectia zonei de stenoza cu bronhoanastomoza este tratamentul de electie si permite

pastrarea intregului parenchim pulmonar.

In tratamentul stenozelor tardive, interventia chirurgicala, chiar la cativa ani dupa

traumatismul initial, are prognostic favorabil.

Concluzii

Ruptura de bronsie primitiva este o complicatie rara a traumatismelor toracice. Bronhoscopia

este indicata la pacientii cu traumastime si pneumotorax sau pneumomediastin si este de

prima importanta in diagnosticul rapid al leziunilor posttraumatice ale cailor aeriene.

Diagnosticul stenozelor traheo-bronsice poate intarzia luni sau ani de zile. Totusi, aceasta nu

afecteaza evolutia perioperatorie, parenchimul pulmonar subiacent fiind relativ normal, in

ciuda atelectaziei prelungite. Rezectia cu bronhoasnastomoza este cheia succesului in aceste

cazuri.

SISTEM CHIRURGICAL COMPLEX PENTRU RECONSTRUCŢIA SOLIDĂ

STERNALĂ: PLASĂ THORATEX, LAMĂ STRATOS ŞI CIMENT KRYPTONITE




Introducere: Lucrarea prezintă 2 cazuri internate în secţia de chirurgie toracică cu diagnosticul

de tumoră sternală: o femeie de 49 de ani cu o tumoră secundară (adenocarcinom tubulo-

papilar) de manubriu sternal după un cancer mamar drept (mastectomie dreaptă tip Halsted,

chimio şi radioterapie pre şi postoperatorie) şi un bărbat de 45 de ani cu o tumoră primară

(condrosarcom) situată la nivelul corpului sternal.

Autorii redau modalităţile de rezecţie şi reconstrucţie sternală efectuate în aceste cazuri,

folosind imagini relevante preoperatorii, intra şi postoperatorii.

Material şi metodă: În ambele cazuri, după rezecţia radicală a formaţiunilor tumorale, s-a

folosit pentru reconstrucţia solidă sternală un sistem complex ce a inclus pe lângă plasa

armată Thoratex o lama din titan tip STRATOS şi ciment osteoconductiv Kryptonite. Pentru

reconstrucţia părţilor moi s-au utilizat lambouri musculare pediculizate din marele pectoral

(pectoralul stâng unic chirurgical în primul caz şi ambii pectorali în cel de-al doilea caz),

complet mobilizate (prin secţionarea inserţiilor humerale, sterno-costale şi claviculare) şi

transpuse medial pentru a acoperii defectul parietal în întregime.

Rezultate: În ambele cazuri s-a realizat atât îndepărtarea în limite oncologice a tumorilor

sternale cât şi o foarte bună reconstrucţie solidă a peretelui toracic anterior. În cel de-al doilea

caz, în cimentul kryptonite au fost incluse fragmente osteocondrale indemne, în vederea

realizării unui neostern (structura poroasă a cimentului este favorabilă intergării şi regenerării

osoase).

Concluzii: Defectele parietale mari care apar după rezecţia în limite oncologice a tumorilor

maligne sternale pot fi reconstruite într-o manieră sigură utilizând acest sistem complex

chirurgical combinat cu reconstrucţia părţilor moi prin transpoziţie de lambouri musculare.

IMPORTANȚA FACTORILOR HISTOPATOLOGICI ÎN STABILIREA

PROGNOSTICULUI PACIENȚILOR OPERAȚI PENTRU CANCER PULMONAR FĂRĂ

CELULE MICI

Suciu B.1, Bud V.

1, Copotoiu C.



3, Fodor D.

1,

Butiurca V.4

Clinica Chirurgie I, Spitalul Clinic Județean de Urgență Mureș

Disciplina de Anatomie, Universitatea de Medicină și Farmacie Tg. Mureș

Clinica ATI, Spitalul Clinic Județean de Urgență Mureș

Student, Universitatea de Medicină și Farmacie Tg. Mureș

Introducere

În ultimele decenii incidența cancerului pulmonar a crescut alarmant. Cancerul pulmonar

reprezintă principala cauză de deces la femei și la bărbați, în Statele Unite ale Americii,

100.000 de noi cazuri fiind înregistrate anual la bărbaţi şi 50000 de cazuri noi la

femei.Scopul studiului nostru este acela de a evalua importanța factorilor

histopatologici în stabilirea prognosticului pe termen lung de pacienţi operaţi pentru cancer

pulmonar.

Material și metodă

Scopul prezentei lucrări a fost acela de a realiza un studiu retrospectiv observational pe o

perioada de 6 ani. Am folosit cazuistica Clinicii Chirurgie nr.1, a Spitalului Clinic Județean de

Urgență Mureș, pe o perioadă de 5 ani, între 1.01.2005 și 31.12.2010. Am inclus în studio 197

pacienți internați și operați pentru tumori bronho-pulmonare în clinica noastră.

Rezultate

Am studiat 197 de pacienți internați și operați în Clinica Chirurgie 1 a Spitalului Clinic

Județean de Urgență Mureș. Am încercat să studiem importanța descriptorului T (tumora) a

stadializării TNM pentru stabilirea prognosticului pe termen lung. Valoarea p a

fost 0.1676 asa ca nu am obţinut o valoare semnificativă din punct de vedere statistic. De

asemenea, am luat în considerare valoarea descriptorului N al clasificării TNM ca un factor

de predicţie pentru supravieţuirepe termen lung la pacienții operați pentru cancer

pulmonar..Parametrul p a fost 0.0152 asa ca putem spune că am obţinut o legătură directă,

semnificativă din punct de vedere statistic între valoarea descriptorului N și supraviețuirea

acestor bolnavi la distanță.

Concluzii

Supraviețuirea acestor pacienți pe termen lung depinde în primul rând de stadiul

histopatologic al tumorii.Rata de predictibilitate a descriptorilor clasificării TNM este mai

bună la pacienții cu vârste peste 60 de ani, comparativ cu cei ale cîror vârste sunt sub 60 de

ani. Rata de predictibilitate a descriptorului N al clasificării TNM este mai bună decât cea a

desciptorului T. Existența în același stadiu a clasificării TNM a unor pacienți cu valori diferite

ale descriptorului N, dovedește limitele clasificării TNM și faptul că această clasificare este

perfectibilă.

Cuvinte cheie : plămân, cancer, prognostic, descriptor

ABORDUL CERVICAL VIDEOMEDIASTINOSCOPIC AL BRONŞIEI PRIMITIVE

STÂNGI - O SERIE DE 6 CAZURI



Institutul National de Pneumologie “Marius Nasta”, Bucuresti

1 – Clinica I Chirurgie Toracica

2 – Departamentul Bronhologie

Introducere

Fistula bontului bronşic (FBB) post-pneumonectomie este o complicaţie de temut a chirugiei

toracice. Din 1996, când Azorin a prezentat în premieră închiderea unui bont bronşic

dehiscent post-pneumonectomie stângă prin mediastinoscopie cervicală, doar 8 cazuri

referitoare la acest abord au fost publicate.

Material şi metodă

Autorii prezintă 6 cazuri de abord transcervical mediastinoscopic al BPS (bronşia principală

stângă), efectuate în perioada Decembrie 2009 - Iulie 2011 pentru diverse indicaţii. Media de

vârstă a fost 44.2 ani (2 femei / 4 bărbaţi). 2 intervenţii s-au efectuat pentru FBB post-

pneumonectomie stângă, iar în 4 cazuri BPS a fost închisă ca prim pas înainte de

pneumonectomie. În situaţiile cu pneumonectomie în 2 timpi, rezecţia pulmonară s-a realizat

după 3 - 4 săptămâni. Pacienţii au fost urmăriţi pe perioade de timp cuprinse între 7 săptămâni

şi 20 luni.

Rezultate

Timpul operator mediu a fost 85 minute. Mediastinul a fost drenat doar la primul pacient. Un

caz a necesitat întărire prin sutură manuală a bontului bronşic datorită unei deficienţe a

stapler-ului. Postoperator pacienţii au avut evoluţie simplă, cu mobilizare la 6 ore şi externare

a treia zi de la operaţie. Nu au survenit recidive ale fistulei. 1 pacient a decedat la 7 săptămâni

din cauze cardiace.

Concluzii

Abordul cervical videomediastinoscopic al BPS reprezintă o alternativă viabilă pentru

toracotomie şi abordul transsternal, fiind indicat în FBB post-pneumonectomie stângă, în

închiderea şi cicatrizarea bronşică la pacienţii cu plămân distrus supurativ. Această procedură

se adresează BPS şi necesită un bont de cel puţin 1,5 cm lungime, instrumentar scump, o

echipă chirurgicală experimentată putând fi aplicată doar în cazuri atent selecţionate.

PLOMBAJ EXTRA-MUSCULO-PERIOSTAL CU BILE FUNCȚIONAL DUPĂ 46 DE ANI



Introducere. Plombajul cu bile a reprezentat o operație extrem de populară în anii 1940-50

datorită simplității și avantajului estetic; ea a fost abandonată atât datorită unor complicații

specifice, cât și datorită rezultatelor favorabile după introducerea tratamentului tuberculostatic

modern.

Material și metodă. Prezentăm un pacient de 81 de ani la care s-a practicat un plombaj extra-

musculo-periostal cu bile la vârsta de 35 de ani (în urmă cu 46 ani) pentru o tuberculoză fibro-

cavitară de lob superior stâng.

Rezultate. Pacientul a avut o evoluție postoperatorie foarte bună, devenind BK negativ,

complet asimptomatic și cu o reinserție socială completă (medic de familie până la 70 de ani),

fiind internat de urgență în clinica noastră pentru un infarct entero-mezenteric și decedând în

ziua a 8-a postoperator (enterectomie segmentară) prin infarct miocardic.

Concluzii. Cazul este interesant prin imagistică și prin evoluția excelentă după o intervenție

cu care actuala generație de chirurgi nu este familiarizată. Recrudescența actuală a

tuberculozei poate aduce în actualitate operații abandonate la un moment dat.

HEMANGIOM PARIETAL TORACIC



Bucureşti

Introducere

Hemangiomele parietale toracice reprezita un procent redus in cadrul leziunilor situate la

acest nivel. Diagnosticul pozitiv şi cel diferenţial este adeseori dificil, cura chirurgicală a

acestora ridicând o serie de probleme de tehnică.


Prezentăm cazul unui pacient în vârstă de 56 ani ce se internează în clinica noastră prezentând

o formatiune tumorala de pererete toracic posterior stâng apărută de circa 1 an. Aceasta

leziune era bine delimitata, întinzându-se pe 2/3 inferioare ale musculaturii paravertebrale

stângi. Examenul computer tomograf toracic certifică şi evaluarea RMN atrage atenţia asupra

gradului mare de vascularizaţie.

Rezultate

Intraoperator s-a descoperit la nivelul planului muscular paravertebral stâng, o tumora cu

aspect angiomatos de aproximativ 20 cm dezvoltată sub teaca superficială a musculaturii. S-a

practicat rezecţia formaţiunii aflată în strânsă legătura cu stratul superficial ale masei

musculare, rezultatul histopatologic fiind de angiom cavernos. Evoluţia postoperatorie a fost

simplă, pacientul fiind externat complet vindecat

Concluzii

Deşi rare, aceste tumori angiomatoase trebuie luate în considerare în evaluarea uneui pacient

cu patologie tumorală parietală toracică.

LEIOMIOFIBROMATOZA CU MULTIPLE LOCALIZARI – ADEVARUL DINCOLO DE

APARENTE – PREZENTARE DE CAZ



Introducere: Leiomiofibromatoza constituie o cauza neobisnuita de tulburări respiratorii şi /

sau digestive, localizarea ei principala fiind genitala.

Material și metodă: Va prezentam cazul unei femei de 22 de ani, cu multiple localizari ale

leiomiofibromatozei, a carei simptomatologie modesta (infecţii respiratorii recurente, pierdere

lenta ponderala, tuse uscată, disfagie recentă la solide) a rămas nediagnosticata si netratata

pentru o perioadă lungă de timp. Interventiile chirurgicale anterioare (chist tireoglos, cataractă

bilaterală) au devenit importante în procesul de elaborare al unui diagnostic precis.

Rezultate: În urma investigaţiilor, pacienta a fost supusa interventiei chirurgicale (rezecţia

extinsă a unei tumori mediastinale posterioare, care includea esofagul, sfincterul esofagian şi

fornixul gastric, şi care deplasează ficatul, plamanul drept si vena cava inferioara, biopsie din

nodulii bronşici şi traheali; înlocuirea cu tub gastric a esofagului) prin abord triplu toraco-

abdomino-cervical. În ziua a 10-a postoperator, se dezvolta o fistula anastomotică cervicala,

care, sub tratament conservator se remite. Rezultatele anatomopatologice confirma

leiomiofibromatoza. Urmarirea la 30 de zile nu indică recidivă.

Concluzii: Lucrarea de fata poate oferi o perspectiva importanta într-o patologie rară, dar

semnificativă cu implicaţii multiple, care nediagnosticata, conduce la o morbiditate asociata

ridicata. Acest caz necesită investigaţii suplimentare, care ar putea elucida etiologia si posibila

asociere cu alta entitate patologică.

TIMECTOMIA VIDEOTORACOSCOPICA IN HIPERPLAZIA TIMICA CU MIASTENIE

GRAVIS


*Clinica de Chirurgie Toracica Iasi, UMF “Gr.T.Popa” Iasi

** Sectia de ATI, Spital clinic de Pneumoftiziologie Iasi

Miastenia gravis (MG) este o afectiune autoimuna, in care autoanticorpii fata de antigenele

placii neuromusculare determina diferite forme de tuburari neuromusculare si oboseala.

Timectomia este recomandata ca optiune terapeutica pentru pacientii fara timom cu MG, in

special la cei cu Ac antireceptori-acetilcolina si sub 60 de ani, pentru a imbunatati

performanta musculara sau chiar remisie a bolii.

In ultima decada s-au dezvoltat tehnici videotoracoscopice cu acces uni- sau bilateral.

In experienta noastra pe 19 cazuri din 288-2011, timectomia videotoracoscopica cu abord pe

dreapta la pacientii cu MG si hiperplazie timica a fost comparabila cu abordul classic

transsternal, cu remisie completa de 95% la 2 ani, fiind asociata cu o morbiditate mai redusa

si sechele estetice neglijabile.

CHISTUL HIDATIC AL MEDIASTINULUI ANTERIOR




Bucureşti

Introducere

Boala hidatică este o problemă actuală în patologia întâlnită în România. Deşi aceste leziuni

se pot întâlni practic în orice organ sau segment anatomic, cel mai frecvente localizări sunt în

ficat şi plămâni. Leziunile cu topografie mediastinală sunt extrem de rare, fiind relativ putine

descrieri în literatura de specialitate.


Obiectivul acestui studiu este de a evalua aspectele clinice şi imagistice şi tratamentul

chirurgical al acestor leziuni rare. În intervalul 1994 – 2011 au fost diagnosticaţi şi trataţi

chirurgical 3 pacienţi cu chiste hidatice mediastinale. Pacienţii au fost 2 bărbaţi şi 1 femeie,

vârstele fiind de 20, 37 şi respectiv 52 de ani. În toate cazurile leziunea a fost localizată în

mediastinul anterior,.Toate leziunile au fost solitare, neasociind şi alte determinări.

Rezultate

Într-un singur caz dignosticul a fost precizat preoperator, celelalte fiind descoperiri

intraoperatorii. La toţi pacienţii abordul a fost prin toracotomie, 1 toracotomie axilară dreaptă,

1 toarcotomie anterolaterală dreaptă şi la un caz a fost preferată toracotomia axilară stângă.

Doar intr-un singur caz chistul era neviabil (chist hidatic timic) în celelalte 2 cazuri chistul era

viabil. În aceste ultime 2 situaţii s-a practicat inactivarea cu alcool 90° urmată de evacuarea

lichidului hidatic şi a cuticulei şi perichistectomie. La cel de-al treilea caz s-a efectuat

chistectomie ideală. S-a înregistrat o singură complicaţie postoperatorie: embolie gazoasă

cerebrală care s-a remis prin tratament medical.

Concluzii

Deşi extrem de rar întâlnite în practică, leziunile hidatice mediastinale trebuie luate în

considerare în evaluarea unui pacient cu o leziune tumorală la nivelul mediastinului anterior.

Tratamentul de elecţie este cel chirurgical, acesta fiind singurul ce asigură vindecarea

completă a acestor pacienţi.

REZECTII PULMONARE IN URGENTA - TUMORA PULMONARA RUPTA IN

PLEURA



Bucureşti

Introducere

Formatiunile tumorale cu densitati parafluide reprezinta adeseori o problema de management

terapeutic. Prezentarea tardiva a pacientului la medic poate genera complicatii cu ruperea

continutului tumoral in spatiul pleural.

Metodă

Prezentăm cazul unei paciente în vârstă de 52 de ani ce se internează în clinica noastră

prezentând dureri toracice si hemoptizii minime de aproximativ 2 luni. Examenul CT toracic

efectuat anterior internarii prezinta o formatiune tumorala voluminoasa, rotund-ovalara

(10/5,5/4cm), cu structura parafluida, relativ omogena, bine delimitata, la nivelul lobului

inferior drept pulmonar, fara alte leziuni patologice asociate.

Starea pacientei se deterioreaza dupa internare, aceasta acuzand dureri toracice accentuate,

dispnee. Examenul CT efectuat confirma ruperea continutului lichidian in pleura

Rezultate

S-a decis intervenţia chirurgicală in urgenta, intraoperator descoperindu-se lichid in cavitatea

pleurala, aproximativ 1000ml, si formatiune tumorala relativ bine delimitata, cu diametru de

5 cm, dura la palpare, ce prezinta spre fata mediastinala pulmonara traiect fistulos prin care se

exteriorizeaza continut cu aspect purulent.

Se practica lobectomie inferioara dreapta cu limfadenectomie si decoticare pleuro-pulmonara

Williams

Formatiunea chistica s-a dovedit a fi o tumora mezenchimala cu zone intinse de necroza,

testele IHC punand diagnosticul de sarcom sinovial.

Concluzii

Acest caz atrage atenţia asupra unei posibilităţi evolutive rare, dar posibilă, a unei tumori

pulmonare.

MANAGEMENTUL RUPTURILOR ESOFAGIENE INTRATORACICE – EXPERIENTA

UNUI SINGUR CENTRU


Nicodin


Introducere:

Prezentam experienta noastra in managementul rupturilor esofagiene, tinand cont de etiologia

acestora si incercarea de a aplica un tratament chirurgical agresiv.

Material si metoda:

Am inclus in studiul nostru pacientii cu perforatii esofagiene tratati in clinica noastra intre

2002 si 2011; au fost 10 cazuri (2 femei si 8 barbati, cu varstele intre 29 si 69 de ani); in 5

cazuri etiologia a fost reprezentata de corpi straini, in 1 caz post interventie chirurgicala, 1 caz

cu neoplasm stentat, 3 cazuri cu sindrom Boerhave; 1 pacient a urmat tratament conservator, 4

au beneficiat de sutura de prima intentie si 5 au avut drenaje pleurale si gastrostoma;

intervalul intre perforatie si tratament a fost intre 12 ore si 4 zile ; am folosit gastrostoma de

alimentatie numai in 2 cazuri de stenoza(postcaustica si neoplazica).

Resultate:

Am inregistrat numai un caz de deces(neoplasm esofagian stentat); spiatalizarea a fost intre 17

si 35 de zile(Sindrom Boerhave); cazul care a fost tratat conservator(cervico-mediastinita

supa ingestia unui os de peste) a fost vindecat fara sechele; interventii chirurgicale seriate au

fost aplicate doar in cazurile cu sindrom Boerhave.

Concluzii:

Diagnosticul a fost in mare parte clinic; s-a utilizat substanta de contrast care a confirmat doar

topografia leziunii; sutura de prima intentie a fost metoda cea mai sigura indiferent de timpul

scurs de la perforatie; drenajuol pleural si gastrostoma au fost applicate doar la cazurile grave.

MANAGEMENTUL CHIRURGICAL AL CARCINOMULUI TIROIDIAN CU INVAZIE

TRAHEALA - EXPERIENTA UNUI SINGUR CENTRU



Introducere

Carcinomul tiroidian bine diferentiat evolueaza lent si rareori invadeaza tesuturile

inconjuratoare. Invazia cailor aeriene data de un neoplasm tirodian este o problema clinica

neobisnuita si importanta.

Atitudinea chirurgicala in invazia traheala este inca subiect de discutie. Sunt studii care afirma

ca rezectia tangentiala este suficienta, in ciuda riscului crescut de recidiva tumorala. Pe de alta

parte, rezectia circumferentiala a traheei este o procedura sigura si scade acest risc.

Material si metoda

In clinica noastra s-au practicat 7 tiroidectomii cu rezectie traheala in perioada ianuarie 2007 -

decembrie 2010. Toti pacientii au fost internati in urgenta cu dispnee. Examenul bronhoscopic

a fost cel mai important in evaluarea exacta a invaziei traheale iar examinarea CT a fost

efectuata pentru a elimina posibilitatea existentei unor metastaze.

S-a efectuat rezectia in bloc a glandei tiroide impreuna cu 3-5 inele traheale, iar intr-un caz s-a

practicat si rezectia portiunii anterioare a cartilajului cricoid. Limfadenectomia locala a fost

facuta in toate cazurile.

Rezultate

Anatomopatologic s-au identificat 3 carcinoame tirodiene nediferentiate si 4 carcinoame

tirodiene bine diferentiate. Mortalitatea postoperatorie a fost nula. Intr-un singur caz de

carcinom tirodian nediferentiat a existat o fistula de anastomoza ce a necesitat traheostomie

definitiva. Supravietuirea la distanta a fost de 6, 9 si 14 luni in cazul pacientilor cu carcinom

tirodian nediferentiat, respectiv 13 luni la un pacient din lotul cu carcinom tirodian bine

diferentiat. Ceilalti trei pacienti supravietuiesc la 9, 16 si respectiv 25 de luni postoperator

fara semne de recurenta a bolii sau metastaze la distanta.

Concluzii

Exista controverse privind metoda chirurgicala optima: rezectia tangentiala cu tesut tumoral

microscopic restant sau rezectia completa tireo-traheala.

Rezectia traheala cu anastomoza in cazurile de carcinoame tiroidiene cu invazia cailor aeriene

aduce paliatie de lunga durata si poate fi curativa pentru un numar semnificativ de pacienti ce

sufera de aceasta boala.

STERNOCONDROPLASTIA CLASICA VERSUS TEHNICA NUSS IN PECTUS

EXCAVATUM RECIDIVAT



Introducere:

Aparitia tehnicilor minim invazive de sternocondroplastie (Nuss) a permis inlocuirea cu

succes tehnicii chirurgicale clasice(Ravitch) pentru o anumita categorie de pacienti. Exista

situatii cand tehnica Nuss poate fi utilizata chiar si in cazul recidivelor dupa tehnica clasica. In

practica noastra am intalnit si situatii inverse in care tehnica minim invaziva nu este infailibila

fiind nevoiti sa apelam la tehnica Ravitch pentru corectarea malformatiei sternocondrale

recidivate dupa Nuss.

Material si metoda:

Cazuistica noastra numara 37 de cazuri de pectus excavatum pe o periaoda de 10 ani(2001 -

2011). Dintre acestea 19 au fost rezolvate prin tehnica minim invaziva, restul prin tehnica

clasica. Din pacate am intalnit si cazuri la care malformatia condrala a recidivat. Prezentam

doua cazuri operate in serviciul nostru cu pectus excavatum recidivat. O pacienta operata

initial la varsta de 5 ani prin tehnica Ravitch, s-a prezentat in serviciul nostru dupa 15 ani cu

recidiva malformatiei sternocondrale care a necesitat recorectare prin tehnica Nuss. Celalalt

pacient, un tanar operat in urma cu 2 ani prin tehnica minim invaziva a revenit in clinica cu

recidiva malformatiei dupa migrarea lamei Lorentz. A fost resolvat prin tehnica Ravitch.

Rezultate:

In ambele situatii reinterventia prin tehnica complementara a fost realizata cu succes, defectul

condrosternal fiind corectat optim.

Concluzii:

Desi exista controverse in alegerea tehnicii de sternocondroplastie, in pectusul excavatum

recidivat dupa tehnica Nuss corectarea se face mult mai bine prin tehnica clasica, in timp ce in

pectusul excavatum recidivat dupa tehnica clasica, tehnica Nuss reprezinta o buna optiune.

EXPERIENŢA NOASTRĂ ÎN ABORDUL CHIRURGICAL ANTERIOR AL

VERTEBRELOR C7-T1

*Adrian Ciuche, *Claudiu Nistor, *Marian Mitrică, **Teodor Horvat



Introducere: Lucrarea prezintă 3 cazuri de traumatisme cervico-toracice soldate cu fractura

corpilor vertebrali C7 sau T1 asociată cu compresiune medulară la acest nivel. Autorii expun

abordul chirurgical anterior al acestor cazuri folosind imagini relevante preoperatorii intra şi

postoperatorii.

Material şi metodă: Explorările imagistice au arătat existenţa de fracturi associate cu

compresie medulară la nivelul vertebrei T1 în primul caz şi la vertebra C7 în ultimele două

cazuri. Tehnica chirurgicală a constat în îndepărtarea corpilor vertebrali C7 şi respectiv T1

împreună cu discurile vertebrale supra şi subiacente. Reconstrucţia vertebrală s-a realizat cu

grefon autogen din osul iliac în primul şi al treilea caz (fixat anterior cu placă de titan) şi cu

implant vertebral de titan în cel de-al doilea caz. Abordul chirurgical anterior al corpilor

vertebrali C7 şi T1 s-a realizat printr-o cervicotomie dreaptă paralelă cu marginea anterioară a

muşchiului sternocleidomastoidian, combinată cu o sternotomie parţială înaltă.

Rezultate: Decompresia medulară s-a realizat prin îndepărtarea fragmentelor vertebrale

herniate. În cel de-al treilea caz a fost necesară efectuarea unei reintervenţii prin aceeaşi cale

de abord, pentru extragerea plăcii metalice (migrate către rădăcinile spinale datorită fixării

ineficiente). Rezultatele postoperatorii au fost satisfăcătoare, cu ameliorarea funcţiei senzitive

şi conservarea celei motorii.

Concluzii: Abordul chirurgical anterior al vertebrelor C7-T1 reprezintă o piatră de încercare

atât pentru neurochirurg (dificultatea rezecţiei şi reconstrucţiei vertebrale având anterior

marile vase) cât şi pentru chirurgul toracic (disecţia la graniţa cervico-toracică cu mobilizarea

lobului drept tiroidian fără lezarea nervului laringeu recurent şi cu mobilizarea şi protejarea

trunchiului arterial brahiocefalic, posterior de care se efectuează practic întreaga intervenţie

chirurgicală).

FISTULA BENIGNĂ POSTESOFAGECTOMIE ÎNTRE TUBUL GASTRIC ȘI

ARBORELE TRAHEOBRONȘIC: PREZENTARE A DOUĂ CAZURI, STUDIU

LITERATURII, CLASIFICARE ȘI PROTOCOL TERAPEUTIC


*Clinica 1 Chirurgie Toracică, Institutul Național de Pneumologie “Marius Nasta”, București

**Clinica de Chirurgie Toracică, Institutul Universitar de Cardiologie și Pneumologie

(IUCPQ), Quebec, Canada

Introducere

Fistula benignă între arborele traheobronșic și tubul gastric ascensionat în torace după

esofagectomie este o complicație foarte rară, cu potențial letal crescut, care necesită tratament

imediat și agresiv. În literatura de specialitate aceast aspect apare sub forma unor serii foarte

mici sau ca prezentări de caz. Nu există încă un protocol de tratament bine stabilit.

Material și metodă

Prezentăm modalitatea de abordare a două astfel de cazuri; managementul a fost diferit pentru

fiecare dintre ele, la fel ca și aspectul clinic și factorii predispozanți. Unul a fost tratat agresiv,

prin intervenție chirurgicală imediată și altul prin masuri conservatoare. Tratatele și articolele

de specialitate oferă informații limitate privitor la această problemă. O căutare în Medline a

permis indentificarea a 42 de cazuri prezentate în literatură. După studierea acestora, am

încercat să stabilim o clasificare și un protocol de tratament general valabil pentru această

complicație.

Rezultate

Închiderea traiectului fistulos a fost obținută în amândouă cazurile prezentate. Prin studierea

literaturii s-a putut identifica un model în ceea ce privește etiologia și factorii favorizanți,

timpul de la operația inițială până la apariția fistulei și modalitățile de tratment, aspecte care

ne-au permis să propunem o clasificare și un protocol terapeutic.

Concluzii

Formarea unei fistule între neoesofag și calea aeriană este o complicație neobișnuită și dificil

de tratat. Simptomatologia, dimensiunile și localizarea traiectului fistulos și durata de timp de

la intervenția inițială vor dicta modalitatea de tratament în vederea restabilirii continuitații

digestive și a căii aeriene și deci, de a rezolva această complicație severă

REZECTIE ETAJATA, SERIATA, PENTRU DUBLA STENOZA TRAHEALA SEVERA

POST INTUBATIE ORO-TRAHEALA



Lucrarea prezinta cazul unei paciente in varsta de 26 ani, diagnosticata cu stenoza traheala

dubla, cervicala si toracica joasa, post IOT, ca urmare a unui accident rutier soldat cu

politraumatism cranio-toracic.

Interventia chirurgicala a constat in rezectie-anastomoza traheala efectuata in 2 timpi la

interval de o luna.

Evolutia post-operatorie a fost favorabila. Controalele bronhoscopice efectuate la o luna de la

ultima interventie, 6 luni, un an, au prezentat un lumen traheal cu calibru pastrat.

EXPERIENTA NOASTRA IN CHIRURGIA TUMORILOR PARIETALE TORACICE


C.Mogoi.


Indroducere:

Patologia tumorala parietala toracica este extrem de interesanta si vasta, ridicand si astazi o

serie de probleme de abordare in ceea ce priveste diagnosticul si tratamentul chirurgical. De

aceea scopul lucrarii este de a prezenta experienta clinicii noastre in confruntarea cu o astfel

de patologie

Material si metoda:

Am analizat o serie de 154 pacienti operati in clinica noastra pe o perioada de 10 ani (2001 –

2011), cu varste cuprinse intre 21 si 74 de ani. 43 de cazuri au prezentat patologie tumorala

benigna si 111 pacietni au avut tumori maligne primare, secundare sau prin contiguitate.

Procedeele chirurgicale aplicate au fost rezectia parietala toracica insotita de reconstructie si

stabilizare folosind diverse materiale(plasa armata tip Thoratex, tehnica „Spider-Web”,

metilmetacrilat) in 25,4% din cazuri si rezectia parietala fara stabilizare in 74,6% din cazuri.

Durata medie de spitalizare a fost de 8 zile.

Rezultate:

In cazul tuturor pacientilor operati mortalitatea si morbiditatea perioperatorie a fost 0.

Evolutia postoperatorie imediata a fost favorabila in 150 de cazuri, 3 pacienti au prezentat

serom de plaga operatorie care a fost tratat conservator, iar un caz a beneficiat de

reconstructie cu lambou muscular in timpul 2 dupa stabilizare cu placa de metilmetacrilat.

Concluzii:

Patologia tumorala parietala toracica ridica inca unele probleme de tratament chirurgical,

unele cazuri fiind o adevarata provocare pentru chirurg, insa dezvoltarea continua a tehnicilor

chirurgicale si a materialelor de reconstructie precum si formarea unor echipe experimentate

de chirurgi toracici au dus la obtinerea de rezultate bune, fara aparitia de complicatii

perioperatorii care sa necesite interventii chirurgicale repetate.

TIMOAMELE ECTOPICE CU DEZVOLTARE LATERALĂ - PARACARDIACĂ




Introducere. Timoamele cu dezvoltare atipică rămân o provocare, atât ca diagnostic, cât și ca

tratament.

Material și metodă. În ultimii 15 ani am avut 4 cazuri trimise în clinica noastră cu diagnosticul

de tumoră mediastinală / pulmonară, la care imagistica preoperatorie a evidențiat tumori

mediastinale cu dezvoltare laterală - paracardiacă. Intraoperator s-au găsit tumori în contact

direct cu pericardul, cu dezvoltare posterior de nervul frenic. La toate cazurile s-a practicat

extirparea completă a tumorii prin abord lateral (toracotomie postero-laterală – 2 cazuri,

toracotomie antero-laterală 2 cazuri). Examenul histo-patologic extemporaneu a fost

neconcludent în toate cele 4 cazuri, diagnosticul fiind pus prin examen histo-patologic

definitiv.

Rezultate. Accesul asupra leziunii a fost excelent în toate cele cazurile. Toți cei 4 pacienți au

avut o evoluție postoperatorie imediată și tardivă favorabilă. Nu am întâlnit recidive la nici

unul din pacienți (urmărire 6 luni – 14 ani).

Concluzii. În cazul tumorilor intratoracice cu localizare paracardiacă trebuie avută în vedere și

posibilitatea unui timom. Abordul lateral oferă un acces bun pe cazuri selecționate. Subliniem

și dificultățile de diagnostic în condițiile din țara noastră.

POSTERS

RARE MEDIASTINAL MASSES: BRONCHOGENIC CYST AND CASTLEMAN'S

DISEASE




Introduction

The differential diagnosis of mediastinal masses includes over 30 different diseases, most

frecquent lymphomas, substernal goiter, thymomas, or, rarely, Castleman’s disease and

bronchogenetic cyst.

Castleman's disease is a rare lymphoproliferative disorder also called angiofollicular lymph

node hyperplasia.

Bronchogenic cysts, although relatively rare, represent the most common cystic lesion of the

mediastinum.

Cases report

A 45 year old male complaining of dyspnoea was presented with a mediastinal mass

mimicking a thymoma. By posterolateral thoracotomy the mass was completely excised.

Pathology examination of specimen showed Castleman's disease.

A 65 year old female was presented with a mediastinal mass compressing the trachea

diagnosed as bronchogenic cyst. Transcervical complete resection was performed with

remission of dyspnoea.

Discussions

The initial presentation of mediastinal masses may be respiratory distress and symptoms can

be life threatening when they produce airway compromise.

Castleman's disease is a lymphoid tumour with majority of lesions occurring within the chest.

The unicentric pattern is usually localized to the mediastinum or pulmonary hilum. Less

commonly sites include neck, pelvis, retroperitoneum and axilla.

The bronchogenetic cysts are usually found using prenatal ultrasonography and in early

childhood or adulthood by routine chest radiography. It is rarely diagnosed in elderly.

Extrathoracic cysts are found in the neck, abdomen, and retroperitoneal space. The

mediastinal cysts are mostly carinal and paratracheal; intrapulmonary cases were reported.

Mostly, the complete resection of the bronchogenic cyst was performed by thoracotomy.

Conclusions

Castleman's disease of the mediastinum is a rare clinical finding often diagnosed after onset of

non-specific thoracic symptoms such as dyspnoea, cough or chest-wall pain.

Bronchogenetic cysts are rare findings in elderly patients and produce symptoms when

altering airway dynamics.

Complete surgical removal of this type of mediastinal masses is usually curative alone. In

cases where subtotal excision has been performed, short-term recurrences were seldom

reported.

PERICARDIAL DRAINAGE IN MALIGNANT EFFUSIONS - EARLY RESULTS




Introduction: Pericardial effusion in neoplasic patient could be a life-threatening

complication.

Material and method: Between March 2010 and August 2011 we performed 27 pericardial

drainages in 25 patients (14 male and 11 female) with pericardial effusion and known

malignancies: 18 of lung, 5 of breast, 1 of cervix and 1 of lip.

The pericardial drainage was performed in emergency in 11 cases (cardiac tamponade, 2 cases

with localised tamponade) and in urgency in 16 cases.

As procedures we performed: 17 paraxyphoidian approaches (62,96%), 5 thoracoscopic

pericardo-pleural windows (18,51%), 2 percutaneous catheter drainages (7,4%), 2 subxyphoid

approach with xyphoid resection (7,4%) and 1 open left pericardial fenestration (3,7%).

The 17 paraxyphoidian approaches were performed under local anestesia, in 10 an

intravenous analgesia was added for patient’s comfort. We performed 3 paraxiphoidian

pericardioscopies (17,64%).

Results: The mean quantity of pericardial liquid extracted in the operating room was 845ml.

Pericardial biopsy was performed in 25 cases – in only 6 patients the histology was malignant

(24%). The cytology was malignant in 16 of 19 cases (84,21%).

The intraoperatory mortality was zero; immediate postoperatory mortality was 3,7% (1 death

at 9 hours after internal cardiac massage for cardiac arrest in tamponade)

In 14 cases the pericarditis was accompanied by pleural effusion: in 5 cases a thoracoscopic

pericardial fenestration was performed (under general anestesia) and in 9 cases patient’s

condition imposed local anestesia and chest tube insertion was performed.

We had a double recidive of 1 pericarditis after a paraxyphoidian drainage and a percutaneous

US-guided pericardiocentesis, which imposed an open left partial pericardiectomy for a

limited tamponade on the emerge of the great vessels.

Conclusions: Because of the possibility of pericardial biopsy, paraxyphoidian approach is a

usefull surgical tool in malignant pericardial effusions. In paraxyphoidian access,

pericardioscopy with zero degrees endoscope is not appropiate.

TRIPLE TRACHEO-BRONCHIAL LESION POST-MEDIASTINOSCOPY AND EBUS



Introduction: Purulent mediastinitis is a severe condition with a high mortality rate even in

treated patients.

Material and method: A 61-y-o female patient is admitted in emergency with suflant and

purulent cervical postoperatory wound, dispneea, cough and purulent sputum. She had a

Carlens mediastinoscopy 6 days before in another department for a mediastinal subcarenal

mass. Before that, an EBUS tumoral biopsy has been performed with incomplete diagnosis

(lymphoid cells). The patient also had insulin-therapy for diabetus and corticoid therapy for

paraneoplastic pemphygus.

Results: Paraclinical investigations revealed pneumomediastinum with cervical

extension, distal tracheal cartilages broken and two endobronchial communications with

mediastinum surrounded by granulation tissue. The diagnosis was acute purulent mediastinitis

secondary to tracheo-bronchial rupture. The mediastinum was drained with a transcervical

silicone tube, small amounts of lavage and repeated tracheo-bronho-aspirations, along with

intensive care support. In spite of all efforts, after 18 days the patient died due to cardio-

respiratory arrest. The hystologic result from previous mediastinoscopy was Hodgkin

lymphoma.

Conclusion: Unrecognised tracheo-bronchial iatrogenic injury can lead to catastrofic

consequences in matter of hospital expenses and cost of life.

MALIGNANT PLEURAL PSEUDOMESOTHELIOMA



Background

Tumors that can present with a pseudomesotheliomatous appeareance include lung tumors

(adenocarcinoma), malignant vascular tumours, synovial sarcoma, thymoma and malignant

lymphoma.

Malignant melanoma is an aggressive cancer which can quickly metastasise. Its annual

incidence has increased dramatically over the past few decades. Secondary determinations

apear most frequently in the lungs, liver, brain and bones. Isolated pleural involvement is very

rare.

Methods

We report the case of a 59 year old woman presenting with exertional dyspnea and dysphonia

starting three months prior. She was diagnosed with a left pleural effusion and managed

conservatively with multiple recurrences in spite of repeated thoracenteses. Radiological

appearance has evolved from large pleural effusion without pleural thickening to a thick

confluent pleural tumor and entrapment of the lung; evolution characteristic for a diffuse

malignant mesothelioma.

She had a history of a right abdominal malignant melanoma resected in June 2008, with

postoperative adjuvant therapy - interferon alfa.

Results

For histological confirmation an open pleural biopsy was performed. This revealed a tumoral,

dark brown, pleural thickening. Histological analysis confirmed the diagnosis of metastatic

malignant melanoma.

Conclusions

Although quite rare, pleural metastasis of malignant melanoma can mimic a diffuse malignant

mesothelioma and should be considered in the differential diagnosis especially in patients

with a history of malignant melanoma.

The prognosis of most of the pseudomesotheliomatous tumours is poor, similar to

mesotheliomas, but there are some exceptions such as malignant lymphomas and thymomas.

One should always obtain histological confirmation of a suspected diagnosis no matter how

suggestive the clinical and imagistical aspects are so that the right, aimed, treatement can be

performed.

BULLOUS DYSTROPHY OF THE MIDDLE LOBE



Background: Bullous dystrophy is a rare variety of congenital malformation of lung found in

newborn.

Materials and Methods: The authors are presenting the clinical case of a 33-year-old female

patient, without significant past medical history, admitted in the clinic for hemoptysis,

persistent right hemithoracic pain, fever and dyspnea, symptoms with a sudden onset three

weeks before presentation. Under antibiotic treatment the symptoms resolve, but the

radiologic findings persist.

Results: Laboratory results show leukocytosis and increased fibrinogen.

Chest X-ray shows multiple cavities with hydroaeric levels situated in the lower third of the

right hemithorax.

Chest contrast-enhanced CT reveals cavities with hydroaeric levels in the middle lobe

(maximal dimensions of 9.2/11.7cm), with fluid and fluid-like contents.

Bronchoscopy visualizes mucopurulent secretions in the middle lobe bronchus and in the

basal segmental bronchi (Microbiological examination: Str. Pyogenes and Candida Albicans).

Intraoperatively emphysematous bulae of different sizes are observed, situated in the middle

lobe, one of which surpassed the fissure towards the superior lobe. Middle lobectomy and

wedge resection of the superior lobe are performed.

Postoperative evolution is favorable.

Conclusion: The particularity of the case stems from the adult age discovery of a congenital

malformation which had hemoptysis as a clinical debut.

IANUSIAN ASPECT OF TYROID PATHOLOGY



Introduction

Thyroid nodules are relatively frequent structural anomalies, identified by palpation or by

ultrasonography of the thyroid.

Tuberculosis is an infectious, contagious disease, caused by Mycobacterium tuberculosis.

Tuberculosis usually affects the lungs, but can also present with extrapulmonary

manifestations: tuberculous meningitis, peritonitis, pericarditis, genito-urinary tuberculosis,

and tuberculosis of the bones and joints, gastrointestinal system, liver, and lymph nodes.

Method

We report the case of a 53 year old woman, presenting with a thyroid nodule, known and

monitored for 10 years. She was admitted in our clinic with dysphagia. Ultrasonographic

evaluation and cervical computer tomography lead to the diagnostic of left thyroid nodule,

with extension to the mediastinum. Histopathological exam from fine-needle aspiration:

chronic thyroiditis.

Rezults

The surgical procedure reveals left inflamed thyroid lobe, at the lower pole, a tumor, about 3

cm in diameter, hard, which extends into the mediastinum.

We performed a hemithyroidectomy and the excision of the cervicomediastinal tumour. The

histopathological exam result was: tuberculosis of the lymph nodes.

Conclusions

This case highlights a rare, but possible tuberculous organ involvement.

The patient was treated a long period of time for thyroid nodules, the correct diagnostic and

treatment were confirmed through the surgical procedure.

GIANT PLEURAL TUMOR – CASE REPORT




Introduction

Solitary fibrous tumors of the pleura (previously called benign mesotheliomas) are rare

neoplasms. Although most are benign, malignant variants have been reported. Approximately

600 cases have been reported in the literature to date.

Case presentation

We report the case of a young woman with a giant solitary fibrous tumor of the pleura. Chest

CT showed large well-delineated heterogeneous mass occupying all the affected hemithorax.

The tumor was diagnosed three years prior to admission, was sensibly smaller, but the patient

refused surgery at that time.

Complete surgical excision was carried out by posterolateral thoracotomy. Tumor size was

32/25/15 cm and weighed 4500 g. Postoperative chest x-ray showed complete lung expansion

and recovery course was uneventful. The pathological diagnosis was benign localized fibrous

tumor of the pleura.

Discussions

Primary tumors of the pleura may be diffuse or solitary. Diffuse tumors are mesotheliomas:

associated with asbestos exposure and commonly fatal. Solitary fibrous tumors are rare

benign pleural neoplasms and unrelated to asbestos exposure or tobacco use. They derive

from fibroblastic stem cells but successive mutations may lead to malignancy. The tumors are

usually asymptomatic. Cough, chest pain or dyspnea occurs occasionally.

These tumors exceptionally grow to large sizes like this. There are very few cases cited with

such impressive dimensions.

Complete surgical resection is usually curative, but local recurrences have been reported.

Resection of the solitary fibrous pleural tumors is generally easy. Large tumors may be

difficult to resect because of extensive adhesions and highly vascular pedicle. The underlying

lung parenchyma can be fully preserved. High operative mortality is due to compression of

mediastinal structures leading to fatal cardiopulmonary complications.

Conclusions

Localized fibrous tumors are considered benign, but malignant cases have been reported.

Benign fibrous tumors of the pleura are unrelated to asbestos exposure. Complete en bloc

surgical resection is usually curative.

THE ROLE OF THE GEROULANOS PROCEDURE IN THE TREATMENT OF LUNG

HYDATIC CYST TODAY


Nicodin


Introduction :

Lung hydatidosis still represents an endemic problem in South-Eastern Europe, a real

challenge for the thoracic surgeon, concerning both the surgical technique and the optimal

recovery of the lung parenchyma.

Objectives :

The purpose of this article is to point out the advantages and relevance of the Geroulanos

technique in resolving the remaining cavity after the surgical treatment of the pulmonary

hydatid cyst.

Method :

Our experience consists in 93 surgical procedures for lung hydatidosis between 2001-2010, 33

of which were solved by using the Geroulanos technique (35,48%) after cystectomy. We

present statistics according to sex, age groups, affected hemithorax, surgical access and

surgical techniques.

Results :

All the cases had good outcome. The technique was clearly succesful in young patients (12

patients under 20 years old). The main advantages are the natural, step-by-step lung re-

expansioning, wihtout artificially modifiying the lung architecture, thus avoiding

complications that occur after other techniques, with very good conservation of lung

parenchyma. In the cases with giant hydatic cysts, the Geroulanos technique allowed sparring

of lung parenchyma by avoiding extended lung resections. The main disadvantage of the

technique is a longer recovery that involves a prolonged evaluation of the patient and of the

drainage.

Conclusions :

Although the Geroulanos technique can be considered of historical interest, in selected

patients it can have optimal results, with both anatomical and functional lung conservation,

also avoiding some of the postoperative complications frequent in other techniques. The only

notable disadvantage is the prolonged recovery time.

ROLE OF MUSCLE FLAPS IN THE TREATMENT OF UNRESECTABLE ABSCESSES




Introduction. The treatment pulmonary abscesses still remains a challenge for actual thoracic

surgery. We report our experience in using muscle flaps for the filling of unresectable

pulmonary abscesses.

Material and method. During the last 9 years we have used different muscle flaps (intercostal,

serratus anterior and latissimus dorsi) in 14 patients with unresectable primary pulmonary

abscesses. Muscle transposition was used alone (3 cases) or during thoracomyoplasties for

lung abscesses complicated with empyema (11 cases). The objective of the procedure was

complete obliteration of the diseases space and closure-reinforcement of the bronchial fistula;

the choice of the flap was made according to the local anatomy. Preoperative preparation was

made by daily lavages with antibiotics and disinfectants, including transparietal punction

using ultrasound guidance.

Results. We have encountered no mortality and no major complications. Hospitalisation

ranged between 25 and 46 days. At late follow-up (6 month – 9 years) we encountered no

recurrence and no major sequelae.

Conclusions. The use of muscle flaps is a valuable solution for unresectable pulmonary

abscesses if the preoperative preparation is an adequate one. Compared to the classic

techniques, the extensive mobilization of the flaps offers a good-quality biological material

with considerable volume.

REVERSAL OF THE FLOW IN THE THORACIC DRAINAGE SYSTEM – RARE

POSTOPERATIVE ACCIDENT



Introduction. In thoracic surgery there are many possible accidents, including some with no

relationship with the activity of the medical stuff.

Material and method. We report a 22 years-old male who underwent a thoracotomy for a

closed thoracic trauma with fracture of ribs 4, 5, 6 and 7, with tube thoracostomy performed

in onether unit, with 4 pulmonary lesions – rib cerclage, pulmonary suture and removal of the

clot and remnant hemothorax. On the 2nd postoperative day, during some unexpected

technical revisions at the central aspiration system, a reversal of the flow in the thoracic

drainage system ocurred, with introduction of air under positive pressure inside the chest of

the patient.

Results. The patient presented intense pain, dyspnea and extended subcutaneous emphysema.

A few minutes after this accident the thoracic drainage system was disconnected, followed by

passive (underwater) drainage, then by active aspiration under negative pressure using a

portable electric system; for the subcutaneous emphysema we placed subcutaneous needles.

The evolution was favourable, with reexpansion of the lung, resolution of the subcutaneous

emphysema, development of pneumonia on the operated lung with resolution under antibiotic

treatment and removal of the drains on postoperative day 10.

Conclusions. Any repairs at the central aspiration system must be announced, especially in the

units with patients under thoracic drainage. Some apparently minor technical incidents may

endanger the life of the patients.

TUMORI MEDIASTINALE RARE: CHIST BRONHOGENETIC SI BOALA

CASTLEMAN MEDIASTINALA



Introducere

Diagnosticul diferential al tumorilor mediastinale cuprinde peste 30 de afectiuni, dintre care

cele mai frecvente sunt limfoamele, gusa mediastinala, timoamele, si, cele mai rare, boala

Castleman sau chistul bronhogenetic.

Boala Castleman este o maladie limfoproliferativa rara, denumita si hiperplazie limfo-

nodulara angiofoliculara.

Chistul bronhogenetic, desi o patologie rara, reprezinta cea mai frecventa cauza de leziune

chistica de la nivelul mediastinului.

Prezentare de cazuri

Un barbat de 45 de ani cu dispnee se prezinta cu o tumora mediastinala ce sugera un timom.

Prin toracotomie posterolaterala tumora a fost excizata complet. Rezultatul anatomopatologic

al specimenului pune diagnosticul de boala Castleman.

femeie de 65 de ani se prezinta cu o tumora mediastinala ce comprima traheea, diagnosticata

drept chist bronhogenetic. Se rezeca in totalitate chistul transcervical cu remisia simptomelor

de dispnee.

Discutii

Primul simptom al tumorilor mediastinale este dispneea, odata cu compresia extrinseca a

cailor respiratorii.

Boala Castleman este un tip de tumora limfoida in principal localizata la nivelul toracelui.

Varianta unicentrica este focalizata la nivelul mediastinului sau a hilului pulmonar. Alte

localizari sunt gatul, pelvisul, retroperitoneul sau axila.

Chistul bronhogenetic este diagnosticat ecografic in perioada prenatala sau ocazional

radiologic in copilarie sau adolescenta. La pacientii in varsta, sunt de regula diagnostice rare.

Localizarile extratoracice includ gatul, abdomenul sau spatiul retroperitoneal. Chisturile

mediastinale sunt predominant subcarinale si paratraheale; cazuri intrapulmonare sunt citate.

Rezectia lor completa se realizeaza cel mai frecvent prin toracotomie.

Concluzii

Boala Castleman mediastinala este o entitate rara, diagnosticata cel mai frecvent dupa debutul

unor simptome toracice nespecifice: dispnee, tuse, durere.

Chistul mediastinal este identificat rar la pacienti in varsta cand acesta produce compresie

asupra cailor aeriene.

Rezectia chirurgicala completa este curativa pentru acest tip de tumori mediastinale. In

cazurile in care se practica o rezectie subtotala, recidive pe termen scurt au fost raportate.

DRENAJUL PERICARDIC ÎN REVĂRSATELE MALIGNE – REZULTATE PRECOCE




Bucureşti

Introducere: Pericardita lichidiană la pacienţii neoplazici este o complicaţie potenţial letală.

Material şi metodă: Între martie 2010 şi august 2011 am efectuat 27 drenaje pericardice la 25

pacienţi (14 bărbaţi şi 11 femei) cu pericardite lichidiene şi neoplasme cunoscute: 18

pulmonare, 5 mamare, 1 de col uterin şi 1 de buză.

Drenajul pericardic a fost efectuat în urgenţă imediată în 11 cazuri de tamponadă cardiacă (2

tamponade localizate) şi în urgenţă amânată la 16 pacienţi.

Procedee de drenaj: 17 aborduri paraxifoidiene (62,96%), 5 fenestrări pericardo-pleurale

toracoscopice (18,51%), 2 drenaje prin cateter percutan (7,4%), 2 aborduri subxifoidiene cu

rezecţia xifoidului (7,4%) şi 1 fenestrare pericardică prin toracotomie stângă (3,7%).

Cele 17 drenaje paraxifoidiene au fost efectuate sub anestezie locală, la care în 10 cazuri a fost

adăugată analgezia i.v. pentru confortul pacientului. Am efectuat 3 pericardoscopii

paraxifoidiene (17,64%).

Rezultate: Cantitatea medie de lichid pericardic evacuată intraoperator a fost de 845ml. Am

efectuat biopsie pericardică în 25 cazuri – în doar 6 cazuri histologia a fost malignă (24%).

Citologia a fost malignă în 16 din 19 cazuri (84,21%).

Mortalitatea intraoperatorie a fost zero; mortalitatea postoperatorie imediată a fost 3,7% (1

deces la 9h după masaj cardiac intern pentru stop cardiac în tamponadă).

În 14 cazuri, pericardita a fost asociată cu pleurezie: în 5 cazuri s-a efectuat fenestrare

pericardo-pleurală prin toracoscopie (anestezie generală) iar la 9 pacienţi starea generală a

impus doar anestezie locală, pleurezia fiind drenată prin pleurotomie minimă asociată.

Am avut 1 caz cu dublă recidivă a pericarditei neoplazice (după drenaj paraxifoidian şi

pericardocenteză eco-ghidată) cu tamponadă localizată la emergenţa marilor vase ce a impus

pericardectomie parţială stângă prin toracotomie.

Concluzii: Deoarece permite biopsierea facilă a pericardului, abordul paraxifoidian este extrem

de util în drenajul pericarditelor maligne. Endoscopul cu vedere la 0 grade nu este potrivit

pentru pericardoscopie paraxifoidiană.

TRIPLĂ LEZIUNE TRAHEO-BRONŞICĂ POST-MEDIASTINOSCOPIE ŞI EBUS



Introducere: Mediastinita purulentă reprezintă o afecţiune gravă cu mortalitate mare chiar şi în

cazul pacienţilor corect trataţi.

Material şi metodă: Pacientă de 61 de ani este internată în urgenţă pentru dispnee, tuse,

expectoraţie purulentă şi plagă cervicală inferioară suflantă, cu secreţii purulente. În urmă cu 6

zile s-a practicat în afara tarii o mediastinoscopie Carlens pentru o tumoră mediastinală

subcarenală. Înainte de aceasta se practicase o biopsie transbronşică ecoghidată cu rezultat

histologic incomplet (celule limfoide). Pacienta este sub insulino-terapie pentru diabet zaharat

şi corticoterapie pentru pemfigus paraneoplazic.

Rezultate: Investigaţiile paraclinice arată pneumomediastin cu extensie cervicală, cartilaje

traheale distale rupte şi două soluţii de continuitate traheo-bronşice, comunicante cu

mediastinul şi mărginite de ţesut de granulaţie. Se confirmă diagnosticul de mediastinită acută

purulentă prin rupturi traheo-bronşice. Se practică drenaj mediastinal transcervical cu tub

siliconat, lavaje repetate reduse cantitativ şi aspiraţii repetate traheo-bronşice, alături de terapie

intensivă specifică. În ciuda tuturor eforturilor, după 18 zile pacienta decedează în urma unui

stop cardio-respirator. Rezultatul histologic în urma mediatinoscopiei este de limfom Hodgkin.

Concluzii: Leziunile traheo-bronşice iatrogene nerecunoscute pot avea consecinţe catastrofice

prin costuri ridicate medico-economice şi decesul pacienţilor.

PSEUDOMEZOTELIOM PLEURAL MALIGN



Bucureşti

Introducere

Aspect pseudomezoteliomatos pot avea metastazele pleurale ale tumorilor pulmonare

(adenocarcinom), tumorilor vasculare maligne, sarcomului sinovial, timomului şi limfomului

malign.

Melanomul malign este o tumoră agresivă ce metastazează rapid cu incidenţă în creştere în

ultimile decade. Determinările secundare apar cel mai frecvent la nivelul plămânilor, ficatului,

creierului şi oaselor. Afectarea singulară a pleurei este foarte rară.


Prezentăm cazul unei paciente în vârstă de 59 de ani ce s-a internat în clinica noastră

prezentând dispnee la eforturi mici, disfonie cu debut în urmă cu trei luni. A fost diagnosticată

cu pleurezie stânga şi tratată conservator în teritoriu cu recidiva pleureziei în ciuda

toracocentezelor repetate. Aspectul radiologic a evoluat de la pleurezie mare, fără afectare

evidentă a pleurei, la pleurezie redusă cantitativ cu seroasă pleurală mult îngroşată şi încarcerea

plămânului; evoluţie caracteristică unui mezoteliom malign difuz.

Din antecedentele personale sunt de menţionat un melanom malign de flanc abdominal drept

operat în iunie 2008, imunotratat – alfa interferon, HTA, arteriopatie cronică obliterantă.

Rezultate

Pentru confirmarea diagnosticului se decide efectuarea unei biopsii pleurale incizionale. Se

evidenţiază pleura ingroşată tumoral de culoare brun închis. Rezultatul examenului

histopatologic a fost de metastază de melanom malign.

Concluzii

Deşi foarte rar, melanomul malign poate fi o cauză de pseudo-mezoteliom intrând în

diagnosticul diferenţial al acestuia mai ales la pacieţii cu antecedente de melanom malign.

Prognosticul pseudomezotelioamelor este de regulă nefavorabil, asemănător cu cel al

mezotelioamelor, dar există şi unele excepţii ca limfoamele sau timoamele maligne.

Trebuie întodeauna obţinută confirmarea histologică a unei suspiciuni diagnostice indiferent cât

de sugestive sunt aspectele clinice şi imagistice, pentru a se putea efectua un tratament corect,

ţintit.

DISTROFIA BULOASĂ DE LOB MEDIU



Bucureşti

Introducere: Distrofia buloasă este o malformaţie congenitală rară descoperită la nou-născut.

Material şi metodă: Autorii prezintă cazul unei paciente în vârstă de 33 ani, fără APP

semnificative, internată în clinică pentru hemoptizii, junghi toracic drept persistent, febră şi

dispnee de efort, simptomatologie ce a debutat brusc cu 3 săptamâni anterior prezentării. Sub

tratament antibiotic, simptomatologia clinică se remite, dar persistă modificările radiologice.

Rezultate:La analizele de laborator se constată leucocitoză şi fibrinogen crescut.

Radiografia toracică evidenţiază mai multe cavităţi cu nivele hidroaerice situate în treimea

inferioară a câmpului pulmonar drept.

CT torace cu substanţă de contrast relevă cavităţi cu nivel hidroaeric la nivelul lobului

mediu(dimensiuni maxime 9.2/11.7cm), cu conţinut fluid şi parafluid.

Bronhoscopic se evidenţiază secreţii mucopurulente în lobara medie şi bazalele drepte (examen

microbiologic: Str. Pyogenes şi Candida albicans).

Intraoperator se constată bule de emfizem de diferite dimensiuni, localizate la nivelul lobului

mediu, una dintre ele depaşind puţin scizura la nivelul lobului superior. Se practică lobectomie

medie şi rezecţie atipică lob superior drept.

Evoluţia postoperatorie este favorabilă.

Concluzii: Particularitatea cazului este reprezentată de descoperirea la vârsta adultă a unei

malformaţii congenitale (distrofia buloasă) care a debutat prin hemoptizie.

ASPECT IANUSIAN DE PATOLOGIE TIROIDIANĂ



Bucureşti

Introducere

Nodulii tiroidieni sunt anomalii structurale ale tiroidei, identificati fie prin palpare fie in cadrul

unei ecografii tiroidiene.

Tuberculoza este o boala infectioasa contagioasa, provocata de Mycobacterium tuberculosis.

Tuberculoza pulmonara este cel mai comun tip al bolii, dar sunt si localizari extrapulmonare:

meningita tbc, peritonita tbc, pericardita tbc, tbc miliara, renala, osoasa si articulara,

gastrointestinala, hepatica, ganglionara.

Metodă

Prezentăm cazul unei paciente în vârstă de 53 de ani, cu nodul tiroidian stang in observatie de

10 ani, ce se internează în clinica noastră prezentând disfagie. Investigatiile paraclinice prezinta

imagini compatibile cu nodul de pol inferior tiroidian stang, plonjant in mediastin. Examen Hp

prin punctie cu ac fin: tiroidita cronica.

Rezultate

S-a decis intervenţia chirurgicală, intraoperator constatandu-se lob stang tiroidian modificat

inflamator; la polul inferior formatiune tumorala dura la palpare, cu diametru de 3 cm, cu

extensie in mediastin.

Se practica hemitiroidectomie stanga si exicizia formatiunii tumorale. Examenul histopatologic

extemporaneu, confirmat ulterior la parafina: adenita TBC.

Concluzii

Acest caz atrage atenţia asupra unei localizari rare, dar posibilă, a tuberculozei.

Pacienta a fost o perioada indelungata tratata pentru nodul tiroidian, stabilindu-se cu ocazia

interventiei chirurgicale diagnosticul si ulterior tratamentul adecvat.

TUMORA FIBROASA SOLITARA PLEURALA GIGANTA – PREZENTARE DE CAZ



Introducere

Tumorile pleurale fibroase solitare, numite in trecut si mezotelioame benigne, sunt neoplasme

rare. Desi majoritatea sunt benigne, malignizari au fost raportate in trecut. Aproximativ 600 de

cazuri au fost citate in literatura pana in prezent.

Prezentare de caz

Prezentam cazul unei femei tinere cu o tumora giganta pleurala fibroasa solitara. Examenul CT

toracic evidentiaza o masa tumorala heterogena bine delimitata ocupand intreg hemitoracele

stang. Tumora a fost diagnosticata in urma cu trei ani, avea dimensiuni mult mai mici, dar

pacienta a refuzat interventia chirurgicala.

S-a realizat excizia completa a tumorii prin toracotomie posterolaterala. Dimensiunile tumorii

au fost de 32/25/15 cm si a cantarit 4500 grame. Radiografia toracica postoperatorie a aratat

expansionare completa a parenchimului pulmonar stang. Cazul a avut o evolutie simpla.

Rezultatul anatomopatologic a fost de tumora pleurala fibroasa solitara.

Discutii

Tumorile primitive pleurale sunt difuze sau solitare. Tumorile difuze sunt mezotelioamele: se

asociaza cu expunerea la azbest si sunt fatale. Tumorile fibroase solitare sunt formatiuni rare,

benigne, fara relatie cu expunerea la azbest sau fumatul. Ele deriva din celule stem

fibroblastice, dar pot suferi mutatii succesive si pot maligniza. Sunt asimptomatice, iar tusea,

durerea sau dispneea apar rar.

Aceste de tumori ajung rareori la dimensiuni importante cum sunt cele ale cazului de fata. Sunt

doar cateva cazuri citate in literatura cu astfel de diametre impresionante.

Rezectia chirurgicala completa este de obicei curativa, dar au fost citate si recidive. Excizia

totala a unei formatiuni fibroase pleurale facila. Tumorile voluminoase sunt greu de manipulat,

pot avea aderente stranse sau un pedicul bine reprezentat. Parenchimul pulmonar subiacent

poate fi salvat in totalitate. Mortalitatea operatorie este data de compresia structurilor

mediastinale cu complicatii cardio-pulmonare fatale.

Concluzii

Tumorile pleurale fibroase solitare sunt benigne, desi cazuri maligne au fost citate. Ele nu sunt

legate de expunerea la azbest. Excizia chirurgicala completa este curativa.

ROLUL ACTUAL AL PROCEDEULUI GEROULANOS IN TRATAMENTUL

CHIRURGICAL AL CHISTULUI HIDATIC PULMONAR


Nicodin


Introducere

Chistul hidatic pulmonar constituie inca o problema endemica pentru sud-estul Europei, iar

pentru chirurgul toracic o provocare tehnica, de rezolvare si recuperare optima a

parenchimului pulmonar.

Obiective

Autorii doresc sa evidentieze avantajele si actualitatea procedeului Geroulanos pentru

rezolvarea cavitatii restante dupa tratarea hidatidei.

Metoda

In Clinica de Chirurgie din Timisoara s-au efectuat in perioada 2001-2010, 93 de interventii

chirurgicale pentru hidatidoza pulmonara. Dintre acestea in 33 de cazuri (35,48%), s-a utilizat

procedeul Geroulanos pentru rezolvarea cavitatii restante postchistectomie. Sunt prezentate

statistici in functie de sex, grupe de varsta, hemitoracele afectat, cai de acces utilizate.

Rezultate

Toate cazurile au evoluat favorabil. Procedeul a fost utilizat cu succes la tineri (12 pacienti

sub 20 ani). Avantajele principale ale tehnicii mentionate constau in expansionarea treptata si

naturala a parenchimului pulmonar, fara modificarea artificiala a arhitecturii

bronhopulmonare. In consecinta au putut fi evitate complicatiile survenite dupa alte procedee,

iar parenchimul pulmonar este conservat integral. In chistele de mari dimensiuni, procedeul

Geroulanos a permis evitarea unor rezectii pulmonare intinse. Dezavantajul principal al

tehnicii este reprezentat de perioada mai indelungata de recuperare care implica si o

monitorizare prelungita a pacientului si a tubului de dren.

Concluzii

Desi procedeul Geroulanos poate fi considerat de interes istoric, in cazuri selectionate, poate

da rezultate excelente, cu recuperare functionala si conservare maxima a parenchimului

pulmonar. Sunt evitate unele complicatii postoperatorii, intalnite dupa alte procedee. Singurul

dezavantaj notabil este timpul prelungit de vindecare.

ROLUL LAMBOURILOR MUSCULARE ÎN TRATAMENTUL ABCESELOR

PULMONARE NEREZECABILE




Introducere. Tratamentul abceselor pulmonare constituie o problemă majoră pentru chirurgia

toracică actuală. Prezentăm experiența noastră în folosirea lambourilor musculare pentru

plombajul unor abcese pulmonare nerezecabile.

Material și metodă. În ultimii 9 ani am folosit lambouri musculare (intercostal, dințat anterior

și mare dorsal) la 14 pacienți cu abcese pulmonare primare nerezecabile. Transpoziția

musculară a fost folosită ca singur gest terapeutic (3 cazuri) sau în cadrul unor

toracomioplastii pentru abcese complicate cu empiem (11 cazuri). Obiectivul intervenției a

fost obliterarea completă a spațiului patologic și sutura-asigurare a fistulei bronșice iar

alegerea lamboului s-a făcut în funcție de anatomía locală. Pregătirea preoperatorie s-a

efectuat prin lavaje zilnice cu antibiotice și dezinfectante, inclusiv prin puncție transtoracică

sub ghidaj ecografic.

Rezultate. Nu am înregistrat mortalitate postoperatorie și nici complicații majore. Durata

spitalizării a variat între 25 și 46 de zile. La urmărirea tardivă (6 luni – 9 ani) nu am înregistrat

recidive și nici sechele majore.

Concluzii. Lambourile musculare constituie o soluție viabilă în cazul abceselor pulmonare

nerezecabile cu condiția unei pregătiri preoperatorii adecvate. Față de tehnicile clasice,

mobilizarea extensivă a lambourilor oferă un material biologic de bună calitate și volum

apreciabil.

INVERSAREA FLUXULUI ÎN SISTEMUL DE DRENAJ TORACIC – ACCIDENT

POSTOPERATOR RAR



Introducere. În chirurgia toracică există numeroase accidente posibile, unele fără legătură cu

activitatea personalului medical.

Material și metodă. Prezenăm cazul unui pacient de 22 de ani la care s-a efectuat toracotomie

pentru traumatism toracic închis cu fractură C4-5-6-7 drenat la un spital orășenesc cu 4

leziuni pulmonare pentru care s-a practicat cerclajul coastelor, pneumorafie, evacuarea

cheagului și a hemotoracelui restant. În ziua a 2-a postoperator, pe fondul unor reparații

neanunțate la sistemul central de aspirație, s-a produs inversarea fluxului în sistemul de drenaj

toracic cu introducerea de aer sub presiune extremă în toracele pacientului.

Rezultate. Pacientul a prezentat durere atroce, dispnee și emfizem subcutanat extins. La

câteva minute de la accident s-a decuplat trusa de aspirație, trecându-se la drenaj pasiv (sub

apă) apoi la aspirație negativă folosind o aspirație electrică portabilă; pentru emfizemul

subcutanat s-au plasat ace. Evoluția ulterioară a fost favorabilă, cu reexpansionarea

plămânului, resorbția lentă a emfizemului subcutanat, apariția unor focare de pneumonie pe

plămânul operat care s-au remis sub tratament medicamentos și extragerea drenurilor în ziua a

10-a postoperator.

Concluzii. Reparațiile la sistemul central de aspirație trebuiesc anunțate prealabil, în special în

serviciile unde există pacienți cu drenaj toracic. Incidente tehnice aparent minore pot pune în

pericol imediat viața pacienților.

Date post:	18-Jan-2016
Category:	Documents
Upload:	min09hihi
View:	170 times
Download:	9 times

Caietul de Rezumate

Documents