Abstracts DGT

Rare case of endobronchial metastasis of a gastric carcinoma

(Abstract ID: 95)

H. Hendrix¹, V. Kamlak¹, G. Prisadov¹, K. Welcker¹

¹Kliniken Maria Hilf GmbH, Mönchengladbach

Background:

Endobronchial metastases of gastric carcinomas are rare. In most cases, it is a bronchoscopic incidental finding, which then leads to the detection of the primary tumor in further diagnostics. We report the case of a 67-year-old female patient who was found to have endobronchial metastasis of a gastric sealring-cell-like adenocarcinoma.

Materials and methods:

The patient had presented with hoarseness and concomitant dysphagia for 5 weeks. In weight she had inadvertently lost 10 kg in 6 months. Laryngoscopically, vocal cord paresis on the left could be detected. In the initial diagnostic imaging (sonography of the neck, CT scan of the neck) the suspicion of a thyroid tumor was expressed.

Results:

Bronchoscopically irregular, tumor-suspicious changes in the mucosa of the main carina, the right main bronchus, the bronchus intermedius and of the complete left bronchial system with narrowing of the lower lobe bronchus were detected. Sample excisions (PE's) were taken from the main carina as well as from the upper / lower lobe carina on the left. Gastroscopy was inconspicuous except for two smaller mucosal islands with a central dent in the gastric antrum from which PEs were taken. The CTscan of the chest and abdomen revealed a large mass in the left lower lobe with infiltration into the mediastinum, metastasis-suspiscious small pulmonary round lesions in the right lung, a questionable liver metastasis, and questionable soft-tissue and osseous metastases. The tumor markers CEA and CA 19-9 were elevated. Histologically, a little differentiated, sealring-cell-like adenocarcinoma was detected in the PE's from the stomach. A similar histological appearance was seen in the PEs of the bronchial mucosa and in a soft tissue metastasis. Thus, it was a multilocular metastatic gastric carcinoma inter alia with endobronchial metastasis.

Conclusion:

Endobronchial metastasis of gastric carcinoma usually represents an advanced tumor stage. Often, the bronchoscopic findings leads to the diagnosis of the primary tumor and allows by histological evidence differentiation to bronchial carcinoma. The treatment is palliative, the prognosis is poor.

Experiences after 100 non-intubated thoracoscopies in the Lungenklinik Hemer

(Abstract ID: 695)

D. Balke¹, M. Stoller², J. Quellenberg², S. Welter²

¹Ernst von Bergmann Klinikum Potsdam

²Lungenklinik Hemer

Background:

NI-VATS are more frequently carried-out because of the lower risk anesthesia and the quick recovery phase of the patients. With increasing experience in a well-rehearsed team, even anatomical resetions can be made without intubation narcosis. Besides that, even multimorbid patients who would not be suitable for a general anesthesia can be operated on.

Materials and methods:

In the Lungenklinik Hemer we carried out 100 thoracoscopies with and without lung resections under spontaneous breathing between February 2017 and July 2019. The average age of the patients was 64 years (29 - 93ys), the mean BMI ws 24kg/m2 (17 - 42), the mean FEV-1 was 80% (29 - 126%). The underlying pathologies were pleural effusions (35%), pneumothoraces (7%), pleural empyemas (7%), pulmonary nodules (20%), interstitial lung diseases (16%), lung carcinomas (14%) and one emphysema with a giant bulla. Seven patients had lobectomies with systemic lymphadenectomy (7%). Anaesthesia was carried out with PDK and LA (79%), PDK only (7%), intercostal block (18%) or LA only (14%). 50 cases were operated uniportal, 48 with 2 ports, 2 cases with 3 ports. The induction of narcosis took 33min on average (5 - 62min), the duration of the operation was 48min on average (12 - 226min)

Results:

There were no major complications. All operations could be carried out successfully. With the subpleural injection of Lidocaine around the Vagus nerve the urge to cough could be adequatly blocked to securely proceed with the operation. Temporary hypoxemias were bypassed with intermittant mask ventilation (5%). A conversion to intubation anaesthesia had to be made in 5 cases (5%) because of hypoxaemia, hypercapnia or strong movements of the diaphragm. All of these could be achieved in lateral positioning. On average, the patients could be discharged on the 7th pod (1 - 23d): the ASA 3 patients (77%) were discharged on 7th pod, the ASA 4 patients (9%) were discharged on the 6th pod on average. There was no postoperative transition syndrome. Clear vigilance shortly after the operation (average Aldrete Score of 9; in ASA 3 Patients:9; in ASA 4 patients: 8,2) facilitated a quick transfer to normal ward. Patients satisfaction with the operation was high, none of the patients noticed anything of the procedure.

Conclusion:

With an experienced team of anaesthesiologists, surgeons and surgical staff, VATS can be carried-out in spontaneous breathing without complications even on high-risk patients. The risks of a general anaesthesia can be avoided that way. The postoperative recovery period was remarcably short.

Comparison of low-tech VATS-Lobectomy with conventional VATS-Lobectomy for lung cancer: Feasibility and cost-effectiveness

(Abstract ID: 559)

S. Schierholz¹, D. Ellebrecht¹, T. Keck¹, E. Palade¹

¹Universitätsklinikum Schleswig-Holstein,Campus Lübeck

Background:

Video-assisted thoracoscopic surgery (VATS) lobectomy is a standard procedure for early stage non-small cell lung cancer. In times of economic pressure, efforts are made to improve cost-effectiveness of VATS procedures, mostly by reducing the duration of hospital stay. Our concept was to reduce the procedure related costs by eliminating endostaplers. This resulted in the so called "low tech" video-assisted thoracoscopic surgery (LT-VATS) lobectomy procedure.

Materials and methods:

This is a single institution retrospective analysis of two surgical procedures. In contrast to the conventional -VATS lobectomy (C-VATS), in the LT-VATS lobectomy all pulmonary vessels are ligated and the bronchial stump and lung parenchyma are sutured. Between October 2018 and September 2019, 15 consecutive patients with non-small cell lung cancer were treated by LT-VATS lobectomy. This group was compared with the larger group (C-VATS group) operated prior to the introduction of LT-VATS lobectomy (propensity matched analysis). Differences in material costs, hospital stay, surgical and clinical outcomes were analyzed.

Results:

In both cohorts there were no relevant major surgical complications. The mean operating time in the LT-VATS-group was 204 min (range: 167–260 min) compared to 187 min in the C-VATS-group. There were no statistical significant differences in the duration of chest drainage, hospital stay and postoperative morbidity and mortality. The cost reduction in LT-VATS lobectomy group was statistically significant.

Conclusion:

In experienced hands, low-tech VATS lobectomy for non-small cell lung cancer is a safe procedure and can be offered as a viable alternative to conventional VATS lobectomy. This approach can dramatically reduce procedure related costs and also the amount of waste related to single use devices.

Outcomes of juvenile myasthenia gravis: A comparison of robotic thymectomy with nonsurgical treatment

(Abstract ID: 880)

J. Rückert¹, Z. Li¹, F. LI¹, H. Zhang¹, A. Meisel¹

¹Charité - Universitätsmedizin Berlin - CCM

Background:

The therapeutic value of thymectomy in juvenile myasthenia gravis (JMG) is still controversial. This study aims to compare the clinical outcomes of JMG patients who underwent robotic thymectomy with that of nonsurgical treatment.

Materials and methods:

This study retrospectively reviewed patients who underwent robotic thymectomy for the treatment of myasthenia gravis (MG) with an age at onset younger than 18 years, which comprised the surgical group. The nonsurgical group consisted of patients who visited our institute for the diagnosis or treatment of MG. Both the baseline characteristics and the clinical outcomes were compared between the two groups. The clinical outcomes were assessed according to the Myasthenia Gravis Foundation of America Post Intervention Status. Kaplan-Meier method was used to plot the cumulative probability of complete stable remission (CSR). Univariable and multivariable analyses using cox proportional hazards regression model were performed to seek for the association of robotic thymectomy with the achievement of CSR and adjust for confounding factors. Wilcoxon signed-rank test was used to compare the use of MG medications at two different follow-up time points.

Results:

Forty-four (32 female: 12 male) of 69 patients who underwent robotic thymectomy for the treatment of MG with an age at onset younger than 18 years were eligible for inclusion as surgical group. Eighteen (14 female: 4 male) out of 30 patients who visited our institute for the diagnosis or treatment of MG comprised nonsurgical group. Significant differences were observed between the surgical group and nonsurgical group in disease duration (16.5 [7.75–25.75] months versus 150 [46-513] months, p<0.001), corticosteroids requirement (52.3% versus 11.1%, p=0.003) and azathioprine requirement (36.4% versus 11.1%, p=0.047) at baseline. Kaplan-Meier curves and log-rank test showed a higher cumulative probability of CSR in the surgical group (p=0.039) as compared to the nonsurgical group. The estimated 5-year cumulative probabilities of CSR were 0.0769 (95%CI: 0–0.211) in the nonsurgical group and 0.4912 (95%CI: 0.2566-0.6517) in the surgical group. Moreover, thymectomy (HR 3.550, 95%CI: 1.015-12.419, p=0.047, Table 3) and age at onset (HR 0.886, 95%CI: 0.794-0.989, p=0.032, Table 3) were still associated with the achievement of CSR after multivariable analysis. Furthermore, a significant steroid-sparing effect was observed only in surgical group, but not in nonsurgical group.

Conclusion:

Robotic thymectomy seems to be more effective than medication therapy in inducing remission of MG. Furthermore, the steroid-sparing effect also favors robotic thymectomy over nonsurgical treatment.

First rib resection for thoracic outlet syndrome: The robotic approach

(Abstract ID: 940)

A. Zehnder¹, G. Kocher², J. Schmidli², R. Schmid²

¹Kantonsspital Winterthur

²Universitätsspital Bern, Inselspital

Background:

Thoracic outlet syndrome (TOS) designates the symptomatic compression of the neurovascular structures as they traverse the thoracic outlet. In case of a triggerable vascular insufficiency or progressive neurologic dysfunction despite conservative treatment, surgical decompression of the space between the clavicle and the first rib is indicated. Herein we present our experience in 22 cases with this robotic assisted minimally invasive approach.

Materials and methods:

Between January 2015 and May 2019, 22 consecutive first rib resections were performed in 19 patients (left: n=7; right: n=15) at our institutions. The etiologies were: venous (vTOS, n=10), arterial (aTOS, n=2), neurogenic (nTOS, n=3) and nonspecific (nsTOS, n=7). The patients with vTOS have been referred by vascular surgeons or angiologists with a history of recurrent thrombosis in the subclavian vein or documented stenosis, mostly after interventional thrombolysis. One patient has been referred with stent in situ. They were offered surgery within 2-4 weeks after thrombolysis. The first rib was removed using 3 access ports for the robotic camera and two working channels with an additional axillary incision in the first 7 cases for extraction of the rib. Postoperatively, anticoagulation was maintained for three to six months.

Results:

Operative time ranged from 88-150 min (median 116.5 min). Mean postoperative hospital stay was two days (range 1 - 4 ). Postoperative courses were uneventful in all patients and all showed partial (n=8) or complete relief (n=11) of their symptoms 3 months after surgery. In vTOS, four patients needed stent placement postoperatively due to scarring and stenosis. In the other patients one re-thrombosis occurred due to low-flow which resolved under anticoagulation. One patient presented with transient dysesthesia of the medial upper arm. In the follow-up examination after one year all veins showed full patency.

Conclusion:

A well developed minimally invasive robotic assisted technique for first rib resection in thoracic outlet syndrome is presented. Excellent postoperative results were achieved and no postoperative complications were noted. The success of this treatment, however, needs an interdisciplinary approach with angiologists and vascular surgeons.

Pazopanib as first line therapy in pulmonary epithelioid hemangioendothelioma

(Abstract ID: 136)

D. Borchert¹, F. Ramirez Fragoso¹, H. Kelm¹, A. Kollar¹, A. Loew¹, A. Gamrekeli¹

¹Ruppiner Kliniken, Neuruppin

Background:

Diagnosis and treatment of pulmonary epithelioid hemangioendothelioma (P-EHE) is challenging. Data on the use of tyrosine kinase inhibitors in P-EHE and its use in the first-line setting in particular is limited. Pazopanib, a multitarget inhibitor, was reported in only one female patient with P-EHE as a successful first line treatment. We report on a second male patient with bilateral P-EHE receiving pazopanib as a first line treatment.

Materials and methods:

A 70 years old gentleman presented with shortness of breath in august 2017. Chest CT scan revealed multiple pulmonary nodules suspicious for a multifocal disease. Bronchoscopy and CT-guided biopsy could not confirm a malignant disease. After left-sided thoracotomy and atypic resection the diagnosis of P-EHE was made.Treatment: After consideration of options with sarcoma specialists at a multidisciplinary tumorboard the patient was started on a palliative first-line therapy with pazopanib 800 mg daily in April 2018.

Results:

Follow-up CT scans showed stable disease according to CHOI criteria. Clinically the patient tolerated pazopanib well. In July 2018 the patient suffered from loss of appetite and weight and progessing shortness of breath. In september 2018 the patient was admitted to hospital for increasing dyspnoea, immobilization and general pain. Pazopanib therapy was stopped due to rapid deterioration. Initially the patient responded to supportive care with minimal improvement of respiratory function and appetite but developed progressive respiratory failure a few days later and died nine days after admission.

Conclusion:

P-EHE is a rare disease presenting a challenge in establishing diagnosis and defining treatment strategies. The use of pazopanib as a first line treatment has only been reported in a female patient before. This female patient had metastatic disease and survived more than two years. In our case pazopanib led to a progression free survival of four month. Therefore, multitarget tyrosine kinase inhibitors may play a role in P-EHE in the first-line setting, as well. Further evaluation of multikinase inhibitors as first-line therapy might be warranted in P-EHE.

Unusual case of a thoracic glass splinter injury

(Abstract ID: 94)

H. Hendrix¹, V. Kamlak¹, G. Prisadov¹, L. Reich¹, K. Welcker¹

¹Kliniken Maria Hilf GmbH, Mönchengladbach

Background:

In the literature reports of thoracic glass slinter injuries are rare. We present an unusual case of an 17 year old patient who suffered multiple glass splinter injuries caused by a fall through a glass door.

Materials and methods:

The young patient presented in the emergency room after jumping through a glass door at home. Upon admission and examination by the trauma surgeon multiple cuts in the area of the nose, sternum and upper extremities were detected. The gaping sternal wound measured 5 x 2 cm. During the wound cleaning and inspection which was carried out digitally no foreign body could be detected. Furthermore deep injuries were found interdigitally in the area of the second and third as well as the third and fourth toe of the right food. Additionally during the initial examination small glass splinters were found in the wounds of the upper extremities but not in the other wounds. Therefore all wounds, including the deep wounds at the right food, were cleaned and sutured. Further diagnostics were not performed and the patient was discharged. One day later the patient was admitted at the clinic for trauma surgery for a planned wound revision of the right food because of a flexor tendon injury. After two days of hospital stay he was discharged with no further complaints.

Results:

Eight days later the patient was again admitted at the hospital and now presented to us because he complained pain in the area of the sternal wound which was swollen. A foreign body could be palpated reaching from the sutured sternal wound to left parasternal. A chest x-ray and CT-scan of the thorax revealed a 11 cm long glass splinter which didn't penetrate the thoracic cavity nor injured heart or lung. We brougth the patient to the operating room, opened the sternal wound, removed the glass splinter, revised the wound and sutured it. The postoperative course was uneventful, the patient did well and was discharged from the hospital three days later.

Conclusion:

Thoracic injuries caused by long glass splinters are seldom. Nevertheless the possibility of such an injury should be considered when a corresponding accident mechanism is described although other injuries appear clinically more prominent. Otherwise there is a risk of delaying diagnosing and treating such injuries.

Cardiac dysfunction after trauma – effects of circulating HMGB-1 and histones on cardiomyocytes

(Abstract ID: 701)

B. Weber¹, I. Lackner¹, M. Baur¹, F. Gebhard¹, B. Relja², I. Marzi², M. Kalbitz¹

¹Universitätsklinikum Ulm

²Goethe University of Frankfurt am Main

Background:

Severe trauma often lead to a systemic inflammatory response, accompanied by release of danger associated molecular patterns (DAMPs) such as the high mobility group box-1 protein (HMGB-1) and extracellular histones. Furthermore, troponin levels are reportedly elevated after heart contusion and were described as a good tool for detection of heart complications after trauma. The aim of this study was to clarify the influence of HMGB-1, extracellular histones and troponin I on cardiomyocytes, in context of posttraumatic cardiac dysfunction.

Materials and methods:

Cell viability, mitochondrial respiration and calcium handling of human cardiomyocytes in presence of extracellular histones, HMGB-1 and troponin I were evaluated. CytoSorb® 300 hemadsorption filter was tested to eliminate extracellular histones and troponin I in vitro and from blood samples of multiple trauma patients (mean injury severity score >16).

Results:

Incubation of human cardiomyocytes with HMGB-1, histones or troponin I were associated with changes in calcium handling, mitochondrial respiration and reduction of cell viability. The presence of troponin I led to impaired cardiomyocyte function in the sense of a bradycardia caused by massive changes in intracellular calcium. Ex vivo Filtration (Cytosorb® 300) of human plasma after multiple trauma showed a significant reduction of histone levels. Furthermore, in vitro analysis of Cytosorb® 300 hemofiltration capacity detected a dose dependant reduction of extracellular histones and troponin I.

Conclusion:

DAMPS as HMGB-1 and histones are associated with changes in cardiomyocyte viability, calcium handling and mitochondrial function in vitro. Moreover, we described for the first time of our knowledge, the damaging effect of troponin I on cardiomyocytes. The CytoSorb® 300 hemadsorption filter is a therapeutic option to reduce high concentrations of DAMPs in patients with post-traumatic cardiomyopathy.

ARDS after asphyxia and hemorrhagic shock in newborn piglets: Role of tight and gap junctions in the development of lung injury

(Abstract ID: 717)

B. Weber¹, M. R. Mendler¹, I. Lackner¹, S. Höfler¹, J. Pressmar¹, H. Hummler², S. Schwarz¹, M. Kalbitz¹

¹Universitätsklinikum Ulm

²Department of Pediatrics, Medicine, Doha

Background:

Asphyxia of newborns is a severe and frequent challenge of the peri- and postnatal period, which leads to the annual death of approximately 1 million newborns worldwide. Lung injury occurs in 25% of all asphyxiated newborns, which ranges from a mild respiratory distress to pulmonary hemorrhage/severe respiratory failure. The purpose of this study was to study early morphological, immunological and structural alterations in lung tissue after asphyxia and hemorrhage (AH).

Materials and methods:

44 neonatal piglets (mean age 32 hrs) underwent AH and were treated according to the international liaison committee of resuscitation (ILCOR) guidelines. For this study, 15 piglets (blood transfusion (RBC) n = 9; NaCl n = 6, mean age 31 hrs) were randomly picked. 4 hours after ROSC (return of spontaneous circulation), lung tissue and blood samples were collected.

Results:

An elevation of myeloperoxidase (MPO) activity was observed 4 hrs after AH accompanied by an increase of surfactant D after RBC treatment. After AH tight junction proteins Claudin 18 and junctional adhesion molecule 1 (JAM1) were down-regulated, whereas Occludin was increased. Moreover, gap junction proteins such as Connexin 40, 43 and 45 were altered in AH-mediated ARDS in newborn pigs. Furthermore, after AH and RBC treatment dephosphorylated active form of Connexin 43 was increased.

Conclusion:

AH in neonatal pigs is associated with early lung injury, inflammation and alterations of tight junctions (Claudin, Occludin, JAM-1) and gap junctions (Connexin 43) in lung tissue, which contributes to the development of lung edema and impaired function. These results are important for the understanding of lung injury and therefore could help to improve therapeutic strategies in case of acute respiratory distress syndrome.

Three-stage management of a complex bronchoesophageal fistula in a young patient with disseminated tuberculosis

(Abstract ID: 553)

M. Hassan¹, S. Wiesemann¹, J. Höppner¹, M. Elze¹, K. Grapatsas¹, B. Passlick¹, S. Schmid¹

¹Uniklinik Freiburg

Background:

Acquired fistulas between the central airways and the esophagus are rare and mostly due to esophageal or lung cancer (50%). The most common cause of nonmalignant fistulae is mechanical ventilation, other causes include trauma, tracheal or esophageal surgery und granulomatous mediastinal infections. Tracheoesophageal fistula due to tuberculosis are particularly challenging and require an orchestrated, interdisciplinary and often staged approach.

Materials and methods:

We present a case of a 29-year-old male with disseminated tuberculosis. Shortly after the initiation of the anti-tuberculotic treatment the patient developed ARDS with severe respiratory failure. The patient was intubated and a Veno-venous extracorporeal membrane oxygenation (ECMO) established. The CT showed diffuse pulmonary opacification. The esophagoscopy and bronchoscopy revealed multiple ulcers in esophagus with a fistula between the esophagus and left main bronchus. Initial treatment of the fistula consisted of double stenting (esophagus and left main bronchus); hereafter the patient could be weaned off ECMO after a total of 50 days. After recovery of respiratory function, the patient was subjected to a right thoracotomy with primary closure of the bronchial fistula by direct suture, reinforcement with an intercostal muscle flap and esophageal resection with cervical diversion. Reversal of the discontinuity with Gastric pull-up reconstruction was finally performed five months later. The follow up Bronchoscopy and barium swallow test showed complete healing of the bronchial fistula with normal postoperative function of the neoesophagus.

Conclusion:

Bronchoesophageal Fistula (BEF) remains a high risk and technically challenging condition. This report emphasizes the significance of a multidisciplinary management of this complicated case of (BEF) due to disseminated tuberculosis, including bridging with ECMO, double stenting and surgical reconstruction, which lead to successful treatment of this rare life-threatening condition.

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