Use of vacuum-assisted closure in the treatment of complex intrapleural infections

Background: Debilitated patients with chronic empyema, who are not fit enough to undergo thoracotomy and decortication due to lung entrapment, may be offered a lower-risk alternative – an open-window thoracostomy. Vacuum-assisted closure (VAC) may accelerate empyema drainage and wound closure. Methods: In this study, we compared two cohorts of patients receiving open-window thoracostomy (OWT) with or without VAC dressing. We included patients with chronic or postresectional empyema with multiple comorbidities or in poor general condition or on immunosuppression. Results: Delayed wound closure by thoracoplasty was performed in 8 (28%) patients in the OWT group and 8 (53%) patients in the OWT-VAC group (OR 2.54; 95% CI: 0.704-9.168). Time until DWC was significantly shorter (p<0.001) in the OWT-VAC group (48.5 ± 27.5 days) compared to the OWT group (316.5 ± 102.5 days). Regarding complications, we found no significant differences between the two groups, except for air leak, which was found in 0 (0%) patients in the OWT group and 6 (40%) patients in the OWT-VAC group (OR 1.67; 95% CI: 1.10-2.52; p<0.001). The percentage of patients who required re-do surgery did not differ significantly between the groups - 1 (3%) patient in the OWT group vs. 2 (13%) patients in the OWT-VAC group (OR 7.0; 95% CI: 0.66 – 74.29; p=0.07). Conclusion: Our experience shows that using VAC therapy in OWT can significantly shorten the overall treatment time. It can be safely used at home and in an outpatient setting

Impact of muscle mass loss on outcomes after esophagectomy for cancer and comparison of other risk factors

UVOD: Rak požiralnika kljub pomembnemu izboljšanju napovedi zaradi napredovanja metod zdravljenja ostaja bolezen s slabo ozdravljivostjo in številnimi zapleti med zdravljenjem. Izguba mišičja se je izkazala za pomemben napovedni dejavnik slabših izidov zdravljenja, njena prepoznava pa nam omogoča prilagoditev zdravljenja. Analiza CT posnetkov lahko prepozna bolnike z izgubo mišične mase (sarkopenijo) in z maščobno infiltracijo mišičja (miosteatozo). Tudi drugi napovedni dejavniki so se izkazali za koristne pri oceni pričakovanega preživetja pri resektabilnem raku požiralnika. NAMEN: Želeli smo ugotoviti prevalenco sarkopenije in miosteatoze med bolniki z rakom požiralnika, zdravljenimi z resekcijo požiralnika z namenom ozdravitve. Zanimal nas je vpliv izgube mišičja na preživetje in zaplete po kirurškem zdravljenju. Želeli smo tudi ugotoviti, kateri od drugih potencialnih dejavnikov tveganja vplivajo na dolgoročno preživetje. METODA: Z radikalno ezofagektomijo z ali brez pridruženega neoadjuvantnega zdravljenja smo zdravili 139 bolnikov. Iz CT posnetkov v višini 3. ledvenega vretenca smo določili površino mišičja (angl. skeletal muscle area, SMA) in atenuacijo mišičja (angl. muscle attenuation, MA). S primerjavo izmerjenih vrednosti z zdravo populacijo smo bolnike razdelili v skupini z ali brez sarkopenije in z ali brez miosteatoze. Skupine smo primerjali med seboj glede celokupnega preživetja in pogostosti zapletov (perioperativna smrtnost, zapleti na presadku, dihalni zapleti, dihalna odpoved, drugi zapleti). Napravili smo tudi multivariatno Coxovo analizo vpliva dejavnikov tveganja na preživetje REZULTATI: Ob diagnozi je imelo 16,5% bolnikov sarkopenijo in 51,8% bolnikov miosteatozo. Obe sta bili povezani s slabšim dolgoročnim preživetjem (log rank p=0,042 za sarkopenijo in p=0,044 za miosteatozo). Sarkopenija in miosteatoza nista bili povezani z večjo pogostostjo opazovanih zapletov. Zapletov na presadku je bilo pri bolnikih z miosteatozo statistično značilno manj (razmerje obetov OR 0,238, 95% CI 0,082-0,692, p=0,005). Miosteatoza, moški spol, izguba telesne mase za 10% ali več, slabo stanje zmogljivosti in višje razmerje med pozitivnimi in odvzetimi bezgavkami so bili statistično značilni napovedniki slabšega preživetja pri multivatiatni analizi preživetja. ZAKLJUČEK: Sarkopenija in miosteatoza, kazalca izgube mišičja in stanja prehranjenosti, sta pri bolnikih, zdravljenih z ezofagektomijo zaradi raka požiralnika, povezana s slabšim celokupnim preživetjem. Noben od obeh kazalcev ni povezan s povečano verjetnostjo za zaplete, zapletov na presadku je bilo pri bolnikih z miosteatozo celo manj. Napovedni dejavniki za slabše preživetje so miosteatoza, moški spol, izguba telesne mase za 10% ali več, slabo stanje zmogljivosti in višje razmerje med pozitivnimi in odvzetimi bezgavkami. Prepoznava in preprečevanje dejavnikov tveganja lahko pomagata pri izboljšanju rezultatov zdravljenja.BACKGROUND: Esophageal cancer remains a disease with poor survival and many complications despite therapeutic advancements and constant improvements of prognosis. Among the possible predictive factors of negative outcomes that can guide our treatment strategies mucle depletion has emerged as a useful parameter in cancer as well as in other diseases. CT image analysis can identify patients with diminished muscle mass (sarcopenia) and poor muscle quality because of fat infiltration (myosteatosis). Other risk factors have also been shown to predict survival in resectable esophageal cancer. AIM: Our aim was to ascertain the prevalence and study the impact of sarcopenia and myosteatosis in resectable esophageal cancer on overall survival and complications. We additionally wanted to test the predictive value of other potential predictors of long term survival. METHOD: 139 patients received a radical esophagectomy with or without neoadjuvant therapy. Skeletal muscle area (SMA) and muscle attenuation (MA) in CT images at the 3rd lumbar vertebra level were recorded and patients were stratified into sarcopenia/non-sarcopenia and myosteatosis/non-myosteatosis groups by comparing their measured values with those of a healthy population. Groups were compared for overall survival (OS) and complication rates (perioperative mortality, conduit complications, pleuropulmonary complications, respiratory failure requiring mechanical ventilation and other significant complications). A multivariate Cox survival analysis was also performed. RESULTS: Prevalence of sarcopenia and myosteatosis at presentation was 16,5% and 51,8%, respectively. Both sarcopenia and myosteatosis were associated with decreased overall survival (log rank p=0,042 and p=0,044, respectively). Myosteatosis but not sarcopenia was associated with a lower incidence of conduit complications (OR 0,238, 95% CI 0,082-0,692, p=0,005). No other association between sarcopenia or myosteatosis and perioperative mortality or other complications was found. Myosteatosis as well as male sex, weight loss of 10% or more, low performance status and a higher ratio of positive to harvested lymph nodes were statistically significant predictors of worse survival in multivariate Cox analysis. CONCLUSION: Sarcopenia and myosteatosis - markers of muscle depletion and nutritional status - before esophagectomy for esophageal cancer are associated with inferior overall survival but not with perioperative mortality or other complications. Myosteatosis was associated with a decreased risk of conduit complications. Myosteatosis, male sex, weight loss of 10% or more, low performance status and a higher ratio of positive to harvested lymph nodes were predictors of poor survival. Identification and prevention of risk factors can help guide therapeutic decisions and improve results

Smernice za zdravljenje bolnikov z rakom požiralnika in ezofagogastričnega stika (EGS)

Oesophageal cancer is a relatively rate tumor with high mortality. It is most frequent in men in their sixties or seventies. In the past years, a constant increase in the incidence of adenocarcinoma of the distal esophagus and esophagogastric juncture (EGS) has been observed in the West. This can probably be attributed changing lifestyle with increases obesity incidence and gastroesophageal reflux disease. The latest, 7th review of the TNM Classification classifies both – cancer of the esophagus and cancer of the esophagogastric juncture – as oesophageal cancer. In a select group of patients this disease is curable, however the treatment is long, usually combined and with high morbidity that can significantly impact the patient’s quality of life. Due to the specific anatomy, cancer of the esophagus and cancer of the esophagogastric juncture develop metastasis early, and the prognosis is worse compared to other gastrointestinal cancers.Rak požiralnika je razmeroma redek tumor z veliko umrljivostjo. Pogosteje zbolijo moški v 6. ali 7. desetletju življenja. V zadnjih letih v zahodnem svetu opažamo stalen porast incidence adenokarcinoma distalnega požiralnika in ezofagogastričnega stika (EGS). Vzrok je najverjetneje posledica spremenjenega načina življenja s povišano incidenco debelosti in gastroezofagealne refluksne bolezni. Nova, 7. Revizija TNM klasifikacije, uvršča rak požiralnika in EGS skupaj pod rak požiralnika. Pri izbrani skupini bolnikov je bolezen ozdravljiva, vendar je zdravljenje dolgotrajno, praviloma kombinirano in z visoko morbiditeto, ki lahko precej zmanjša kakovost bolnikovega življenja. Zaradi specifične anatomije rak požiralnika in EGS zgodaj zaseva in je zato v primerjavi z ostalimi malignomi prebavil prognostično slabši

Guidelines for Treating Patients with Cancer of the Esophagus and Esophagogastric Juncture (EGS)

Oesophageal cancer is a relatively rate tumor with high mortality. It is most frequent in men in their sixties or seventies. In the past years, a constant increase in the incidence of adenocarcinoma of the distal esophagus and esophagogastric juncture (EGS) has been observed in the West. This can probably be attributed changing lifestyle with increases obesity incidence and gastroesophageal reflux disease. The latest, 7th review of the TNM Classification classifies both – cancer of the esophagus and cancer of the esophagogastric juncture – as oesophageal cancer. In a select group of patients this disease is curable, however the treatment is long, usually combined and with high morbidity that can significantly impact the patient’s quality of life. Due to the specific anatomy, cancer of the esophagus and cancer of the esophagogastric juncture develop metastasis early, and the prognosis is worse compared to other gastrointestinal cancers

Smernice za zdravljenje bolnikov z rakom požiralnika in ezofagogastričnega stika

no abstractZadnje Smernice za zdravljenje bolnikov z rakom požiralnika in ezofagogastričnega stika (EGS) so bile izdane leta 2016. Nameravali smo jih posodobiti. Kljub ne prav dolgi dobi od takrat je medicina naredila tak napredek, da bi bila posodobitev premalo. Napisati smo morali nove smernice, dodati nekatera nova poglavja, brez katerih so sodobne smernice pomanjkljive. Le s celostnim in sodobnim pristopom lahko bolnikom ponudimo zdravljenje, ki jim omogoča čim boljši rezultat sicer prognostično neugodne bolezni