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Postoperative atrial fibrillation is a common complication after lung resection. It is burdened by increased mortality and morbidity, prolonged hospitalization, and higher resource utilization in thoracic surgery patients. Therefore, some kind of pharmacological prophylaxis is recommended. In our patients, diltiazem, a calcium antagonist, is administered. We collected data on all 608 patients having undergone lung resection (no less than lobectomy) between November 2012 and May 2015. This period included patients having received diltiazem during their postoperative stay in our Intensive Care Unit and surgical ward, and those that did not receive it. Patients having had atrial fibrillation before the surgery and patients with cardiac pacemaker were excluded from the trial. Other patients were divided into three groups: patients with some kind of antiarrhythmic therapy before and continued after the surgery; patients with diltiazem prophylaxis; and patients without any antiarrhythmic prophylaxis. The data collected were statistically analyzed. We found no statistically significant difference in the incidence of postoperative atrial fibrillation among the groups (p<0.05).

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AIM: To investigate whether the fluid volume administered during esophageal cancer surgery affects pulmonary gas exchange and tissue perfusion. METHODS: An exploratory single-center randomized clinical trial was performed. Patients with esophageal cancer who underwent Lewis-Tanner procedure between June 2011 and August 2012 at the Department of Thoracic surgery "Jordanovac", Zagreb were analyzed. Patients were randomized (1:1) to receive a restrictive volume of intraoperative fluid (≤8 mL/kg/h) or a liberal volume (>8 mL/kg/h). Changes in oxygen partial pressure (Pao2), inspired oxygen fraction (FiO2), creatinine, and lactate were measured during and after surgery. RESULTS: Overall 16 patients were randomized and they all were analyzed (restrictive group n=8, liberal group n=8). The baseline value Pao2/FiO2 ratio (restrictive) was 345.01±35.31 and the value six hours after extubation was 315.51±32.91; the baseline Pao2/FiO2 ratio (liberal) was 330.11±34.71 and the value six hours after extubation was 307.11±30.31. The baseline creatinine value (restrictive) was 91.91±12.67 and the value six hours after extubation was 100.88±18.33; the baseline creatinine value (liberal) was 90.88±14.99 and the value six hours after extubation was 93.51±16.37. The baseline lactate value (restrictive) was 3.93±1.33 and the value six hours after extubation was 2.69±0.91. The baseline lactate value (liberal) was 3.26±1.25 and the value six hours after extubation was 2.40±1.08. The two groups showed no significant differences in Pao2/FiO2 ratio (P=0.410), creatinine (P=0.410), or lactate (P=0.574). CONCLUSIONS: Restriction of intraoperative applied volume does not significantly affect pulmonary exchange function or tissue perfusion in patients undergoing surgical treatment for esophageal cancer.

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We report a case of immeasurable levels of serum phosphate in a patient with juvenile type Diabetes mellitus and diabetic ketoacidosis who developed respiratory failure. A 27-year-old female with juvenile type insulin-dependent Diabetes mellitus was admitted because of suspected acute mediastinitis and respiratory failure, probably, among other responsible factors, caused and complicated by undetectable levels of serum phosphate. The serum phosphate concentration three days after aggressive treatment was only 0.2 mmol/L. Furthermore, a significant improvement in weakness and lethargy was observed. To the best of our knowledge, this is the first described case of immeasurable levels of serum phosphate. In patients with Diabetes mellitus, serum phosphate concentrations should be routinely checked in order to avoid additional complications.

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The current approach to the anesthetic procedure and postoperative intensive therapy after esophageal resection for esophageal carcinoma, as well as characteristic perioperative pathophysiological events are presented. The contributory factors of severe postsurgical morbidity are considered too. Esophagectomy is an extented procedure which includes laparotomy, thoracotomy and often cervicotomy, and carries a great surgical stress with a huge fluid shift. It is mostly performed in the aged population with a certain co-morbidity: malnutrition, compromized immune status, respiratory and cardiovascular diseases. Standardization of esophageal resection and reconstructive techniques together with the optimal perioperative management significantly reduce operative mortality. Preoperatively, the patients' nutritive, respiratory and cardiac status should be improved. Intraoperatively, beside adequate depth of anesthesia which enables the optimal metabolic response to surgical stress, the invasive hemodynamic monitoring with insertion of pulmonary artery catheter is of great importance. The aim is to ensure adequate tissue perfusion and oxygenation avoiding pulmonary overhydration at the same time. Postoperatively, important role has epidural analgesia, allowing proper breathing and coughing and routine usage of fiberbronchoscopy for clearance of pulmonary secretion. After resection there are several conditions which contribute to cough and swallow disturbances: bilateral vagotomy, the absence of upper and lower esophageal sphincters, transient aperistalsis of the substitute, sometimes a transient vocal cord paresis. All of these make patients prone to regurgitation and aspiration of duodenal and gastric juice. Currently, the pulmonary complications are the leading problems after this procedure, so their prevention and early treatment are the key tasks for the clinicians.

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