Pneumonectomy: quality of life and long-term results.

AIM: Pneumonectomy is the standard surgery for resectable locally advanced lung cancer. Objectives of this study were: 1) to assess the overall survival; 2) to evaluate the pulmonary and cardiac function impairment; 3) to monitor quality of life (QoL) in a consecutive series of patients undergoing pneumonectomy, defining the potential risk factors of a poor prognosis. METHODS: From January 2003 to March 2010, 71 patients undergoing pneumonectomy for lung cancer or mesothelioma were prospectively enrolled in this study. Twenty-six patients underwent right pneumonectomy (2 of them underwent intrapericardial pneumonectomy), 31 left pneumonectomy (3 of them underwent intrapericardial pneumonectomy), 3 extended pneumonectomy, 3 extrapleural pneumonectomy and 5 patients underwent completion pneumonectomy. Three patients were not included in the study for early postoperative deaths (4.3%). All patients underwent complete preoperative assessment and one year after surgery. QoL was assessed by a questionnaire. RESULTS: One and five-year survival rate was 93% (N.=63) and 20% (N.=14), respectively. Mean values of FEV1 decreased from 2.59±0.75 L to 1.8±0.72 L (P<0.001). One year after surgery all patients showed moderate tricuspid valve insufficiency, PASP significantly higher and right ventricular free wall thickness moderately increased. An increased negative effect was recorded in the QoL scores with P<0.001. Three clinical and surgical parameters were identified as risk or protective factors for the survival outcome. CONCLUSION: Postoperative mortality (4.3%) and five-year survival (20%) after pneumonectomy seem to be satisfactory. Late cardiopulmonary insufficiency is uncommon and acceptable QoL is still achievable.

[T4 lung cancer: results of surgical treatment]. / Il tumore polmonare T4: risultati del trattamento chirurgico.

Stage T4 non small cell lung cancer (NSCLC) includes an heterogeneous group of locally advanced tumors. Results of surgery alone and of chemo and/or radiotherapy are disappointing with 5-year survival rates under 10%. Although palliative chemo-radiotherapy is the treatment of choice in most cases, radical resection has shown prognostic benefit in selected groups of patients with tumor infiltrating Superior Vena Cava, carina, aorta, left atrium and vertebral bodies. Completeness of resection and absence of mediastinal nodal involvement are fundamental conditions for the long-term success of surgery. Increased postoperative 30-day mortality and 90-day mortality rates have been reported up to 8% and 18% respectively. Neoadjuvant therapy, in the last decades, has shown to improve survival of T4 NSCLC patients undergoing surgery and to increase the number of patients suitable for surgical resection. Surgical resection is not indicated in patients with neoplastic pleural effusion since it is generally related to a worse prognosis in such cases. Conversely, patients with T4 tumor due to neoplastic satellite nodule in the same lobe are good surgical candidates. In some studies, these patients show a significant survival advantage after surgical treatment with respect to patients with other types of T4 tumors, when no mediastinal nodal involvement is associated.

Autologus platelet gel for the management of persistent alveolar fistula after lung resection.

Postoperative alveolar fistula (AF) associated with pleural cavity (PC) is a serious complication and a therapeutic challenge in thoracic surgery. The purpose of this study was to assess the efficacy of the use of the autologous platelet gel for the treatment of AF and PC. We treated a patient with post lung resection persistent alveolar fistula using a autologous platelet gel, a cellular compose produces at the Division of Immunohaematoligy and Trasfusion. The platelet gel-PRP (Platelet-Rich Plasma) is a biological material made of autologous platelets, extracted from a small amount of the patient's blood, centrifuged at 1100 g for 9 min. The PRP obtained was activated by addition of autologous thrombin and calcium chloride to form a matrix of fibrin (PRFM) thick. The patient presented important air leak after middle lobe wedge resection for solitary lung lesion with standard open decortication for important pleural adhesions post pleuritis. On postoperative day XIII the patient developed a thoracic empyema and consequently underwent a antibiotic pleural irrigation through the chest drainage based on the microbiological analysis of the pleural fluid. After a week we obtained the resolution of the empyema but a residual space remained and air leak persisted. We treated the patient with autologous platelet gel. We administer 7.5 mL of the autologous platelet gel across the chest drainage ever 72 hours for 3 times. After the third application we had the closure of the cavity and the cessation of air leak. Autologous platelet gel is easy to use, safe and inexpensive. It can be considered a valid therapeutic option in selected patients with a alveolar fistula and a lung partial re-expansion. The product consist of a significant amount of cellular components with healing anti-inflammatory an proregenerative properities that permit the body to heal tissue wounds faster and more efficiently. A sterile pleural cavity is fundamental conditions for the final success of the procedure.

[Surgical treatment of iatrogenic perforations of the distal third of the esophagus. Personal experience]. / Trattamento chirurgico delle perforazioni iatrogene del terzo inferiore dell'esofago. Esperienza personale.

AIM: The esophageal perforations are associated with a high mortality and morbidity when they are not diagnosed and treated quickly. The aim of our study is to analyze the treatment and prognosis of the distal iatrogenic esophageal perforations on the basis of time of onset, concomitant disease and size of perforations. METHODS: The retrospective review was performed on 10 patients treated for distal iatrogenic esophageal perforations at our Institution from 1994 to 2003. The cause of perforations was: pneumatic dilation (7 patients) and esophageal endoprosthesis placing (3 patients). Seven patients presented within 24 h (Group A), and 3 patients presented after 24 h (Group B). In Group A, 4 patients underwent primary repair, 2 patients required esophagectomy and 1 patient was treated conservatively. In Group B, 2 patients were treated conservatively and 1 patient required an esophagectomy. RESULTS: Hospital morbidity was 20% and mortality was 30%. In Group A no patients died. In Group B hospital mortality was 100%. The most common cause of death was multiorgan failure resulting from sepsis. CONCLUSIONS: The prognosis for esophageal perforations is influenced by the time elapsed between diagnosis and treatment. Esophagectomy is indicated for patients with extensive perforation and necrosis of the esophagus when primary repair cannot be carried out. It is indicated also as treatment for the concomitant disease.

[Mechanical cervical esophagogastric anastomosis after esophagectomy for cancer]. / Anastomosi meccanica esofagogastrica dopo esofagectomia per neoplasia.

AIM: Fibrous stenosis of the esophagogastric cervical anastomosis remains a significant complication occurring in up to one third of cases. Trying to reduce the incidence of this complication, we describe our technique of cervical esophago-gastric anastomosis using endoscopic linear stapler which seems to reduce the incidence of fibrous stricture formation after resection of esophageal cancer. METHODS: Between March 2000 and December 2004, 34 patients (20 males and 14 females) underwent esophagectomy using tubulized stomach for reconstruction. Mean age was 57 years. Eight patients with advanced stage (5 T3 and 3 T4) underwent induction chemotherapy. The most of patients was affected by squamous cell carcinoma. In all cases we performed cervical esophagogastric anastomosis using linear endoscopic stapler. The occurrence of postoperative anastomotic leak and development of anastomotic stricture were recorded and analyzed. RESULTS: All patients survived esophagectomy and 30 of them (88%) were available for postoperative follow-up at 6 months. Anastomotic leak developed in 1 case. No patient developed fibrous stenosis that required dilatation therapy. CONCLUSIONS: Complete mechanical esophago-gastric anastomosis, using endoscopic linear stapler is effective and safe, even when a narrow gastric tube is used as esophageal substitute. These technique seems superior to other techniques to reduce the incidence of postoperative anastomotic complications.

[Mini-invasive treatment of pectus excavatum in adolescence. Initial experience]. / Trattamento mini-invasivo del petto escavato in età adolescenziale. Esperienza iniziale.

BACKGROUND: Personal preliminary experience with Minimally Invasive Repair of Pectus Excavatum (MIRPE), "Nuss" procedure, using VATS is reported. METHODS: From January 2001 to February 2002, MIRPE has been performed on 5 patients (age range 13-18 y; mean 14.8 y). Under general anesthesia, a curved steel bar is inserted into the retrosternal tunnel between 2 bilateral midaxillary line incisions. The tunnel passes initially under the pectoral muscles and enters the pleural space at level of the mammilary line. Under thoracoscopic vision, the bar is passed through the tunnel with the concavity facing the front and then is turned over thereby correcting deformity. An epidural catheter relieved perioperative pain successfully. RESULTS: In all patients the repair has been good. Mean hospital length of stay has been 6.8 d. Pneumothorax occurred in 1 patient requiring tube thoracostomy. After 45 d 1 patient had a bar displacement requiring a reoperation. All patients have a normal life. CONCLUSIONS: The Minimally Invasive Repair of Pectus Excavatum is an effective procedure even in adolescence. Thoracoscopic vision makes safer the creation of the retrosternal tunnel and the passage of the bar. Short-term results have been good. Further follow-up is necessary to determine long-term results.

Lung transplantation for cystic fibrosis.

BACKGROUND: Lung transplantation is a robust therapeutic option to treat patients with cystic fibrosis. PATIENTS AND METHODS: Since 1996, 109 patients with cystic fibrosis were accepted onto our waiting list with 58 bilateral sequential lung transplants performed in 56 patients and two patients retransplanted for obliterative bronchiolitis syndrome. RESULTS: Preoperative mean FEV(1) was 0.64 L/s, mean PaO(2) with supplemental oxygen was 56 mm Hg, and the mean 6-minute walking test was 320 m. Transplantation was performed through a "clam shell incision" in the first 29 patients and via bilateral anterolateral thoracotomies without sternal division in the remaining patients. Cardiopulmonary bypass was required in 14 patients. In 21 patients the donor lungs had to be trimmed by wedge resections with mechanical staplers and bovine pericardium buttressing to fit the recipient chest size. Eleven patients were extubated in the operating room immediately after the procedure. Hospital mortality of 13.8% was related to infection (n = 5), primary graft failure (n = 2), and myocardial infarction (n = 1). Acute rejection episodes occurred 1.6 times per patient/year; lower respiratory tract infections occurred 1.4 times per patient in the first year after transplantation. The mean FEV(1) increased to 82% at 1 year after operation. The 5-year survival rate was 61%. A cyclosporine-based immunosuppressive regimen was initially employed in all patients; 24 were subsequently switched to tacrolimus because of central nervous system toxicity, cyclosporine-related myopathy, or renal failure, obliterative bronchiolitis syndrome, gingival hyperplasia, or hypertrichosis. Ten patients were subsequently switched to sirolimus. Freedom from bronchiolitis obliterans at 5 years was 60%. CONCLUSIONS: Our results confirm that bilateral sequential lung transplantation is a robust therapeutic option for patients with cystic fibrosis.

[Experience of 10 years with the surgical treatment of lung cancer in elderly patients]. / Esperienza di dieci anni nel trattamento chirurgico del cancro del polmone nel paziente anziano.

The surgical treatment of lung cancer in elderly patients is correlated with a lot of complications that in most cases are cardiopulmonary type; for this reason, in past times these patients were left out of the surgical treatment. Today, the progress of surgical, diagnostic and anesthetic techniques permit to execute pulmonary resections in patients older than 70 years too. The aim of this study is to evaluate postoperative complications and long-term and long-term survival in patients under and over the age 70. Between January 1990 and June 2000 we have assessed 172 patients with lung neoplasm. We have divided patients in two groups: those younger than 70 years of age (group 1, n = 119) and those older than 70 years of age (group 2, n = 53). Postoperative mortality for group 2 was 7.5% and for group 5.1%. The overall postoperative complication rate for group 2 was 30.2% and for group 1 10.9%. Within group 1 main complications have been of surgical type (61.5%) while in group 2 medical type (cardiopulmonary), with higher frequency in patients ASA 3 or ASA 4. The mortality at 12 months for non-neoplastic causes was 10.2% for group 2 and 2.5% for group 1. On the contrary, the mortality at 12 months for neoplastic causes was 8.2% for group 2 and 6.7% for group 1. We haven't noticed an important correlation between the extension of the resection and the recurrence of disease. The survival at 3 years was 46.5% for group 1 and 41% for group 2 and associated with neoplastic causes.