What counts more: the patient, the surgical technique, or the hospital? A multivariable analysis of factors affecting perioperative complications of pulmonary lobectomy by video-assisted thoracoscopic surgery from a large nationwide registry.

OBJECTIVES: Inherent technical aspects of pulmonary lobectomy by video-assisted thoracoscopic surgery (VATS) may limit surgeons' ability to deal with factors predisposing to complications. We analysed complication rates after VATS lobectomy in a prospectively maintained nationwide registry. METHODS: The registry was queried for all consecutive VATS lobectomy procedures from 49 Italian Thoracic Units. Baseline condition, tumour features, surgical techniques, devices, postoperative care, complications, conversions and the reasons thereof were detailed. Univariable and multivariable regressions were used to assess factors potentially linked to complications. RESULTS: Four thousand one hundred and ninety-one VATS lobectomies in 4156 patients (2480 men, 1676 women) were analysed. The median age-adjusted Charlson index of the patients was 4 (interquartile range 3-6). Grade 1 and 2 and Grade 3-5 complications were observed in 20.1% and in 5.8%, respectively. Ninety-day mortality was 0.55%. The overall conversion rate was 9.2% and significantly higher in low-volume centres (<100 cases, P < 0.001), but there was no significant difference between intermediate- and high-volume centres under this aspect. Low-volume centres were significantly more likely to convert due to issues with difficult local anatomy, but not significantly so for bleeding. Conversion, lower case-volume, comorbidity burden, male gender, adhesions, blood loss, operative time, sealants and epidural analgesia were significantly associated with increased postoperative morbidity. CONCLUSIONS: VATS lobectomy is a safe procedure even in medically compromised patients. An improved classification system for conversions is proposed and prevention strategies are suggested to reduce conversion rates and possibly complications in less-experienced centres.

VATS thymectomy for early stage thymoma and myasthenia gravis: combined right-sided uniportal and left-sided three-portal approach.

The traditional approach to thymectomy requires median sternotomy based on the assumption that it is the best means to achieve adequate resection margins, complete removal of the thymus and clearance of the anterior mediastinal fat. However, in recent years, VATS thymectomy has been gaining acceptance as a means to achieve adequate oncologic results and symptomatic improvement of myasthenic symptoms with less impact on the patient. We have adopted a flexible approach based on the location of the tumor and on whether the patient has myasthenia gravis (MG) or not when planning minimally invasive VATS thymectomy. A preferential approach from the left side is chosen for clinical stage I-II thymomas located on the left side or on the midline in patients without MG, and a bilateral approach (uniportal VATS on the right side and three-portal VATS on the left side) for MG patients with or without thymoma in order to achieve complete clearance of the anterior mediastinal fat on both sides. Such techniques are herewith clearly illustrated in hope that surgeons wishing to endeavor in such an effort will be facilitated.

Acute respiratory distress caused by a giant mediastinal lipoblastoma in a 16-month-old boy.

Lipoblastoma is a rare benign tumor arising from embryonic fat; it occurs mainly in the extremities and almost exclusively in infants and children younger than 3 years. We present a case of giant mediastinal lipoblastoma in a 16-month-old boy who presented with acute respiratory distress. The mass was completely excised through a left posterolateral thoracotomy. The postoperative course was uneventful, and the pathologic final diagnosis was lipoblastoma. Although extremely rare, mediastinal lipoblastoma can be life threatening; therefore, it should be included in the differential diagnosis of mediastinal mass in younger subjects.

A rare cause of dyspnea in adult: a right Bochdalek's hernia-containing colon.

Symptomatic cases of Bochdalek's hernia (BH) are uncommon in adults; symptoms arise only due to complications. Most of symptomatic cases are related to a left-sided hernia. Right colon herniation in adults has never been reported. We present a case of a 70-year-old woman with right BH-containing colon. The patient was successfully treated by combined laparoscopic and thoracoscopic approach.

[Non-small cell lung cancer (NSCLC): the evolution of neo-adjuvant chemotherapy in the last 15 years]. / Tumore polmonare non a piccole cellule: evoluzione della chemioterapia neo-adiuvante negli ultimi 15 anni.

Retrospective analysis of surgical data-base of NSCLC have showed that, except stage IA, the prognosis of locally advanced disease is very poor if treated with surgery and/or radiotherapy and it is probably due to distant micrometastasis present at the diagnosis. The aim of neo-adjuvant chemotherapy is to address early the distant micrometastasis and to allow, through a downstaging, surgical resection of tumor not suitable to surgery or partially respectable at diagnosis.

[Mediastinoscopy for diagnosis of diseases of the chest and staging of lung cancer: our experience in 253 cases]. / La mediastinoscopia nella diagnostica delle malattie del torace e nella stadiazione del cancro del polmone: nostra esperienza di 253 casi.

The main indications for cervical mediastinoscopy are preoperative staging of lung cancer and diagnostic biopsy of mediastinal mass (lymphoma, sarcoidosis, tuberculosis etc.). We undertook a retrospective review of our experience of mediastinal exploration by cervical media-stinoscopy: 253 mediastinoscopies were performed on 252 patients (195 male and 57 female; mean age 53 years, range 14-88 years) between 1995 and June 2003. Four extended mediastinoscopies were performed and 1 patient had a re-mediastinoscopy following a non-diagnostic procedure. 319 lymph nodal stations were investigated in 253 procedures. We observed no mortality, while 2 patients had major bleeding (0.7%), with the need for open surgical treatment in order to achieve haemostasis. The median length of hospital-stay was one day, with discharge in the first postoperative day. 69 out of 170 patients, who eventually resulted to be affected by a histologically proven lung cancer, had a negative mediastinoscopy. Fifteen of them resulted N2 at the time of surgery: 8 patients with a false negativity in a biopsied station (4 in station 4R and 4 in station 7), while 7 cases showed infiltration in stations which were not sampled (5 in station 5, 1 in station 8 and 1 in station 7, the latter being the only one in which a standard cervical mediastincoscopy could have been able to stage it correctly). So, having observed 61 true negatives and 8 false-negatives in the sampled stations, in our experience the negative predictive value of cervical mediastinoscopy was 88.4%, with 78.2% of patients correctly staged without using other diagnostic tools. In conclusion, mediastinoscopy is an important procedure for the diagnostic biopsy of mediastinal mass and a useful tool in preoperative staging of lung cancer, especially if associated with chest CT-scan and Positron Emission Tomography (PET). In our experience, the spreading of PET does not lead to a reduction of cervical mediastinoscopies, both for the contemporary introduction of new chemotherapeutic preoperative protocols and, above all, for the not negligible incidence of false-positive results using PET, suggesting that media-stinoscopy should always be performed in patients affected by a PET-positive mediastinal growth.

Lack of prognostic implications of HER-2/neu abnormalities in 345 stage I non-small cell carcinomas (NSCLC) and 207 stage I-III neuroendocrine tumours (NET) of the lung.

HER-2/neu oncogene activation by either gene amplification and/or protein overexpression has been documented in several human malignancies. Irrespective of protein overexpression, HER-2/neu gene amplification is rare in lung cancer and studies on its prevalence and clinicopathological implications in early stage non-small cell lung cancer (NCSLC) and neuroendocrine tumours (NET) of the lung are lacking. We evaluated HER-2/neu abnormalities in 345 Stage I NSCLC and 207 Stage I-III NET of the lung of all the diverse histological types, by using immunohistochemistry and fluorescent in situ hybridization in selected cases. Overall, HER-2/neu immunoreactivity was detected in 23% of 345 NSCLC and in 7% of 207 NET. Gene amplification was seen in only 7 (7.4%) of the immunoreactive tumours, with high-level amplification (HER-2/neu gene to chromosome 17 ratio > 4.0) in 3 adenocarcinomas, 1 squamous-cell carcinoma and 1 large-cell neuroendocrine carcinoma (LCNEC), and low-level amplification (HER-2/neu gene to chromosome 17 ratio from 2.0 to 4.0) in 1 squamous-cell carcinoma and 1 LCNEC. None of tested carcinoids and SCLC showed gene amplification. All but 1 gene amplified case exhibited 2+ or 3+ membrane labeling. No relationship was found between gene amplification or protein overexpression and patients' survival or other clinicopathological variables. HER-2/neu gene amplification and protein overexpression are not closely correlated in lung carcinomas and do not bear any prognostic implication. Among neuroendocrine tumours, LCNEC show a slightly higher prevalence of either HER-2/neu gene amplification or protein overexpression.

Bronchoplastic procedures for central carcinoid tumors: clinical experience.

OBJECTIVE: To evaluate the short-term and the long-term results of bronchoplastic resections (BR) performed for central carcinoid tumors (CCT). METHODS: Retrospective study of patients who underwent BR for a CCT between 1966 and 2003. RESULTS: BRs were performed in 25 patients out of 92 (27%) who were resected for CCT. Median age was 37 years. All patients were symptomatic. Preoperative bronchoscopy was diagnostic in 15 patients. The bronchoplasties performed were: 11 sleeve lobectomies, 1 sleeve segmentectomy, 8 wedge lobectomies, 4 flap lobectomies and 1 wedge segmentectomy. There were 22 typical and 3 atypical carcinoids without nodal metastasis. No major complications or mortality occurred. One patient with a typical carcinoid developed pretracheal metastatic adenopathy 19 years after resection. No recurrence or stenosis has occurred at the sites of bronchoplasty so far. Three patients died of unrelated disease. Overall the 10-, 15- and 20-year survival rates were 100, 100 and 71%. CONCLUSIONS: Bronchoplastic resections are the treatment of choice for CCT. Short- and long-term results are excellent. Life-long follow-up is necessary, however, due to the possibility of late recurrence.

Invasive pulmonary aspergillosis after renal transplantation treated by surgery.

Invasive pulmonary aspergillosis is a serious complication in immunocompromised patients. In those unresponsive to pharmacological treatment, or when drug toxicity is excessive, surgery may resolve the condition. A 48-year-old woman with invasive pulmonary aspergillosis after renal transplantation underwent resection of the right upper lobe and the apical segment of the inferior lobe, followed by complete recovery.