Early tracheostomy following lung transplantation.

BACKGROUND: Despite the common use of tracheostomy in lung transplant (LT) patients, little data exist regarding the indications, timing, periprocedural complications, and impact on outcomes of the procedure. METHODS: We retrospectively analyzed some characteristics and timing of all tracheostomies performed in our lung transplant recipients during a 5-year period. RESULTS: Between January 2004 and November 2009, 31 of 126 lung transplant patients (24.6%) underwent a tracheostomy. They included 14 men with a mean age of 42 years (range, 10 to 61 years) and 17 women with a mean age of 45 years (range, 10 to 64 years). Twenty eight patients undergoing a tracheostomy had a prior bilateral sequential LT and 4 had accepted a single lung. Tracheostomy was surgically performed (ST) in 6 of 31 patients (19.3%); percutaneous tracheostomy (PT) techniques were applied for the other 25 (80.6%) cases. The decision to perform a tracheostomy was made within 4 days from LT in 21 of 31 patients (67.7%), within 8 days in 6 (19.3%) and after 10 days for the other 4 (12.9%) cases. There were no major complications during the PT procedures; no conversion to ST, no loss of airway, no paratracheal insertion, and no accidental tracheal extubation. No pneumothorax, pneumomediastinum, hypotension, hypoxemia, or arrythmyas were recorded in the early post-procedural period. The mean post-LT duration of cannulation was 17 days (range, 5 to 72 days). DISCUSSION: An early tracheostomy may be of considerable benefit for the debilitated patient who will likely require prolonged mechanical ventilation because of a complicated intraoperative course and poor recovery of graft function. PT was performed more quickly and was associated with fewer postoperative complications than ST. We recommend an aggressive strategy in the immediate posttransplant period when extubation fails or is delayed for various reasons.

Endobronchial valve for secondary pneumothorax in a severe emphysema patient.

Secondary pneumothorax represents a challenging problem in patients with chronic obstructive pulmonary disease, due to their compromised health status. In this case, an endobronchial one-way valve was inserted in the left lower lobe by flexible bronchoscopy, resulting in a complete resolution of air leak and lung reexpansion. Endobronchial valve could represent a new option for the management of persistent air leak in patients not suitable for surgical procedures.

Thoracic epidural analgesia in lung transplantation.

Achieving optimal pain relief after lung transplantation (LT) is often difficult, because both systemic analgesics and regional techniques have specific advantages and disadvantages. Uncontrolled pain impedes repeated powerful coughs and hinders valid respiratory excursions and graft expansion; these consequences markedly increase the risk of pulmonary complications. Thoracic epidural analgesia (TEA) is a universally accepted method of pain management after unilateral or bilateral thoracotomy, and in clinical experience it has proven to be the best option after LT. The combination of epidural local anesthetic plus opioid is associated with significant reduction in pain scores and/or supplementary analgesic requirement compared with parenteral opioid analgesia. Even though the benefits of epidural techniques in reduction of respiratory morbidity and protection from stress response to surgery have to be weighted against the risk of spinal bleeding, a well functioning thoracic sensory blockade provides satisfactory pain control and avoids the excessive sedation associated with systemic opiates. Multiple factors determine the quality of postoperative assistance, and a clear relationship between "adequate" or "high-quality" postoperative analgesia and improved outcome is difficult to establish. However, an individualized perimedullary analgesic regimen may certainly contribute to greater cooperation with physical maneuvers, avoid noxious limitations to graft expansion, and possibly decrease overall morbidity.

Bronchial carcinoid tumours in children: surgical treatment and outcome in a single institution.

BACKGROUND: Carcinoid tumors are low grade, malignant, neuroendocrine neoplasms. Although rare, they represent the most common primary bronchial tumours in childhood. The aim of our study was to analyse the long-term survival and surgical treatment outcome in our young patients operated for carcinoid tumour. PATIENTS: We retrospectively reviewed the data of 15 paediatric patients who underwent surgery at our Institution. There were 11 male and 4 female patients with a median age of 15 years (range 8-18). All carcinoids were centrally located and symptomatic. RESULTS: We performed 10 (66.7%) parenchyma-saving procedures (5 sleeve lobectomies, 3 sleeve resections of the main bronchus, 2 bronchoplasties associated with lung resection) and 5 (33.3%) standard resections (3 bilobectomies and 2 lobectomies). There were 13 typical and 2 atypical carcinoids. Three patients (20%) had nodal metastases. There were no surgery-related deaths or complications. At long-term follow-up all patients presented with regular growth and all but one are alive. Two (13.3%) patients needed re-operation. CONCLUSIONS: Results suggest that, in experienced and skilled hands, conservative procedures are the treatment of choice for the management of paediatric bronchial carcinoids. Relapses can be successfully treated with re-operation and they can occur even after many years, underlining the importance of long-term follow-up.

Noninvasive ventilation in postoperative care of lung transplant recipients.

Noninvasive positive pressure ventilation (NIPPV), which provides consolidated treatment of both acute and chronic respiratory failure, is increasingly being used in the postoperative care of lung transplant patients. Graft- and patient-related respiratory insufficiency requiring mechanical ventilation are common features in the postoperative period; they may persist for hours to days. Prolonged intubation, particularly in these immunocompromised patients, has been considered one of the main predisposing factors for developing nosocomial pneumonia. It has been associated with increased length of intensive care unit (ICU) stay as well. Noninvasive mechanical ventilation is nowadays an attractive choice to shorten weaning time and avoid reintubation following lung transplantation. Rapid extubation plus prompt NIPPV application is a useful strategy for lung recipients who do not completely fulfill the criteria for safe extubation. Unloading respiratory muscles, decreasing respiratory rate and sensation of dyspnea, improving ventilation/perfusion abnormalities, decreasing the heart rate, and improving hemodynamics are among the recognized benefits. Adding a noninvasive inspiratory support plus positive end-expiratory pressure (PEEP) to lung transplant recipients has been helpful to prevent airway injury and infections, avoiding the need for reintubation in cases of extubation failure, facilitating nocturnal sedation, treating the post-reimplantation syndrome and postoperative phrenic nerve dysfunction, and preventing reintubation in cases of readmission to the ICU. In our practice, the helmet system has emerged as the preferred interface; in cases of dyshomogeneous dorsobasal lung infiltrates, it allows effective ventilatory support in the prone position as well.

Noninvasive ventilation in adult liver transplantation.

Noninvasive ventilation (NIV) has proven to be a safe and effective technique in the treatment of respiratory failure complicating various medical and surgical diseases. In recent years, a growing interest has emerged in its adoption for ventilatory assistance in immunocompromised patients, such as those undergoing bone marrow, liver, lung, cardiac, and kidney transplantation. Weaning from the ventilator after liver transplantation can take longer because of unsatisfactory gas exchange during various attempts of T-piece trials. Rapid extubation followed by an immediate NIV application should be considered in this setting to shorten and accelerate the weaning process in those recipients who do not completely fulfill the criteria for safe extubation. By adding the pressure support (PS) mode with a continuous positive end expiratory pressure (PEEP), NIV could prevent the loss of vital capacity and impede severe lung derecruitment following extubation. Clinical experience has shown that properly delivered NIV mostly benefits moderately dyspneic recipients in acute respiratory failure, while it appears less promising and efficient in patients ventilated for extended periods of time. It has proven safe and efficient mainly as (1) a tool to promote an early ventilatory discontinuation and extubation; (2) a prophylactic strategy for preventing postoperative pulmonary complications; and (3) a simple method to start with in cases of acute hypoxic and/or hypercapnic respiratory failure. The improvements in arterial hypoxemia, the decreased ventilatory demand provided with an inspiratory support, as well as the scarcity of hemodynamic repercussions are among the major benefits of this method.

Lung transplantation for emphysema.

Emphysema is a major cause of morbidity and mortality worldwide. Despite optimal medical therapy, smoking cessation, and pulmonary rehabilitation, a large number of patients remain symptomatic with a poor quality of life. A pool of patients with end-stage disease can benefit from surgical treatments like bullectomy, lung volume reduction, or lung transplantation. Emphysema represents the most common indication leading to lung transplantation. A functional improvement and better quality of life are clear benefits deriving from lung transplantation, while a survival advantage has not yet been proven.

Overexpression of squamous cell carcinoma antigen in idiopathic pulmonary fibrosis: clinicopathological correlations.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a chronic progressive disorder with a poor prognosis. Epithelial instability is a crucial step in the development and progression of the disease, including neoplastic transformation. Few tissue markers for epithelial instability have been reported in IPF. Squamous cell carcinoma antigen (SCCA) is a serine protease inhibitor typically expressed by dysplastic and neoplastic cells of epithelial origin, more often in squamous cell tumours. At present, no information is available on its expression in IPF. METHODS: SCCA and transforming growth factor beta (TGFbeta) expression in surgical lung biopsies from 22 patients with IPF and 20 control cases was examined. An in vitro study using A549 pneumocytes was also conducted to investigate the relationship between SCCA and TGFbeta expression. SCCA and TGFbeta epithelial expression was evaluated by immunohistochemistry and reverse transcription-PCR (RT-PCR). SCCA values were correlated with different pathological and clinical parameters. Time course analysis of TGFbeta expression in A549 pneumocytes incubated with different SCCA concentrations was assessed by real time RT-PCR. RESULTS: SCCA was expressed in many metaplastic alveolar epithelial cells in all IPF cases with a mean value of 24.9% while it was seen in only two control patients in up to 5% of metaplastic cells. In patients with IPF, SCCA correlated positively with extension of fibroblastic foci (r = 0.49, p = 0.02), expression of TGFbeta (r = 0.78, p<0.0001) and with carbon monoxide transfer factor decline after 9 months of follow-up (r = 0.59, p = 0.01). In vitro experiments showed that incubation of cultured cells with SCCA induced TGFbeta expression, with a peak at 24 h. CONCLUSION: Our findings provide for the first time a potential mechanism by which SCCA secreted from metaplastic epithelial cells may exert a profibrotic effect in IPF. SCCA could be an important biomarker in this incurable disease.

Sleeve resections and bronchoplastic procedures in typical central carcinoid tumours.

BACKGROUND: Typical carcinoids are low grade malignant neuroendocrine neoplasms, mostly located centrally in the tracheobronchial tree. The aim of our study was to analyse the long-term survival and surgical treatment outcome in patients submitted to parenchyma-sparing resections for typical central carcinoid tumours. METHODS: We retrospectively reviewed the data of 70 patients who underwent sleeve resections or bronchoplastic procedures. We performed 21 sleeve lobectomies, 9 sleeve resections of the main bronchus, 25 bronchoplasties associated with lung resections and 15 isolated wedge bronchoplasties. Nine patients (12.8%) had nodal metastases. RESULTS: There was no operative mortality; postoperative complications occurred in one patient (1.4%) who presented an empyema. At long-term follow-up evaluation, we were able to report good results: all patients were alive and nobody manifested recurrence; one patient had a late cicatricial bronchial stenosis, which was treated with laser therapy. CONCLUSIONS: This series of central typical bronchial carcinoids, treated with sleeve or bronchoplastic resection, demonstrated an excellent outcome. Our results suggest that, in experienced and skilled hands, conservative procedures must be considered the treatment of choice for the management of these tumours.

Surgical treatment of posttransplant bronchial stenoses: case reports.

BACKGROUND: Bronchial stenoses are still a frequent complication after lung transplantation. The stenosis usually involves the anastomotic site, but rarely a distal site. The first choice treatment is an endoscopic balloon dilatation, laser ablation, and stenting. Unrelenting strictures may require an open surgical approach. MATERIALS AND METHODS: Between 1995 and 2006, 154 patients underwent lung transplantation, including 134 who survived the perioperative period and were followed to evaluate the incidence of bronchial stenosis. Among 219 anastomoses at risk, 13 (5.9%) stenoses occurred in 11 patients. Conservative endoscopic management was effective for eight patients, but a surgical approach was necessary for three patients with segmental distal stenosis. RESULTS: One patient received a lower sleeve bilobectomy; one patient, wedge bronchoplasty of the bronchus intermedius; and another patient, an isolated sleeve resection of the bronchus intermedius. All patients had good outcomes with resolution of stenosis. CONCLUSIONS: Although rare, the surgical approach for bronchial strictures after lung transplantation is a good option. Parenchyma-sparing techniques are feasible and effective.

Favorable tissue effects of quantum molecular resonance device (Vesalius) compared with standard electrocautery. A novel paradigm in lung surgery.

BACKGROUND: Electrosurgical devices are largely employed in thoracic surgery but their use is burdened by extensive necrosis and second intention healing. METHODS: A rat model of thoracotomy was performed on 46 adult male rats using a standard electrocautery or a new quantum molecular resonance (QMR) instrument called Vesalius. Skin, muscle and lung specimens were obtained immediately and 2 weeks after surgery to evaluate acute and late effects. RESULTS: Both in the short- and long-term study, Vesalius produced less severe tissue damage than that of standard electrocautery. CONCLUSIONS: The use of the QMR device may provide an alternative to gold-standard electrosurgical devices in thoracic surgery.

Long-term results of surgical management of pulmonary metastases from renal cell carcinoma.

BACKGROUND: Metastatic renal cell carcinoma (RCC) has a poor prognosis and conventional treatments such as chemoradiotherapy show little efficacy. Surgical resection of pulmonary metastases from RCC is a widely accepted treatment, even if selection criteria based on prognostic factors have still not been defined. The aim of this study was to determine the long-term survival, clinical outcome and prognostic factors after surgery. METHODS: Between 1988 and 2004, 59 patients underwent resection of pulmonary metastases from RCC. Univariate and multivariate analysis of prognostic factors was carried out. RESULTS: Complete resection was achieved in 54 (91.5 %) patients. No intra- or postoperative mortality occurred, 5 (8.5 %) patients experienced postoperative complications. Overall, the 1-, 3-, and 5-year survival rates were 86.5 %, 63 % and 53 %, respectively. Age at the time of pulmonary resection was found to be the only independent factor influencing prognosis. CONCLUSION: Pulmonary resection of metastases from RCC is a safe and effective treatment associated with a low morbidity and mortality and with high long-term survival. The lack of other effective therapies suggests use of the surgical approach whenever possible.

The surgeon and the oncologist in non-small cell lung cancer (NSCLC).

A strict collaboration is necessary between the oncologist and the surgeon, both must know the respective problematic and competences and must contribute together to all phases of clinical management of patients affected by NSCLC.

Actinic keratosis treated with an immune response modifier: a case report of six patients.

Actinic keratoses (AKs) are intraepidermal tumours, which result from the proliferation of transformed neoplastic keratinocytes. They are typically induced by chronic exposure to ultraviolet radiation, and can often develop into squamous cell carcinoma (SCC). Six patients, who presented with AKs located on the head, face and chest, were treated with the immune response modifier, imiquimod, as a 5% cream five times per week for up to 8 weeks. The majority of patients experienced mild to moderate side-effects, consisting of erythema, itching and burning. Topical application of imiquimod for 4-8 weeks resulted in complete clearance in all patients. No new or recurrent lesions were observed during a 6-8 month follow-up period.

Successful treatment of multiple filiform facial warts with imiquimod 5% cream in a patient infected by human immunodeficiency virus.

Imiquimod, an imidazoquinoline amine, is approved for the topical treatment of external anogenital warts induced by human papilloma virus. Several clinical trials have shown imiquimod to be an effective and safe drug for treatment of anogenital warts. Consequently, it was considered that imiquimod might be effective on warts caused by the same aetiological agent located on other skin areas. We describe the favourable outcome of a case of multiple facial verrucae in a human immunodeficiency virus (HIV)-infected patient treated with imiquimod 5% cream. This is a promising finding which supports those of two previous reports. We feel that imiquimod could be used in HIV-infected patients with multiple facial warts in whom conventional therapies are ineffective or produce significant side-effects.

Type I lamellar ichthyosis improved by tazarotene 0.1% gel.

The efficacy of tazarotene 0.1% gel in a 30-year-old woman with type I lamellar ichthyosis is reported. The drug was applied to 15% of the total body surface area as follows: once daily for 2 weeks, three times a week for further 2 weeks, followed by a once weekly maintenance application. During the first week of treatment there was partial improvement obtained and in the next 14 days further reduction of scaling within the tazarotene-treated areas was observed. After 4 months of maintenance application, there was a marked overall improvement in the treated areas. Side-effects consisted only of mild pruritus, slight burning and irritation. In essence, the therapeutic benefit obtained was comparable with that of systemic retinoids but without the adverse systemic side-effects. As noted in other reports, tazarotene 0.1% gel seems to be a valuable and safe therapeutic option for this severe genodermatosis.

Diagnosis of pigmented skin lesions by dermoscopy: web-based training improves diagnostic performance of non-experts.

BACKGROUND: Dermoscopy has been shown to enhance the diagnosis of melanoma. However, use of dermoscopy requires training and expertise to be effective. OBJECTIVES: To determine whether an Internet-based course is a suitable tool in teaching dermoscopy, and to evaluate the diagnostic value of pattern analysis and diagnostic algorithms in colleagues not yet familiar with this technique. METHODS: Sixteen colleagues who were not experts in dermoscopy were asked to evaluate the dermoscopic images of 20 pigmented skin lesions using different diagnostic methods (i.e. pattern analysis, ABCD rule, seven-point checklist and Menzies' method), before and after an Internet-based training course on dermoscopy. Mean +/- SEM sensitivity, specificity and diagnostic accuracy, and kappa (kappa) intraobserver agreement were evaluated for each diagnostic method before and after training for the 16 participants. Differences between mean values were assessed by means of two-tailed Wilcoxon rank-sum tests. RESULTS: There was a considerable improvement in the dermoscopic melanoma diagnosis after the Web-based training vs. before. Improvements in sensitivity and diagnostic accuracy were significant for the ABCD rule and Menzies' method. Improvements in sensitivity were also significant for pattern analysis, whereas the sensitivity values were high for the seven-point checklist in evaluations both before and after training. No significant difference was found for specificity before and after training for any method. There was a significant improvement in the kappa intraobserver agreement after training for pattern analysis and the ABCD rule. For the seven-point checklist and Menzies' method there was already good agreement before training, with no significant improvement after training. CONCLUSIONS: We demonstrated that Web-based training is an effective tool for teaching dermoscopy.