Lung cancer and cardiovascular diseases: occurrence, comorbidity and surgical timing.

AIM: The authors discuss tumor histological type, TNM staging and time of first occurrence of lung cancer, as well as related cardiovascular diseases, underlining type of treatment, surgical timing, surgical mortality, post-surgical complications and potentially additional therapies. METHODS: A total of 189 patients underwent surgery for non-small cell lung cancer (NSCLC) (Stage I-II), 35 (17.5%) of which presented with surgically relevant concurrent cardiovascular disease (8 coronary artery disease, 4 carotid stenosis, 8 obstructing artery disease, 15 aortic aneurysm). In most cases, surgical timing provides for cardiovascular disease treatment completion first, followed by lung resection only afterwards. Alternatively, concomitant cardiovascular and lung cancer treatment averts the need for repeated surgery, even though the intraoperative complications rate is higher, as long as patients are hemodynamically stabile. RESULTS: No remarkable surgical mortality was observed; stay in hospital ranged from 8 to 18 days. A 5-year follow-up was carried out in only 95/189 patients; 11/18 (61%) with concurrent cardiovascular disease and 46/77 (59%) with lung cancer alone are still alive. CONCLUSIONS: In 17% of cases, surgical treatment by the simultaneous and the differentiated approach for cancer and cardiovascular disease proved essential; comorbidity as an identifier of the strong correlation between the two diseases had a major impact on prognosis.

[Post-operative analgesia in thoracic surgery: physiopathological features, therapeutic framework and methodologies]. / Analgesia post-operatoria in chirurgia toracica: aspetti fisiopatologici, basi terapeutiche e metodi.

Pain after surgery is a major handicap for patients as it bounds and decreases ability for spontaneous movement, cough and deep breathing, aiding the onset of complications and invalidating the recovery capabilities of operated patients. In thoracic surgery, the need to compile and employ guidelines for post-surgical pain management has become a pressing requirement in recent years. Currently available protocols include several options of treatment that are frequently a subject in the most recent scientific papers and play a key role, as they constitute the framework upon which building with changes and fixes that take account of incidental circumstances, in relation to both patients and surgery, again for both the organizational and structural features of the surgical environment. Purpose of this job is a thorough analysis of post-operating analgesic treatments for thoracic surgery, introducing the most effective ones currently available as for channels and procedures of administration, as well as possible side effects or complications.

[Percutaneous radio frequency thermal ablation of non-resectable lung cancer: state of the art]. / Termoablazione percutanea con radiofrequenza dei tumori polmonari inoperabili: stato dell'arte.

BACKGROUND: Unfortunately, as of yet, most lung cancers are not operable as soon as diagnosis is available; in these situations chemo- and radio-therapy still play a key role, albeit palliative, improving survival rate moderately, but are not lacking in toxic effects, especially in case of concurrent pathology, reduced cardio-respiratory functionality or being advanced in years. Therefore thermal ablation mini-invasive techniques, already employed as ancillary treatments of hepatic cancer or in place of surgery, have been performed for these pathologies. AIM: Aim of this work is to define the current state of the art for Radio-Frequency Ablation (RFA) to be performed on non-resectable lung cancer, also by means of a thorough review of international literature, from which to infer purposes, suggestions, methodologies, effectiveness, safety, complications and achievements, also in terms of the possible improvement of life quality and/or survival expectancy. PATIENTS AND METHODS: Patients have been carefully selected. Pulmonary nodules have been treated with TC or echo-guided percutaneous thermal ablation and, afterwards, evaluated by radiological and clinical (sometimes histopathological) follow-up. RESULTS: The size of the RFA-treated nodules is necessary in order to evaluate full or partial necrosis extent and, therefore, average survival rate. CONCLUSIONS: Availability of more extensive and homogeneous case histories, as well as standard follow-up (TC and/or histopathological sampling) methodologies, is required. Nevertheless several authors agree that RFA is a safe and effective technique within the framework of a substitutive or complementary treatment of non-operable lung cancer. The best results can be achieved for cancers less than 3 cm wide; RFA, performed before chemo- and/or radio-therapy, plays a neoadjuvant role for larger cancers, decreasing cancer volume and weakening the symptoms.

[Malignant pleural mesothelioma: early diagnosis and multimodality management]. / Diagnosi precoce e terapie integrate del mesotelioma pleurico maligno.

Malignant pleural mesothelioma (MPM) is a cancer with a poor prognosis, and its incidence increase, mainly as a result of exposure to asbestos. Universally acknowledged therapeutic approaches still don't exist at the moment, because of its refractory behaviour to all standard therapies; treatment protocols inclusive of either surgery, radiotherapy or chemotherapy have been largely employed, but usually with little impact on survival. For potentially operable pleural mesotheliomas new treatments tend to combine surgery both with new chemotherapy drugs and radiotherapy, in order to improve remarkably survival rates in selected cases. Other approaches, i.e. palliative, proved to be useful in the treatment of two major symptoms, namely dyspnea and thoracic pain. In this work the Authors are reporting their experience with malignant pleural mesothelioma, stressing the role of videothoracoscopy in the early diagnosis, weighing the radical cancer resection option and the effectiveness of multimodal treatment.

[Safety and effectiveness of lung volume reduction surgery for treatment of chronic obstructive pulmonary disease]. / Sicurezza ed efficacia della riduzione chirurgica di volume polmonare nel trattamento della broncopneumopatia cronica ostruttiva.

Lung volume reduction surgery (LVRS) has been proposed and performed in order to decrease dyspnea and improve wordly life without major impairments in oxygen-dependent patients affected by serious chronic obstructive pulmonary disease (COPD) and severe dyspnea that doesn't suffer drastic alterations notwithstanding rehabilitation procedures tailored for the specific case. The purpose of LVRS is to optmize thoraco-pulmonary dynamics, considerably compromised in these patients, relaxing the serious expiratory restraint to airflow and improving the muscular respiratory functionality. In this work the authors bring forth the physio-pathological foundations that justify the use of LVRS, also analyzing data brought by the international literature about surgery guidelines, short-term morbidity and mortality, clinical-functional effects and long-term survival. They also underline the need for careful evaluation research, aimed at getting a precise account of cardio-respiratory functional outcome, that will enable the positive accomplishement of the demanding and risky surgery, especially whenever the pathology has reached remarkable proportions or appears to be bilaterally localized. Only committing to painstaking analysis, setting and customization protocols, the latter especially addressing carefully chosen patients, can the surgeon rely on to achieve both short and long-term positive outcomes.

[Thromboembolic risk and prevention of deep venous thrombosis in open and laparoscopic surgery]. / Rischio tromboembolico e profilassi della trombosi venosa profonda in chirurgia tradizionale e in chirurgia laparoscopica.

Deep Vein Thrombosis (DVT) and pulmonary embolism are the dangerous and serious complications in patients undergoing surgery. It is known that prognosis is strictly linked to timely recognition of the pathogenetic-clinical phase of the thromboembolic disease and that prevention, therefore, plays the leading role in patients at risk. The most recent series show that, in absence of prophylaxis, the frequency of DVT, diagnosed by objective tests, is still significant in abdominal surgery. Modern diagnostic tools make possible to identify relatively silent clinical thrombosis, also with laboratory tests (i.e., D-dimer plasma levels). The Authors report a study on thromboembolic episodes in patients who underwent pneumoperitoneum with CO2 during laparoscopic abdominal surgery, compared to a control group submitted to open surgery. They underline the importance of a careful preoperative evaluation of the venous system, by Doppler study, in order to identify, patients at risk of DVT and establish a suitable anti-thrombotic prophylaxis.

[Surgical treatment of hydatid cysts]. / Trattamento chirurgico delle cisti idatidee complicate.

Hydatidosis represents a form of helminthic zoonosis with a stronger medical, social and economic impact. It is endemic in some areas of the world including Mediterranean countries, and therefore Italy. The disease is often diagnosed in an advanced phase, due to the poor symptomatology in the early stages. The best treatment is surgery. Emergency surgery is similar to elective surgery, though in some cases is preferable only a drainage procedure until the stabilization of the genreal and local conditions of the patient allow a radical intervention. The Authors report on their five year experience of surgical treatment of compliated pulmonar hydatidosis pointing out that exeresis must be aimed at preserving pulmonar function as much as possible.

[Haemothorax and chylothorax: surgical approach]. / Emotorace e chilotorace: il loro interesse chirurgico.

Diseases causing blood accumulation in the pleural space (or haemothorax) are usually very demanding for diagnosis and require a multidisciplinar therapeutical approach in emergency. So, their treatment should always be immediate and should aim to restore the optimal patient's haemodynamic conditions and to find the site of bleeding. Chylothorax, a lymphatic effusion in the pleural space, is also a very important pathology, as it effects the nutritional and immunological state of the patient causing pleural involvement and respiratory insufficiency. Stabilisation of vital parameters with adequate systemic therapies (blood perfusions, fluids and pro-coagulation factors, TPN) preceeds surgery, which can be the placement of a thoracic drain or emergency thorascopy and/or thoracotomy. The Authors report the casistic of the latest three years for diagnosis and treatment of haemothorax and chylothorax stressing the advantages of a minimal invasive approach for evacuation and identification of the origin of bleeding and haemorrhage and/or lymphatic effusion control.

[Surgical treatment of celomic cysts]. / Trattamento chirurgico delle cisti celomatiche.

Celomic cysts (pericardiopleural or serous cysts) are rare, as they account for about 30% of all the homoplastic disembryogenetic lesions of the mediastinum. There is not usually a characteristic symptomatology associated with this anomaly, which is, however, easily diagnosed by means of the most common radiologic techniques. The TC together with the MRI provides all the necessary data for an appropriate management of the patient. The Authors report on their five year experience of the surgical treatment of celomic cysts, pointing out that surgery must be aimed at preserving pulmonary function as much as possible. They finally maintain that the first surgical approach should be video-thoracoscopic with the aid of a minithoracotomy, if necessary.

[Combined video-thoracoscopic, surgical and endovascular treatment in a case of ascites and recurrent bilateral pleural effusion]. / Trattamento combinato video-toracoscopico, chirurgico ed endovascolare in un caso con ascite e versamento pleurico bilaterale recidivante.

Among recurrent pleural effusions a role of remarkable importance is held by those combined with ascitis due to the difficulty of their treatment, even using widely tested techniques. The incidence of such pathology varies from 4% to 6% of patients suffering from cirrhotic pathology, reaching 10% in cases with advanced illnesses. Pleural effusions involve the right emithorax more frequently than the left one, but it can show up bilaterally too. Its etiopathogenesis is tied up to the direct passage of ascitic liquid into the chest and, during the past years, numerous theories have been described to explain this migration. The Authors report the case of a patient with interesting considerations for the diagnostic difficulties and the peculiarity of the treatment performed.

[Bronchial arteries: anatomical and clinical studies and strategies in surgical approach]. / Arterie bronchiali. Studio anatomo-clinico e strategie di accesso chirurgico.

One of the most important and controversial aspects of thoracic surgery is due to the topographical and surgical anatomy of the vascular structures involving the mediastinum. The knowledge of the so-called "vascular time", in fact, allows to face more complicated surgical situations, typical of the most specialistic thoracic surgery. The bronchial arteries represent a paradigm of what we have just stated. The study of their anatomy (number, position, origin, distribution and relationships with the mediastinal structures) is of relevant importance, not only for the interest the bronchial vascular tree arises in tracheo-bronchial surgery and in pulmonary transplantology, but also for the knowledge of the pathogenesis of some processes regarding pulmonary and pleural pathologies. The aim of this paper is to evaluate the real clinical interest of bronchial arteries, with an analytic study of the anatomy of vessels, and with the possibility to show the most frequent and characteristic anomalies involving the origin and course of these arteries.

[Evaluation of lung function as a prognostic index before and after surgical resection due to NSCLC]. / Valutazione pre e postoperatoria della funzionalità respiratoria come indice prognostico dopo resezione polmonare per NSCLC.

BACKGROUND: Although there were several studies on survival, death and morbidity rates after lung resection, considering both limited and extended resections, lung exercise capacity has been quite seldom taken into account as an index for prognosis. The aim of this study compare the consequences of three kinds of lung resections (pneumonectomy, lobectomy and wedge resection), to test pre- and post-surgery exercise capacity for patients affected by NSCLC in order to obtain more detailed prognostic indices. METHODS: All the patients were studied by means of thorough lung static function and hemogas analytical tests before and after surgical resection, from 15 days to 12 twelve months' time past surgery. RESULTS: In fact, in relation to lung resection due to neoplasms, several studies pointed out that zone-limited resections show an obvious anatomical benefit in terms of parenchyma spair compared to lobectomy; however, it is underlined that the functional benefits of small resections don't really prevail over post-lobectomy anatomical advantages. Furthermore local relapses are more common after small resections rather than after lobectomy. CONCLUSIONS: Neither limited lung resection nor lobectomy alone, therefore, in accordance with nearly all the recent and still ongoing studies in this huge research field, has a significant effect on exercise capacity. Only pneumonectomy is associated with impaired exercise performance, and, nevertheless, quite below our expectations.

[Role of thymectomy in the treatment of myasthenia gravis: considerations and personal cases]. / Ruolo della timectomia nel trattamento della miastenia gravis: considerazioni e casistica personale.

The therapeutic impact of thymectomy on the clinical course of myasthenia gravis is still very controversial. In fact, while nowadays the surgical approach is widely adopted for thymomas, its role is still debatable in patients suffering from myasthenia gravis. The surgical approach of choice for total thymectomy is represented by median sternotomy. Other surgical methodologies include cervical access and partial sternotomy. All these approaches have shown excellent results in the exeresis of the thymus. More recently video-assisted thoracoscopic thymectomy has been proposed as a less invasive and similarly effective technique for the removal of this organ and the treatment of myasthenia gravis. Aim of the present study is to report Author's experience with thymectomy, emphasizing the data available in the international literature on the surgical mortality, complications and aesthetical results of the different surgical accesses.

[Intraoperative pleural lavage for restaging of bronchogenic carcinoma]. / Lavaggio pleurico intraoperatorio nel restaging del carcinoma polmonare.

BACKGROUND: Although lung cancer staging has been recently reviewed, a significant number of recurrences and an increased incidence of mortality is common also in the initial stages of the disease. All that is probably due to disease staging underestimation and emphasizes that an exact system of staging cannot be considered a stand-alone prognostic and therapeutic index. METHODS: Between October 2000 and November 2001, 37 patients have undergone surgical intervention for NSCLC in our Surgical Unit; 28 of them were male (75.7%), 9 female (24.3%), aged between 55 and 70. Neither cancer-related pleural effusion, nor mediastinal lymphoadenopathy had been detected under Rx and TC inspection in any patient. RESULTS: Pre-surgical pleural washing (PLC), which defines the positiveness of the cytological result (D+), in 17 patients (45.9%) was positive, in the remaining 20 (54.1%) negative. The positiveness of PLC was 35.3% (6/17) and 64.7% (11/17) in the initial stage of T (T1 and T2) and in the advanced stage (T3 and T4) respectively. CONCLUSIONS: On the basis of personal experience, the authors, suggest that pre-surgical resection pleural washing searching premature microscopic pleural disseminations in NSCLC-affected patients should become an important prognostic factor for the disease outcome. Moreover, they emphasize how this procedure is easy, with a small increase in the surgical intervention time, and nearly costless.

[Pulmonary hernia]. / Le ernie polmonari.

Chest-wall hernia is a very unusual pathological event. The Authors report a singular diagnostic case of chest-wall hernia, miming rib tumor. Instrumental diagnostic tools and surgical treatment is reported. Finally patient's follow-up is discussed.

[Intestinal angiodysplasia]. / Angiodisplasie intestinali.

Intestinal angiodysplastic lesions represent one frequent source of gastro-enteric tract serious bleedings, endowed with present-day therapeutic implications. The Authors report a singular case of a bleeding of this kind. A selective arteriography analysis of the superior mesenteric artery immediately pointed out the necessity for a surgical intervention, which however has not proved being resolutive for recovery, because massive intestinal hemmorrhage recurrence occurred. The left gastric artery anomalous origin, being discovered in the first branch of the mesenteric artery, which was not recognized fully in advance, stressed, in fact, the need for a partial gastrectomy, firstly, and a full gastrectomy, subsequently. The post-surgery course got more serious for a small leak of the oesophageus-digiunal anastomosis and for a serious renal failure. NPT and haemodialysis helped to quickly solve those complications. Other hemorrhagic events have not occurred anymore, 5 years having passed since the surgical intervention.

[Endoscopic obstruction treatment]. / Terapia disostruttiva endoscopica.

The Authors reported the last year personal experience of disobstruction endoscopic therapy; they described therefore an examination of the several techniques proposed from the international literature and in particular dwell upon laser-therapy and airway stents implantation. They emphasized the treatment importance, mostly palliative, but the effective symptomatology improvement due to airway obstruction, bleeding, pain and secretions retenction. They emphasize finally the necessity of a careful and scrupulous patients selection for disobstruction endoscopic therapy.

[Surgical indications in pulmonary tuberculosis]. / Indicazioni chirurgiche nella tubercolosi polmonare.

Since the begin of the century, the surgery for treatment of pulmonary tuberculosis showed an important evolution. The procedure has proved to be useful in the 20% of patients. It appears that the percentage is drug-resistant or complicated. The authors describe their experience in the years from 1992 to 1997 and, in accordance with the literature in this field, outline the good prognosis to 5 years, with a percentage of 90-96% of non-infected patients. Very important is the time of surgical intervention, the compliance of the medical treatment in the previous 6 months, excepting in the emergency, and the perfect obliteration of pleural cavity to avoid next reinfection and the development of broncopleural fistulas.

[Reconstruction of the thoracic wall]. / La ricostruzione della parete toracica.

The resection of the thoracic wall for cancer, traumas or results of radiotherapy could require a reconstruction of the same wall with prosthetic material of different nature to the purpose of protect the important intrathoracic structures, avoid the flail chest and maintain a ventilation adjusted with aesthetically acceptable results. Numerous and varied they have been and they are the materials used to such aim, but the more numerous experiences concern the reconstructions of the wall with the employment of nets of Marlex or the patch of Gore-Tex. In the complete two years eight patients have arrived at our observation in which a prosthetic reconstruction has been performed with heterologous material. In three of them has been used the net of Marlex, in five the patch of Gore-Tex of two millimeters of thickness. The prostheses have stayed well you bear and in all the patients the authors have gotten a good stabilization of the thoracic wall.

[Azygos lobe and spontaneous pneumothorax]. / Lobo azygos e pneumotorace spontaneo.

The association azygos lobe-pneumothorax is a very rare event described in literature. The Authors report a case observed. The surgical procedure performed by traditional thoracotomy, was carried out with the section of the azygos and the resection of small blebs in pulmonary apex. Finally, emphasized possible different pathogenetic mechanisms.