Trocar vs. Seldinger small bore pleural drains: does the technique influence the outcomes? A prospective single-centre study.

OBJECTIVE: The aim of this study is to compare two positioning techniques of 12-French (Fr) thoracic drains in terms of efficacy, safety, and patient comfort. PATIENTS AND METHODS: This is a prospective, non-randomized, competitive, non-inferiority study comparing the Seldinger vs. Trocar technique. The primary endpoint was an analysis of the factors that led to unsuccessful drainage positioning. Between the two groups, clinical variables, procedure times, pain, and complications were compared. RESULTS: Seventy-two patients were enrolled in group 1 (Seldinger) and 45 in group 2 (Trocar). The mean procedural time was 7.93±3.02 min vs. 7.09±3.67 min, respectively (p: 0.33). The mean VAS for procedural pain was 2.22±1.47 vs. 2.80±1.88, p: 0.07, and the mean at day 2 was 3.6±1.2 in the SBWGD group vs. 2.7±1.1 in the Unico Group (p: 0.04). There was no difference in terms of complications, residual effusion, and pneumothorax at the first post-procedural chest X-ray. Four days after the procedure, the drain removal rate was 11.6% in group 1 vs. 25% in group 2 p: 0.063). The chest tube was removed after a mean period of 8.87±7.20 days after resolution of pleural effusion or tube dislodgement (7 cases in group 1 vs. 11 in group 2, p: 0.053). CONCLUSIONS: The two techniques resulted in comparable pain and complication rates. Both drains are well-tolerated and efficient at draining pleural effusion, with very low rates of complications and failure. We recommend inserting a longer tube for patients who require chest drainage for an extended period of time.

Pneumonectomy with and without induction chemo-radiotherapy for non-small cell lung cancer: short and long-term results from a single centre.

BACKGROUND AND OBJECTIVES:   Pneumonectomy for non small cell lung cancer (NSCLC) after induction radio-chemotherapy (IT) has been associated with high peri-operative risk and its safety and efficacy is still debated. The aim of this retrospective study was to compare short and long-term results of pneumonectomy in patients treated with and without IT (radiotherapy plus chemotherapy) for NSCLC. MATERIALS AND METHODS: From 1995 to 2008, 85 consecutive patients underwent pneumonectomy: 49 received pre-operative radiotherapy and chemotherapy (IT group), and 36 patients did not (non-IT group). Peri-operative and long-term outcomes were compared. RESULTS: Major complications rate was 14.3% for IT group and 16.7% for non-IT group (p = n.s.). Mortality rate was 2% in IT group and 5.5% in non-IT group (p = n.s.). Post-operative hospital stay was significantly longer in the IT group (p < 0.0001) as the need for blood transfusion (p = 0.002). Indeed, the mortality rate was similar in the left- and right-sided operations. 5 years survival was 45.3% for IT group and 38.4% for non-IT group (p = n.s.) and 5 year disease free survival rates were 42.3% vs. 37.8% for the two groups, respectively (p = n.s.). Among the clinical, surgical and pathological features no differences on long term outcomes were found with regards to IT. DISCUSSION: Pneumonectomy is a feasible and safe procedure even after pre-operative IT. Our results showed a prolonged hospitalization and the need for blood transfusion in the IT group.

Multiple primary laryngotracheal adenoid cystic and left thyroid follicular carcinoma with right vocal cord paralysis: the crucial role of surgery.

BACKGROUND: Primary tracheal tumors are rare, accounting for only 0.2% of all thoracic cancers. Adenoid cystic carcinoma (ACC) diagnosed in the trachea is very uncommon and its coexistence with second histologically distinct malignant tumors of he neck region has never been reported. SUMMARY: We now report a case of multiple primary laryngotracheal ACC and thyroid follicular carcinoma surgically successful treated with an incidental 8 years follow-up. CONCLUSIONS: The laringotracheal resection with en-bloc thyroidectomy can be adopted for treating multiple primary tumor of tracheal and thyroid carcinoma with good long-term prognosis.

Malignant solitary fibrous tumour of the chest wall: a challenging case.

Solitary fibrous tumors are very rare neoplasms that seldomly appear in extra-serosal soft tissues. In such cases, an accurate preoperative diagnosis is often difficult and challenging, especially in extrapleural ones. Traditionally, extrapleural solitary fibrous tumours have been regarded as indolent neoplasms similar to their intra-thoracic counterparts, although there has been some evidence that this subgroup could be a subset of more aggressive malignant tumours. For these reasons, surgical excision is mandatory and represents, to date, the best therapeutic option. In this article we report a case of a malignant solitary fibrous tumor of the chest wall in a 58-year-old man. Problems related to differential diagnosis and the possible pitfalls that can be encountered in the diagnostic process of such rare tumors are discussed.

Complete transmural gastric migration of PTFE mesh after surgery for a recurrent hiatal hernia.

Complications directly associated with the use of prosthetic materials in large hiatal hernia repair are rarely cited events in the literature. We herein report a case of a 47 year-old woman who came to our attention for a subacute onset of severe dysphagia and weight loss. She previously underwent laparotomic Nissen fundoplication with PTFE dual-mesh cruroplasty for a large recurrent hiatal hernia. With the clinical suspicious of "Tight Nissen", an endoscopy was performed and revealed a circular stenosis in the lower esophagus, a rotation of the stomach and, surprisingly, the presence of PTFE mesh free-moving in the gastric lumen With the use of rattooth forceps, the foreign body was removed and, after few days, the patient underwent a surgical debridement of hiatal scar tissue and a gastropexy procedure. In conclusion, dysphagia may manifest during the early postoperative period after mesh repair antireflux surgery, but such dysphagia usually resolves; if it doesn't or if it worsens, mesh migration must be excluded.

[Clinical effect of bovine pericardial strips on air leak after stapled pulmonary resection in "frail" patients: early results]. / Impiego clinico di suturatrici rivestite con pericadio bovino nella prevenzione delle perdite aeree postoperatorie in pazienti "fragili" sottoposti a resezione polmonare.

AIM: Postoperative air leaks and in particular persistent air leaks (>5 days) after pulmonary resection still represent a common complication and the first cause of hospital stay delay. Aim of this experimental trial was to investigate the efficacy of the use of bovine pericardium strips (in terms of reduction of postoperative leakage and hospital stay) in "critical" patients (COPD, emphysema etc.) who underwent pulmonary resection. METHODS: From October 2010 to February 2011, eight patients (experimental group, Group A) were preoperative selected and underwent pulmonary resection with bovine pericardium strips (Peri-Strips Dry; Synovis ). The inclusion criteria of a "frail patient" were established by a dedicate pneumologist according with clinical and functional data (predicted postoperative FEV1 ranging from 35% and 80% of the theorical predicted value). For comparison, from January 2010 to September 2010, we retrospectively reviewed the data of 28 patients who satisfied the same inclusion criteria and underwent pulmonary resection with standard surgical procedures. This group of patients represents our control group (Group B). RESULTS: There were no significant differences between the two groups in age, gender, preoperative risk factors for developing a postoperative air leak, preop FEV1 and type of resection. No technical deficiencies in the use of bovine pericardium strips were observed in Group A. Postoperative leakage was significant different in the two groups being persistent air leak detected in 0% in Group A versus 17.8% of Group B (P=0.046). Consequently, chest tube duration (6.75±0.84 days [Group A] vs. 9.70±1.26 days (Group B), P=0.019) and hospital stay (10.13±0.83 days [Group A] vs. 12.95±1.37 days [Group B], P=0.013) were lower in the experimental group. CONCLUSION: Bovine pericardium strips are safe and easy-to-do technique to reduce postoperative air leaks after pulmonary resection in "critical" patients.

The radioguided 111In-pentetreotide surgery in the management of ACTH-secreting bronchial carcinoid.

BACKGROUND AND OBJECTIVES: A correct intra-operative detection of the tumour and, therefore, the complete surgical resection is critical to success in ACTH-secreting bronchial carcinoids. To date, all available preoperative and intra-operative procedures remain not entirely satisfactory. The use of intra-operative 111In-pentetreotide detection could offer a potentially reliable and rapid tool of real time assessment to achieve a radical resection. MATERIALS AND METHODS: In two cases of ACTH-secreting bronchial carcinoids, after a preliminary 111In-pentetreotide scan, radio-guided surgery was performed using a hand-held gamma probe 24 h after i.v. administration of the tracer. RESULTS: The 111n-pentetreotide radioguided surgery with hand-held gamma probe, if compared with pre-operative 111In-pentetreotide, significantly improved the intra-operative surgical management by detecting a millimetric nodule in one case; detecting mediastinal lymph node metastasis in both cases and ruling out any other disease localization. DISCUSSION: Intra-operative 111In-pentetreotide detection appears to be safe and easy to perform. This technique allowed to achieve a complete resection of all the tumor locations, that would have been impossible to detect with conventional surgical approach. On the basis of these results we advocate for a wider investigation of the potentialities connected with the radioguided surgery coupled with pre-operative 111In-pentetreotide scan as a promising procedure in the management of ACTH-secreting bronchial carcinoids.

Huge primary pericardial liposarcoma.

Liposarcomas are the second most common soft tissue sarcoma in adults. They occur predominantly in the lower limbs and retroperitoneum, whereas primary mediastinal liposarcomas are extremely rare. Liposarcomas are often asymptomatic and may reach a considerable size before causing any symptoms related to direct invasion or compression of other thoracic organs. We report a case of a 69-year-old woman with a giant primary pericardial liposarcoma causing cardiac tamponade and discuss its clinical and imaging features and surgical treatment and review the literature.

Small-bore wire-guided chest drains: safety, tolerability, and effectiveness in pneumothorax, malignant effusions, and pleural empyema.

BACKGROUND: The use of small-bore wire-guided chest drains for pleural effusions and pneumothorax has become popular; however, limited data are available on its efficacy and morbidity. The aim of this retrospective study is to measure, via the analysis of the so far largest reported cohort, the efficacy, safety, and tolerability of this approach in different clinical conditions. METHODS: In the period from January 2002 to December 2008, 1092 patients have undergone the positioning of a small-bore wire-guided chest drain (12F) for the evidence of pneumothorax or pleural effusion and have been monitored over time for morbidity, pain at the time of insertion (measured via the visual analogue scale), and drain failure for misplacement or blockage. Patients with trauma were excluded from this study. RESULTS: Male/female ratio and mean age were respectively 418:674 and 55.85 ± 18.6. Three-hundred ninety-nine (36.5%) drains were inserted for pneumothorax, 324 (29.7%) for malignant effusion, 97 (8.9%) for empyema, and 272 (24.9%) for nonmalignant effusion. The pain experience was on average "very mild" (mean visual analogue scale = 4.6 mm). The overall drain failure rate was 12.9%. The percentage of successful cases was 93.8% in malignant effusion, 93% in pneumothorax, and 92.3% in nonmalignant effusion; in the cases of pathologically diagnosed empyema, drains were more likely to get blocked (74.2%). We recorded 1 serious complication within the malignant effusion group. CONCLUSIONS: Wire-guided 12F Seldinger-type drains are a well-tolerated and effective method of treating pneumothorax and uncomplicated pleural effusions (malignant and nonmalignant) with acceptable morbidity. The use of 12F small-bore chest drain is not indicated for the treatment of empyema.

Is pulmonary function damaged by neoadjuvant lung cancer therapy? A comprehensive serial time-trend analysis of pulmonary function after induction radiochemotherapy plus surgery.

OBJECTIVE: We have analyzed short- and long-term variations of pulmonary function in locally advanced non-small cell lung cancer after induction chemoradiotherapy. METHODS: Twenty-seven patients with stage IIIA (N2) non-small cell lung cancer underwent resection with radical intent after induction chemoradiotherapy in the period 2003 to 2006. Pulmonary function has been evaluated by spirometry, diffusing capacity of the lung for carbon monoxide, and blood gas analysis before induction chemoradiotherapy (T0), 4 weeks after induction chemoradiotherapy and before surgery (T1), and 1 (T2), 3 (T3), 6 (T4), and 12 months (T5) after surgery. RESULTS: A 22.80% decrease of diffusing capacity of the lung for carbon monoxide (P < .001) was observed at T1. At T2 significant decreases in the following were present: vital capacity, -20.50% (P < .001); forced vital capacity, -22.50% (P < .001); forced expiratory volume in 1 second, -23.00% (P < .001); peak expiratory flow, -29.0 (P < .001); forced expiratory flow 25% to 75%, -13.7% (P = .005); and diffusing capacity of the lung for carbon monoxide, 43.6% (P < .001). However, in the interval between T2 and T5, a progressive improvement of lung function in most parameters was observed, but only diffusing capacity of the lung for carbon monoxide presented a significant increase (P < .001). Within the same time gap (T2 to T5), subjects 65 years of age or younger showed an increasing trend for vital capacity, forced expiratory volume in 1 second, total lung capacity, and residual volume significantly different from that of elderly patients, in whom a decrease in these parameters is reported. CONCLUSIONS: An impairment of respiratory function is evident in the immediate postoperative setting in patients with non-small cell lung cancer receiving induction chemoradiotherapy. In the long-term period, a general recovery in diffusing capacity of the lung for carbon monoxide was found, whereas an improvement of forced expiratory volume in 1 second, vital capacity, total lung capacity, and residual volume was detected in the younger population only.

Induction cisplatin-gemcitabine-paclitaxel plus concurrent radiotherapy and gemcitabine in the multimodality treatment of unresectable stage IIIB non-small cell lung cancer.

BACKGROUND: To evaluate feasibility and safety of induction three-drugs combination chemotherapy and concurrent radio-chemotherapy in stage IIIB NSCLC. PATIENTS AND METHODS: Patients with stage IIIB NSCLC were treated with three courses of induction chemotherapy, cisplatin 50 mg/m(2), paclitaxel 125 mg/m(2) and gemcitabine 1000 mg/m(2) on days 1,8 of every 21 day cycle. Patients without distant progressive disease were then treated with radiotherapy and concurrent weekly gemcitabine (250 mg/m(2)). Toxicity and response of radio-chemotherapy treatment have been assessed. RESULTS: Between Jan 01 and Nov 02, 46 patients were enrolled. Grade 3+ hematological and non-hematological toxicity during the induction phase were 41.3% and 13.1%, respectively. In 38 patients a Clinical Response or Stable Disease was recorded and these patients underwent to concurrent radio-chemotherapy. Grade 3+ hematological and non-hematological toxicities were 8.2% in this group. Further response was observed in 66% of patients. Overall median survival time was 17.8 months, with a 3-year survival rates of 23%. CONCLUSION: Three-drugs induction chemotherapy and concurrent radio-chemotherapy with weekly gemcitabine in locally advanced stage IIIB NSCLC is feasible and safe.

Neoadjuvant concurrent radiochemotherapy in locally advanced (IIIA-IIIB) non-small-cell lung cancer: long-term results according to downstaging.

BACKGROUND: To report the efficacy of induction treatment (IT) protocol with concurrent radiochemotherapy in locally advanced non-small-cell lung cancer (NSCLC), and to analyze downstaging as a surrogate end point. PATIENTS AND METHODS: Patients with histo- or cytologically confirmed stage IIIA or IIIB NSCLC were treated according to an IT protocol followed by surgery. Downstaging was assessed for all resected patients. RESULTS: In the period between February 1992 and July 2000, 92 patients were enrolled in the study (57 IIIA, 35 IIIB). Response was observed in 63 patients; 56 patients underwent radical resection. Patients downstaged to stage 0-I (DS 0-I) showed a statistically significant improved disease-free survival (26.2 months pStage 0-I versus 11.2 months pStage II-III; P=0.0116) and overall survival (median 32.5 months pStage 0-I versus 18.3 months pStage II-III; P=0.025). Patients with DS 0-I had a significantly lower probability (P=0.0353) of developing distant metastases estimated in 0.2963 odds ratio. CONCLUSION: Neoadjuvant radiochemotherapy is feasible with good pathological DS results. Pathological downstaging was confirmed to have high predictive value. Its use is suggested in the short-term evaluation of induction protocols efficacy in locally advanced NSCLC.

Tailored surgery for esophageal body diverticula.

OBJECTIVE: The aim of our study was to identify the presence of associated functional disorders (dysmotility or gastro-esophageal reflux, GER), to select patients who need surgery and to plan a tailored surgical treatment in patients affected by esophageal body diverticula. METHODS: We report on 51 consecutive patients with esophageal body diverticula, observed at our department, who underwent a thorough functional evaluation by means of radiology, endoscopy and manometry; 24 h pH-monitoring was performed in 11 patients who complained of symptoms of GER. The treatment of choice was planned in each patient on the basis of the following elements: the need of diverticulum excision and correction of esophageal body dismotility, LES dysfunction or GER. RESULTS: An esophageal motor dysfunction was detected in 73% (37 patients) of our total cases with an impaired LES function in 53% (27 patients); GER was identified in nine out the 11 patients submitted for 24 h pH-monitoring. On the overall series, we observed dysmotility or GER in 49/51 patients (96%). Sixteen patients did not require surgical treatment and eight patients refused it; 27 patients underwent tailored surgery. The overall complication rate was 11% (two esophageal fistulae, one acute coronary disease) with 7% mortality rate (one septic shock from esophageal leakage and one myocardial infarction). At follow up (average 47 months; range 6-103 months) 92% satisfactory results (Visick I and II) and only 8% of poor results were observed in our series. None of 13 patients who underwent conservative management had major complications at mean follow-up of 64 months. CONCLUSIONS: Based upon our experience, we believe that any case of diverticulum of the esophageal body deserves a complete physiopathological evaluation because an underlying functional disorder is associated in most cases. The evidence that the diverticulum per se can be considered as the ultimate phenomenon of an underlying functional disease determined the need for a tailored surgery, planning treatment of the functional disorder as the primary goal, not necessarily associated with a diverticulectomy. In our experience a tailored surgical treatment provided best results.