Third-Degree Atrioventricular Block And Asystole After Lung Resection: A Rare Complication.

Surgical resection remains the optimal therapeutic option for early-stage operable NSCLC. Despite significant advances in recent years related to anesthetic and surgical techniques, cardiopulmonary complications remain major causes for postoperative morbimortality. In this paper we present a case of a patient who developed complete AV block followed by asystole after lung resection surgery. The patient underwent surgery via right VATS and the procedure was uneventful.  On the first post-operative day patient developed a third-degree atrioventricular block followed by 6 seconds asystole. Pharmacological treatment was instituted and implementation of a permanent pacemaker occurred on the third post-operative day, without complications. The remaining postoperative course was uneventful and the patient was discharged home on the sixth post-operative day. It is the objective of the authors to report and highlight this rare and potencial fatal complication of lung resection.

Outcomes Of Surgically Treated N2-Positive Non-Small Cell Lung Cancer.

INTRODUCTION: The role of surgery in the treatment of stage IIB/IIIA lung cancer is still a matter of debate. To assess the outcomes of N2-positive patients, we performed a retrospective 10-year study including all patients with histologically proven N2 disease submitted to lung resection surgery by the same surgical team in three different hospitals. MATERIALS AND METHODS: Demographic, clinical, surgical and survival data were collected from patients' clinical registries. Patients were divided into groups according to evidence of neoadjuvant chemotherapy and number of positive N2 stations. Outcomes regarding survival time within and between groups were calculated and compared. RESULTS: Sixty-four patients were included in our study, with a mean age of 62,2 years. Surgery was performed by uniportal VATS in 43.8% of cases. A mean of 3 nodal stations were sampled and 35 patients (54.7%) had one single positive N2 station. Post-operative complications occurred in 27% of patients but no post-operative mortality was recorded. Twenty-seven patients (42.2%) were submitted to neoadjuvant chemotherapy. Survival time within this group was of 67,7±10,5 months, which was not statistically different from those who performed upfront surgery (survival time 48±5,2 months). Patients with single N2 positive stations had a longer survival time than those with multiple N2 positive stations (p<0.05). Within the group of patients with single N2 disease (n=35), no difference in survival time was found regarding neoadjuvant therapy. CONCLUSIONS: Surgery is effective in selected patients with N2 disease, in particular those with single-N2 positive stations. Neoadjuvant chemotherapy may not grant survival benefit. Adequate pre-operative staging is essential.

Spreading Through Air Spaces And Thinking About Lung Metastases.

INTRODUCTION: Spread through air spaces (STAS) is a novel pattern of invasion in primary lung cancers, which was introduced in the 2015 World Health Organization classification. Several studies have validated STAS to be a predictor of clinical outcome in lung adenocarcinoma. However, little is known about STAS as a mode of intraparenchymal diffusion of pulmonary metastases (PMs). OBJECTIVES: The aim of this study was to investigate the incidence of STAS among PMs and the association between STAS and clinicopathological characteristics of PMs. METHODS: From August 1, 2017 to July 31, 2022, 50 patients underwent pulmonary metastectomy in our center. Clinicopathological characteristics of patients were retrospectively evaluated. Continuous variables were compared by using unpaired Students t-test or MannWhitney test, as appropriate. Categorical variables were compared by using Qui-squared test or Fishers exact test as appropriate. RESULTS: A total of 50 patients with PMs who underwent surgical resection were analyzed, 68% being male. The median age of the study population was 60 years (range 24-80). Most patients had primary cancer originating from epithelial tissue (n=45) and the remaing from mesenchymal tissue (n=5). Colorectal cancer was the most frequent primary site of PMs (n= 32), followed by kidney (n=4) and osteosarcoma (n=3). 60% of patients (n=30) underwent sublobar resection (wedge resection or anatomic segmentectomy). STAS was observed in 10 patients (20%): 7 patients with PMs from CRC, 1 with PM from palatine tonsil, 1 from kidney and 1 from uterus. STAS was more frequent in elder patients (62 years, SD=7.099 vs 60 years, SD= 13.889; p = 0.034). Notably, STAS was significantly more frequent in PMs with larger dimension (2.8 cm, SD=2.049 vs 2.03 SD=1.104; p = 0.010), patients with lymph node metastases (p = 0.004) and in patients who underwent lobectomy rather than sublobar resection (70% vs 32.5%; p = 0.03). Although without statistically significant difference, locorregional recurrence and mortality was higher in patients with STAS+ (40% vs 22.5% and 40% vs 20%, respectively). CONCLUSION: VSTAS is nowadays considered to be a lung-specific tumour invasion pattern and is commonly observed in PMs of different origins.

On the footsteps of Hippocrates, Sanctorius and Harvey to better understand the influence of cold on the occurrence of COVID-19 in European countries in 2020.

COVID-19 pandemic has been characterized by a pattern of consecutive declines and regrowth in European countries in 2020. After being partially regressed during the summer, the reappearance of the infection during fall 2020 in many temperate countries strongly suggests that temperature and cold may play a role in influencing the infectivity and virulence of SARS-CoV-2. While promoting medicine as an art, Hippocrates interpreted with logical reasoning the occurrence of diseases such as epidemics, as a consequence of environmental factors, in particular climatic variations. During the Renaissance, Sanctorius was one of the first to perform quantitative measurements, and Harvey discovered the circulation of blood by performing experimental procedures in animals. We think that a reasoning mixing various observations, measurements and experiments is fundamental to understand how cold increases infectivity and virulence of SARS-CoV-2. By this review, we provide evidence linking cold, angiotensin-II, vasoconstriction, hypoxia and aerobic glycolysis (the Warburg effect) to explain how cold affects the epidemiology of COVID-19. Also, a low humidity increases virus transmissibility, while a warm atmosphere, a moderate airway humidity, and the production of vasodilator angiotensin 1-7 by ACE2 are less favorable to the virus entry and/or its development. The meteorological and environmental parameters impacting COVID-19 pandemic should be reintegrated into a whole perspective by taking into account the different factors influencing transmissibility, infectivity and virulence of SARS-CoV-2. To understand the modern enigma represented by COVID-19, an interdisciplinary approach is surely essential.

VIDEO-ASSISTED THORACOSCOPIC SURGERY WITHOUT CHEST DRAIN PLACEMENT.

BACKGROUND: Placement of chest drain following thoracoscopic procedures has been the gold standard. Nevertheless, a drainless approach may be safe and feasible in selected patients and procedures. In this study we aim to report our clinical experience after drainless video-assisted thoracoscopic surgery. METHODS: We retrospectively analyzed data of all subjects submitted to drainless video-assisted thoracoscopic surgery at our centre between January 1, 2010 and December 31, 2019. The preoperative clinical and surgical data and the immediate postoperative data were retrospectively evaluated through the consultation of the clinical processes and the computer registry system. We used descriptive statistics: mean or median, according to data distribution, and absolute or relative frequencies. RESULTS: We included 161 patients, mean age of 31 years (min:15; max:78). We analyzed data from patients submitted to: thoracic sympathectomy(67.1%), wedge resection, for lung biopsy, metastasis or small nodules resection (21.7%), mediastinal cysts removal (6.2%), pleural lesions resection (3.7%) and emphysematous bullae resection (1.2%). The average length of stay was 1 day. Residual pneumothorax was noted in 15 patients (9.3%). Postoperative pleural drain placement due to pneumothorax occur in 4 patients (2.5%). There was no intra-hospitalar mortality. CONCLUSIONS: Video-assisted thoracoscopic surgery without postoperative chest drain seems to be valid and safe according to our results.

Safety And Risk Factors For The Morbidity And Mortality Of Pneumonectomy: A Retrospective 10- Year Study In A Single Institution.

OBJECTIVES: Pneumonectomy is a procedure with high post-operative morbidity and mortality. This study aims to assess and identify possible risk factors that can affect post-operative outcome, therefore determining the safety of pneumonectomy in specific groups. METHODS: A total of 63 patients submitted to pneumonectomy at our centre, from February 2008 to February 2018, were included in our retrospective study. Age, gender, side of intervention, diagnosis, pre-operative symptoms, substance abuse and comorbidities were assessed. Early and late post-operative complications, as well as death were our major outcomes. We analysed the impact of preoperative variables on major outcomes using SPSS statistics. RESULTS: We found a 9,8% surgery-related mortality and 1-year survival rate of 76,2%. The incidence of early complications in our population was of 35% while eleven patients (17,4%) developed late post-operative complications. No statistical difference was found when comparing survival time between genders or age groups. Right sided pneumonectomies seem to be associated with an higher mortality risk. No other association between risk factors and outcomes reached statistical significance in both univariate and multivariate analysis. CONCLUSIONS: Pneumonectomy is a viable option regardless of age whenever the patient has a good functional and cardiopulmonary status. Gender and diagnostic group do not seem to influence adverse event risk, although right-sided pneumonectomies show an increased risk for post-operative death. Care should be taken with patients submitted to neoadjuvant therapy. All patients should be encouraged to cease smoking as early as possible before surgery, given the increased risks for post-operative complications.

Uniportal Video-assisted Thoracic Surgery Anatomical Resections - Does Previous Tobacco Exposure Adversely Influence Post-Operative Outcomes?

A high percentage of patients presenting for lung surgery are either current or former smokers, which is typically associated with many anatomical and physiological pulmonary changes. The influence of tobacco on postoperative pulmonary complications remains controversial. The main goal of this study was to analyse the effects of smoking on the risk of post-operative complications and morbidity in patients submitted to lung resection surgery through uniportal VATS. Peri-operative data on all cases of anatomical lung resection surgery through single-port VATS performed between December 2013 and July 2018 at three Portuguese institutions were collected and retrospectively reviewed Demographic data, diagnosis, pre-operative lung function tests, in-hospital length of stay (LOS) and intra and post-operative drainage levels were registered. Patients were divided in two groups according to tobacco exposure. Post-operative complications and morbidity were compared through statistical analysis We performed 313 procedures, 303 of which were evaluated in regard to outcome. Mean age at time of surgery was of 62,85 years (SD=12,24). One hundred and sixty patients (52,81%) had a history of tobacco use, while 47,19% (n=143) had never smoked. Non-smokers had significantly better lung function than smokers (p<0,05). Smoking history showed a contribution to post-operative prolonged air leaks (p=0,025) morbidity (p=0,05), 2-day longer LOS (µ=5,36 days vs. µ =7,53 days; p<0,05), longer operative times and higher intra and post-operative drainage levels. A history of smoking during a patient's life negatively impacts morbidity in patients submitted to uniportal VATS for anatomical lung resection, increasing early post-operative complications and prolonging in-hospital stays.

Endoscopic Third Ventriculostomy for the Treatment of Hydrocephalus in a Pediatric Population with Myelomeningocele.

BACKGROUND: Hydrocephalus develops in up to 90% of patients born with myelomeningocele. Although endoscopic third ventriculostomy (ETV) is currently considered the preferred treatment for obstructive hydrocephalus, its results have been inconsistent in patients with myelomeningocele. This study focuses on clinical and radiologic outcomes of ETV in children with hydrocephalus related to myelomeningocele. METHODS: Medical records of 18 pediatric patients with myelomeningocele treated with ETV from 1998 to 2015 at the Centro Hospitalar São João (Porto, Portugal) were reviewed retrospectively. Patients' caregivers were contacted to evaluate their clinical manifestations before and after surgery regarding signs and symptoms of hydrocephalus and Chiari malformation. Control neuroradiologic imaging of 9 patients was obtained and analyzed. Success of ETV was defined by clinical resolution and radiologic confirmation. RESULTS: ETV was successful in 8 of 18 cases (44.4%). Groups of patients were compared according to age at the time of surgery, with a 40% (2/5) success rate in newborns and a 50% success rate (3/6) in children older than 1 year. Eight patients underwent ETV as a first option, with a 37.5% success rate. Ten patients underwent the procedure after previous ventriculoperitoneal shunt (VPS), 5 for malfunction and 5 for VPS infection with 60% and 40% success rates, respectively. Early postoperative complications occurred in 2 patients. CONCLUSIONS: ETV can be performed in patients with myelomeningocele and hydrocephalus with success rates of almost 50%. Prior VPS or VPS malfunction or infection do not contraindicate ETV. If possible, the procedure should be delayed until the patient is at least 1 month old.