Extracorporeal carbon dioxyde removal for additional pulmonary resection after pneumonectomy.

Additional pulmonary surgery in a previously pneumonectomized patient requires apnea during surgical manipulation of the surviving lung. We report on a novel approach to manage the intraoperative apnea period, combining apneic oxygenation and minimally invasive, low flow extracorporeal CO2 removal. A 69-year-old man previously submitted to left pneumonectomy was scheduled for wedge resection of a single right upper lobe lesion. During the intraoperative apnea period, oxygenation was maintained through apneic oxygenation with continuous positive airway pressure (CPAP) of 5 cmH2O and inspiratory oxygen fraction (FiO2) of 1 and respiratory acidosis was prevented through extracorporeal CO2 removal, performed with the Decap® system (Hemodec, Salerno, Italy), a veno¬venous pump-driven extracorporeal circuit including a neonatal membrane lung. The extracorporeal circuit was connected to the right femoral vein, accessed via a 14 Fr double lumen catheter. The blood flow through the circuit was 350 mL/min and the sweep flow of oxygen through the membrane lung was 8 L/min. The intraoperative apnea period lasted 13 minutes. Our approach allowed maintaining normocapnia (PaCO2 38,5 and 40 mmHg before and at the end of the apnea period, respectively), preserving oxygenation (P/F ratio 378, 191, 198 and 200 after 3, 6, 9 and 12 min of apnea, respectively). Our report suggests that the minimally invasive CO2 removal associated with apneic oxygenation is an useful technique for managing anesthesiological situations requiring moderate apnea periods.

[Evaluation of the environmental monitoring's effects on the anaesthetic gases concentrations in the operating theatres]. / Valutazione degli effetti del monitoraggio ambientale sulle concentrazioni di gas anestetici nelle sale operatorie.

The aim of this study was to evaluate the efficacy of anaesthetic gases monitoring in the operating theatre. From January 1997 to December 2007, in compliance with the Ministerial Circular on Professional anaesthetic exposure in operating theatres (5/89), we conducted an environmental monitoring of nitrous oxide (N2O) in 71 operating rooms of 31 public hospitals to determine the respect of limits established by circular (50 ppm). The results show that number of surgery rooms with airborne concentrations of nitrous oxide outside normative limits reduced varying approximately from 40% without monitoring activity, to 15% after a cycle of 10 monitorings. This study demonstrate that the environmental monitoring is crucial, efficacy and should be the first step in developing work practices and worker education programs. To the best of our knowledge, this study demonstrates the efficacy of anaesthetic gases monitoring in the operating theatre was evaluated.

[Environmental quality of the operating theatres in Campania: long lasting monitoring results]. / La qualità ambientale di sale operatorie nella regione Campania: i risultati di un monitoraggio pluriennale.

In this study the microbiological, physical and chemical results of an investigation concerning the environmental conditions of operating theatres in 38 public hospitals of the Campania Government are presented. The analysis of the results has been made by considering specific standards suggested by national and international regulations. The results showed that 84% of the operating theatres presented normal microbiological values, in relation to the total bacterial load, while 16% did not. By considering the microclimatic monitoring 55% of the operating theatres showed normal values while 45% at least a microclimatic index did not. In relation to the concentrations of anaesthetics gases the survey pointed out that the nitrous oxides was within non prescribed environmental limits (50 ppm for N2O); while 15% of the halogenated was not in normal values.

[Lung resection in the elderly: some limits]. / Resezioni polmonari nell'anziano: quali limiti.

INTRODUCTION: A progressive and constant increase of mean life duration in the last century has determined the challenge of the treatment of lung cancer even in the elderly with good functional status. The aim of the present study is to evaluate the results obtained in the elderly, over seventy years old, who underwent pulmonary resection at our Division of Thoracic Surgery of Polyclinic of Bari from 1985 to 1995. PATIENTS AND METHODS: 938 patients with NSCLC have been operated on, from January 1985 to December 1995. 189 were over seventy and 19 were over eighty years old. We have performed the following surgical procedures: 21 pneumonectomies, 108 lobectomies/bi-lobectomies, 44 wedge resections, 16 staging thoracotomies. RESULTS: Post-operative complications were as follows: atelectasis 57, air leak 37, empyema 9, broncho-pleural fistula 3, arrhythmia 103, pulmonary edema 8, cardiac ischemia 3, pulmonary embolisms 1, delirium 2, hemothorax 3, exitus 5. There were 3 deaths caused by acute myocardial ischemia, one by pulmonary embolism, one by main right bronchus broncho-pleural fistula. Two and five-year overall survival were 67.1 and 37.8, respectively. CONCLUSION: Diagnostic and therapeutical procedures for lung cancer should be different in the elderly. In our experience, main post-operative complications were cardiovascular, consequent to the entity and duration of surgical operation and intra-operative blood leaks. The elderly require a more careful post-operative monitoring to prevent this kind of complications.

Endothoracic nodules in patients who under-went nephrectomy for renal cell carcinoma. Results of surgical resection.

AIM: A review of our experience with surgical resection of endothoracic nodules in patients who underwent nephrectomy for renal cell carcinoma (RCC) is presented, to evaluate the incidence of metastases in our series and the effectiveness and the opportunity of surgical treatment in this sort of patients. METHODS: Between January 1988 and January 2002, 41 consecutive patients (33 men, 8 women) underwent resection for suspected endothoracic metastases from RCC; 1 more male patient for metastases from an occult renal cancer. Mean age was 62 y (range: 43-80 y). Mean time between nephrectomy and 1st pulmonary resection in 41 patients was 29 mo (range: 0-120 mo). Nineteen patients had solitary lesions, 11 multiple unilateral and 12 bilateral. Antero-lateral thoracotomy was performed in 37 patients, median sternotomy in 1, simultaneous bilateral thoracotomy (clam-shell) in 2, sterno-laparotomy in 1, thoracofrenolaparotomy in 1. Wedge excision was performed in 36 patients, lobectomy with lymphadenectomy in 5, mediastinal limphadenectomy in 1. Six patients had repeat resection for recurrent metastases. RESULTS: Only 24 patients (57%) had histologic diagnosis of pulmonary metastases from RCC; 11 (26%) had benign lesions; 7 (17%) primary lung cancer. Mean follow-up was 25 mo (range: 1-91 mo). Overall, 4-y survival was 50%. Patients with solitary metastasis had a lower survival than those with 4 and more lesions. CONCLUSION: The evidence of pulmonary nodules in patients submitted to nephrectomy for RCC is not necessarily indicative of metastatic disease. Pulmonary resection for RCC metastases, even bilateral and recurrent, may help prolong survival in selected patients.

[The one-time surgical repair of postintubation esophagotracheal fistulae]. / Riparazione chirurgica in tempo unico di fistole esofagotracheali post-intubazione.

Personal experience in the treatment of the tracheal-esophageal non-neoplastic fistula is reported. In the last years, three cases of FTE, concerning some cannula tracheal-stomachal beare patients from 14, 2, 1 months have been examined. In two cases the patients were in spontaneous ventilation, on the contrary a mechanical ventilation was employed in the third. In two patients the fistular way was located correspondingly of the decubitus point of the tracheal stomachal cannula, on the membranaceous pars, and it was not associated with concomitant tracheal stenosis. The first stage of the treatment was removal of the nasogastric probe, supporting the decubitus phenomenon subtending the establishment and the extension of the FTE, then the preparation of a gastrostomy to assure the drainage of secretions under the fistula and a jejunum anastomosis to allow a suitable feeding and recovery of the patients. In these three cases the restoring operation was accomplished by a cervicotomy with a direct opening of the fistula, a suture of the esophageal wall, a suture of the membranaceous pars on the healthy tissue and then a protection of these sutures by interposition, between trachea and esophagus, of the prethyroid muscles transposed and fixed to the prevertebral band. In two cases the post-operative course did not present complications, while the patients kept in assisted ventilation during the postoperative course showed a relapse of the FTE on the twelfth day and then the progressive establishment of a septic state and the exitus on the twentieth day. It is underlined how the success of the reparation of the fistula is largely conditioned by the respiratory autonomy of the patient that guarantees the recurrence of decubitus and infection phenomena causing the lesion.

Primary bronchial amyloidosis. A case report.

A case of primary bronchial amyloidosis in a 58-year old patient, with haemoptysis, cough, purulent sputum and fever, is described. Bronchoscopy showed nodules and yellow wax plaques in the lower lobar bronchi. Histology of bioptic specimens showed the amyloidosic nature of the lesions. The search of other localizations was negative.

[Lung resections for cancer in the elderly]. / Resezioni polmonari per cancro nell'anziano.

BACKGROUND: The purpose of this study is to investigate the value of surgical treatment for lung cancer in the elderly. Results are compared with findings in younger patients operated on during the same period (1985-1990). METHODS: 137 patients 70 years of age or older (range: 70 yrs-87 yrs) (group A) underwent surgical resection [pneumonectomy in 19 (13.8%), lobectomy or bilobectomy in 84 (61.3%), segmentectomy or wedge resection in 22 (16%)]. In group B (younger patients) 561 were treated by pneumonectomy in 156 (27.8%), lobectomy or bilobectomy in 294 (52.4%) and segmentectomy or wedge resection in 64 (11.4%). RESULTS: The overall 2-year survival rate was 64.6% in group A and 61.4% in B. The 5-year survival rate was 36.2% (group A) and 43.2% (group B). CONCLUSIONS: These data suggest that advanced age should not be a contraindication to curative pulmonary resections. More attention must be paid to pre-codiseases of the increasing risk of postoperative complications.

[What is the prognostic significance of histomorphology in small cell lung carcinoma?]. / Quale è il significato prognostico della istomorfologia nel carcinoma a piccole cellule del polmone?

What is the prognostic significant of the histomorphology in the small cell carcinomas of the lung? After the WHO classification of the lung cancer (1981), several studies criticized the subdivision of the small cell carcinoma in three sub-types (oat-cell, intermediate cell and combined types). The role of histology in the prognostic predition has been devaluated. In order to verify the prognostic value of the morphology of the small cell types of lung cancer, we performed a multivariate analysis in 62 patients. The survival rate was analytically compared with the following parameters: nuclear maximum diameter, nuclear form, nuclear chromatism, chromatine distribution, presence of nucleolus, evidence of cytoplasm. The results showed that none of these parameters are able to express a prognostic value. According to the recent studies, we think that the small cell carcinoma of the lung is a neoplasia with a multiform histologic pattern. Differences observed in clinical management are not correlate with the morphology, but with other biological parameters still unknown.