Intraoperative identification and effective "blood patch" prevention of persistent air leak in lung resections.

Persistent air leak (PAL) is the most common complication after lung resection, requiring additional treatments and hospital stay. Intraoperative prevention of PAL is usually left to the surgeon's subjective judgement, with inconsistent results. The aim of the study was to establish systematic, reproducible quantification of air leaks at thoracotomy in order to identify those which are potentially persistent, to be preventively treated by intraoperative "blood patch" pneumo-stasis. In a consecutive series of 570 lung resections, parenchymal suture air tightness was tested intraoperatively at end-inspiratory pressure intervals from 15 to 35 cm H2O. Air leaks at 15 cm H2O (n=40) were considered too critical, while air escape beyond 30 cm H2O (n=437) was deemed quickly self-sealing postoperatively; these conditions were managed by further surgery and standard chest tubes only, respectively. Air leaks between 16 and 30 cm H20 (n=93) were assumed to be the main source of postoperative PAL and were preventively treated with 50 cc of blood left in the cavity for 3 hours after closing the thoracotomy. Chest tubes were set up so as to avoid tension pneumothorax or occult bleeding. No early or late major complications were related to the intraoperative "blood patch" procedure. The cumulative incidence of PAL was 1.4%, most of which (6/8) belonging to the group leaking air in the 16-30 cm H2O pressure interval. In contrast, the PAL rate in the 437 patients reputed to be at low risk was 0.2%. The overall mean hospital stay was 7.2 days, the mean duration of chest tube duration 3.5 days, and the complication rate 15%. According to our retrospective data, air leaks occurring between 16 and 30 cm H2O of pressure in the intubated lung were identified as carrying the highest risk of becoming persistent postoperatively; intraoperative "blood patch" pneumo-stasis is a convenient and successful preventive method to minimize PAL occurrence in this group of patients.

[Thoracic outlet syndrome: clinical staging]. / Sindrome dello stretto toracico superiore: stadiazione clinica.

The clinical and instrumental manifestations of thoracic outlet syndrome are well known but the therapeutic choices frequently differ in relation to the physician's experience. Thus, there is no univocal opinion regarding the therapy of this complex syndrome. To solve this problem we have attempted to bring together the clinical and instrumental pictures in a single classification that includes the three fundamental aspects of the syndrome, namely nerve, artery and vein injury (NAV). Our goal was to achieve a universally accepted therapy-oriented staging system, as is the case with the TNM system for malignant tumours. From 1984 to 2002, in our institution 156 patients with thoracic outlet syndrome were evaluated. These were grouped in 4 stages depending on their NAV status. Subsequent therapy was in accordance with stage. Our results confirmed the accuracy of NAV. On the basis of our preliminary experience, the NAV staging system is useful for correct patient grouping. Now a prospective multicentre study is needed for universal scientific validation.

[Pleuro-pneumonectomy, RT and CT for pleural mesothelioma. Prospective study]. / Pleuro-pneumonectomia, RT e CT per mesotelioma pleurico. Uno studio prospettico.

Though associated with substantially prolonged survival, the favourable results of Sugarbaker's trimodality treatment for malignant pleural mesothelioma are controversial and have yet to be extensively reproduced. The aim was to evaluate the prospective medium-term (3-year) reproducibility of the results of trimodality treatment in a significant group of patients staged using the international IMIG classification. Forty-three patients with malignant pleural mesothelioma were candidates for extended pleuropneumonectomy, followed by chemo- and radiotherapy. At thoracotomy, 33 of the 43 surgical candidates underwent extended pleuropneumonectomy and 71% of the 30 evaluable operated patients completed the scheduled course of adjuvant chemotherapy. The perioperative mortality rate was 6% and the major morbidity rate 36%. At 3 years the overall survival of the 30 evaluable patients was 30% and the disease-free survival rate was 25%, with a prevalence of epithelial pI and pII IMIG stages. Clinical understaging was appreciable. Survival was less favourable for stage pIII and for mixed tumours. Most of the disease recurrences were due to incomplete local postsurgical monitoring. This series confirms the reproducibility of trimodality treatment for malignant pleural mesothelioma. The treatment is associated with prolonged survival in the case of early-stage tumours and has an acceptable complication rate. Early diagnosis, accurate staging, preoperative induction and better local monitoring are avenues to be explored when seeking to achieve curability of malignant pleural mesothelioma.