Patient's home care management in persistent air leaks and chronic pneumothorax using a new drainage system.

The management of persistent air leaks (PALs) is one of the most common problems in general thoracic surgery, especially after elective pulmonary resections. The statistically most frequent air leak is caused by alveolar-pleural fistula (APF), which is defined as a link between the pulmonary parenchyma distal to a segmental bronchus, and the pleural space. Prolonged air leaks result in an increase in patient's hospital length of stay with possible infectious complications, aside from an overall hospitalization cost increase. The ability to discharge a patient who would otherwise depend on continuous aspiration, because chronic PALs represent a very important clinical and technological improvement. We describe the case of a patient with chronic PALs and pneumothorax due to pulmonary fibrosis secondary to rheumatoid arthritis, with diffuse pulmonary nodules, in which surgical attempts to manage air leaks were ineffective. He was successfully home-assisted with a new chest drainage system with automatic constant negative suction pressure.

The significance of associated pre-invasive lesions in patients resected for primary lung neoplasms.

OBJECTIVE: To evaluate the prevalence and clinico/prognostic significance of the presence of pre-invasive lesions in patients resected for primary lung neoplasm. METHODS: From 1993 to 2002, 1090 patients received resection for primary lung carcinomas. Of these, 73 presented an associated pre-invasive lesion in the surgical specimen distant from the primary tumour. Classification of pre-invasive lesions included Atypical Adenomatous Hyperplasia (AAH); Carcinoma In Situ (CIS) either diffuse or at the bronchial resection margin; Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH). Correlation between the presence of pre-invasive lesion and the following variables were calculated by logistic regression analysis: sex, age, median tumour size, histology, histologic differentiation, histologic evidence of invasiveness (vascular and perineural invasion), peritumoural lymphocytic infiltrate, pTNM, lobe location, history of previous malignancy. Survival rates were computed using Kaplan-Meier method and survival differences with the total patient population of resected lung carcinomas were tested using the log-rank method. RESULTS: There were 28 AAH, 42 CIS (5 at the bronchial resection margin) and 3 DIPNECH. Histology of the primary tumor included bronchioloalveolar carcinoma (9 patients), adenocarcinoma (19), squamous cell carcinoma (39), typical carcinoid tumour (3) and adenosquamous carcinoma (3). Overall prevalence of pre-invasive lesion was 6.7%. A strong correlation was found between the presence of AAH and the co-existence of either adenocarcinoma, bronchioloalveolar carcinoma or mixed adenocarcinoma-containing tumours (P = 0.00002) between CIS and squamous cell carcinoma (P = 0.009) and between DIPNECH and carcinoid tumours (P = 0.001). No significant correlation was found between the presence of any type of pre-invasive lesion and sex, age, median tumour size, histologic differentiation, histologic evidence of invasiveness, pTNM, lobe location and history of previous malignancy or the probability to develop a second primary lung carcinoma in the remaining lobe(s) after resection. Survival rates in the patients with AAH and CIS were not significantly different from those of patients without pre-invasive lesion (P = 0.3 and P = 0.1). CONCLUSIONS: Associated pre-invasive lesions in patients resected for primary lung neoplasms are not infrequent. AAH is associated with adenocarcinoma, CIS with squamous cell carcinoma, DIPNECH with typical carcinoid tumours. Our experience indicates that in these patients histology, stage distribution and survival do not differ from the total population of resected patients with lung tumors.

Stapler blebectomy and pleural abrasion by video-assisted thoracoscopy for spontaneous pneumothorax.

BACKGROUND: This study aims to evaluate the efficacy of video-assisted thoracoscopic surgery (VATS) pleurodesis in the treatment of spontaneous pneumothorax with particular reference to the postoperative period and the rate of recurrence after pleural abrasion. METHODS: One hundred and thirty-three patients who underwent VATS management of primary spontaneous pneumothorax were retrospectively reviewed. They were 113 males and 20 females with median age of 26 (range 12-37). Among these patients, 114 underwent VATS for recurrent pneumothorax and 19 for persistent air-leakage at the first episode. During surgical procedure, in 78% of cases, parenchymal blebs were identified and resected by stapler resection. All patients were submitted to pleural abrasion. RESULTS: No intra- or postoperative deaths occurred. Postoperative complications were persistent air-leak for more than 7 days in 6 patients (4.3%) bleeding in 3 patients (2.2%). The median chest-tube duration and hospital stay were 2 (range 2-11) and 3 (range 3-12) days, respectively. Median follow-up period of 53 (range 6-96) months was complete for all patients. Five episodes of recurrent pneumothorax were encountered and 4 of them, because of major entity, required re-do VATS with stapler resection and pleural abrasion: their postoperative period and residual follow-up was uneventful. CONCLUSIONS: The goal in the surgical management of spontaneous pneumothorax, which often affects "apparently healthy" young patients, is to secure the less recurrence rate with no mortality and quite null morbidity and functional impairment. VATS stapler resection and pleural abrasion is a safe procedure allowing a good management of the disease with low complication rate, short chest-drain duration, hospital stay and recurrence rate quite similar to those referred for other procedures such as pleural poudrage or limited pleurectomy.

Descending necrotizing mediastinitis: surgical management.

OBJECTIVE: Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. METHODS: Between April 1994 and April 2000, 13 patients, mean age 39.23+/-18.47 (median 38, range 16-67) years, with DNM were submitted to surgical treatment. Primary odontogenic abscess occurred in six, peritonsillar abscess in five and post-traumatic cervical abscess in two patients. Diagnosis was confirmed by computed tomography (CT) of the neck and chest. All patients underwent surgical drainage of the cervico-mediastinal regions by a bilateral collar incision associated with right thoracotomy in ten cases. RESULTS: Six patients out of 13 required reoperation. Two patients previously submitted only to cervical drainage required thoracotomy; four patients, which have been submitted to cervico-thoracic drainage, underwent contralateral thoracotomy in two cases and ipsilateral reoperation in two cases. Ten patients evolved well and were discharged without major sequelae; three patients died of multiorgan failure related to septic shock. Mortality rate was 23%. CONCLUSION: Early diagnosis by CT of the neck and chest suggest a rapid indication of surgical approach to DNM. Ample cervicotomy associated with mediastinal drainage via large thoracotomic incision is essential in managing these critically ill patients and can significantly reduce the mortality rate for this condition, often affecting young people, to acceptable values.

Videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease.

OBJECTIVE: Interstitial lung diseases (ILD) require lung biopsy for the diagnosis in more than 30% of patients. Open lung biopsy (OLB) was generally considered the most reliable method of biopsy and tissue diagnosis. This study tests the diagnostic accuracy and safety of the videothoracoscopic lung biopsy (VTLB) in the diagnosis of ILD. METHODS: During the last 5 years, 58 patients were submitted to VTLB under general anesthesia. The mean age was 49.6 +/- 12.0 years (range 21-69). All the biopsies were performed by an endostapler EndoPath 30 or 45. Conversion to minithoracotomy was necessary in only one patient because of extensive pleural sinfisis. All the specimens were sent to the microbiology and pathology department for microbiological and histopathological diagnosis. One chest-tube (28F) was positioned and connected to a drainage-system and placed on suction. RESULTS: The histopathological diagnosis was obtained for all patients and therefore the diagnostic accuracy of the procedure was 100%. No postoperative haemothorax occurred and only two patients experienced a prolonged air-leakage (3.4%). The median duration of the chest-drain was 3 days (range 1-7) and the median hospital stay was 4 days (range 2-7). CONCLUSION: VTLB provides adequate specimen volume for histopathologic diagnosis and achieves a very high diagnostic accuracy (100% in our series). The postoperative morbidity and mortality rates are lower than those related to OLB. We conclude that VTLB is an effective and safe procedure in the diagnosis of ILD.

Neurophysiologic assessment of nerve impairment in posterolateral and muscle-sparing thoracotomy.

OBJECTIVE: This study was aimed at analyzing the degree of intercostal nerve impairment in posterolateral and muscle-sparing thoracotomy and at correlating the nerve damage to the severity of long-lasting postthoracotomy pain. METHODS: Neurophysiologic recordings were performed 1 month after either posterolateral or muscle-sparing thoracotomy to assess the presence of the superficial abdominal reflexes (mediated in part by the intercostal nerves), the somatosensory-evoked responses after electrical stimulation of the surgical scar, and the electrical thresholds for tactile and pain sensations of the surgical incision. RESULTS: The patients who underwent a posterolateral thoracotomy showed a higher degree of intercostal nerve impairment than the muscle-sparing thoracotomy patients as revealed by the disappearance of the abdominal reflexes, a larger reduction in amplitude of the somatosensory-evoked potentials, and a larger increase of the sensory thresholds to electrical stimulation for both tactile perception and pain. In addition, these neurophysiologic parameters were highly correlated to the postthoracotomy pain experienced by the patients 1 month after surgery, indicating a causal role for nerve impairment in the long-lasting postoperative pain. CONCLUSIONS: This study shows for the first time the pathophysiologic differences between posterolateral and muscle-sparing thoracotomy and suggests that the minor long-lasting postthoracotomy pain in muscle-sparing thoracotomy patients is partly due to a minor nerve damage. In addition, because nerve impairment is responsible for the long-lasting neuropathic component of postoperative pain, it is necessary to match specific treatments to the neuropathic pain-generating mechanisms.

Control of postoperative pain by transcutaneous electrical nerve stimulation after thoracic operations.

BACKGROUND: Transcutaneous electrical nerve stimulation (TENS) has been used extensively to control postoperative pain, but its effects are controversial. This is probably due to the different types of operations performed and, therefore, to the varying intensity of postoperative pain. Here we present an extensive study with TENS in 324 patients who underwent different types of thoracic surgical procedures: posterolateral thoracotomy, muscle-sparing thoracotomy, costotomy, sternotomy, and video-assisted thoracoscopy. METHODS: Each patient cohort was randomly subdivided into three treatment groups: TENS, placebo TENS and control. The effectiveness of TENS was assessed by two factors: the time from the beginning of treatment to the request for further analgesia and the total medication intake during the first 12 hours after operation. RESULTS: Whereas posterolateral thoracotomy produced severe pain, muscle-sparing thoracotomy, costotomy, and sternotomy caused moderate pain, and video-assisted thoracoscopy caused only mild pain. The TENS treatment was not effective in the posterolateral thoracotomy group, but it was useful as an adjunct to other medications in the muscle-sparing thoracotomy, costotomy, and sternotomy groups. In contrast, representing the only pain control treatment with no adjunct drugs, it was very effective in patients having video-assisted thoracoscopy. CONCLUSIONS: These findings show that TENS is useful after thoracic surgical procedures only when postoperative pain is mild to moderate; it is uneffective for severe pain.

Videothoracoscopy and video-assisted small thoracotomy for the treatment of pulmonary malignancies.

Video-assisted thoracic surgical procedures continue to be performed with increased frequency; the role of this new technique in the treatment of pulmonary malignancies or metastatic mediastinal adenopathies is not yet defined. Out of a series of 100 consecutive video-assisted thoracic operations, 22 patients resulted affected by a malignancy in the lung or in the subcarinal lymphnodes: six patients had a primary lung cancer and were operated with a video-assisted small thoracotomy of 5 cm (three lobectomy and three segmentectomy) because of a very poor respiratory reserve. Nine patients received a video-assisted wedge resection of a nodule resulted at the frozen section a metastasis of a carcinoma: a small thoracotomy of 8 cm was made and a hand entered the thoracic cage to obtain a careful palpation of the entire lung; five patients had enlarged lymphnodes only in posterior and inferior mediastinum, inaccessible by cervical mediastinoscopy or anterior mediastinotomy: thoracoscopic exploration obtained a useful mediastinal nodal sampling for these adenopathies. In selected cases video-assisted thoracic surgery can be used for resection or assessment of thoracic malignancies.

Bronchial sleeve resection distal to the main bronchi with complete pulmonary preservation. Report on three successful cases.

Three successful cases of low grade malignant bronchial tumors resected by means of a bronchial sleeve resection distal to the main bronchi with complete pulmonary preservation are presented. Reconstruction of the bronchial tree was accomplished by suturing together the distal lobar bronchi and then anastomosing the double-barrel suture to the proximal residual bronchus. All patients presented excellent results, although in one patient postoperative course was complicated by persistent mucopurulent secretions. Bronchial sleeve resection distal to the main bronchi can be successfully performed for benign or low-grade malignant bronchial tumors. Technically, the operation is more complex than standard sleeve resection of the main bronchus and requires an experienced team. Postoperatively, an increased morbidity rate, mostly represented by secretions retention, may usually be anticipated, necessitating an aggressive medical and bronchoscopic management.

Combined radiosurgical treatment of Pancoast tumor.

Operative technique and long-term results of 60 consecutive patients with Pancoast tumor treated with combined radiosurgical treatment were evaluated. External radiation therapy was administered preoperatively in a dose of 30 Gy in 50 patients. Operation was considered radical (R0) in 36 patients (60%). A microscopic invasion of the margin of resection (R1) was observed in 5 patients (8.3%). In 19 patients (31.6%) the operation was considered presumably not radical (R2). Three patients died in the postoperative period (5%). Fourteen major postoperative complications occurred in 13 patients (21%). Seven patients had recurrence of pain postoperatively. Overall 3- and 5-year actuarial survival rates were 34% and 17.4%, respectively. The corresponding figures for the R0 and combined R1-R2 groups were 45.8% and 23.5% (R0), and 11.4% (R1-R2; no 5-year survivors were observed in this group) (p < 0.025). Median survivals in the R0 and combined R1-R2 patients were 19 and 7 months, respectively. Different median survivals for the patients with residual tumor were as follows: intervertebral foramina, 5 months; subclavian artery (isolated), 9 months; subclavian artery (in association), 7 months; brachial plexus, 4 months; and vertebral body, 7 months. We conclude that combined radiosurgical treatment represents a valuable therapeutic option in the treatment of Pancoast tumor. In case of residual tumor a poor outcome may usually be anticipated, but in the majority of these patients the operation permits good control of the pain.

[Post-traumatic hernia of the diaphragm]. / Le ernie post-traumatiche del diaframma.

The paper reports the series of post-traumatic hernias of the diaphragm observed during the period between 1954 and June 1992. This group of 77 patients (59 males and 18 females) were aged between 6 and 75 years old. Both acute and chronic hernias were reported; in 60 cases the diaphragmatic lesion was on the left, in 9 cases on the right, and there were 8 cases of laceration to both hemidiaphragms. The most frequently herniated organ was the stomach, followed by the transverse colon and spleen. With regard to the access route used, the authors draw attention to the fact that during the first twenty years of the series thoracotomies were prevalently used, whereas during the last decade laparotomy has been used in cases of early post-traumatic hernia, thoracotomy in cases of chronic post-traumatic hernia or if there is suspected damage to organs and intrathoracic structures.

The value of selective mediastinoscopy in predicting resectability of patients with bronchogenic carcinoma.

From 1980 to 1990, 1505 patients underwent thoracotomy as definitive treatment for non small cell lung cancer. Computed tomography (CT) of the chest has been used routinely since 1984 for assessment of mediastinal lymph node involvement. A total of 235 cervical mediastinoscopies and 71 anterior parasternal mediastinotomies were performed on the same patient population as preoperative staging when CT scan demonstrated mediastinal lymph nodes larger than 1 cm. Radical resections showed a constant increase in number from 70.1% in the period 1980-84 to 82.7% in the period 1985-90. Exploratory thoracotomies and thoracotomies with residual tumor showed a parallel reduction: 14.5% in 1980-84 to 7.4% in 1985-90 for the former, 15.4% in 1980-84 to 9.8% in 1985-90 for the latter. The percentage of N2 disease to the total number of thoracotomies decreased from 23.6% in 1980-81 to 11.2% in 1989-90. We conclude that a selective use of cervical mediastinoscopy and anterior parasternal mediastinotomy, based upon the results of CT scan, may have contributed to reduce the number of exploratory thoracotomies and thoracotomies with residual tumor.

[Treatment of N2-3 pulmonary carcinoma. Preoperative radio-chemotherapy]. / Trattamento del carcinoma polmonare N2-3. Radio-chemioterapia preoperatoria.

Preoperative integrated neo-adjuvant radio-chemotherapy was performed in 8 patients suffering from NSCLC bronchial carcinoma at stages IIIA-IIIB (N3 mediastinal). After treatment, 7 patients underwent apparently radical pulmonary exeresis, whereas the patient with adenocarcinoma (T2 N2 M0) was not operated due to the recurrence of disease following supraclavicular lymph node metastasis. Preoperative radio-chemotherapy allows the sub-staging of the disease and the insertion of these patients into the operating programme.

Tracheal stenosis. A study of 100 cases.

A series of 100 cases of tracheal stenoses, 66 non-neoplastic and 34 neoplastic, are reviewed; tracheal resection was performed in 28 inflammatory stenoses and in five tumours. A T-tube stent was used in 12 patients. Results were good in 81% of resections for non-neoplastic stenoses; two out of three resections for adenoid cystic carcinoma are alive after ten years and the third died after two years with metastases; two patients who received a tracheal resection for epidermoid carcinomas died after three and four years with metastases. Inflammatory tracheal stenoses treated using T-tube achieved good results only in one third of cases. Pre-operative preparation is the most important factor to obtain good results: end-to-end anastomosis requires a healthy mucosa without infection or ulcers.

[Prevention of deep venous thrombosis with defibrotide in chest surgery. Controlled multicenter study versus heparin]. / Profilassi con defibrotide delle trombosi venose profonde in chirurgia toracica. Studio multicentrico controllato verso eparina.

The effectiveness and tolerability of defibrotide in the prevention of post-surgery deep vein thrombosis (DVT) were compared with those of heparin in a multicentric randomized controlled study. One hundred-eight-four both sexes patients submitted to thoracic surgery were randomly allocated to defibrotide (400 mg b.i.d. by IV route, n = 94) or to calcium heparin (5000 I.U. t.i.d. s.c., n = 90); both treatments were started the day before the operation and withdrawn when patients were allowed to stand up (i.e., after 7 days). No patients developed DVT in the defibrotide group, while a single case of DVT was detected in the heparin group; furthermore, a more prominent bleeding was observed in the latter, in the early post-operative period (normal bleeding: 2nd day: defibrotide 70/92 pts, heparin 53/90 pts, p less than 0.02; 3rd day: defibrotide 87/92 pts, heparin 76/90 pts, p less than 0.05, chi 2 test), while the healing rate of surgical wounds was similar in the two groups. No relevant modifications in laboratory parameters were seen throughout the observation period. Thus, these preliminary data suggest that defibrotide is at least as effective as heparin in the prevention of post-thoracic surgery DVT and that the former drug has a possibly better tolerability profile, due to a lesser tendency to bleeding.