Lung volume reduction surgery 10 years later.

AIM: The purpose of this study was to evaluate whether favorable short-term results in term of functional outcome and survival following lung volume reduction surgery persist for longer periods. Composite preoperative and early postoperative variables were analysed. METHODS: This study was conducted on 52 emphysematous patients who underwent lung volume reduction surgery (LVRS) from 1993 to 2000, through a delayed retrospective analysis that has allowed us to evaluate a long-term follow-up (10 years or more); lung function and other variables were considered with respect to survival; 11 patients submitted to lung transplantation were also evaluated. RESULTS: Upper lobe distribution of emphysema (P=0.02, HR:2.43) and systolic PAP (P=0.04, HR=2.11) were significantly correlated to survival in a multivariate analysis; these variables seem to identify a small subgroup of 14 patients with longer survival (more than 10 years). Lung transplantation performed in some worsening patients (mean FEV1%:17±4) showed a trend of better survival when we compared the observed survival (55±47 months) with expected survival (39.5±15 months) (P=ns). CONCLUSION: We conclude that LVRS can lead to a very long survival (10 years or more) in a small subgroup of patients, with improvement of pulmonary functional data. Some preoperative data (upper lobe distribution of emphysema and pulmonary arterial pressure) appear to predict survival. Lung transplantation can be offered to these patients, showing a trend to improved life expectancy.

Lung volume reduction surgery 10 years later.

AIM:The purpose of this study was to evaluate whether favorable short-term results in term of functional outcome and survival following lung volume reduction surgery persist for longer periods. Composite preoperative and early postoperative variables were analysed. METHODS: This study was conducted on 52 emphysematous patients who underwent lung volume reduction surgery (LVRS) from 1993 to 2000, through a delayed retrospective analysis that has allowed us to evaluate a long-term follow-up (10 years or more); lung function and other variables were considered with respect to survival; 11 patients submitted to lung transplantation were also evaluated. RESULTS:Upper lobe distribution of emphysema (P=0.02, HR:2.43) and systolic PAP (P=0.04, HR=2.11) were significantly correlated to survival in a multivariate analysis; these variables seem to identify a small subgroup of 14 patients with longer survival (more than 10 years). Lung transplantation performed in some worsening patients (mean FEV1%:17±4) showed a trend of better survival when we compared the observed survival (55±47 months) with expected survival (39.5±15 months) (P=ns). CONCLUSION: We conclude that LVRS can lead to a very long survival (10 years or more) in a small subgroup of patients, with improvement of pulmonary functional data. Some preoperative data (upper lobe distribution of emphysema and pulmonary arterial pressure) appear to predict survival. Lung transplantation can be offered to these patients, showing a trend to improved life expectancy.

Efficacy of fleece-bound sealing system (TachoSil®) in delayed anterior tracheal lacerations secondary to ischemic tracheal necrosis after total thyroidectomy.

Thyroidectomy is one of the commonest surgical operations performed in endocrine surgery; results are generally excellent and morbidity and mortality usually are negligible. Total thyroidectomy's complication rates are low, with an overall incidence of 4.3% among experienced surgeons: the most frequent complications are vocal cord paresis or paralysis, hypoparathyroidism, hypocalcemia, haematoma and wound infection. Tracheal injury following thyroidectomy is even more rare. As reported from some authors, inadvertent tracheal injury has an incidence of 0-0.6% during thyroidectomy. Tracheal laceration (generally located in the posterolateral surface) is often recognized and repaired immediately, during the same intervention. Rarely, following a total thyroidectomy, a delayed tracheal rupture may occur secondary to an ischemic damage of the trachea. This has been described in few cases reported in literature. In this paper we report of a case in which delayed tracheal lacerations appeared 10 days after the patient underwent total thyroidectomy: a prompt surgical operation was efficient using both direct sutures of tracheal breaches and a patch of fibrinogen-thrombin coated collagen fleece covering the entire surface.

Two-stage treatment of a secondary aortoesophageal fistula after thoracic endovascular aneurysm repair.

Secondary aortoesophageal fistula is a relatively rare but very often lethal complication that may develop after thoracic endovascular aneurysm repair (TEVAR). The clinical syndrome is well explained by the Chiari triad: midthoracic pain and/or dysphagia, and sentinel minor hematemesis followed by massive hematemesis. The incidence of this serious complication has increased with the growing number of patients undergoing TEVAR. This case report describes a patient who was seen in the emergency department at this hospital because of fever, sepsis and thoracic pain radiating to the back and unresponsive to drug therapy, diagnosed with a secondary aortoesophageal fistula and subsequently treated with a two stage surgical procedure.

Preliminary results of a new small-bore percutaneous pleural catheter used for treatment of malignant pleural effusions in ECOG PS 3-4 patients.

BACKGROUND: In cancer patients with malignant pleural effusions(MPEs),the commonest procedure to treat them with palliative intention is talc pleurodesis (TP) which can be obtained with talc slurry (TS) using small-bore catheters(SBC)or with thoracoscopic poudrage. SBC use is therefore rapidly increasing. The aim of this paper is to present our preliminary TP results using a new percutaneous chest drainage system(UNICO®, Redax, Mirandola Modena, Italy). METHODS: In the period 1st March-20th of July 2011,seven consecutive ECOG PS 3-4 patients(4 females, mean age 73.2 ± 12.1 years),unfit for thoracoscopic talc poudrage, were enrolled in our study. All patients received many thoracentesis before the placement of a chest drainage(median thoracentesis number:4.42 ± 1.13).UNICO® was bedside placed in all cases and TS was administered through the drainage when the overall fluid amount didn't exceed 150-200 ml/24 h and the lung was correctly re-expanded at the chest X-ray control. RESULTS: There were no clinical complications following the placement of the drainage: its placement was easy, safe and well-tolerated by all patients. The median chest tube stay, before TS, was 7.2 ± 2.7 days while the median chest tube stay after TS was 1.5 ± 0.7 days. A satisfactory radiological lung expansion was achieved in all cases; PL effectiveness and dyspnea relief were complete in 6 and 4 cases, respectively. No patients required any further thoracentesis. CONCLUSIONS: TS through UNICO® is safe and efficient. The drainage was well-tolerated by all patients, even in case of its long-term stay. We may conclude that bedside TS through this new small-bore percutaneous drainage should be proposed as a viable clinical solution for MPEs in ECOG PS 3-4 patients, unfit for a thoracoscopic procedure. Moreover, with this device, we believe that TS might be an accessible procedure for pulmonologists and oncologists too.

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.

Digital air leak monitoring after lobectomy for primary lung cancer in patients with moderate COPD: can a fast-tracking algorithm reduce postoperative costs and complications?

AIM: Prolonged air leaks remain one of the most important complication after pulmonary resection. The aim of this study was to test a new fast-track chest tube removal protocol using a new drainage system, which digitally records postoperative air leaks, compared to the traditional one, with subjective visual air leak assessment. METHODS: Patients with moderate COPD undergoing lobectomy for primary lung cancer at the Department of Thoracic Surgery of the University of Torino were randomised in two groups with different chest drainage systems and different removal protocols: in Group A the drainage was removed after digitally recordered measurement of air leaks; in Group B the tube was removed according to the air leaks visualization by bubbling in the water column. The following variables were evaluated: first and second drainage removal day; overall hospital length of stay; overall hospitalization costs. RESULTS: First and second drainages were removed sooner in those patients with the digital drainage system. An earlier drainage removal is associated with significative reduction in hospital length of stay and overall hospitalization costs. CONCLUSION: The digital and continuous air leak measurement reduces the hospital length of stay by a more accurate and reproductive air leaks measurement. Further studies are mandatory to corroborate our preliminary results.

Chest wall and hemidiaphragm reconstruction with Gore-Tex mesh and omolateral latissimus dorsi flap. A case report.

There are various method of reconstruction when chest wall resection is performed for the treatment of tumors of the chest wall. In this case a chest wall resection and reconstruction was performed using an omolateral latissimus dorsi flap, together with Gore-Tex mesh. A 42-year-old woman was diagnosed as having a huge low grade chondrosarcoma and underwent surgical resection which interested the anterior chest wall from the level of the IV to X rib and the right hemidiaphragm. Gore-Tex mesh was fixed to the residual chest wall and an ipsilateral pedicled latissimus dorsi muscle flap was placed on the alloplastic mesh. The patient was discharged from the hospital 17 days postoperatively. The postoperative course was uneventful and the wound was fine.

The role of surgery in the management of solitary pulmonary nodule in breast cancer patients.

AIMS: To assess the role of surgery in the diagnosis and treatment of a solitary pulmonary nodule (SPN) in patients who had received previous surgery for breast cancer. METHODS: A series of 79 consecutive patients who underwent surgery for an SPN between 1990 and 2003 after a curative resection for breast cancer were reviewed. RESULTS: Surgical diagnosis was obtained by open procedure before 1996 (37 cases), and by video-assisted thoracoscopic surgery (VATS) after 1996 (33 out of 42 cases, 9 open procedures) and intraoperative evaluation. Histology of SPN was primary lung cancer in 38 patients, pulmonary metastasis of breast cancer in 27, and benign condition in 14. VATS was converted to open procedure for anatomical resection in primary lung cancer and for the palpation of the lung in metastatic disease. Average disease-free interval from the initial mastectomy was significantly longer in primary lung cancer than in metastatic patients (179+/-107 vs 51+/-27 moths). Manual palpation identified multiple pulmonary nodules in 3 out of 27 metastatic patients. Five-year survival rate after pulmonary metastasectomy was 38% and was significantly influenced by disease-free interval; 5-year survival rate after resection of primary lung cancer was 43% and was significantly influenced by the pathological stage. CONCLUSIONS: VATS is a good procedure for diagnostic management of peripheral SPN. As SPN in breast cancer patients is primary lung cancer in half cases, it deserves confirmation of pathological diagnosis and appropriate surgical treatment. When breast cancer metastasis is demonstrated, open procedure must be performed to palpate the entire lung to exclude previously unknown nodules.

Lung donors selection criteria: a review.

Lung transplantation has had increasing success worldwide and it became an acceptable treatment modality in end-stage pulmonary diseases. The insufficient supply of donor lungs, resulting in prolonged waiting time, and the significant rise of patients on the waiting list, have forced the most experienced transplantation centers to redefine the acceptable lung donor criteria including marginal allografts. Existing standard lung donor criteria have been established in the first period of lung transplantation activity, based mainly on opinions and individual experiences rather than on existing evidences: the paucity of donors may be also explained by the rigid application of these criteria. The quality of donor organs has a significant impact on early and long-term recipient outcome. Recent studies have demonstrated that the use of marginal donors did not affect early and late recipient outcome, and significantly increased the number of transplants performed. The aim of this paper is to review how the main lung donor selection criteria have been changed and how they influence the recipient outcome.

Subarachnoid-pleural fistula due to blunt chest trauma. A case report.

Subarachnoid pleural fistula (SPF) due to blunt chest trauma is rare. When SPF isn't associated with any neurological deficits, its clinical diagnosis is possible only with high degree of suspicion. Presentation symptoms include dyspnea and respiratory distress caused by the collection of cerebral-spinal fluid in the pleural cavity. Computed tomography scan after myelography is helpful in confirming the site of the fistula. Possible dangerous complications are infections or pneumoencephalus. Some cases resolved spontaneously after bed rest or pleural drainage alone, while others required surgical repair. We report a case of spontaneous closure after pleural drainage and a brief period of mechanical ventilation.

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.

Solitary pericardial hydatid cyst.

Hydatid cyst of the heart is an uncommon presentation of human echinococcosis which may lead to life-threatening conditions. Diagnosis should be suspected in every case of cyst-like mass in persons coming from areas where echinococcus granulosus is endemic. Echocardiography, computed tomography and magnetic resonance imaging can help in the differential diagnosis of the lesion. Even if some reports of successful therapy with benzimidazoles have been described, the treatment of choice is the surgical excision of the cyst. Pericardiectomy with cyst removal is feasible with low morbidity and mortality rates even in elder patients. The authors describe the successful surgical management of a single giant pericardial hydatid cyst in a 78-year-old woman from North Africa.

[Bronchopulmonary carcinoid tumours]. / I tumori carcinoidi broncopolmonari.

Carcinoids are neuroendocrine neoplasms. Bronchial carcinoids are unusual, malignant primary neoplasms that characteristically involve the central airways and typically exhibit well-defined margins and bronchial-related growth. Bronchial carcinoids include low-grade typical carcinoids and the more aggressive atypical ones. They usually affect patients in the 3rd through the 7th decade of life who are often symptomatic with cough, hemoptysis or obstructive pneumonia. Rarely, the initial symptoms are related to the secretion of hormones causing carcinoid or other endocrine syndromes. Bronchial carcinoids radiologically manifest as hilar or perihilar masses, with or without associated atelectasis, pneumonia or bronchiectasis. At CT-scan the relationship of these tumors with the bronchial tree is usually seen, and they show contrast enhancement or calcification. Even if the radiological signs may be suggestive for bronchial carcinoid, the definitive diagnosis is reached only by the tissue sampling. Bronchoscopic biopsy is the more effective way to identify the nature of carcinoid tumors because of their frequent central location. The treatment of choice is the surgical resection which should be carried out with maximum respect for the residual lung and bronchial tissues. Endoscopic ablations in well defined cases, bronchotomy and lung resections with or without bronchoplastic procedures have been described. Hilar and mediastinal lymph node sampling and examination should be ever performed during open procedures. Positivity of the nodal tissues could influence the resection procedure and is related with the prognosis, specially for the atypical carcinoids. Chemo- and radiation therapy are not effective in improving the long-term outcome in those patients with advanced disease. The long-term outcome is strictly related with the histological subtype and the lymph node status. Local recurrences and distant metastases are more frequent in the atypical carcinoids which manifest a more aggressive behavior. During the last decade, the importance of the use of somatostatine analogues (octreotide) in the staging, early detection of the recurrent disease and its management such as that of the associated carcinoid syndrome became clear.

The role of gastroesophageal reflux disease in chest pain.

Gastroesophageal reflux disease (GERD) is thought to play an important role in the pathogenesis of non-cardiac, unexplained, chest pain. The physiopathological mechanism of this extraesophageal manifestation, remains unclear but it is supposed that the ache could be triggered by the stimulation of acid-sensitive nociceptors of the mucosa. The esophageal origin of the symptom may be identified by an empiric trial of high-dose antisecretory drugs or an abnormal prolonged ambulatory pH monitoring study. Less important is the role of endoscopy especially in subjects without typical symptoms of GERD. The use of manometry or provocative tests can consent to evaluate for esophageal motility abnormalities. It is generally accepted that in clinical practice, in patients with non-cardiac chest pain, the administration of proton pump inhibitors, could serve as a first approach. It is cost-effective in the short-term period, when compared with investigation for gastrointestinal causes, with cost savings persisting beyond a year. In conclusion, patients with non-cardiac chest pain of unknown origin should be carefully screened for the occurrence of GERD, but further research is needed to clarify the role of the latter on the pathogenesis of this symptom.

Severe hypoglycaemia associated with a giant solitary fibrous tumor of the pleura.

Solitary fibrous tumors (SFT) of the pleura are a rare neoplasm, with benign biological behaviour. Recurrences are rare, and no distant metastases are described in the literature. SFT can secrete hormone-like substances, responsible for paraneoplastic syndromes. The authors describe a case of severe hypoglycaemia due to insulin-like growth factor II (IGF-2)'s secretion by a giant SFT of the pleura. Hypoglycaemia was controlled by the resection of the tumor. Diagnosis and surgical management of these neoplasms are also discussed.

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.

The esophageal chest pain. An update for clinicians.

Chest pain is a common symptom and even when there is evidence of only minor obstructive coronary artery disease on angiography, it leads to disability and imposes a substantial economic burden on health care system. Gastroesophageal reflux disease (GERD) and esophageal dysmotility disorders are thought to play an important role in the genesis of non-cardiac chest pain. Its pathogenetic mechanism remains unclear. The esophageal origin of the symptom may be identified by an aggressive trial of high-dose antisecretory drugs or an abnormal prolonged ambulatory pH monitoring study. Endoscopy is often normal and less useful in this population than in those with heartburn as presenting symptom. The use of manometry, with provocative testing to evaluate for esophageal motility abnormalities or esophageal sensitivity, allows optimal evaluation of those who do not have GERD. Patients with non-cardiac chest pain of unknown origin should be carefully screened for the occurrence of esophageal disorders but further research is needed to clarify the role of the latter on the pathogenesis of this symptom.