Multidisciplinary approach to a septic COVID-19 patient undergoing veno-venous extracorporeal membrane oxygenation and receiving thoracic surgery.

A multidisciplinary approach appears to be fundamental for the treatment of critically ill patients with COVID-19, improving clinical outcomes, even in the most severe cases. Such severe cases are advisable to be collegially discussed between intensivists, surgeons, infectious disease, and other physicians potentially involved.

Management of intrathoracic benign schwannomas of the brachial plexus.

Primary tumours of the brachial plexus are rare entities. They usually present as extrathoracic masses located in the supraclavicular region. This report describes two cases of benign schwannomas arising from the brachial plexus with an intrathoracic growth. In the first case the tumour was completely intrathoracic and it was hardly removed through a standard posterolateral thoracotomy. In the second case the tumour presented as a cervicomediastinal lesion and it was resected through a one-stage combined supraclavicular incision followed by left video-assisted thoracoscopic surgery. A brachial plexus tumour should be suspected not only in patients with a supraclavicular or cervicomediastinal mass but also in those with intrathoracic apical lesions. A preoperative magnetic resonance imaging study of brachial plexus should be performed in such cases in order to plan the correct surgical approach.

Unusual presentation of mediastinal neurogenic tumours.

Mediastinal neurogenic tumours generally arise as single benign lesions and their typical location is the costovertebral sulcus. In about 10% of cases mediastinal neurogenic tumours may extend to the spinal canal; occasionally they may extend to the cervical region and, more rarely, may be multiple or associated with other synchronous mediastinal lesions. The treatment of choice is surgical resection. This report describes three cases of unusual presentation of mediastinal benign schwannomas successfully treated at our Hospital. In the first case multiple simultaneous paravertebral lesions were resected through a posterior approach. In the second case a tumour of the posterior mediastinum extending to the cervical region was excised through a one-stage combined supraclavicular incision followed by left mini-invasive video-assisted thoracoscopic surgical techniques. The third case describes a patient with a posterior neurogenic mediastinal tumour with a synchronous parathyroid adenoma of the anterior mediastinum, which were both successfully resected by video-assisted thoracoscopic surgery.

Montgomery T-tube placement in the treatment of benign tracheal lesions.

INTRODUCTION: Although surgery remains the gold standard for the treatment of benign tracheal stenosis, airway stenting may be indicated in the event of complex lesions or associated diseases. We retrospectively investigated Montgomery T-tube placement as an alternative or complementary treatment to surgery. METHODS: From January 1984 to March 2008, 158 patients were treated for benign tracheal lesions. Eighty-three patients underwent airway resection and reconstruction as the only treatment. Seventy-five other patients with complex lesions or major associated diseases were treated with a T-tube and were retrospectively analysed. Seven of them had undergone unsuccessful treatment with Dumon stents. T-tube placement was the only procedure adopted in 51 patients with a contraindication to surgery (group I), a temporary measure in 15 patients prior to surgery (group II), and in 9 patients (group III) for complications of airway reconstruction, 5 of whom were referred from other institutions. RESULTS: Complications after T-tube placement were: stent dislocation in 3 (4%) patients, endoluminal granulomas in 14 (19%), subglottic edema in 3 (4%), and sputum retention in 7 (9%). Treatment of complications (tracheostomy cannula, steroid infiltration, Argon/LASER coagulation, and bronchoscopy) was required in 20 (27%) patients. In group I, the tube was removed in 12 (24%) patients after 35.3 +/- 8.2 months following resolution of the stenosis. In group II, the tubes were maintained in place before surgery for 17.1 +/- 4.8 months. In group III, three stents were removed following tracheal healing after 115.3 +/- 3.7 months. After 5 years the stents were in place in 82%, 7% and 100% of the patients, respectively in groups I, II and III. CONCLUSIONS: Montgomery T-tube placement represents a useful option in patients with complex benign tracheal stenosis or associated diseases as an alternative or complementary treatment to surgery, and is effective even when other types of stents are unsuccessful.

Results of surgical treatment after neoadjuvant chemotherapy for stage III non-small cell lung cancer.

BACKGROUND: The potential benefits of an approach combining neoadjuvant chemotherapy and surgery in stage IIIA and IIIB NSCLC have to be weighed against a potential increase in postoperative complications. We evaluated the results in terms of postoperative complications and survival in patients with stage III NSCLC who underwent complete surgical treatment after neoadjuvant chemotherapy with two regimens: mitomycin, vinblastine, and cisplatin (MPV) versus gemcitabine and cisplatin (GC). METHODS: From March 1991 to September 2005, 110 patients with stage III NSCLC (86 stage IIIA and 24 stage IIIB) underwent complete surgical treatment after neoadjuvant chemotherapy. Ninety-two patients were men and 18 were women, with a mean age of 59 (range, 39-80) years. The neoadjuvant chemotherapy regimen was MPV in 72 patients and GC in 38. RESULTS: The overall response (>50%) to chemotherapy was 84%. Postoperative mortality and morbidity were 1.8% and 20%, respectively. Overall 5-year survival was 46%. Minor response to neoadjuvant chemotherapy (<50%) and residual nodal N2 involvement in stage IIIA had an adverse impact on survival (p < 0.05). CONCLUSIONS: Favorable long-term survival was observed after neoadjuvant chemotherapy with MPV and GC regimens in stage IIIA and IIIB NSCLC, with relatively low postoperative mortality and morbidity. Caution should be taken when offering surgical treatment to patients with minor response to induction chemotherapy and residual N2 disease in view of the significantly reduced survival.

Acupuncture for diagnostic fiberoptic bronchoscopy: a prospective, randomized, placebo-controlled study.

Patients usually fear fiberoptic bronchoscopy (FBS) and they report a low level of satisfaction after this examination. We evaluated the efficacy of acupuncture in decreasing patient anxiety before diagnostic FBS and in improving tolerance to the examination. In a prospective double-blind study, we enrolled 48 patients scheduled to undergo diagnostic FBS. Patients were randomly assigned to one of three groups. Group A (16 patients): standard FBS, with airway topic anesthesia; Group B (16 patients): standard FBS, with airway topic anesthesia and acupuncture treatment; Group C (16 patients): standard FBS, with airway topic anesthesia and sham acupuncture. EKG, non-invasive arterial pressure, and pulse oximetry were monitored on a routine basis. We evaluated patient anxiety before and after acupuncture and, at the end of FBS, the discomfort suffered during the examination by a 100-mm Visual Analog Scale (VAS). Patient satisfaction in Group A was 50% worse than in Group B (p = 0.04). We observed a strong, even if not statistically significant, tendency toward a lower pre-FBS anxiety in Group B. Patients in group C had values very close to those recorded in group A. We observed no adverse event and no differences in cardio-respiratory parameters in these three groups; in particular, we did not observe a respiratory depression in Group B. Acupuncture seems an effective resource for a Thoracic Endoscopic Room to improve patient tolerance to FBS.

Endobronchial migration of prosthetic patch after congenital diaphragmatic hernia repair.

Surgical repair of congenital diaphragmatic hernia (CDH) can be performed by means of either direct suturing of the diaphragm or positioning of a prosthetic patch. However, half of all prosthetic patches show evidence of reherniation. We describe the case of an 8-year-old girl who presented with prosthesis dislocation and fistulization in the right lower bronchus as a complication of a CDH repair that she underwent when she was 1 year old. Abdominal ultrasound and magnetic resonance imaging suggested a hernia relapse, whereas chest computed tomographic scan failed to identify the diaphragmatic defect. Only fibrobronchoscopy allowed fistulization of the prosthesis into the bronchi to be correctly diagnosed.

Video-assisted thoracoscopic surgery for pulmonary nodules: rationale for preoperative computed tomography-guided hookwire localization.

OBJECTIVES: Video-assisted thoracic surgery (VATS) provides a minimally invasive means to resect pulmonary nodules (PN). Deep localization of PN may jeopardize VATS lung resection. The aim of this study was to establish the utility of preoperative computed tomography (CT)-guided hookwire localization of PN. METHODS: Between January 1993 and September 2001, we performed 151 VATS resections for PN. Preoperative CT-guided hookwire localization was not performed in 98 patients (group I); it was done just before surgery in 53 patients (group II) when, at CT scan, the distance of PN from the lung surface was >15 and/or when the size was <10 mm. RESULTS: Pneumothorax occurred in four patients (7.5%). Hookwire dislodged in four patients, but the hematoma left on the visceral pleura made thoracoscopic localization possible in three of these. Seventeen patients (17%) in group I and 4 (7.5%) in group II required conversion to thoracotomy (P< or =0.05). The most common reason for conversion was impossibility to localize PN in group I (nine cases) and deep localization requiring local enucleation in group II (two cases). In 31 group II patients (58%) hookwire positioning led to successful VATS resection that would otherwise have been impossible because PN were neither visible nor palpable. CONCLUSIONS: Preoperative CT-guided hookwire localization for pulmonary nodules is an effective technique which allows VATS resection of PN <10 mm located >15 mm from the pleural surface. Even when PN are subpleural but <10 mm, hookwire localization makes VATS resection faster. Apical and diaphragmatic localization of PN are limitations to the procedure.