Videothoracoscopic approach to stage I non-small cell lung cancer.

AIM: Aim of this study is to evaluate the validity of videothoracoscopic staging and treatment in a twenty-year-long series of 286 VATS lobectomies for Clinical Stage I NSCLC. MATERIAL OF STUDY: We retrospectively reviewed 1549 candidates to resection after conventional staging from November 1991 to December 2013, and routinely submitted to videothoracoscopy immediately before the procedure. Patients deemed operable at videoexploration were resected by thoracoscopy or thoracotomy. Out of 534 VATS resections 286 thoracoscopic lobectomies for clinical stage I cancers were performed with strict indications and standardized technique; more advanced tumours were converted even when thoracoscopically resectable. Impact of preliminary videothoracoscopy and and longterm Kaplan-Meier survival was analyzed. RESULTS AND DISCUSSION: Out of 1549 patients, videothoracoscopy disclosed inoperability in 62 (4 %), mostly for pleural carcinosis (33pts.-2.1%) or mediastinal infiltration (22pts-1.4%). 534 (34.5%) patients had videothoracoscopic resection (286 lobectomies, 7 pneumonectomies, 241 wedge resections), 919 (59.3%) had thoracotomy resection, 34 (2.2%) had an exploratory thoracotomy (ET). Thoracoscopy had an accuracy rate of 72.4%, was reliable in excluding unresectability (NPV 0.95), and decreased the rate of ETs to 2.1%, ,sparing 596 (38.5%) thoracotomies. There was no intraoperative mortality or recurrence. Stage I patients had 83.8% 3-yr survival and 64.3% 5-yr survival. Five-year survival was significantly better (p=0.004) for T1N0 patients (70%) than T2N0 (55%) and for patients younger than 55 (86.4%) or with lesion < 2 cm (80.8%). CONCLUSIONS: Preliminary videothoracoscopy reliably assesses tumor resectability and feasibility of thoracoscopic resection, limiting unnecessary thoracotomies. Videolobectomies are safe and survival is comparable to open lobectomy. KEY WORDS: Lobectomy, Lung cancer, Minimally invasive surgery, Thoracoscopy, VATS.

Routine surgical videothoracoscopy as the first step of the planned resection for lung cancer.

OBJECTIVES: Notwithstanding preoperative staging, a number of procedures still end in an exploratory thoracotomy as a result of unexpected findings. The aim of this work is to evaluate the validity of routine videothoracoscopy, performed as the first step of every planned resection for non-small cell lung cancer, to assess tumor resectability and feasibility of the resection through thoracoscopy. METHODS AND RESULTS: From November 1991 to December 2007, in our department, 1306 patients with non-small cell lung cancer, judged operable at conventional staging, underwent videothoracoscopy before the operation. Thoracoscopy revealed inoperability in 58 (4.4%) patients, mostly owing to pleural dissemination (2.5%) or mediastinal infiltration (1.7%). In the remaining 1248 (95.6%), thoracoscopy did not reveal inoperability. Of these, 449 (34.4%) underwent thoracoscopic resection. The other 799 (61.2%) underwent thoracotomy: 767 underwent resection, but 32 (2.5%) had an exploratory thoracotomy. Thoracoscopy had suggested unresectability in 7 (0.5%) patients, had been incompletely carried out in 4 (0.3%), and was unfeasible in 21 (1.6%) owing to insurmountable technical reasons. In our previous series from 1980 to 1991 the exploratory thoracotomy rate had been 11.6%. In the present series, after the introduction of routine thoracoscopy in the staging process, the exploratory thoracotomy rate was 2.5%. Thoracoscopy was reliable in excluding unresectability (negative predictive value 0.97). The global percentage of correct staging was significantly better (P < .0001) by thoracoscopy (73.3%) than by computed tomography (48.7%). Considering T descriptor, video-assisted thoracic surgery correctly matched with final pathologic staging in 96.2% of patients. CONCLUSIONS: Routine preliminary videothoracoscopy ensured assessment of tumor resectability and feasibility of the resection through thoracoscopy and limited unnecessary thoracotomies.

Management of solitary pulmonary nodule.

OBJECTIVES: The pulmonary nodule is an important diagnostic and therapeutic problem. Diagnostic certainty is only obtained by histological examination. Mini-invasive surgery allows removal of the nodule with minimal sequelae for the patient. METHODS: From October 1991 to December 2006, 370 resections for a pulmonary nodule were performed at our Department of General Surgery of the University of Milan: 276 wedge resections and 94 lobectomies. RESULTS: Frozen section was performed in all the wedge resections, and in the presence of cancer (77 cases), whenever possible (61 cases), the intervention was converted to lobectomy in the same session. In the other 94 cases, the nodule was removed by lobectomy due to the impossibility of performing a wedge resection. CONCLUSIONS: Despite the refinement of diagnostic techniques, only exeresis of a pulmonary nodule ensures a definitive diagnosis, thus resolving the problem of benign pathologies and initiating the correct therapy for malignant lesions in the same session.

Tracheal sleeve pneumonectomy: long-term outcome.

Selected primary lung cancers less than 2cm from the carina or invading the tracheo-bronchial angle, formerly considered inoperable, can be amenable to tracheal sleeve pneumonectomy (TSP). Such a delicate technique, can entail remarkable post-operative morbidity and mortality, and only few clinical series are reported. Purpose of this paper is to examine complications and long-term survival of our personal series and those reported in literature. At our academic department from 1983 to December 2004, out of 99 patients with NSCLC less than 2cm from the carina, 35 (35.4%) were deemed inoperable after conventional staging; the remaining 64 underwent surgery. Since 1993 in every patient with lung cancer we perform a thoracoscopic exploration as the first step of the intervention. Unexpected causes of inoperability were found at thoracotomy in nine patients (14.1%) and at thoracoscopy in two other patients. Of the remaining 53 patients, 52 had a right TSP and one a left TSP. Intraoperative mortality was nil. Perioperative mortality was 7.5%. Major complications occurred in 11.3% of the patients. Thirty (56.6) patients are alive and disease-free 23-97 months after surgery; for 18 (33.4%) of these, more than 5 years have elapsed after the operation. TSP is the only concrete option for treating lung cancer originating less than 2 cm from the carina. The review of our experience and of other reported series suggests that, with careful selection of patients and meticulous surgical technique, operative mortality and complications are acceptable. Long-term survival and prognosis are encouraging.

Long-term survival after videothoracoscopic lobectomy for stage I lung cancer.

STUDY OBJECTIVES: The aim of this study was to evaluate our personal experience and survival curves after video-assisted thoracic surgery (VATS) lobectomies for stage I lung cancer, in comparison with the results reported in existing literature. DESIGN: Retrospective analysis of our experience and an overview of literature. SETTING: Department of Surgery, San Giuseppe Hospital, University of Milan. PATIENTS: From October 1991 to December 2001, of 257 patients with clinical stage I lung cancer, 193 patients underwent VATS lobectomy, 7 patients were declared inoperable at thoracoscopic exploration, and 57 patients were converted (18 patients for oncologic reasons and 39 patients for technical reasons). RESULTS: We observed no intraoperative mortality and no recurrence. Survival data were analyzed with the Kaplan-Meier method along with a log-rank test for statistical significance. The global survival rates at 3 years and 5 years were 77.7% and 63.64%, respectively. T1N0 patients had a better survival curve at 3 years and 5 years (83.50% and 70.21%, respectively) compared to T2N0 patients (71.13% and 56.12%). Patients < 70 years of age had better 3-year and 5-year survival rates (82.37% and 73.32%, respectively) than those > 70 years of age (57.49% and 37.09%). This difference was statistically significant (p < 0.01). CONCLUSIONS: Our results after the VATS approach match the "best" results reported in literature following conventional surgery. Minimally invasive surgery seems to imply reduced tissue damage and decreased impairment of immunologic function. VATS lobectomy permits radical oncology as accurately as lobectomy by thoracotomy, provided that long-established standards are respected. In spite of technical difficulties, it could therefore become a valid alternative in treating stage I lung cancer.

Non-small cell lung cancer with chest wall invasion: evolution of surgical treatment and prognosis in the last 3 decades.

STUDY OBJECTIVES: The treatment of patients with non-small cell lung cancer (NSCLC) that is invading the chest wall is still debated. We aim to illustrate the improvements in treatment results that have occurred over last decade. DESIGN: Retrospective analysis of our experience and an overview of the literature. SETTING: Department of Surgery, San Giuseppe Hospital, University of Milan. PATIENTS: From January 1970 to December 1999, of 2,738 patients with NSCLC, we operated on 146 patients (5.4%) with chest wall invasion by NSCLC. Superior sulcus tumors and tumors invading the diaphragm or mediastinum were excluded. We reclassified all cases according to the current TNM classification. RESULTS: We registered one postoperative death (0.69%) and five major complications (3.4%). From 1970 to 1979, of 32 patients, 10 underwent an exploratory thoracotomy (ET) and 22 underwent a radical resection (stage IIB disease, 17 patients; stage IIIA disease, 5 patients). The 5-year survival rate was 22.7% (25% for stage IIB disease). From 1980 to 1989, of 67 patients, 11 underwent an ET and 56 underwent a radical resection (stage IIB disease, 34 patients; stage IIIA disease, 12 patients; stage IIIB disease, 5 patients; and stage IV disease, 5 patients). The survival rate following radical resection was 14.1%, ranging between 23.5% for patients with stage IIB disease and 0% (3 years, 14%) for those with stage IIIA disease. From 1990 to 1999, of 47 patients, 2 underwent an ET, 2 underwent an exploratory thoracoscopy, and 43 underwent a radical resection (stage IIB disease, 23 patients; stage IIIA disease, 20 patients). The survival rate was 42.7% (stage IIB disease, 78.5%; stage IIIA disease, 7.2%). CONCLUSIONS: Considering the low morbidity, mortality, and significant improvement in survival during the last decade, we advocate the performance of radical en bloc resection for the treatment of chest wall invasive NSCLC.

Thoracoscopy and transplantation: a new attractive tool.

BACKGROUND: Transplanted patients on immunosuppressive treatment have an increased risk of infections or neoplasms. Transplantation candidates with infection or a suspected malignancy are excluded from transplantation. In patients already transplanted, thoracoscopy can resolve complications or treat the pulmonary pathology without compromising the precarious existing reactive equilibrium. These patients require an approach that is as least traumatic as possible. METHODS: From September 1991 to December 2000, of 2068 videothoracoscopic procedures carried out at our hospital, 2 were in patients who had undergone transplantation and 3 in candidates for kidney, liver, and bone marrow transplantation. Starting from our personal experience in videothoracoscopy as a diagnostic and therapeutic approach, the possibilities of the method in the field of transplantation are reported by a review of the literature carried out by consulting the reference systems of the most important data banks. CONCLUSIONS: In our experience, videothoracoscopy had a major impact on the management of candidates for transplant, because it allowed us to rule out or treat conditions that would have determined exclusion from a transplant program. In transplanted patients, videothoracoscopy allows a correct diagnosis and treatment with minimal trauma.

La apendicectomia videolaparoscopica técnica y experiencia en 700 casos / Appendicectomy laparoscopy in 700 cases

La videolaparoscopia ha sido propuesta, desde hace algunos años, para la realización de la apencectomía, encontrado en el mundo siempre mayor difusión por las ventajas que ofrece respecto a la vías tradicional. La elevada tecnología avanzada en el instrumental videoendoscópico ha convertido esta operación en una intervención fácil, segura, como también rápida luego de un adecuado entrenamiento. Desde enero de 1992 a octubre de 1996, en el servicio de Cirugía General del Hospital "San Giuseppe" de la Universidad de Milán, se han realizado 700 apendicectomías por vía videolaparoscópica. La Técnica de ejecución recalca la metódica utilizada por otros autores, pero con algunas variaciones personales. La operación fue convertida en 36 casos (5,1 por ciento) y en dos casos se presentó una complicación postoperatoria que requirió una re- intervención. En todos los pacientes se tuvo una rápida recuperación y un óptimo resultado estético. La vía videolaparoscópica respecto a la laparotómica mejora la exploración de la cavidad abdominal, facilita la identificación del apéndice, reduce el período de inactividad y también en las apendicectomías "difíciles",permite un óptimo resultado estético

La videotoracoscopia en el tratamiento del neumotorax espontaneo recidivante: una revisión de 120 casos / The videothoracoscopic in the treatment of the recurrent spontaneus pneumothorax: a review of 120 cases

Los autores ilustran su experiencia sobre el uso de la Pleurectomía Videotoracoscópica en pacientes con diagnóstico de Neumotorax espontáneo recidivante. "San Giuseppe"-Orden San Juan de Dios de Milán, Italia, 120 pacientes con diagnóstico de Neumotorax espontáneo fueron sometidos a intervención quirúrgica videotoracoscópica. El seguimiento de 10 a 60 meses no ha evidenciado recidivas. La edad media fue 34 años. Todas las operaciones fueron concluidas por vía Videotoracoscópica. En cinco casos fue necesario reintervenir (siempre por vía Videotoracoscópica) por sangramientos postoperatorios. No tuvimos mortalidad ni intra ni postoperatoria. La técnica Videotoracoscópica en la pleurectomía ha permitido obviar el principal inconveniente de la terapia quirúrgica, ligado a la vía de acceso toracotómica, es decir, la importante sintomatología dolorosa postoperatoria, responsable de una disminuida funcionalidad respiratoria. Obteniendo también un reintegro precoz a las actividades laborales y un óptimo resultado estético