Can a standardised Ventilation Mechanical Test for quantitative intraoperative air leak grading reduce the length of hospital stay after video-assisted thoracoscopic surgery lobectomy?

We standardised a Ventilation Mechanical Test (VMT) after video-assisted thoracoscopic surgery (VATS) lobectomy that classifies intraoperative alveolar air leaks (IOAALs) in mild, moderate and severe. We assumed that mild IOAALs (<100 mL/min) are self-limiting, whereas severe IOAALs (>400 mL/min) must be treated. An IOAAL between 100 and 400 mL/min was defined moderate and constituted the study population of a prospective multicentre randomised trial on the use of a polymeric biodegradable sealant (ProgelTM Pleural Air Leak Sealant, Bard Davol, USA) in case of moderate IOAAL compared with no treatment. We assumed that the standardised VMT allows to accurately selected patients needing treatment, thus limiting unnecessary sealant use. We analysed data of the randomised trial to assess the cost-effectiveness of Progel treatment in VMT selected patients. This is a multicenter randomised controlled trial. Patients with moderate IOAAL were randomised to Progel (group A) or "no treatment" (group B).The primary efficacy endpoint of the study was the postoperative duration of air leakage. The secondary outcome measures included: mean time to chest drain removal, mean length of hospitalisation, the percentage of postoperative complications occurring within two months, and cost of treatment. Between January 2015 and January 2017, 255 VATS lobectomies were performed in 4 centres, 55 met the inclusion criteria, and they were randomly assigned to 2 different groups (28 in the Progel and 27 in the control group). The mean air leakage duration was statistically different between the two groups: in the group A was 1.60 vs. 5.04 days in group B (P<0.001). The average duration of chest drainage was statistically shorter in group A than in the control group (4.1 vs. 6.74 days; P=0.008). The mean time to hospital discharge was also statistically shorter in group A than in group B (5.75 vs. 7.85 days, P=0.026). In the Progel group, a statistically significant reduction of hospitalisation costs compared with the control group was observed (Progel group =12,905£, Control group =39,690£; P<0.001). Our standardised VMT helps in reducing the length of hospital stay after VATS lobectomy because in case of IOAALs between 100 and 400 mL/min the use of ProgelTM significantly reduces postoperative air leak, time to drain removal and length of hospitalisation compared with no treatment. This shorter hospital stays results in significant cost saving benefits. Selection of patients with standardised VMT is essential to limit unnecessary intraoperative sealant treatments, thus contributing to limit the costs.

Cost-effectiveness analysis of sealant impact in management of moderate intraoperative alveolar air leaks during video-assisted thoracoscopic surgery lobectomy: a multicentre randomised controlled trial.

BACKGROUND: Intraoperative alveolar air leak (IOAAL) is one of most common complications after video-assisted thoracoscopic surgery (VATS) lobectomy. The study aimed to evaluate if, in moderate IOAAL, intraoperative polymeric biodegradable sealant (ProgelTM) reduced postoperative air leak (PAL) and consequently was cost-effective. METHODS: Patients with moderate IOAAL were randomised in a multicentre trial to intraoperative use of a sealant (Sealant group) or standard management of air leaks (Control group). Primary endpoint was the postoperative duration of air leakage. Secondary outcomes included: time to drainage removal, length of hospital stay, postoperative complications within 2 months, and cost analysis. RESULTS: Between January 2015 and January 2017, 255 VATS lobectomies were performed in four centres. Fifty-five met inclusion criteria and were randomly assigned to Sealant group [28] and Control group [27]. The mean air leakage duration was statistically different between groups (Sealant group =1.60 days, Control group =5.04 days; P<0.001). The average length of drainage was significantly (P=0.008) shorter in Sealant group (4.1 days) than in Controls (6.74 days). The mean time of hospital stay was statistically shorter in sealant group (Sealant =5.75 days, Control =7.85 days; P=0.026). Sealant group observed a statistically significant reduction of costs. CONCLUSIONS: In moderate IOAAL after VATS lobectomy, polymeric biodegradable sealants are safe and efficient. Compared with standard treatments, sealant significantly reduces PAL, time to drain removal and length of hospital stay resulting in significant costs benefits.

Management of tracheal chondrosarcoma almost completely obstructing the airway: a case report.

BACKGROUND: Primary malignant tracheal tumors account for only 0.2 % of all malignancies of the respiratory tract. Tracheal chondrosarcoma is a rare condition and only 17 cases have been described in the literature from 1965 to date. Herein we report the very unusual case of a patient with a tracheal chondrosarcoma, electively treated by curative surgery despite the virtually complete obstruction of the airway. CASE PRESENTATION: We present the case of a 79-year old Caucasian man with long-lasting wheezing misdiagnosed as asthma and affected by a tracheal chondrosarcoma almost completely obstructing the airway. Videobronchoscopy and imaging investigations revealed a well-circumscribed mass arising from the cartilaginous rings of the cervical trachea with a posterior residual respiratory space of about 1 mm. Because of the mobility and flaccidity of the uninvolved pars membranacea, the tiny respiratory space slightly expanded during inspiration and expiration allowing the patient to be treated without an essential emergency procedure. Standard tracheal intubation was impossible. Rigid bronchoscopy enabled placement of a small tracheal tube distally to the tumor. Successful cervical tracheal resection and reconstruction was then performed, achieving complete tumor excision. Histologically, the mass was characterized as a low-grade tracheal chondrosarcoma. Videobronchoscopy performed 9 months after surgery showed a wide, well healed tracheal anastomosis. Ten months after surgery, the patient is alive and disease free. CONCLUSION: Complete surgical resection is the treatment of choice for tracheal chondrosarcoma. Rigid bronchoscopy is an essential tool for diagnostic and therapeutic purposes. It allows the palliative maneuvers for obstruction relief but also, in resectable patients, the intraoperative safe and straightforward management of the obstructed airway.

Video-assisted thoracoscopy in thoracic injury: early or delayed indication?

The aim of this study was to evaluate the diagnostic role and therapeutic effectiveness of videothoracoscopy in chest trauma. Between 1st January 1993 and 30th September 2003, 112 traumatized patients underwent a videothoracoscopy. The origin of trauma was different: 60 road accidents, 42 accidental falls, 7 knife wounds and 3 firearm wounds. Seventy-six patients presented hemothorax, 21 hemopneumothorax, 10 suspected diaphragmatic injury and 5 pericardium effusion. All patients were hemodynamically stable and conscious. In suspected diaphragmatic rupture patients, videothoracoscopy confirmed the presence of 4 lesions with diameter from 7 to 10cm. The etiopathogenetic causes in the other clinical patterns were: 20 lung lacerations, 17 apical adhesion lacerations, 11 diaphragmatic lesions, 16 wall bleedings and 38 vessel lesions. Ninety patients (80.3%) were treated with video assisted thoracic surgery. The remaining procedures were : 17 drainage tube insertions, 4 thoracotomies and 1 laparotomy. Videothoracoscopy made the use of the primary intention drainage tube obsolete in stable traumatized patients with hemothorax or hemopneumothorax. It is a safe technique that allows the diagnostic and surgical management of the lesions.