Endovascular Surgery of Descending Thoracic Aorta Involved in T4 Lung Tumor.

PURPOSE: Surgical treatment of primary lung T4 tumors is controversial especially when the cancer invades the mediastinal structures or the descending thoracic aorta. Conventional surgical treatment is associated with a high perioperative mortality and morbidity rate. Thoracic EndoVascular Aortic Repair has emerged as a valid off-label alternative to conventional surgery. We aimed to assess perioperative and midterm aortic-related outcome of patients who have undergone aortic stent-graft implantation, followed by en bloc surgical treatment of the involved aorta and lung cancer resection. MATERIALS AND METHODS: From July 2017 to May 2020, we treated 5 patients diagnosed with a T4 lung cancer by the involvement of the descending thoracic aorta. When only the descending thoracic aorta is involved, a 2-stage procedure was considered, with aortic stent-graft implantation performed before tumor resection. One-stage strategy, with stent-graft implantation carried out before thoracotomy, was preferred for patients with the involvement of cardiac and/or other vascular mediastinal structures. RESULTS: The mean age was 58.4 ± 6.2 years. All patients were affected by non-small cell lung cancer. All 5 patients required a single stent-graft to completely cover the involved segment of aorta. Four patients underwent a 2-stage procedure. One patient, with the involvement of the left inferior pulmonary vein, required a 1-stage en bloc resection of the left lower lobe, aortic wall adventitia, left inferior pulmonary vein, and reconstruction of the left atrial wall. Primary procedural success was achieved in all. At follow-up, no patient developed aortic-related complications. One patient died 2 years after surgery, due to local recurrence of the tumor. CONCLUSION: T4 lung resection combined with aortic stent-graft implantation can be safely performed. Endovascular surgery, by avoiding the use of cardiopulmonary bypass, aortic cross-clamping, and graft replacement, can reduce significant morbidity and mortality rate. Postoperative and long-term outcome of these patients treated with endovascular surgery is mainly related to pulmonary disease, not to aortic treatment.

Bleeding during Learning Curve of Thoracoscopic Lobectomy: CUSUM Analysis Results.

BACKGROUND: The management of intraoperative bleeding during thoracoscopic lobectomy is challenging, especially for non-experienced surgeons. We evaluated intraoperative bleeding in relation to learning curve of thoracoscopic lobectomy, the strategies to face it, the outcomes, and the target case number for gaining the technical proficiency. METHODS: This was a retrospective single center study including consecutive patients undergoing thoracoscopic lobectomy for lung cancer. Based on cumulative sum analysis, patients were divided into early and late experience groups, and the differences on surgical outcomes, with particular focus on vascular injury, were statistically compared. RESULTS: Eight-three patients were evaluated. Cumulative sum charts showed a decreasing of operative time, blood loss, and hospital stay after the 49th, the 43th, and the 39th case, respectively. Early (n = 49) compared with late experience group (n = 34) was associated with higher conversion rate (p = 0.08), longer operative time (p <0.0001), greater blood loss (p <0.0001), higher transfusion rate (p = 0.01), higher postoperative air leak rate (p = 0.02), longer chest tube stay (p <0.0001), and hospitalization (p <0.0001). Six patients (7%) had intraoperative bleeding during early phase of learning curve, successfully treated by thoracoscopy in four cases. Patients with vascular injury (n = 6) compared with control group (n = 77) presented a longer operative time (p = 0.003), greater blood loss (p = 0.0001), and higher transfusion rate (p = 0.001); no significant differences were found regarding postoperative morbidity (p = 0.57), length of chest tube stay (p = 0.07), and hospitalization (p = 0.07). CONCLUSION: Technical proficiency was achieved after 50 procedures. All vascular injuries occurred in the early phase of learning curve; they were safely managed, without affecting surgical outcomes.

The Prediction of Fissure Integrity by Quantitative Computed Tomography Analysis.

BACKGROUND: Incomplete interlobar fissure may increase the difficulty of thoracoscopic lobectomy. Herein, we compared the accuracy of visual versus quantitative analysis to predict fissure integrity in lung cancer patients undergoing thoracoscopic lobectomy and evaluated the effects of fissure integrity on surgical outcome. METHODS: This was a single-center retrospective study including consecutive patients undergoing VATS (video-assisted thoracoscopic surgery) lobectomy for lung cancer. The target interlobar fissures were classified as complete or incomplete by visual and quantitative analysis. Using the intraoperative finding as the reference method, the diagnostic accuracy of the two methods to define fissure completeness (dependent variable) was calculated and statistically compared. Yet, we evaluated differences in postoperative outcomes between patients with complete and incomplete fissure integrity. RESULTS: A total of 93 patients were included in the study; 33/93 (36%) presented complete fissure. Visual and quantitative analyses correctly identified complete fissure in 19/33 (57%) and 29/33 (88%) patients, respectively, and incomplete fissure in 56/60 (93%) and 58/60 (96%) patients, respectively. Quantitative analysis had better diagnostic accuracy than visual analysis (81 vs. 93%; p = 0.01). Patients with incomplete fissure compared with those with complete fissure had a higher conversion rate (6 vs. 13%; p = 0.43), higher persistent air leak rate (0/33 vs. 14/60; p = 0.03), and longer hospitalization (12.6 ± 3.8 vs. 7.1 ± 2.4 days; p = 0.01). CONCLUSION: Quantitative analysis accurately predicted the fissures' integrity; it may be useful for selecting suitable cases for thoracoscopic lobectomy especially for surgeons with limited minimally invasive experience.

Macrophage-polarizing stimuli differentially modulate the inflammatory profile induced by the secreted phospholipase A2 group IA in human lung macrophages.

In this study we investigated the effects of snake venom Group IA secreted phospholipase A2 (svGIA) on the release of inflammatory and angiogenic mediators from human lung macrophages (HLMs). HLMs were incubated with lipopolysaccharide (LPS) or svGIA with or without macrophage-polarizing stimuli (IL-4, IL-10, IFN-γ or the adenosine analogue NECA). M2-polarizing cytokines (IL-4 and IL-10) inhibited TNF-α, IL-6, IL-12, IL-1ß, CXCL8 and CCL1 release induced by both LPS and svGIA. IL-4 inhibited also the release of IL-10. IFN-γ reduced IL-10 and IL-12 and increased CCL1 release by both the LPS and svGIA-stimulated HLMs, conversely IFN-γ reduced IL-1ß only by svGIA-stimulated HLMs. In addition, IFNγ promoted TNF-α and IL-6 release from svGIA-stimulated HLMs to a greater extent than LPS. NECA inhibited TNF-α and IL-12 but promoted IL-10 release from LPS-stimulated HLMs according to the well-known effect of adenosine in down-regulating M1 activation. By contrast NECA reduced TNF-α, IL-10, CCL1 and IL-1ß release from svGIA-activated HLM. IL-10 and NECA increased both LPS- and svGIA-induced vascular endothelial growth factor A (VEGF-A) release. By contrast, IL-10 reduced angiopoietin-1 (ANGPT1) production from activated HLMs. IFN-γ and IL-4 reduced VEGF-A and ANGPT1 release from both LPS- and svGIA-activated HLMs. Moreover, IL-10 inhibited LPS-induced ANGPT2 production. In conclusion, we demonstrated a fine-tuning modulation of svGIA-activated HLMs differentially exerted by the classical macrophage-polarizing cytokines.

Pulmonary Hamartoma Associated With Lung Cancer (PHALC Study): Results of a Multicenter Study.

PURPOSE: Pulmonary hamartoma is the most common benign tumor of the lung. We analyzed a 20-year historical series of patients with pulmonary hamartoma undergoing surgical resection, aiming to evaluate the characteristics, the outcomes, and the association between hamartoma and lung cancer. METHODS: It was a retrospective multicenter study including the data of all consecutive patients with pulmonary hamartoma undergoing surgical resection. The end-points were to evaluate: (i) the characteristics of hamartoma, (ii) outcomes, and (iii) whether hamartoma was a predictive factor for lung cancer development RESULTS: Our study population included 540 patients. Upfront surgical or endoscopic resection was performed in 385 (71%) cases while in the remaining 155 (29%) cases, the lesions were resected 20 ± 3.5 months later due to increase in size. In most cases, lung sparing resection was carried out including enucleation (n = 259; 48%) and wedge resection (n = 230; 43%) while 5 (1%) patients underwent endoscopic resection. Only two patients (0, 2%) had major complications. One patient (0.23%) had recurrence after endoscopic resection, while no cases of malignant degeneration were seen (mean follow-up:103.3 ± 93 months). Seventy-six patients (14%) had associated lung cancer, synchronous in 9 (12%) and metachronous in 67 (88%). Only age > 70-year-old (p = 0.0059) and smokers > 20 cigarettes/day (p < 0.0001) were the significant risk factors for lung cancer. CONCLUSION: PH was a benign tumor, with no evidence of recurrence and/or of malignant degeneration after resection. The association between hamartoma and lung cancer was a spurious phenomenon due to common risk factors.

Hemopatch to Fix Mobile Lobe after Thoracoscopic Lobectomy.

Herein, we report a new technique of middle lobe fixation using Hemopatch after thoracoscopic right upper lobectomy. A 3-0 atraumatic polypropylene suture is passed first through the Hemopatch, then two not-inflated lobes, and then again patch. The lung is half-inflated, and the Hemopatch is placed onto the surface of the two half-inflated lobes in a bridging manner over the fissure. The suture is then tied by a clip. This procedure was successfully applied in five consecutive patients after thoracoscopic right upper lobectomy for cancer. No complications occurred during and after operation.

Cardio-Pulmonary Changes After Bronchoscopic Lung Volume Reduction with Endobronchial One-Way Valves.

INTRODUCTION: To evaluate the cardio-pulmonary hemodynamics changes before and after valve treatment, and their correlation with lobe volume reduction. METHODS: This retrospective multicentre study included consecutive patients undergoing bronchoscopic valve treatment for heterogeneous emphysema. In addition to standard functional evaluation, patients underwent cardiac evaluation by Doppler trans-thoracic echocardiography. The difference in respiratory and cardio-pulmonary hemodynamics indexes before and 3-month after the procedure, and their relationship with changes in lobar volume were evaluated. RESULTS: Seventy-seven patients were included in the study; of these 13 (17%) presented pulmonary hypertension. Only patients with target lobar volume reduction ≥ 563 mL (n = 50) presented a significant improvement of forced expiratory volume in one second, residual volume, 6 min-walk test, and St. George's Respiratory Questionnaire score; a significant reduction of pulmonary artery pressure, and an improvement of left and right ventricle end-systolic volume; of left and right ventricle end-diastolic volume, and of left and right ventricle stroke volume. The change in residual volume was significantly correlated with changes in forced expiratory volume in one second (r = 0.68; p < 0.001); in 6 min-walk test (r = 0.71; p < 0.001); in St. George's Respiratory Questionnaire (r = 0.54; p < 0.001); in pulmonary artery pressure (r = 0.39; p = 0.001), in left (r = 0.28; p = 0.01) and right (r = 0.33; p = 0.002) ventricle end-systolic volume, in left (r = - 0.29; p = 0.008) and right (r = - 0.34; p = 0.007) end-diastolic volume, and in left (r = - 0.76; p = 0.009) and right (r = - 0.718; p = 0.001) ventricle stroke volume. CONCLUSION: Bronchoscopic valve treatment seemed to have positive effects on cardio-pulmonary hemodynamics, and these changes were correlated with reductions of lobar volume.

Proteomics analysis of human serum of patients with non-small-cell lung cancer reveals proteins as diagnostic biomarker candidates.

Non-small-cell lung carcinomas (NSCLC) is the most common type of lung cancer and it has a poor prognosis, because overall survival after 5 years is 20-25% for all stages. Thus, it is extremely important to increase the survival rate in the early stages NSCLC by focusing on novel screening tests of cancer identifying specific biomarkers expression associated with a more accurate tumor staging and patient prognosis. In this study, we focused our attention on quantitative proteomics of three heavily glycosylated serum proteins: AMBP, α2 macroglobulin, and SERPINA1. In particular, we analyzed serum samples from 20 NSCLC lung adenocarcinoma cancer patients in early and advanced stages, and 10 healthy donors to obtain a relative quantification through the MRM analysis of these proteins that have shown to be markers of cancer development and progression. AMBP, α2 macroglobulin, and SERPINA1 were chosen because all of them possess endopeptidase inhibitor activity and play key roles in cancer. We observe a variation in the expression of these proteins linked to the stage of the disease. Therefore, we believe that proteins like α2 macroglobulin, αmicroglobulin/bikunin, and SERPINA1 could be useful biomarkers for early detection of lung cancer and in monitoring its evolution.

Nanoparticle-biomolecular corona: A new approach for the early detection of non-small-cell lung cancer.

Lung cancer (LC) is the most common type of cancer and the second cause of death worldwide in men and women after cardiovascular diseases. Non-small-cell lung cancer (NSCLC) is the most frequent type of LC occurring in 85% of cases. Developing new methods for early detection of NSCLC could substantially increase the chances of survival and, therefore, is an urgent task for current research. Nowadays, explosion in nanotechnology offers unprecedented opportunities for therapeutics and diagnosis applications. In this context, exploiting the bio-nano-interactions between nanoparticles (NPs) and biological fluids is an emerging field of research. Upon contact with biofluids, NPs are covered by a biomolecular coating referred to as "biomolecular corona" (BC). In this study, we exploited BC for discriminating between NSCLC patients and healthy volunteers. Blood samples from 10 NSCLC patients and 5 subjects without malignancy were allowed to interact with negatively charged lipid NPs, leading to the formation of a BC at the NP surface. After isolation, BCs were characterized by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). We found that the BCs of NSCLC patients was significantly different from that of healthy individuals. Statistical analysis of SDS-PAGE results allowed discriminating between NSCLC cancer patients and healthy subjects with 80% specificity, 80% sensitivity and a total discriminate correctness rate of 80%. While the results of the present investigation cannot be conclusive due to the small size of the data set, we have shown that exploitation of the BC is a promising approach for the early diagnosis of NSCLC.

Endobronchial Ultrasound for Benign Tracheal Stenosis.

We reported the role of endobronchial ultrasound as complement to standard diagnostic exams to better define the benign tracheal stenosis (i.e., thickness and tracheal cartilage integrity) and to plan the treatment with flexible instead of rigid bronchoscope. Under sedation and spontaneous ventilation, the flexible bronchoscope was inserted through the laryngeal mask airway that assured the ventilation. The stenosis was first resected with cold scissors and then dilated with balloon catheter. This strategy was successfully applied in five consecutive patients. Inclusion criteria for the procedure were stenosis < 1 cm in length, without tracheomalacia and with integrity of airway cartilage.

Ultrasonic Technology for Management of Primary Spontaneous Pneumothorax.

To manage primary spontaneous pneumothorax, we use an alternative technique for bleb resection and we induce pleurodesis with an ultrasonic-driven scalpel. This technique was successfully performed in nine consecutive patients with primary spontaneous pneumothorax with small (<20 mm) and limited number of blebs (<2) and without significant underlying lung disease. After identification of air leakage, the jaws of the instrument were clamped onto the bleb and included a margin of normal lung. Power level 3 energy was applied to resect the bleb and to seal the parenchyma. Finally, the parietal pleura was partially scarified using the same instrument to achieve pleurodesis. Histologic findings showed complete sealing of the resection line by coagulative tissue.

A New Modified Evans Blue Dye Test as Screening Test for Aspiration in Tracheostomized Patients.

OBJECTIVE: The authors assessed the diagnostic accuracy of a new modified Evans blue dye test (MEBDT) as a screening test for aspiration in tracheostomized patients. DESIGN: Monocentric retrospective study performed between October 2013 and December 2015. SETTING: Anesthesia and Intensive Care Unit, Second University of Naples. PARTICIPANTS: Among 62 eligible patients, 5 were excluded. The authors' study population included 57 patients. INTERVENTIONS: Patients underwent both fiberoptic endoscopic examination of the swallow (FEES) and MEBDT to evaluate swallow. The MEBDT results were compared with those of FEES and the diagnostic accuracy of MEBDT was calculated using the FEES as the gold standard. MEASUREMENTS AND MAIN RESULTS: The authors found that both FEES and MEBDT were positive for aspiration in 40 patients (true-positive MEBDT); FEES and MEBDT were negative in 10 (true-negative MEBDT). On the other hand, FEES was positive with an MEBDT negative in 7 patients (false-negative MEBDT), and there were no FEES negative and MEBDT positive (false-positive MEBDT). MEBDT had a sensitivity, specificity, positive, and negative predicted value of 85%, 100%, 100%, and 58.82%, respectively. CONCLUSIONS: MEBDT could be a supplementary diagnostic test for aspiration. Patients with positive MEBDT should not undergo oral feeding, while patients with negative MEBDT should undergo FEES before starting oral feeding.

Percutaneous dilatational tracheostomy using the ETView Tracheoscopic Ventilation Tube®: a teaching course in a pig model.

OBJECTIVE: We planned a training course for trainees of different specialties with the aim of teaching the skills of a new procedure for performing percutaneous dilatational tracheostomy (PDT) with an ETView tracheoscopic ventilation tube instead of standard bronchoscopy in an ex vivo pig model. METHODS: The endotracheal tube, with a camera-embedded tip, was used as an alternative to standard bronchoscopy for visualization of patient airways. The procedure was performed on a home-made animal model. The participants were asked to perform PDT in three different sessions to improve their dexterity. The primary endpoint was the reduction of complications seen during the different sessions of the training course. The secondary endpoint was the satisfaction of the participants as assessed by an anonymous survey. RESULTS: Thirty-seven residents in anesthesiology and 7 in thoracic surgery in the first 2 years of their training and without any confidence with percutaneous tracheostomy participated in the study. Tracheal cuff lesions and impalement of the tracheal tube were the most observed complications, and were concentrated in the early sessions. A significant reduction in complications and operative time was seen during the ongoing sessions of the course. No lesions of the posterior tracheal wall and only a ring fracture occurred during the last session of the course. All participants were satisfied with the course. CONCLUSIONS: Our course seems to confer the technical skills to perform percutaneous tracheostomy to trainees and instill confidence with the procedure. However, the experience acquired on a training course should be evaluated in clinical practice.

Sublobar resection versus lobectomy for stage I non-small cell lung cancer: an appropriate choice in elderly patients?

PURPOSES: The aim of this study was to evaluate whether sublobar resection could achieve recurrence and survival rates equivalent to lobectomy in high-risk elderly patients. METHODS: We conducted a retrospective multicenter study that including all consecutive patients (aged >75 years) who underwent operation for clinical stage I non-small cell lung cancer (NSCLC). The clinicopathological data, postoperative morbidity and mortality, recurrence rate and vital status were retrieved. The overall survival, cancer-specific survival and disease-free survival were also assessed. RESULTS: Two hundred and thirty-nine patients (median age 78 years) were enrolled. Lobectomies were performed in 149 (62.3 %) patients and sublobar resections in 90 (39 segmentectomies, 51 wedge resections). There were no differences in the recurrence rates following lobar versus sublobar resections (19 versus 23 %, respectively; p = 0.5) or the overall survival (p = 0.1), cancer-specific survival (p = 0.3) or disease-free survival (p = 0.1). After adjusting for 1:1 propensity score matching and a matched pair analysis, the results remained unchanged. A tumor size >2 cm and pN2 disease were independent negative prognostic factors in unmatched (p = 0.01 and p = 0.0003, respectively) and matched (p = 0.02 and p = 0.005, respectively) analyses. CONCLUSIONS: High-risk elderly patients may benefit from sublobar resection, which provides an equivalent long-term survival compared to lobectomy.

Is a vessel-sealing system useful for resection of anterior mediastinal mass?

OBJECTIVE: To valuate if the LigaSure (Valleylab, Boulder, Colorado, United States) vessel-sealing system could reduce operative time, intraoperative blood loss, drainage duration, and hospital stay in patients with anterior mediastinal mass undergoing open resection. METHODS: Forty consecutive patients having resection of anterior mediastinal mass were randomized into two groups according to whether LigaSure was used (n = 20) or not (n = 20). Tumor size, operative time, intraoperative blood loss, chest tube output and duration, length of hospital stay, morbidity, and mortality were prospectively recorded, then intergroup differences were statistically analyzed. RESULTS: Both groups were well matched for age, tumor size, pathologic diagnosis, and incidence of complications. LigaSure significantly reduced operative duration (p < 0.0001) compared with the traditional technique but without leading to any significant reduction in intraoperative blood loss (p = 0.2), chest tube output (p = 0.2) and duration (p = 0.2), and length of hospital stay (p = 0.5). CONCLUSIONS: The reduced operative time using LigaSure translates into less exposure to general anesthesia, which is particularly important for patients with myasthenia and potentially reducing cost.

Incidence, Risk Factors, and Analysis of Survival of Unexpected N2 Disease in Stage I Non-Small Cell Lung Cancer.

BACKGROUND: To evaluate the incidence, predictors, and survival of unexpected pN2 disease in patients with clinical stage I non-small cell lung cancer. METHODS: This is a retrospective observational multicenter study on all consecutive patients operated for clinical stage I non-small cell lung cancer from January 2006 to December 2012. Medical records were reviewed to investigate the incidence and risk factors for unexpected pN2 disease. Then, the survival of patients with unexpected pN2 disease was statistically compared with that of patients with clinical N2 disease operated after induction therapy in the same period. RESULTS: Our study population counted 901 patients. An incidence of 12% (108/901) unexpected pN2 disease was found. Among 3,389 lymph nodes sampled, 124 distinct metastases were found. Of the 108 patients, 92 (85%) had metastases in single N2 station and 16 (15%) patients had disease in multiple N2 stations; 47 (44%) had pN2 disease without pN1 involvement (skip metastases) and 61/108 (56%) had also pN1 metastases. Factors associated with unexpected pN2 disease were central tumor location (p < 0.003), cT2a (p < 0.0001) and pT2a stage (p < 0.0001), pN1 disease (p = 0.004), and a standard uptake value > 4.0 (0.007). Patients with pN2 disease compared with patients with cN2 disease presented a better median overall survival (56 versus 20 months; p = 0.001) and disease-free survival (46 versus 11 months; p < 0.0001). CONCLUSIONS: The preoperative effort to discover unexpected pN2 disease in patients with clinical stage I non-small cell lung cancer is not justified, considering their good survival. Thus, preoperative invasive mediastinal procedures in such cases are not indicated.

Tracheal ring fracture secondary to percutaneous tracheostomy: is tracheal flaccidity a risk factor?

OBJECTIVE: To evaluate the risk factors of tracheal ring fracture and whether previous tracheal ring flaccidity predisposes to it in consecutive, mechanically ventilated, intensive care unit patients undergoing different percutaneous dilatational tracheostomy procedures (Ciaglia Blue Rhino, PercuTwist, and Ciaglia BlueDolphin). DESIGN: Single-center retrospective study performed between November 2006 and July 2013. SETTING: Single-center university hospital. PARTICIPANTS: Two hundred nineteen consecutive intensive care unit patients. INTERVENTIONS: Video bronchoscopic percutaneous dilatational tracheostomies using different techniques, including Ciaglia Blue Rhino, PercuTwist, and Ciaglia BlueDolphin, were performed consecutively. During the procedure, the tracheal wall response to the routine external palpation was evaluated endoscopically to find the interanular space. An abnormal change in the tracheal ring shape (fingerprint) with anterior airway wall collapse was diagnosed as tracheal flaccidity. MEASUREMENTS AND MAIN RESULTS: Tracheal ring fracture occurred in 21 patients (9.6%). The proportion of tracheal ruptures was 16 (76.2%) after PercuTwist, 3 (14.3%) after Ciaglia Blue Dolphin, and 2 (9.5%) after the Blue Rhino technique. Significant risk factors for tracheal rupture were PercuTwist procedure (p = 0.02), tracheal flaccidity (p = 0.0001), and a period of intubation before a percutaneous dilatational tracheostomy procedure>14 days (p = 0.01). CONCLUSIONS: In addition to the PercuTwist technique and intubation>14 days before tracheostomy, tracheal flaccidity was a significant risk factor for tracheal ring fracture. In the presence of this finding, a less traumatic tracheostomy procedure should be applied.

The Feasibility of LigaSure to Create Intestinal Anastomosis: Results of Ex Vivo Study.

OBJECTIVE: To evaluate the feasibility and the effectiveness of LigaSure Forced Triad to create intestinal anastomosis in an ex vivo porcino model. METHODS: Colon samples (n = 100) were prospectively randomized into 2 groups: LigaSure group (n = 90) and Stapler group (n = 10). The LigaSure group was divided into 9 subgroups, each of 10 samples, according to the different power levels of the LigaSure system (Bar 1, Bars 2, and Bars 3) and radiofrequency application (1 application, 2 applications, and 3 applications) used. All anastomoses were tested for early burst pressure. The LigaSure subgroup having the highest burst pressure was compared with the Stapler group. Finally, the specimen was reviewed by the same pathologist. RESULTS: The burst pressures of the 9 subgroups of LigaSure segments were the following: 29.7 ± 4.5 (Subgroup a); 27.4 ± 3.1 (Subgroup b); 25.3 ± 4 (Subgroup c); 32.9 ± 2.3 (Subgroup d); 30.7 ± 3.8 (Subgroup e); 25.7 ± 4.8 (Subgroup f); 42 ± 4.7 (Subgroup g); 31.8 ± 3.8 (Subgroup h); and 28.5 ± 3 (Subgroup j). Subgroup g (3 bars-power levels/1 frequency application) had the highest burst pressure (P < .001; ANOVA test). No significant difference was found between burst pressure of Subgroup g and Stapler group (42 ± 4.7 vs 42 ± 4.3, respectively, P = .9). On histological view, the LigaSure anastomosis was formed by collagen sealed without cavitation defects. CONCLUSIONS: Our study seems to confirm the feasibility of creating intestinal anastomosis using LigaSure. However, further researches in in vivo models are mandatory before recommending its clinical usage in such settings.

The influence of body mass index and weight loss on outcome of elderly patients undergoing lung cancer resection.

BACKGROUND: The aim of the study was to evaluate the influence of nutritional status on outcome of elderly patients resected for lung cancer. MATERIALS AND METHODS: A total of 117 consecutive patients aged ≥ 70 years undergoing lung cancer resection were enrolled. In addition to routine preoperative evaluations, other variables such as body mass index, weight loss, serum albumin, lymphocytes, and transferrin were counted. According to the body mass index value, patients were divided into Group A (≤ 18.5, underweight) and Group B (> 18.5) and risk factors for morbidity and mortality were analyzed. RESULTS: Group A and Group B counted 21 and 96 patients, respectively. The mean age was 74.9 ± 2.6; body mass index of Group A was significantly lower than that of Group B (16.7 ± 1.3 vs. 23.5 ± 1.7, respectively, p < 0.0001). On multivariate analysis, significant risk factors for complications were pneumonectomy (p = 0.001), stage (p = 0.006), predictive postoperative flow expiratory volume in 1 second (ppoFEV1%) (p = 0.003), and coronary disease (p = 0.04) and significant risk factors for early mortality were pneumonectomy (p = 0.0002), ppoFEV1% (p < 0.0001), BMI (0.02), and weight loss (0.007). The median survival time of Group A and Group B was 41 versus 54 months, respectively (p = 0.1). However, body mass index of less than 18.5 (p = 0.01) and weight loss of > 5% before operation (p = 0.01) were independent risk factors for 1 year mortality. CONCLUSIONS: In elderly patients, malnutrition was a significant additional risk factor for early death. Nutritional assessment should be included in the routine preoperative selection. In malnourished patients, nutritional support before and after operation and a careful postdischarge care might be beneficial, but it should be corroborated by further prospective studies.

Use of the LigaSure device and the Stapler for closure of the small bowel: a comparative ex vivo study.

PURPOSE: To evaluate the feasibility and effectiveness of the LigaSure device in closing divisions of the small bowel in an ex vivo porcine model. METHODS: Two types of closure were performed: stumps created by "muco-mucosa" fusion and stumps created by "sero-serosa" fusion. For each type of closure, different power levels of the LigaSure system were tested in combination with different numbers of applications and then compared with the Stapler group. RESULTS: With both types of intestinal closure, the highest value of burst pressure was obtained with the application of a power level of three bars and one frequency application. The high burst pressure of the muco-mucosa stump group was significantly lower than that of the Stapler group (41.8 ± 5.9 vs. 75.8 ± 5.9, respectively, p < 0.01). No differences were found between the high burst pressure of the sero-serosa stump group and the Stapler group (74.1 ± 5.5 vs. 75.8 ± 5.9, respectively, p = 0.2). CONCLUSIONS: Our preliminary results showed that the LigaSure is an efficient tool for closing the intestines when sero-serosa stumps are created. The second step of our work will be to evaluate the feasibility of this tool in creating intestinal anastomoses.