Is video-assisted thoracic surgery justified at first spontaneous pneumothorax?

OBJECTIVE: The fundamental role of video-assisted thoracic surgery (VATS) in the treatment of spontaneous pneumothorax is generally acknowledged today. This study intends to evaluate whether VATS is justified at the onset of a first spontaneous pneumothorax through analysis of parameters tested on two group of patients treated respectively with pleural drainage and VATS. PATIENTS/METHODS: The study includes 70 patients affected by first spontaneous pneumothorax divided into two groups of 35 patients for the purpose of therapeutic treatment. The first group underwent pleural drainage while the second underwent VATS. Parameters analyzed were as follows: (1) prolonged air leaks (more than 6 days); (2) time required for pleural drainage; (3) time of hospital stay; (4) management costs; (5) recurrences (follow-up at 12 months). RESULTS: Prolonged air leaks occurred in four patients (11.4%) in the first group and two patients (5.7%) in the second; recurrences occurred in eight patients in the first group (22.8%), and only one in the second group (2.8%). Mean time for drainage and hospitalization was, respectively, 9 and 12 days in patients with pleural drainage against 3.9 and 6 days of those using VATS. Average management costs per patients including hospitalization was calculated at $2,750.00 per patient for the first group compared with $1,925.00 for the second group. CONCLUSIONS: The use of VATS at first spontaneous pneumothorax is justified in the interest of both patients and health administrations as demonstrated by the number of recurrences in patients in the first group and economy savings resulting from use of VATS.

[Translaryngeal tracheostomy using the Fantoni technique: report of 104 cases]. / La trachéotomie translaryngée selon la technique de Fantoni: à propos de 104 observations.

OBJECTIVE: Surgical tracheostomy morbidity led the authors to investigate new election techniques. The aim of this retrospective study was to assess the translaryngeal tracheostomy (TLT), complications and cost. METHODS: From January 1998 to January 2001, 104 patients were treated with TLT modified: 69 males (66.3%) and 35 females (33.7%), average age 52.6 +/- 9.5 years. The original pathologies were: traumatical (36), neurological (37), surgical (9), heart (4), respiratory (18). The average time between intubation and execution of TLT was 4.2 +/- 1.3 days. RESULTS: Fifty four patients died (52%) and 50 patients lived (48%). Two complications (1.9%) occurred in those who survived: a breaking of the guidewire in traction. Extraction of the tracheostomy tube by clamp, a haemorrhage in 2nd post-operative day due to a thyroid vessel lesion. The haemostasis was performed by classical tracheostomy. The average number of days to decannulation was 25 +/- 1 days. CONCLUSIONS: TLT reduces trauma or trachea and neighbouring structures. This technique is safe and easy. TLT is an effective method, in non-urgent situations, in children and adults, as well as in brachytypes and the obese.

[Tumors of the chest wall]. / I tumori della parete toracica.

The aim of this work was to evaluate the different surgical repair procedures and to discuss their technical applications according to the indications. From april 1989 to november 1999 we observed 18 patients, 12 males (66.7%) and 6 females (33.3%) presenting tumors of the chest wall. All patients were submitted preoperatively to a general respiratory check-up, and to an assessment of loco-regional and metastatic lesions. In 13 patients (72.2%), on the basis of topographical and morphological characteristics of the mass, we performed a transthoracic needle biopsy under scanner monitoring. The exeresis, in 6 patients (33.3%), implied a large resection of osteo-muscular structures. In 10 patients (55.6%), the benign nature of lesion, required extirpation solely of the tumor. In 2 patients (11.1%), owing to the extensive infiltration of the primary neoplasm, solely complementary treatment was carried out. Reconstruction of the thoracic wall was performed using associated myoplasty in all cases. In 3 subjects a prosthesis was installed; in 1 case a costal transposition association is necessary. Histological observation of the excised material revealed 16 primary tumors, 12 benign (75%) and 4 malignant (25%). Transthoracic needle biopsy under scanner monitoring confirmed the diagnosis in 100% of the cases operated. Fourteen patients (87.5%) are alive 73 +/- 35 months after intervention, without resumption of the disease. Two patients died (12.5%) VIII and VI months following the operation. Two patients not operated, died after VI and V months. Appropriate choice of techniques and of repair materials allowed valid oncological, aesthetical and functional results independently from the extent of the parietal defect.

[Combined surgical treatment of pulmonary neoplasms with single brain metastasis]. / Trattamento chirurgico combinato delle neoplasie polmonari con metastasi cerebrale unica.

The combined surgical treatment of primitive lung cancer with single brain metastasis is a frequently debated but still controversial problem. Up to day several therapeutic approaches are generally integrated (surgery, radiotherapy, chemotherapy) according to the clinical patterns and the technical possibilities. In general, the combined surgical operation (thoracotomy + craniotomy) when it is possible to be done, followed or proceeded by chemo-radiotherapy, has allowed to achieve a prolonged survival in these patients, maintaining an acceptable quality of life. The authors analyze 10 cases treated by thoracotomy and craniotomy at the Chair of Thoracic Surgery of University of L'Aquila. Although consisting of a small number of cases, this experience allows to detect the particular problems concerning these patients. The indications to the combined surgical treatment are considered, evaluating the surgical operation which is to be performed as first on the basis of lung cancer staging and of the location and size of the brain metastases. Finally the patients survival and their quality of life are considered.

[Therapeutic approach in non-postoperative pleural empyema]. / L'approccio terapeutico nell'empiema pleurico non post-chirurgico.

The Authors carried out an retrospective analysis on 81 patients, 67 men and 14 women, suffering from non post-surgical thoracic empyema, to evaluate the different therapeutic procedures and respective indications. The unsuccessful response to the preserving approach (intercostal drainage and pleural lavage twice a day with specific antibiotics or antiseptics) in 56 cases, induced the Authors to carry out a video-thoracoscopy (VAT), that allowed them to define the infection stage and subsequent treatment (the carrying on of a pleural drainage-lavage in 32 cases, the transcurrent pleural irrigation in 10 cases, the open window thoracostomy followed by myoplasty in 6 cases with bronchopleural fistula, the decortication with associated pleural exeresis in 6 cases with bronchopleural fistula, the decortication with associated pleural exeresis in 6 cases, the streptokinase in pleural cavity in 2 cases). There were registered totally 3 deaths (3.7%). The Authors in conclusion assert that the VAT, carried out after the unsuccessful preserving treatment, allows the evaluation of the infection stage and consequently suggests therapy.

[Current role of open window thoracostomy]. / Attuale ruolo dell'open window thoracostomy.

The Open Window Thoracostomy (OWT) surgical method find its origin in the treatment of chronic tuberculous empyemas, in the cases where the drainage alone not permitted a sufficient cleaning of pleural cavity. In the recent years the indications for the execution of this method are extended also to metapneumoniae and post-pneumonectomy empyemas (for benign and malignant pathology), with or without bronco-pleural fistula, when these pathologies produces a general severe decline in the patient (septic shock). This method permit to effect a daily cleaning of a pleural cavity, through the introduction of a sterile gauzes imbued of specific antibiotic, reducing at least the purulent infection effects's previously present and favouring the reduction of the same cavity, in prevision of other reconstructive operations (thoracoplasty). Generally not many beloved by surgeons and patients (for the difficult management, aesthetic outcomes, the long stay in hospital), the OWT can often reestablish a dangerous situation, especially in the patients with a risk of septic shock. This study aims to analyse present indications, problems and therapeutics outcomes of this method, through the evaluation of 27 cases of OWT treated in the Department of Thoracic Surgery University of L'Aquila between the 1984 and the 1998.

[Recurrent giant retroperitoneal leiomyosarcoma. Report of a clinical case]. / Leiomiosarcoma retroperitoneale gigante recidivante. Descrizione di un caso clinico.

The Authors report the case of a male patient, 52 year old, suffering from retroperitoneal leiomyosarcoma, submitted to multiple operations in the space of about seven years, for the presence of liver metastases and local relapses; the good general health state, the moderate grade of the neoplasm and the disease's fair interval free, have justified the therapeutic attitude adopted; the patient at present enjoys good health.

[Chondro-costal abnormalities of anterior wall of the chest: operative indications and surgical technique]. / Le malformazioni condro-costali della parete anteriore del torace: indicazioni operatorie e tecnica chirurgica.

The aim of this study is to evaluate the utility of surgical treatment in patients with pectus excavatum (PE) or pectus carinatum (PC). Fifteen patients underwent surgical treatment because of their psycological and anatomical condition, more serious in 6 patients (5 with PE and 1 with PC). The degree of these chest wall deformities was evaluated as resulting from CT scan of the thorax, by the ratio between the transversal and the front/back diameters, according to Haller. The Authors recommend surgical operation in the post-puberal age up to 21 years because of good results obtained using Ravitch approach (only 1 case of partial relapse of PE), even though modified in PE cases with the application of flat steel prosthesis and in PC cases for uncutting the perichondral beds. The choice of surgical procedure derives, in our opinion, from the correction of these anatomic deformities and from the greater sense of improved cosmesis that might result.

[Total intravenous anesthesia in thoracotomy with one-lung ventilation]. / Anestesia totalmente endovenosa nella toracotomia con ventilazione monopolmonare.

BACKGROUND: The aim of this study was to evaluate the benefits of total intravenous anaesthesia (TIVA), with the administration of drugs intravenously and the maintenance of pulmonary ventilation with oxygen enriched air, with respect to inhalatory anaesthesia, in thoracotomies with single lung ventilation. METHODS: The study, devoloped in collaboration between the Service of Anaesthesia and Resuscitation and the Division of Thoracic Surgery of the Hospital of Teramo, was carried out in two groups of patients chosen at random; fifty patients divided into two groups of twenty-five were studied. Pre-medication and induction was similar in both groups; maintenance, however, varied: a total intravenous anaesthesia was given to patients in group A whereas patients in group B received an inhalatory anaesthesia. These parameters were considered: pressure values, heartbeat, PaO2 and PaCO2 levels, SatO2 and EtCO2. RESULTS: Both protocols respected anaesthetic guidelines in terms of controlling pressure values, heartbeat and levels of PaCO2 during bipulmonary ventilation. Significantly statistical differences were observed in the oxygenation during one lung ventilation: the mean values of PaO2 being significantly higher in group A. CONCLUSIONS: On the basis of this experience, it can be conclude that TIVA offers the following advantages: a better oxygenation during one lung ventilation, good recovery of post operative consciousness with no psychomotor disturbances, absence of pollution in the operating theatre.

[Malformative giant emphysema bulla. Report of a case in childhood]. / Bolla d'enfisema gigante malformativa. Presentazione di un caso in età pediatrica.

Bullous pneumopathy is considered a surgical disease, although her treatment is still discussed. The initial attempts of surgical treatment were founded on erroneous physiopathological concepts and date back to early years of 1900. These surgical treatments intended to external drainage of giant bullae, their marsupialized or to reduction of extension of bullae by pneumoperitonaeum, section of phrenic nerve or thoracoplasty. The definition of emphysematous bullae has been much improved with the development of computed tomography. A precise study of their size, of their position and of condition of residual pulmonary parenchyma may be considered important to decide the surgical treatment: this must determine the removal of bulla and the reexpansion of compressed pulmonary parenchyma. The Authors report a case of giant bulla, initially wrong interpreted as pneumothorax, of exceptional observation for her malformative origin, diagnoses and surgical treated on an eleven years old child.