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.

Perioperative identifications of non-palpable pulmonary nodules: a narrative review.

Early detection of lung cancer is the key to improving treatment and prognosis of this disease, and the advent of advances in computed tomography (CT) imaging and national screening programs have improved the detection rate of very small pulmonary lesions. As such, the management of this sub-centimetric and often sub-solid lesions has become quite challenging for clinicians, especially for choosing the most suitable diagnostic method. In clinical practice, to fulfill this diagnostic yield, transthoracic needle biopsy (TTNB) is often the first choice especially for peripheral nodules. For lesions for which TTNB could present technical difficulties or failed, other diagnostic strategies are needed. In this case, video-assisted thoracic surgery (VATS) is the gold standard to reach the diagnosis of lung nodules suspect of being malignant. Nonetheless it's often not easy the identification of such lesions during VATS because of their little dimensions, non-firm consistency, deep localization. In literature various marking techniques have been described, in order to improve intraoperative nodules detection and to reduce conversion rate to thoracotomy: CT-guided hookwire positioning, methylene blue staining, intra-operative ultrasound and electromagnetic navigation bronchoscopy are the most used. The scientific evidence on this matter is weak because there are no randomized clinical trials but only case series on single techniques with no comparison on efficacy, so there are no guidelines to refer. From this standing, in this article we conducted a narrative review of the existing literature on the subject, with the aim of outlining a framework as complete as possible. We analyzed strengths and weaknesses of the main techniques reported, so as to allow the clinician to orient himself with greater ease.

Circulating biomarkers in malignant pleural mesothelioma.

Malignant pleural mesothelioma (MPM) is an aggressive tumor strictly connected to asbestos exposure. Prognosis is dismal as diagnosis commonly occurs in advanced stage. Radiological screenings have not proven to be effective and also pathological diagnosis may be challenging. In the era of precision oncology, validation of robust non-invasive biomarkers for screening of asbestos-exposed individuals, assessment of prognosis and prediction of response to treatments remains an important unmet clinical need. This review provides an overview on current understanding and possible applications of liquid biopsy in MPM, mostly focused on the utility as diagnostic and prognostic test.

Effectiveness of home-based preoperative pulmonary rehabilitation in COPD patients undergoing lung cancer resection.

OBJECTIVE: To investigate the effectiveness of a home-based preoperative rehabilitation program for improving preoperative lung function and surgical outcome of patients with chronic obstructive pulmonary disease (COPD) undergoing lobectomy for cancer. METHODS: This was a prospective, observational, single-center study including 59 patients with mild COPD who underwent lobectomy for lung cancer. All patients attended a home-based preoperative rehabilitation program including a minimum of 3 sessions each week for 4 weeks. Each session included aerobic and anaerobic exercises. Participants recorded the frequency and the duration of exercise performed in a diary. The primary end point was to evaluate changes in lung function including predicted postoperative (PPO) forced expiratory volume in 1 second (FEV1), 6-minute walking distance test (6MWD), PPO diffusing capacity for carbon monoxide (DLCO) %, and blood gas analysis values before and after the rehabilitation program. Postoperative pulmonary complications were recorded and multivariable analysis was used to identify independent prognostic factors (secondary end point). RESULTS: All patients completed the 4-week rehabilitation program. Thirteen of 59 (22%) patients (Group A) performed <3 sessions per week (mean sessions per week: 2.3±1.3); 46 of 59 (78%) patients (Group B) performed ⩾3 sessions per week (mean sessions per week: 3.5±1.6). The comparison of PPO FEV1% and 6MWD before and after rehabilitation showed a significant improvement only in Group B. No significant changes in PPO DLCO% or in blood gas analysis values were seen. Nine patients presented postoperative pulmonary complications, including atelectasis (n = 6), pneumonia (n = 1), respiratory failure (n = 1), and pulmonary embolism (n = 1). Group A presented higher number of postoperative pulmonary complications than Group B (6 vs 3; p = 0.0005). Multivariate analysis showed that the number of weekly rehabilitation sessions was the only independent predictive factor (p = 0.001). CONCLUSIONS: Our simple and low-cost rehabilitation program could improve preoperative clinical function in patients with mild to moderate COPD undergoing lobectomy and reduce postoperative pulmonary complications. All patients should be motivated to complete at least 3 rehabilitation sessions per week in order to obtain significant clinical benefits. Our preliminary results should be confirmed by larger prospective studies.

Hemorrhagic complication during robotic surgery in patient with thymomatous myasthenia gravis.

The advantages of thymectomy as part of the treatment of myasthenia gravis has been demonstrated repeatedly in the literature. Both single-institution and multi-institution trials have shown robotic thymectomy to be safe, feasible and associated with better early clinical outcomes than the trans-sternal approach. Most reports have also documented the superiority of robotic technology in the dissection of the superior mediastinum over conventional thoracoscopy, thanks to instruments with more degrees of movement and freedom. However, in case of a vascular injury in the superior mediastinum, after an initial management with minimally invasive approach, one should not hesitate to convert to sternotomy if the bleeding control hasn't been definitely established. In this way it is possible to avoid catastrophic injuries, also in relation to the limitations that, in our opinion, the robotic surgery has once a major vascular injury occurs in the mediastinum.

Reasons for conversion during VATS lobectomy: what happens with increased experience.

Although controlled studies have demonstrated the benefits of a minimally invasive approach for pulmonary lobectomy over thoracotomy, reports have also documented that significant complications can occur during thoracoscopic lobectomy and sometimes require planned or emergent conversion to open surgery. Several authors have identified and reported causes and implications of intraoperative conversion to thoracotomy using different types of classification. The aim of this single centre retrospective review is to evaluate how the reasons for conversion change with increased experience, dividing patients who were converted to thoracotomy during video-assisted thoracic surgery (VATS) lobectomy, between 2011 and 2017, in two groups: those treated during learning curve (LC group) and those treated after learning curve (ALC group). Our research suggests that the conversion rate, with increased skills, decreases but a variety of reasons for conversion persist. Of these, calcified, benign or malignant hilar adenopathy is the most frequent and represents the leading cause of conversion to open surgery due to complicated vascular dissection or vessel injury. It's strongly recommended, with increased confidence in performing VATS lobectomies, also to develop management strategies and techniques to prevent and control possible intraoperative adverse events.

Morgagni hernia repair in adult obese patient by hybrid robotic thoracic surgery.

Morgagni hernia is a relatively uncommon congenital diaphragmatic hernia in which abdominal contents protrude into the chest through the foramen of Morgagni. It usually occurs on the right side of the chest but may occur on the left side or in the midline. In adults, it commonly presents with non-specific symptoms such as dyspnea, cough, gastroesophageal reflux disease and other. Surgical repair should be always performed to prevent the risk of hernia incarceration. Transthoracic approach has been proposed especially in cases with indeterminate, anterior pericardial masses. We believe that in adult obese patients with Morgagni hernia and voluminous hernial sac containing only omentum, the transthoracic approach can represent a valid alternative to transabdominal approach. The use of hybrid robotic thoracic surgery can be strongly recommended because it allows, through robotic instruments, to perform delicate surgical maneuvers in difficult to reach anatomical areas and, with the final extension of a port-site incision, to remove voluminous specimens from the thoracic cavity, avoiding the chest wall discomfort that follow the thoracotomy access.

Hybrid robotic thoracic surgery for excision of large mediastinal masses.

Between April 2016 and October 2017, we retrospectively reviewed all patients undergoing excision of large mediastinal masses using a hybrid robotic thoracic approach at the Unit of Thoracic Surgery of Monaldi Hospital in Naples. The inclusion criteria for this approach were: evident unilateral predominance of the mass; absence of invasion to surrounding structures. Planned conversion to sternotomy was necessary in one patient for tenacious adhesions between the mediastinal goiter and the left innominate vein. In all cases the postoperative course was uneventful. The hybrid robotic approach, adopted in our Unit, consists of a thoracic procedure performed completely with articulated surgical instruments under three-dimensional vision and followed by final extension of a port-site incision to retrieve the voluminous specimen. This approach uses all the advantages of robotic technology that enables to perform a fine dissection in the small space of the anterior mediastinum and at the same time, through the simple extension of a minimally invasive access, avoids the painful sequelae of thoracotomy. In selected cases, with increased experience in robotic surgery, it can be proposed for excision of large mediastinal masses, although a longer follow-up period is necessary to validate our findings.

Antero mediastinal retrosternal goiter: surgical excision by combined cervical and hybrid robot-assisted approach.

Most intrathoracic goiters are located in the anterior mediastinum. Surgical resection is usually recommended in case of morbidity associated with the goiter's mass effect or for suspicion of malignancy difficult to diagnose without resection. Intrathoracic goiters are usually resected through a cervical approach, with sternotomy needed in selected cases. We report a case of antero mediastinal retrosternal goiter in old age patient undergoing surgical excision by combined cervical and hybrid robot-assisted approach. All steps of the thoracic procedure were completely performed using the da Vinci robot system with final extension of a port-site incision to extract the specimen. This approach provides more advantages than sternotomy regarding post operative clinical benefits and allows a more accurate surgical resection in the antero-superior mediastinum than conventional thoracoscopy.

Conversion to thoracotomy during VATS segmentectomy for treatment of symptomatic endobronchial hamartoma.

INTRODUCTION: Most hamartomas are located peripherally in the lung parenchyma and are rarely identified as an endobronchial lesion. Clinically patients with an endobronchial hamartoma are often symptomatic and may present with various symptoms including: fever, wheezing, hemoptysis and obstructive pneumonia. CASE PRESENTATION: A 68-year-old man presented with complaints of fever and cough for 1 month. Chest X-ray revealed a right infrahilar density, which on chest CT was found to be a lesion obstructing the superior segmental bronchus of the right lower lobe and extending outside of the bronchus. A round rubbery mass obstructing the same segmental bronchus was noticed during bronchoscopy and endoscopic biopsy yielded a pathological diagnosis of hamartoma. DISCUSSION: Bronchoscopy is most helpful in diagnosis and management of endobronchial hamartomas but if the lung distal to the obstruction is irreversibly damaged or imaging studies suggest that tumor extends outside of the bronchus, pulmonary segmentectomy, lobar resection or even pneumonectomy may be indicated. CONCLUSION: When a benign tumor of the lung, as endobronchial hamartoma, is located in a segmental bronchus and presents extrabronchial spread, we recommend to perform a parenchymal-sparing surgical resection. In this case surgical team, however, should keep in mind, due to difficult individual dissection of the segmental bronchovascular elements, the possibility of conversion from VATS (video-assisted thoracic surgery) to open thoracotomy.

Elective surgery treatment in patient living in rural area with history of recurrent primary spontaneous pneumothorax: A procedure to avoid in absence of pneumothorax. A case report.

INTRODUCTION: Pneumothorax is defined as accumulation of air in the pleural space with secondary lung collapse resulting in dyspnea or chest pain. Currently the optimal management of spontaneous pneumothorax has been standardized, but the question of elective surgery treatment remains unresolved in patients living in rural area with history of recurrent Primary spontaneous pneumothorax [PSP]. PRESENTATION OF CASE: A 41 years-old white man living in rural area, with a history of recurrent right spontaneous pneumothorax (three subsequent episodes) treated by positioning of chest tube, was admitted to our unit. No respiratory symptoms and normal physical exam were observed on admission although anxiety states was noted. Chest CT scan showed small apical bullae in the right upper lobe without cystic change in the pulmonary parenchyma. DISCUSSION: Recurrence of primary spontaneous pneumothorax represents a complication most frequently occurring within the first year. Among the treatment options, surgical management is needed in 25-50% of all patients suffering from PSP, due to persistent air leak or recurrence. We report the operative complications after elective surgery in a white man living in rural area with a history of recurrent right primary spontaneous pneumothorax. CONCLUSION: This case report highlights that elective surgery in patients living in rural area with history of recurrence PSP can lead to post-operative complications as bleeding or prolonged air leaks following the lysis of multiple pleural adhesions.

Endoscopic treatment with fibrin glue of post-intubation tracheal laceration.

Post-intubation tracheal laceration (PITL) is a rare and potential life-threatening condition requiring prompt diagnosis and treatment. A conservative treatment is indicated in patients with laceration <2 cm in length while surgery is the treatment of choice for laceration >4 cm. For laceration between 2-4 cm, the best treatment is debate; some authors recommend surgery while others do not definitely exclude endoscopic treatment. Herein, we reported the endoscopic treatment with fibrin glue of PITL. The procedure is performed using a standard video-bronchoscopy in operating room; the patient is in spontaneous breathing and deep sedation. After identification of tracheal laceration, the fibrin glue is injected through a dedicated double lumen catheter into the lesion. After mixing both components of fibrin glue, polymerization of fibrin occurs resulting in an elastic and opaque clot that closes the lesion. The key success of the procedure is based on accurate patient selection. Patients are eligible if (I) they are clinically stable and in spontaneous respiration; (II) with a small and superficial tracheal laceration (≤4 cm in length and without oesophageal injury); (III) localized at level of the upper or middle trachea; and (IV) without clinical and/or radiological signs of mediastinal collection, of emphysema or pneumomediastinum progression, and of infection.

Three-dimensional virtual bronchoscopy using a tablet computer to guide real-time transbronchial needle aspiration.

Objectives: We proposed a new virtual bronchoscopy tool to improve the accuracy of traditional transbronchial needle aspiration for mediastinal staging. Methods: Chest-computed tomographic images (1 mm thickness) were reconstructed with Osirix software to produce a virtual bronchoscopic simulation. The target adenopathy was identified by measuring its distance from the carina on multiplanar reconstruction images. The static images were uploaded in iMovie Software, which produced a virtual bronchoscopic movie from the images; the movie was then transferred to a tablet computer to provide real-time guidance during a biopsy. To test the validity of our tool, we divided all consecutive patients undergoing transbronchial needle aspiration retrospectively in two groups based on whether the biopsy was guided by virtual bronchoscopy (virtual bronchoscopy group) or not (traditional group). The intergroup diagnostic yields were statistically compared. Results: Our analysis included 53 patients in the traditional and 53 in the virtual bronchoscopy group. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for the traditional group were 66.6%, 100%, 100%, 10.53% and 67.92%, respectively, and for the virtual bronchoscopy group were 84.31%, 100%, 100%, 20% and 84.91%, respectively. The sensitivity ( P = 0.011) and diagnostic accuracy ( P = 0.011) of sampling the paratracheal station were better for the virtual bronchoscopy group than for the traditional group; no significant differences were found for the subcarinal lymph node. Conclusions: Our tool is simple, economic and available in all centres. It guided in real time the needle insertion, thereby improving the accuracy of traditional transbronchial needle aspiration, especially when target lesions are located in a difficult site like the paratracheal station.

In the era of ultrasound technology, could conventional trans-bronchial needle aspiration still play a role in lung cancer mediastinal staging?

BACKGROUND: To evaluate the feasibility of a combined strategy including conventional-trans-bronchial needle aspiration biopsy (C-TBNA) and endobronchial ultrasounds transbronchial needle aspiration (EBUS-TBNA) for sampling mediastinal adenopathies in patients with lung cancer in order to determinate whether in the era of ultrasound technology C-TBNA could still play a role in mediastinal staging. METHODS: It was a retrospective multicenter study including all consecutive patients with lung cancer and radiological mediastinal adenopathies undergoing TBNA for mediastinal staging (January 2014 - July 2016). C-TBNA was performed as first diagnostic procedure. All negative C-TBNA results were corroborated by EBUS-TBNA, and, if EBUS-TBNA was negative, by mediastinoscopy or surgery. The diagnostic yield of C-TBNA were then calculated. RESULTS: A total of 175 patients were included in the study for a total of 197 mediastinal adenopathies sampled. C-TBNA was positive in 125 cases and negative in 72 cases who underwent EBUS-TBNA. It was positive in 58 cases and negative in 14 patients. After surgical exploration (n=12) and mediastinoscopy (n=2), 11 patients did not present metastases (true negative) while 3 presented mediastinal involvement (false negative). Thus, C-TBNA had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of 67.2%, 100%, 100%, 15.3% and 69.0%, respectively. The sensitivity increased for sampling paratracheal versus subcarinal stations (80% versus 49%; P<0.001); and large adenopathies (≥15 mm) versus small adenopathies (<15 mm) (83% versus 43%; P<0.001). In all re-staging patients (n=4), Conventional-TBNA results were false negative. CONCLUSIONS: The combined use of C-TBNA and EBUS-TBNA as the most cost-effective strategy in the setting of mediastinal staging. C-TBNA performed before EBUS-TBNA is indicated for sampling large mediastinal adenopathies near to carina while EBUS-TBNA remains the first choice for puncturing small adenopathies far from carina and for re-staging after induction therapy.

Risk factors for postoperative recurrence of spontaneous pneumothorax treated by video-assisted thoracoscopic surgery†.

OBJECTIVES: Over the past two decades, video-assisted thoracoscopic blebectomy and pleurodesis have been used as a safe and reliable option for treatment of spontaneous pneumothorax. The aim of this study is to evaluate the long-term outcome of video-assisted thoracoscopic surgery (VATS) treatment of spontaneous pneumothorax in young patients, and to identify risk factors for postoperative recurrence. METHODS: We retrospectively analysed the outcome of VATS treatment of spontaneous pneumothorax in our institution in 150 consecutive young patients (age ≤ 40 years) in the years 1997-2010. Treatment consisted of stapling blebectomy and partial parietal pleurectomy. After excluding 16 patients lost to follow-up, in 134 cases [110 men, 24 women; mean age, 25 ± 7 standard deviation years; median follow-up, 79 months (range: 36-187 months)], we evaluated postoperative complications, focusing on pneumothorax recurrence, thoracic dysaesthesia and chronic chest pain. Risk factors for postoperative pneumothorax recurrence were analysed by logistic regression. RESULTS: Of 134 treated patients, 3 (2.2%) required early reoperation (2 for bleeding; 1 for persistent air leaks). Postoperative (90-day) mortality was nil. Ipsilateral pneumothorax recurred in 8 cases (6.0%) [median time of recurrence, 43 months (range: 1-71 months)]. At univariate analysis, the recurrence rate was significantly higher in women (4/24) than in men (4/110; P = 0.026) and in patients with >7-day postoperative air leaks (P = 0.021). Multivariate analysis confirmed that pneumothorax recurrence correlated independently with prolonged air leaks (P = 0.037) and with female gender (P = 0.045). Chronic chest wall dysaesthesia was reported by 13 patients (9.7%). In 3 patients, (2.2%) chronic thoracic pain (analogical score >4) was recorded, but only 1 patient required analgesics more than once a month. CONCLUSIONS: VATS blebectomy and parietal pleurectomy is a safe procedure for treatment of spontaneous pneumothorax in young patients, with a 6% long-term recurrence rate in our experience. Postoperative recurrence significantly correlates with female gender and with prolonged air leakage after surgery.