Not only acute respiratory failure: COVID-19 and the post-intubation/tracheostomy upper airways lesions†.

Background: An increasing number of patients have been subjected to prolonged invasive mechanical ventilation due to COVID-19 infection, leading to a significant number of post-intubation/tracheostomy (PI/T) upper airways lesions. The purpose of this study is to report our early experience in endoscopic and/or surgical management of PI/T upper airways injuries of patients surviving COVID-19 critical illness. Materials and Methods: We prospectively collected data from patients referred to our Thoracic Surgery Unit from March 2020 to February 2022. All patients with suspected or documented PI/T tracheal injuries were evaluated with neck and chest computed tomography and bronchoscopy. Results: Thirteen patients (8 males, 5 females) were included; of these, 10 (76.9%) patients presented with tracheal/laryngotracheal stenosis, 2 (15.4%) with tracheoesophageal fistula (TEF) and 1 (7.7%) with concomitant TEF and stenosis. Age ranged from 37 to 76 years. Three patients with TEF underwent surgical repair by double layer suture of oesophageal defect associated with tracheal resection/anastomosis (1 case) or direct membranous tracheal wall suture (2 cases) and protective tracheostomy with T-tube insertion. One patient underwent redo-surgery after primary failure of oesophageal repair. Among 10 patients with stenosis, two (20.0%) underwent primary laryngotracheal resection/anastomosis, two (20.0%) had undergone multiple endoscopic interventions before referral to our Centre and, at arrival, one underwent emergency tracheostomy and T-tube positioning and one a removal of a previously positioned endotracheal nitinol stent for stenosis/granulation followed by initial laser dilatation and, finally, tracheal resection/anastomosis. Six (60.0%) patients were initially treated with rigid bronchoscopy procedures (laser and/or dilatation). Post-treatment relapse was experienced in 5 (50.0%) cases, requiring repeated rigid bronchoscopy procedures in 1 (10.0%) for definitive resolution of the stenosis and surgery (tracheal resection/anastomosis) in 4 (40.0%). Conclusions: Endoscopic and surgical treatment is curative in the majority of patients and should always be considered in PI/T upper airways lesions after COVID-19 illness.

Case report: Successful multimodal assessment and management of chemothorax.

Dislocation or wrong placement of central venous catheters into the pleural cavity is rare, but if undiagnosed, may cause major, sometimes life-threatening, complications (pneumothorax, hemothorax, infection, and migration) and accidental pleural effusion due to intravenous injection of fluids containing drugs (i.e. chemotherapy, antibiotics, parenteral nutrition, other). We report a rare case of pleural effusion consisting of chemotherapy (chemothorax) directly injected into the pleural cavity due to the wrong placement of a central venous catheter (Porth-A-Cath) in a woman with breast cancer. A multidisciplinary management consisting of antidote administration, followed by removal of the venous device and washing of the pleural cavity through video-assisted thoracic surgery (VATS), avoided any major complication related to the adverse event.

Multidisciplinary Approach in the Treatment of Descending Necrotizing Mediastinitis: Twenty-Year Single-Center Experience.

Descending necrotizing mediastinitis (DNM) is an acute, rare, severe condition with high mortality, but the optimal management protocol is still controversial. We retrospectively analyzed the results of multidisciplinary management in patients treated for DNM at our center over the last twenty years. Fifteen male patients, mean age 49.07 ± 14.92 years, were treated: 9 with cervico-pharyngeal etiopathogenesis, 3 peri-tonsillar/tonsillar, 2 odontogenic, 1 post-surgical; 6 with DNM type I, 6 with type IIA, and 3 with type IIB (Endo's classification). Mean time between diagnosis and treatment was 2.24 ± 1.61 days. In all cases, mediastinum drainage via thoracotomy was performed after neck drainage via cervicotomy, associated with tooth treatment in two; one required re-operation; tracheostomy was necessary in 9, temporary intensive care unit stay in 4; 6 developed complications, without post-operative mortality. Main isolated germs were Staphylococci and Candida; 7 had polymicrobial infection. The most used antibiotics were meropenem, metronidazole, teicoplanin, third-generation cephalosporins and clyndamicin; anti-fungal drugs were fluconazole, caspofungin and anidulafungin. On multivariate analysis, presence of cardiovascular disease was statistically significantly associated with longer chest tube duration and hospital stay. DNM requires early diagnosis and treatment to reduce mortality and morbidity. The most effective treatment should provide a multidisciplinary approach, combining cervicotomy and thoracotomy to drain all infectious collections with administration and monitoring of the proper antimicrobial therapy.

Lymph Nodes Involvement and Lymphadenectomy in Thymic Tumors: Tentative Answers for Unsolved Questions.

Thymic tumors are the most common primary neoplasms of the anterior mediastinum, although, when compared with the entire thoracic malignancies, they are still rare. Few studies addressed the questions about lymph node involvement pattern in thymic neoplasms, about which subgroup of patients would be appropriate candidates for lymph node dissection or about the extent of lymphadenectomy or which lymph nodes should be harvested. The aim of this review is to collect evidence from the literature to help physicians in designing the best surgical procedure when dealing with thymic malignancies. A literature review was performed through PubMed and Scopus in May 2021 to identify any study published in the last 20 years evaluating the frequency and the extent of lymph node dissection for thymic tumors, its impact on prognosis and on postoperative management. Fifteen studies met the inclusion criteria and were included in this review, with a total of 9452 patients with thymic cancers; lymph node metastases were found in 976 (10.3%) patients in total. The current literature is heterogeneous in the classification and reporting of lymph node metastases in thymic carcinoma, and data are hardly comparable. Surgical treatment should be guided by the few literature-based pieces of evidence and by the experience of the physicians.

Resectable IIIA-N2 Non-Small-Cell Lung Cancer (NSCLC): In Search for the Proper Treatment.

Locally advanced non-small cell lung cancer accounts for one third of non-small cell lung cancer (NSCLC) at the time of initial diagnosis and presents with a wide range of clinical and pathological heterogeneity. To date, the combined multimodality approach involving both local and systemic control is the gold standard for these patients, since occult distant micrometastatic disease should always be suspected. With the rapid increase in treatment options, the need for an interdisciplinary discussion involving oncologists, surgeons, radiation oncologists and radiologists has become essential. Surgery should be recommended to patients with non-bulky, discrete, or single-level N2 involvement and be included in the multimodality treatment. Resectable stage IIIA patients have been the subject of a number of clinical trials and retrospective analysis, discussing the efficiency and survival benefits on patients treated with the available therapeutic approaches. However, most of them have some limitations due to their retrospective nature, lack of exact pretreatment staging, and the involvement of heterogeneous populations leading to the awareness that each patient should undergo a tailored therapy in light of the nature of his tumor, its extension and his performance status.