Is Myotomy Plus Diverticulopexy Suitable for Symptomatic Zenker's Diverticula?

The aim of the study was to prospectively evaluate the outcome of myotomy plus diverticulopexy over short and long-terms. A prospectively collected consecutive series (2007-2017) of 37 patients undergoing myotomy plus diverticulopexy was analyzed for clinical condition, operative information, peri-operative events, and follow-up by means of interview and physical examination. Diverticulopexy was scheduled regardless of the diverticulum's features and patient condition, other than operability. There was no choice or selection between possible treatment options. Patients were evaluated pre-operatively, at post-operative day 30 and after 1 year. Follow-up aimed at assessing the subjective condition following treatment. During the interview, patients were asked to self-assess their ability to swallow before and after surgery. No patient had peri-operative events, complications associated with the procedure, wound infection or impaired swallowing. All patients could start drinking the day after operation, could return to solid diet on post-operative day 2 and be discharged on post-operative days 3-4. Barium swallowing was not necessary before discharge. Full solid diet was resumed according to patient's compliance from post-operative day 2 (some patients refused solid diet soon after the operation even if asymptomatic). Follow-up ranged between 1 and 8 years. No patient was lost at follow-up. No disease recurrence was observed. Finally, no patient needed or sought for a clinical examination between the follow-up calls. Patients reported at least 50% improvement of symptomatology after 1 year. Diverticulopexy appears to be clinically safe, methodologically reproducible, and an effective procedure; it avoids suturing and offers good outcome results along with high patient satisfaction.

Atypical parathyroid tumor: clinical and parathyroid hormone response to surgical treatment.

Purpose: Primary hyperparathyroidism (PHPT) is caused by typical adenoma (TA), multiglandular disease (MD), or parathyroid carcinoma (PC), and in a smaller percentage of cases by atypical parathyroid tumor (APT). The objective of this study is the retrospective analysis of clinical features and parathyroid hormone (PTH)/calcium response to surgery in patients who underwent parathyroidectomy for symptomatic PHPT with histological evidence of APT. Methods: We retrospectively reviewed our institutional experience in the management of PHPT from January 2016 to December 2021 focusing on those patients presenting APTs. We analyzed the clinical features of this disease and PTH/calcium response to surgical treatment in APTs compared to the other pathological conditions causing PHPT. Results: In a cohort of 125 patients with PHPT we found 112 TAs (89.6%), 6 APTs (4.8%), 6 PCs (4.8%), and only 1 MD (0.8%). APTs in comparison to other parathyroid diseases showed peculiar features such as adhesion to the surrounding structures and a frequent intrathyroidal location, which may justify thyroid loboistmectomy adopted in most of the observed cases. APTs showed significantly higher preoperative PTH values compared to TA + MD and were relevant to PC. Conclusion: Due to its rarity, there is a lack of specific indications in the management of APTs. Biochemical features observed in APT and PC can be related to similar biological behavior. However, some specific features observed preoperatively in some cases of PHPT might suggest presence of an APT, which could be helpful mostly in surgical and postoperative management. Further studies are required to confirm the results of the present preliminary report.

Indications and Results of Sternal Allograft Transplantation: Learning From a Worldwide Experience.

BACKGROUND: Reconstruction of the anterior chest wall defect after sternectomy is a challenge for cardiothoracic surgeons. In 2010, the Padua group published the first case of cadaveric sternum transplantation after sternectomy. This multicenter study reports the clinical indications and early and long-term results of sternal chondral allograft transplantation. METHODS: This is a retrospective multicenter study from 7 academic centers. We collected demographic data, surgical indications, technical details, and early postoperative results. The complications, long-term stability, and tolerance of the allografts were also analyzed. RESULTS: Between January 2008 and December 2019, 58 patients underwent sternectomy followed by reconstruction using cadaveric-cryopreserved sternochondral allografts. Thirty-two patients were male, median age 63.5 years (interquartile range, 50-72 years). Indications for sternectomy were secondary sternal tumors (n = 13), primary sternal tumors (n = 15), and nonneoplastic disease (n = 30). Thirty patients underwent total sternectomy, 16 lower-body sternectomy, and 12 upper-body manubrium resection. The 30-day mortality was 5%; overall morbidity was 31%. Six early reoperations were necessary because of bleeding (n = 1), titanium plate dislocation (n = 1), and resuture of the skin in the lower part of the incision (n = 4). Overall, 5-year survival was 74%. In all the survived patients, the reconstructions were stable and free from mechanical or infective complications. CONCLUSIONS: The main indications for sternal allograft implantation were complex poststernotomy dehiscence followed by primary or secondary tumor involvement of the sternum. The collected results demonstrate that sternochondral allograft transplantation is a safe and effective method in reconstructing the anterior chest wall after sternectomy. Further studies to demonstrate the integration of the bone grafts into the patients' sternal wall will be made.

Chest wall resection and reconstruction for tumors: analysis of oncological and functional outcome.

BACKGROUND: Tumors of the chest wall have a large spectrum of well-assessed indications for resection. However, whether a reconstruction is required or not is not always clear. Complications after chest wall resection and reconstruction (CWRR) are described in literature and potentially severe. There is no evidence of how non-reconstructive management may influence the post-operative complication rate. METHODS: A total of 71 patients underwent thoracic demolition for tumors between April 2000 and October 2016. The patients were divided into two groups based on pathological findings: group 1: primary chest wall tumors; group 2: non-small cell lung cancer (NSCLC) invading the thoracic wall. They were then retrospectively analyzed by means of following criteria: TNM staging, histology, infiltration depth, 5-year survival, overall survival (OS), disease-free survival (DFS), relapse rate, R-0 resection, number of resected ribs, site of surgical resection and post-operative respiratory complications, flail chest, chronic pain, deformity of the chest wall and cosmetic results. RESULTS: Five-year survival, OS, DFS and risk of relapse showed a significant correlation with the presence of free surgical margins in both groups. In group 2, another parameter which correlated to survival, risk of relapse and DFS was lymph-nodal status. Moreover, the risk of post-operative respiratory complications was directly correlated with non-reconstruction after demolition of the chest wall in certain topographical sites. CONCLUSIONS: free surgical margins are the main oncological prognostic factor in these patients. In patients who underwent resection of two or more ribs in a critical area, reconstruction of the bony thorax can significantly reduce the post-operative respiratory complication rate.

Operative complications and early mortality after induction therapy for lung cancer.

OBJECTIVE: Induction therapy for advanced lung cancer allows improvement of completeness of resection and survival. However, predictive risk factors for postoperative complications and early mortality remain controversial. We report our 14-year experience with this combined approach. METHODS: One hundred and thirty-nine patients (100 males and 39 females) underwent induction therapy and surgery for stage IIIA and B lung cancer. The mean age was 58.4+/-7.7 years. We retrospectively collected demographic data, preoperative functional parameters, type of operation, associated disorders, staging, induction regimen (chemotherapy alone or associated with radiotherapy). Univariate and multivariate analyses were performed to identify predictors of postoperative complications and early mortality. RESULTS: One hundred and nine patients received chemotherapy (mainly based on cisplatin and gemcitabine) and 30 received chemoradiotherapy (median dose 50Gy). Complications developed in 49 patients (35%). The most frequent was persistent air leakage (23-30% of the lobectomies), followed by cardiac complications, respiratory failure, and infections. Five patients (3.5%) died in the postoperative period and four of them had received pneumonectomy (mortality for pneumonectomy: 12.5%). The statistical analysis demonstrated that only pneumonectomy was associated with an increased mortality risk with no differences between intra- and extrapericardial dissection or right and left pneumonectomy. CONCLUSIONS: Induction therapy seems to be associated with an increased incidence of air leakage; the risk of other complications is acceptable. Pneumonectomy is associated with an increased risk of mortality and should be performed in selected patients.

Multidisciplinary approach to chest wall resection and reconstruction for chest wall tumors, a single center experience.

BACKGROUND: Chest wall resection and reconstruction (CWRR) is quite challenging in surgery, due to evolution in techniques. Neoplasms of the chest wall, primary or secondary, have been considered inoperable for a long time. Thanks to evolving surgical techniques, reconstruction after extensive chest wall resection is possible with good functional and aesthetic results. METHODS: In our single-center experience, seven cases of extensive CWRR for tumors were performed with a multidisciplinary approach by both thoracic and plastic surgeons. Patients have been retrospective analyzed. RESULTS: Acceptable clinical and aesthetical results have been recorded, with a smooth post-operative course and a low rate of post-surgical complications. Two early complications and one late complication (asymptomatic bone allograft fracture on the site of the bar implant) were recorded. Neither postoperative deaths nor local recurrences were registered after a median follow-up period of 13 months. CONCLUSIONS: Surgical planning is most effective when it is tailored to the patient. Specifically, in the treatment of selected chest wall tumors, the multidisciplinary approach is considered mandatory when an extensive demolition is required. Indeed, here, the radical wide en-bloc resection can lead to good results provided that the extent of resection is not influenced by any anticipated problem in reconstruction.

The role of bronchoscopy in the diagnosis of early lung cancer: a review.

Lung cancer is the leading cause of cancer-related deaths worldwide with an overall 5-year survival rate of 17% after diagnoses. Indeed many patients tend to have a very poor prognosis, due to being diagnosed at an advanced stage. Conversely patients who are diagnosed at an early stage have a 5-year survival >70%, indicating that early detection of lung cancer is crucial to improve survival. Although flexible bronchoscopy is a relatively non-invasive procedure for patients suspected of having lung cancer, only 29% of carcinoma in situ (CIS) and 69% of microinvasive tumors were detectable using white light bronchoscopy (WLB) alone. As a result, in the past two decades, new bronchoscopic techniques have been developed to increase the yield and diagnostic accuracy, such as autofluorescence bronchoscopy (AFB), narrow band imaging (NBI) and high magnification bronchovideoscopy (HMB). However, due to the low specificity and the limitation to detect only proximal bronchial tree, new probe-based technologies have been introduced: radial endobronchial ultrasound (R-EBUS), optical coherence tomography (OCT), confocal laser endomicroscopy (CLE) and laser Raman spectroscopy (LRS). To date, although tissue biopsy remains the gold standard for diagnosing malignant/premalignant airway disease and some techniques are still investigational, bronchoscopic technologies can be considered the safest and most accurate tools to evaluate both central and distal airway mucosa.