A multicentric evaluation of pediatric lung transplantation in Italy.

BACKGROUND: Pediatric lung transplantation is performed in highly experienced centers due to the peculiar population characteristics. The literature is limited and not representative of individual countries' differences. The purpose of this study was to analyze the Italian experience. METHODS: A multicentric retrospective analysis was performed on 110 pediatric patients (<18 years old) who underwent lung transplantation from 1992 to 2019 at 9 Italian centers. Heart-lung transplantations and lung retransplantations were excluded. RESULTS: The population was composed of 44 male and 66 female patients, with a median age of 15 years. The most frequent indication was cystic fibrosis (83%). One quarter of patients were transplanted in an emergency setting. Median donors' Oto score and age were 1 and 15 years, respectively, with 43% of adult donors. In 17% of patients a graft reduction was performed. Postoperatively, the median duration of mechanical ventilation, intensive care unit, and in-hospital stay were 48 hours, 11 and 35 days, respectively. Thirty-day mortality was 6%, and 1-, 5-, and 10-year survival was 72%, 52%, and 33%, respectively. Risk factors for mortality were Oto score and recipients' body mass index. CONCLUSIONS: The outcomes of pediatric lung transplantation in Italy are comparable with current literature. Particular attention should be paid to the Oto score and recipient body mass index. Conversely, adult donors and graft reductions can be safely used to expand the donor pool.

Sternal transplant using cadaveric allograft: quantitative and qualitative assessment of bone healing by computed tomography.

BACKGROUND: Sternal transplant using cadaveric allograft (STCA) is a complex and rarely performed surgical procedure usually applied for massive bone tissue loss, sternotomy complications, or neoplastic resections. Although radiological imaging and especially computed tomography (CT) is routinely applied for the post-surgical assessment, up to now, a standardized approach evaluating the outcome of STCAs is missing. Therefore, aim of this study was to qualitatively and quantitatively evaluate, by CT, bone healing after STCA. METHODS: The first and the last available postsurgical CT of patients who underwent STCA in two tertiary centers between 2009 and 2017 were collected. Standardized regions of interest were applied on the cancellous bone along the transplanted sternum, and, as reference, on the fourth thoracic vertebra, at both time points, collecting the density values. The areas nearby the fixation devices were assessed by a four-points qualitative score. To evaluate the mineralization, the analysis of the variance (ANOVA) with post-hoc Bonferroni correction was applied for the quantitative measurements while the Wilcoxon test was used for the qualitative score (P<0.05). To evaluate the intra-rater reliability of the qualitative and the quantitative analyses, the same rater repeated the measurements after two months and the Cohen's kappa (k) and the intraclass correlation coefficient (ICC) were computed. RESULTS: Fourteen patients (11 females, 61±12.8 years) were examined. The first control CTs were performed 32±40.26 days after the STCA and the last CT were acquired after 729±745 days. The quantitative and the qualitative score significantly increased between the two intervals (P<0.05, each). The density of the transplanted sternum was lower than that of the vertebral reference at the first CT (P=0.006) while no differences occurred at the last control (P=0.361). The assessments showed high intra-rater reliability and agreement (ICC ≥0.890, k≥0.906). CONCLUSIONS: The hereby-proposed qualitative and quantitative methods demonstrated to be good tools for assessing bone healing after STCA.

Long-Term Metabolic Assessment of Cryopreserved Sternal Allograft: A Case Series.

BACKGROUND: Sternal resection and reconstruction with cryopreserved allografts provides a safe alternative to traditional methods of anterior chest wall reconstruction. Despite favorable results, successful integration of the graft sternum has never been demonstrated owing to the invasiveness of bone biopsy. We describe our experience of using 18F-sodium fluoride positron emission tomography/computed tomography scans as a noninvasive method of evaluating graft integration. METHODS: Seven patients underwent surgery and radiologic follow-up. Surgical indications were sternal metastases (n = 5) and sternal dehiscence (n = 2). Sternal reconstruction was performed using a cryopreserved cadaveric sternal allograft fixed in place with titanium plates and screws. Follow-up with 18F-sodium fluoride positron emission tomography/computed tomography scans was performed at 1 and 2 years after surgery. RESULTS: Three patients underwent total sternectomy. Two underwent partial upper sternectomy involving the manubrium, clavicle (1 patient only), and upper sternal body; and 2 had partial sternectomy of the sternal body and xiphoid process. Focal tracer accumulation occurred at the junctions between native bone and graft bone. The median maximum standardized uptake value at 1 year was 16.8 (range, 11.2 to 37.9; interquartile range, 13.6 to 19.4), and at 2 years it was 10.8 (range, 6.1 to 30.2; interquartile range, 8.9 to 15.1). In 6 cases accumulation was lower at the second scan, whereas in 1 patient the accumulation was higher at the second scan. CONCLUSIONS: Sternal reconstruction with cryopreserved allograft is safe and well tolerated. The 18F-sodium fluoride positron emission tomography/computed tomography scans are a useful and promising noninvasive method of demonstrating the metabolic activity of the graft and its incorporation into the host skeleton during follow-up.

Sternal reconstruction after post-sternotomy dehiscence and mediastinitis.

PURPOSE: Post-sternotomy dehiscence and mediastinitis remains a serious complication in cardiothoracic surgery. The aim of this work is to report our experience over a period of 8 years in the surgical treatment and risk factor analyses of post-sternotomy dehiscence and mediastinitis. METHODS: All patients treated for post-sternotomy dehiscence at our Thoracic Surgery Unit in the last 8 years were retrospectively collected. We identified 237 patients with post-sternotomy dehiscence/mediastinitis. Forty-two patients had simple fractures of the metal steel wires, 61 had an asymmetric sternotomy with multiple sternal fractures, 113 had a symmetric sternotomy with multiple sternal fractures, 14 had a failed Robicsek procedure, and 7 had sternal dehiscence with mediastinal abscess. RESULTS: Different surgical techniques and materials were used to repair the sternum. In 21 patients, the first revision failed and a second reoperation was required. At multivariate analyses, we have identified risk factors for revision failure and in-hospital mortality. Mortality rate was significantly higher in patients who underwent more than one surgical revision (8% vs 19%, p < 0.001). CONCLUSIONS: Patients with sternal dehiscence are very fragile due to multiple preoperative comorbidities as reflected by postoperative morbidity and risk factors for in-hospital mortality. A correct evaluation of the characteristics of sternal dehiscence is important to guide the most appropriate repair strategy. Patients who need repeated sternal revisions had a higher mortality. Further randomized studies are needed to evaluate different techniques and medical devices to define the gold standard procedure to reduce significantly sternal wound complications in high-risk patients as defined by well-known risk factors.

A new image-guided technique for intraoperative localization of lung small solid nodules or ground-glass opacities with a self-expanding tract sealant device: a preliminary experience.

OBJECTIVES: The aim of this study was to evaluate a new self-expanding tract sealant device, designed to prevent pneumothorax after computed tomography (CT)-guided lung biopsy, as an intraoperative marker for small pulmonary nodules or ground-glass opacities during minimally invasive thoracic surgery. METHODS: Three patients with pulmonary nodules underwent CT-guided biopsies in our radiology department. During the same procedure, using a 19-gauge coaxial needle, a self-expanding tract sealant device was positioned in the lung nodule to be used not only for the prevention of pneumothorax but also as an intraoperative marker. A few days later, conventional thoracoscopic surgery was scheduled. A visual examination was performed. The site of the deployment of the BioSentry device was determined by checking for the proximal end of it beyond the visceral pleura. Thoracoscopic wedge resections using endoscopic staplers were performed to confirm histological characteristics, surgical margins and correct placement of the plug. RESULTS: Three consecutive patients underwent CT-guided placement of this self-expanding tract sealant device (BioSentry) before surgery, without complications. The thoracoscopic resection was performed with success. The plug was easy to visualize with the scope, and all removed nodules had surgical free margins and the plug was correctly positioned in all patients. CONCLUSIONS: The self-expanding tract sealant device was created for the reduction of pneumothorax and chest tube placement rates after percutaneous lung biopsy. We used it for the first time for intraoperative localization of peripheral small solid nodules or ground-glass opacities with good results.

The influence of the trocar choice on post-operative acute pain after thoracoscopy.

BACKGROUND: Acute post-operative pain following thoracic surgery procedures is still an unresolved problem despite the introduction of minimally invasive procedures such as video assisted surgery. Until now it is never investigated if different surgical instruments could influence post-operative pain. The aim of our study is to investigate the role of different type of trocar on post-operative pain in minimally invasive thoracic surgery. METHODS: This was a prospective randomized single center study. We identified 53 patients randomized into three groups underwent single port thoracoscopy for malignant pleural effusion with drainage of the fluid and talc poudrage. The three groups differ for the trocar type, rigid, flexible and wound protector. RESULTS: We compared the postoperative pain between the three groups in which there was no statistical difference. Rigid trocar seems to give a more stable level of pain during the days, flexible trocar gains more pain in the first few hours, however the pain at discharge decreases significantly, reaching the similar values, in all the three groups. The association between pain at discharge and operative time or days of drainage was analyzed by means of linear regression, no statistically significant difference was found. CONCLUSIONS: Our study showed that different type of trocars during video assisted thoracic surgery (VATS) produces similar level of acute postoperative pain. In future, further randomized study with a great number of patients enrolled needs to confirm our results.

Unilateral pulmonary vein atresia without anomalous connection in adult patient with recurrent severe hemoptysis.

Isolated unilateral pulmonary vein atresia (UPVA) is a rare congenital malformation and the management remains controversial. In adults, pneumonectomy is the treatment of choice when significant hemoptysis becomes life-threatening. We report a case of a 28-year-old male with isolated unilateral right atresia of the pulmonary vein who had life-threatening hemoptysis treated with bronchial arteries embolization followed by successful right pneumonectomy.

Uniportal video-assisted removal of a right paratracheal pericardial cyst: an unusual location.

Cystic lesions of the pericardium are a rare entity. Generally, they are congenital and located in the cardiophrenic angle. The right paratracheal location is unusual and differential diagnosis in particular with bronchogenic cyst is difficult even when using magnetic resonance imaging (MRI). The surgical indication exists in case of symptomatic patients or huge mass with compression of nearby structures. Different surgical approaches have been reported in literature to treat mediastinal cysts. We report a case of uniportal thoracoscopic removal of an unusual located right paratracheal pericardial cyst.

Uniportal thoracoscopic resection of intralobar and extralobar pulmonary sequestration.

Pulmonary sequestration (PS) is a rare congenital malformation of the respiratory tract. Two main variants are described, the intralobar and the extralobar PS. Clinical manifestations vary from accidental findings to life threatening complications. Surgical resection is the definitive and indicated treatment of PS. The operation could be performed through an open thoracotomy or video-assisted thoracic surgery approach. We report the management of two patients with diagnosis of extralobar PS in the first case and intralobar PS in the second case. Both patients underwent uniportal video-assisted thoracic surgery resection of PS with success. In our experience, we confirm that uniportal video-assisted thoracic surgery is a safe and feasible approach for extralobar and intralobar PS.

Micro-incision thoracoscopic treatment of primary spontaneous pneumothorax: the "loop" technique.

Primary spontaneous pneumothorax has been defined as the disease of the 'young and healthy'. There are multiple possible therapies and in recent years, surgery has evolved towards the use of the uniportal thoracoscopic approach. The objective of our study is to describe and present an innovative approach to access to the thoracic cavity in patients with spontaneous pneumothorax. The surgery was performed using a single access of 20 mm at the level of the 8th intercostal space. For the isolation and suspension of any dystrophic area, we use a 'loop' of non-absorbable braided suture inserted through the IV intercostal space and successive wedge resection using an endoscopic 10 mm mechanical stapler. Using this access, we were able to visualize and dissect the pulmonary ligament and perform complete pleural abrasion. We had no complications. The operative time was 60 min, the chest tube was removed the 2th postoperative day and the patient was discharged the day after. The operation we propose permits the reduction of the dimension of the access to the thoracic cavity. We were able to resect blebs without problems, the recovery was excellent and no complications related to the procedure were reported.

Video-assisted thoracoscopic surgery lobectomy using "the caudal approach": results and evolution.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has become a common surgical approach in the diagnosis and treatment of lung and mediastinal diseases. In this study, we reported our current experience of thoracoscopic surgery using a new caudal position technique for anatomical lung resections and compared it with the standard anterior VATS technique. METHODS: From January 2016 to October 2017, 92 consecutive patients with lung cancer underwent VATS lobectomy. Among these, 34 patients were treated by conventional anterior three portal VATS lobectomy, and 58 patients were treated using the caudal three port VATS lobectomy. The mean operative time, conversion rate, hospital stay, post-operative drainage, reoperation, post operative pain were compared between each group. RESULTS: No differences between the two groups are showed in terms of surgical time, post-operative drainage, incidence of prolonged air leaks and post-operative pain. CONCLUSIONS: The caudal approach to major pulmonary resection of thoracoscopic lobectomy results in a reliable and comfortable procedure for the surgeon. Once demonstrated the reliability of the VATS lobectomy with three accesses using the caudal position, we are starting to standardize biportal and uniportal VATS with the surgeon in the caudal position.

Pulmonary Metastases from NSCLC and MPLC (Multiple Primary Lung Cancers): Management and Outcome in a Single Centre Experience.

BACKGROUND: This is an institutional review of surgical management of second pulmonary tumours in patients with history of Non-small Cell Lung Cancer (NSCLC) resection according to The American College of Chest Physicians' (ACCP) revision to the Martini and Melamed's criteria for the classification of multiple primary lung cancers (MPLC). METHODS: All patients who underwent iterative pulmonary resections for pulmonary metastasis (Group A) or MPLC (Group B) between 2006 and 2012 were reviewed and their survivals compared accordingly. The main criteria of insertion in Group B were different histology and the same histology with disease-free interval ≤ 4 years; we excluded loco-regional recurrence in nodes and/or on bronchial stump. RESULTS: Group A: Twenty patients; Disease free time (DFT) after first operation was 15.2 months (range 2-44). One, two and three years overall survival after second resection was 74%, 29%, 14% respectively. Group B: Thirty-six patients. One, two and three years overall survival was 94%, 81%, and 69% respectively. No statistical differences on outcome were found between the two groups in spite of the apparent worse survival rate for Group A (p=.197). CONCLUSIONS: A further resection for additional nodules, whether designated as intrapulmonary metastases or second primary NSCLC, can be an appropriate curative strategy in selected patients with unimpaired respiratory function and no evidence of distant metastatic disease. The site, the extent of the second resection, the histology and even the stage are unlikely to be related to survival.