Bronchoscopic management of prolonged air leak.

Broncho-pleural fistula (BPF) is an atypical communication between the tracheobronchial tree and the alveolar/pleural space, with prolonged air leak (PAL). BPF is frequent and related to significant morbidity, prolonged length of hospital stay, and mortality. Nevertheless, in about 10%, more than 5 days of an air leak is considered a PAL, accounted for significant morbidity. Endobronchial valve is a novel device for the PAL management with minimal morbidity if related to surgical repairs. While it is suggested that surgical treatment should be undertaken when possible, endobronchial valves should be recommended as a therapeutic choice in high-risk patients. Placement techniques remain operator and patient friendly and allow the procedure to be performed with relative ease. Prospectively conducted, randomised, controlled clinical trials are needed where valve treatment is compared with other bronchoscopic techniques, surgical procedures, or both.

Diaphragmatic and pericardial reconstruction after surgery for malignant pleural mesothelioma.

Extrapleural pneumonectomy (EPP) and pleurectomy-decortication (P/D) are both recognised surgical procedures for selected cases affected by malignant pleural mesothelioma (MPM). Surgical techniques have ameliorated over the last years, remaining the complete macroscopic resection of the disease the main surgical principle. EPP is defined as an en-bloc resection of the visceral pleura, parietal pleura, pericardium and diaphragm alongside the pneumonectomy. The thoracic domain of the International Association for Study of Lung Cancer (IASLC) recently clarified the, previously confused, surgical terminology. "Extended P/D" is considered as parietal and visceral pleurectomy, diaphragmatic and pericardial resection with the purpose to remove all macroscopic disease. The term "radical" was replaced by "extended" to underline that this procedure does not have oncologic radicality aims. Both operations above are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. The technical aspects of resection and reconstruction are described and the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.

Endobronchial Pagetoid Spread of a Breast Carcinoma Metastatic to the Lung.

A case of endobronchial pagetoid spread of a breast carcinoma metastatic to the lung is described. A 73-year-old woman underwent wedge lung resection after the cytological diagnosis of lung metastasis from ductal invasive breast carcinoma. The breast carcinoma had been surgically removed 6 years previously; at the time of diagnosis it was a T1N0, grade 3 invasive ductal carcinoma, with HER-2 amplification. The lung metastasis measured 1,9 cm and showed the same histology and biological profile of the primary tumor. In addition, numerous neoplastic cells, with large cytoplasm and atypical nuclei, appear to spread along the mucosa of the bronchi adjacent to the metastatic lesion as well as that of the main lobar bronchus, intermingled with the columnar ciliated cells. The neoplastic elements were negative for TTF-1 and strongly HER-2 positive; these features appeared consistent with endobronchial pagetoid spread by the metastatic breast carcinomatous cells.

An unusual case of persistent pneumothorax.

We herein report a case of a 45-year-old white male who referred to the emergency department for a right pneumothorax. A chest tube was emergently placed. Due to incomplete lung reexpansion, the patient underwent a right thoracoscopy disclosing the presence of several kinky vessels consistent of localized pleural angiomatosis, and a talc pleurodesis was performed. Computed tomographic scan and angiography confirmed an anomalous vascular connection between systemic and pulmonary circulation. Thus, a vascular percutaneous transcatheter embolization of the abnormal vessel was successfully executed and the patient was discharged without consequence.

An unusual foreign body after dental filling.

We report a case of a 71-year-old Caucasian woman who was referred to our emergency department for acute onset of dyspnoea and dry cough. She underwent dental filling for caries ~2 h before. During the treatment, the distal part of the odontoiatric drill unintentionally fell off into the patient's oral cavity and was accidentally inhaled. Posteroanterior chest X-ray evidenced the foreign body localized in the right bronchial tree. A chest computed tomography scan showed the drill (with the tip pointed upward) wedged at the beginning of the right basal pyramid. A subsequent fiberoptic bronchoscopy confirmed the tip of the drill in the right lower bronchus, and the foreign body was easily removed due to the favorable position of the tip. The patient was discharged in first postoperative day without consequences.

Mediastinal germ cell tumour with massive pulmonary involvement.

Multimodality treatment, with chemotherapy and surgery, is potentially curative in case of non-seminomatous germ cell tumours. The authors present the case of a primitive mediastinal GTC with bilateral lung metastases. The patient was treated with five cycles of chemotherapy. Restaging showed reduction of the extent and of 18 FDG intake and ß-HCG serum levels. The patient underwent two-step surgical excision of the tumours: mediastinal lesion and 35 lung metastases were resected by a right thoracotomy and 39 metastases were removed by a left thoracotomy. Histology showed absence of viable tumour in all the specimens. Twelve months after surgery the patient is free of disease.

Limited upper sternotomy in general thoracic surgery.

PURPOSE: To evaluate the status of limited upper sternal split in general thoracic surgery. METHODS: We reviewed the clinical files of 100 consecutive patients operated on through limited upper sternotomy at a hospital in Italy during the 10 years between January 1995 and December 2004. RESULTS: Thymus surgery represented the main indication for this approach (n = 51): for myasthenia without thymoma in 28 patients, for thymus neoplasms with or without myasthenia in 22, and for intrathymic parathyroid adenoma in 1. Thyroid surgery constituted the second main indication for upper sternal split (n = 32) for benign retrosternal goiter in 18 patients, for mediastinal nodal metastasis of thyroid cancer in 11, and for malignant retrosternal goiter in 3. The remaining indications were as follows: to assess residual disease following chemotherapy for Hodgkin's disease in 7 patients and for non-Hodgkin lymphoma in 1; for tracheal surgery in 7; and for excision of nodal mediastinal metastasis of non-thyroid cancer in 2. All operations were completed through the upper sternal split. There was no surgical mortality but complications developed in eight patients. CONCLUSION: The upper sternal split provides a satisfactory access to perform a surgical procedure in the superior mediastinum in most diseases. The procedure is safe and involves minimal surgical trauma.

Elective intensive care after lung resection: a multicentric propensity-matched comparison of outcome.

The study was aimed at assessing the influence of the elective ICU admission on the early outcome after major lung resection by analyzing the different postoperative management policies of two centers. Center A managed all patients in a dedicated ward, resorting to ICU for complications requiring invasive assisted ventilation. In center B, high-risk patients were electively transferred to ICU immediately after operation. Propensity score was used to match those patients of center B electively admitted to ICU (96 of 157), with counterparts from center A (96 of 205). The outcome of these matched pairs were then compared. There was a trend of reduced total morbidity (23% vs. 35%, respectively; P=0.06), cardiovascular (13.5% vs. 23%, respectively; P=0.09) and pulmonary complication rates (9.3% vs. 18%, respectively; P=0.09), but a longer postoperative hospital stay (11.5 vs. 9.7, respectively; P=0.015) in the patients electively admitted to ICU, compared to matched center A patients. Mortality rates were not different (7.3% vs. 7.3%; P=1). Since the elective postoperative ICU admission did not show a clear-cut outcome benefit over the management in a dedicated ward, this practice should be limited to highly selected patients in order to efficiently utilize the available resources.

Role of fiberscopic transbronchial needle aspiration in the staging of N2 disease due to non-small cell lung cancer.

BACKGROUND: Transbronchoscopic needle aspiration (TBNA) can offer a unique opportunity to identify surgically unresectable lung cancer and to avoid surgical mediastinal exploration in many patients with mediastinal lymph node extension of the tumor. The aim of this study was to assess the yield of TBNA performed with either histology or cytology needles in mediastinal staging of N2 disease due to non-small cell lung cancer (NSCLC). METHODS: Retrospective chart review was carried out on 194 TBNA procedures performed between January 1997 and September 2000 at a single institution. Inclusion criteria were pathologic evidence of NSCLC; contrast enhancement computed tomography scan of the chest suggesting N2 disease; and negative bronchoscopic examination for possible neoplastic lesions at the site of RESULTS: Overall sensitivity and diagnostic accuracy were 71% and 73%, respectively, with no significant differences between 19-gauge and 22-gauge cytology needles. Procedures performed for right paratracheal and subcarinal lymph node stations had a significantly higher yield than those for the left paratracheal station. CONCLUSIONS: TBNA mediastinal staging, performed during the initial diagnostic evaluation of NSCLC, can spare costs and risks of more invasive procedures in patients with inoperable tumors, in patients who are not candidates for operation because of coexistent significant comorbidities, and in patients with N2 disease.