Reconstruction of the heart and the aorta for radical resection of lung cancer.

INTRODUCTION: We report a single-center experience of resection and reconstruction of the heart and aorta infiltrated by lung cancer in order to prove that involvement of these structures is no longer a condition precluding surgery. METHODS: Twenty-seven patients underwent surgery for lung cancer presenting full-thickness infiltration of the heart (n = 6) or the aorta (n = 18) and/or the supra-aortic branches (subclavian n = 3). Cardiac reconstruction was performed in 6 patients (5 atrium, 1 ventricle), with (n = 4) or without (n = 2) cardiopulmonary bypass, using a patch prosthesis (n = 4) or with deep clamping and direct suture (n = 2). Aortic or supra-aortic trunk reconstruction (n = 21) was performed using a heart-beating crossclamping technique in 14 cases (8 patch, 4 conduit, 2 direct suture), or without crossclamping by placing an endovascular prosthesis before resection in 7 (4 patch, 3 omental flap reconstruction). Neoadjuvant chemotherapy was administered in 13 patients, adjuvant therapy in 24. RESULTS: All resections were complete (R0). Nodal staging of lung cancer was N0 in 14 cases, N1 in 10, N2 in 3. No intraoperative mortality occurred. Major complication rate was 14.8%. Thirty-day and 90-day mortality rate was 3.7%. Median follow-up duration was 22 months. Recurrence rate is 35.4% (9/26: 3 loco-regional, 6 distant). Overall 3- and 5-year survival is 60.9% and 40.6%, respectively. CONCLUSIONS: Cardiac and aortic resection and reconstruction for full-thickness infiltration by lung cancer can be performed safely with or without cardiopulmonary bypass and may allow long-term survival of adequately selected patients.

Successful Total Tracheal Replacement by Cryopreserved Aortic Allograft in a Patient Post-COVID-19 Infection.

This is the first report to our knowledge of a successful total tracheal replacement in a post-COVID-19 patient by cryopreserved aortic allograft. The graft was anastomosed to the cricoid and carina; a silicon stent was inserted to ensure patency. The patient was extubated on the operative table and was immediately able to breathe, speak, and swallow. No immunosuppression was administered. Three weeks after surgery, the patient was discharged from hospital in excellent health, and was able to resume his normal lifestyle, work, and activity as an amateur cyclist. Two months after surgery, the patient assumes aerosol with saline solution three times per day and no other therapy; routine bronchoscopy to clear secretions is no longer needed.

Direct Cross-Clamping for Resection of Lung Cancer Invading the Aortic Arch or the Subclavian Artery.

BACKGROUND: Resection of lung cancer infiltrating the aortic arch or the subclavian artery can be accomplished in selected patients with the use of cardiopulmonary bypass (CPB). Direct cross-clamping of the aortic arch and the left subclavian artery without CPB for radical resection of the tumor can be an alternative. This study presents one group's experience with this technique. METHODS: Between October 2016 and May 2019, 9 patients (5 male, 4 female) underwent radical resection of lung cancer infiltrating the aortic arch (n = 5) or the left subclavian artery (n = 4) by direct cross-clamping technique at Sapienza University of Rome, Italy. Seven left upper lobectomies, 1 left pneumonectomy, and 1 left upper sleeve lobectomy were performed. Reconstruction of the aortic arch was performed by direct suturing or polyethylene terephthalate (Dacron) patch, whereas the subclavian artery was reconstructed with a Dacron conduit. Three patients received neoadjuvant chemotherapy. RESULTS: Patients' mean age was 64.7 ± 13.3 years (range, 36 to 78 years). Aortic arch resection was partial in all cases (adventitial in 1 and full thickness in 4); left subclavian artery resection was adventitial in 2 patients and circumferential in 2. All the resections were complete. Prosthetic reconstruction was performed in 4 cases. Mean operative time was 130 ± 25.6 minutes; mean vascular clamping time was 28.2 ± 3.2 minutes. No mortality occurred. The major complication rate was 11.1 %. At a mean follow-up of 17 ± 9 months (range, 5 to 29 months), the recurrence rate was 33.3%. Median survival was 20 months. CONCLUSIONS: Direct cross-clamping as an alternative to CPB for resection of lung cancer infiltrating the aortic arch or the subclavian artery is a feasible, safe, and reliable procedure in selected patients.

Analysis of pneumothorax recurrence risk factors in 843 patients who underwent videothoracoscopy for primary spontaneous pneumothorax: results of a multicentric study.

OBJECTIVES: Risk factors for pneumothorax recurrence after videothoracoscopy for primary spontaneous pneumothorax are still being debated. The goal of this study was to assess whether the pleurodesis technique and other variables are possibly associated with the postoperative ipsilateral recurrence of pneumothorax. METHODS: We retrospectively collected data of 1178 consecutive ≤40-year-old patients who underwent videothoracoscopy for primary spontaneous pneumothorax in 9 centres between 2007 and 2017. We excluded patients with hybrid pleurodesis and/or incomplete follow-up, leaving for analysis 843 cases [80% men; median age (interquartile range) 22 (18-28) years]. Univariable and multivariable analyses were performed by logistic regression and tested by Cox regression model to assess factors related to ipsilateral pneumothorax recurrence including age, gender, body mass index, smoking habit, cannabis smoking, respiratory comorbidity, dystrophic severity score, surgical indication, videothoracoscopy port number and side, lung resection, pleurodesis technique and postoperative prolonged air leak (>5 days). RESULTS: Blebs/bullae resection was performed in 664 (79%) patients. Pleurodesis was achieved by partial pleurectomy in 228 (27%) cases; by pleural electrocauterization in 176 (21%); by pleural abrasion in 121 (14%); and by talc poudrage in 318 (38%). During a median follow-up period of 70.0 months (95% confidence interval 66.6-73.4), pneumothorax recurred in 79 patients (9.4%); among these, 29 underwent redo surgery; 34, chest drain/talc slurry; and 16, clinicoradiological observation. The only independent risk factor for recurrence was postoperative prolonged air leak (P < 0.001) that was significantly related to blebs/bullae resection (P = 0.03). CONCLUSIONS: In this multicentric series, postoperative ipsilateral pneumothorax recurrence was remarkable and independently related to prolonged postoperative air leak; besides the retrospective study setting, the pleurodesis method did not have an impact on recurrence. To prevent prolonged air leak, blebs/bullae treatment should be accurate and performed only if indicated.

Surgical treatment of pulmonary sequestration in adults and children: long-term results.

OBJECTIVES: Few experiences comparing paediatric and adult patients treated for pulmonary sequestration (PS) have been reported. Surgical treatment is considered the best choice, but the time of surgery is still controversial. We present our experience in this setting, comparing characteristics, histological results and outcome of paediatric and adult patients undergoing PS resection. METHODS: Between 1998 and 2017, a total of 74 patients underwent lobectomy or sublobar resection for PS. Sixty patients were children (group A: ≤16 years old) and 14 were adults (group B: >16 years old). Preoperative diagnosis was radiological. PS was intralobar (42 cases) and extralobar (32 cases). The operation was a muscle-sparing lateral thoracotomy or video-assisted thoracoscopic surgery. Preoperative characteristics, histological results and short-/long-term results of the 2 groups were retrospectively analysed and compared. RESULTS: Thirty-seven percent of the patients in group A presented with respiratory symptoms and 79% in group B (P = 0.44). Most symptomatic patients were treated with a lobectomy. In group A, 2 patients (3%) had a malignant transformation of the lesion. Patients with a prenatal diagnosis treated after the age of 1 year became more symptomatic than those operated on before the age of 1 year (57% vs 23%; P = 0.08). No differences were found in postoperative complications. Long-term stable remission of respiratory symptoms was obtained in 91% of patients in group A and 100% in group B. Adulthood (P = 0.03) and the association with congenital cystic adenomatoid malformation (P = 0.03) were negative prognostic factors for the development of respiratory symptoms. CONCLUSIONS: Surgical treatment of PS is safe and feasible. Despite the small number of patients included, study results indicated that an early operation during childhood may prevent the subsequent development of respiratory symptoms. Surgical treatment is also recommended to prevent the rare transformation into malignancy.

Chronic Pain After Lung Resection: Risk Factors, Neuropathic Pain, and Quality of Life.

CONTEXT: Chronic postsurgical pain (CPSP) can occur frequently after thoracic surgery. OBJECTIVES: This retrospective study aimed to determine CPSP prevalence, risk factors, neuropathic pain (NP) occurrence, and its impact on quality of life. METHODS: About 200 patients who underwent lung resection via minithoracotomy or thoracoscopy between January 2017 and December 2017 were assessed 4-12 months postoperatively via phone interview for chronic pain by a 0-10 Numeric Rating Scale, for NP using the Douleur Neuropathique 4 test, and for quality of life using a Short Form-36 (SF-36) Health Survey (Italian version). RESULTS: CPSP incidence was 35% (n = 70 of 200; 95% CI 41-28) of which 31.5% (n = 22 of 70; 95% CI 41-21) was with NP. Only 10% of patients with CPSP reported severe chronic pain. According to univariate analysis, CPSP was associated to moderate and severe acute postoperative pain (P < 0.001), open surgery (P = 0.001), and female gender (P = 0.044). According to multivariable analysis, independent risk factors for CPSP development included moderate-to-severe acute postoperative pain occurrence (odds ratio 32.61; 95% CI 13.37-79.54; P < 0.001) and open surgery (odds ratio 6.78; 95% CI, 2.18-21.03; P = 0.001). NP incidence was higher in female patients (16% in women and 6% in men, respectively; P = 0.040). A significant decrease in all SF-36 Health Survey domain scores was recorded for patients with CPSP and NP (P < 0.001). CONCLUSION: More than one of three patients who underwent lung resection could develop CPSP, frequently showing neuropathic component. Female gender reported a higher CPSP and NP incidence. Moderate-to-severe acute postoperative pain occurrence and open surgery seem to be independent risk factors for CPSP. Chronic pain and NP have a negative impact on quality of life, decreasing the SF-36 scores of all domains.

Mediastinal staging: when and how?

Mediastinal staging for lung cancer includes both the assessment of mediastinal lymph nodes status before treatment and the postoperative pathological staging obtained by lymph-node removal performed during surgery. In patients with early stage NSCLC, the aim is to exclude with the highest certainty and the lowest morbidity the presence of mediastinal node involvement. Before treatment, mediastinal staging is based on imaging techniques, endoscopic techniques, and surgical procedures. Final pathological staging is based on lymph-node removal performed with lung resection according with different modalities (sampling, systematic dissection, etc.) and various approaches (thoracotomy, VATS, robotic). Data and indications from literature evidences are reported and discussed.

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: preoperative optimisation.

Preoperative patient optimisation is a key point of enhanced recovery after thoracic surgery pathways. This could be particularly advantageous when considering video-assisted thoracic surgery (VATS) lobectomy, because reduced trauma related to minimally invasive techniques is one of the main factors favouring improved postoperative outcome. Main specific interventions for clinical optimisation before major lung resection include assessment and treatment of comorbidities, minimizing preoperative hospitalization, optimisation of pharmacological prophylaxis (antibiotic and thromboembolic) and minimizing preoperative fasting. Literature data and clinical evidences in this setting are reported and discussed.

Enhanced recovery after surgery (ERAS) and fast-track in video-assisted thoracic surgery (VATS) lobectomy: preoperative optimisation and care-plans.

Main specific interventions for preoperative clinical optimisation of patients undergoing lung cancer surgery include assessment and treatment of comorbidities, minimizing preoperative hospitalization, minimizing preoperative fasting, and optimisation of antibiotic and thrombo-embolic prophylaxis. Preoperative patient optimisation is considered a crucial part of enhanced recovery after thoracic surgery pathways. Potentially, advantages of this fast-track management could be even higher when considering video-assisted thoracic surgery (VATS) major lung resection, because reduced trauma related to minimally invasive techniques is one of the main factors improving postoperative outcome. Literature data and clinical evidences in this setting are reported and discussed.

Reimplantation of the upper lobe bronchus after lower sleeve lobectomy or bilobectomy: long-term results.

OBJECTIVES: The advantages of a bronchial sleeve resection are well established. A clear majority of reported cases are of upper lobe sleeve resection. Reimplantation of the upper lobe bronchus after a lower sleeve lobectomy or bilobectomy (the so-called Y-sleeve resection) is infrequent. Related technical peculiarities are the main issues. We present our experience and results in this setting. METHODS: Between 1989 and 2015, we performed 28 Y-sleeve resections of the left lower lobe (n = 18) or right middle and lower lobes (n = 10). The lung-sparing reconstructive operation was performed for non-small-cell lung cancer in 23 cases, for bronchial carcinoid tumour in 4 cases and for a cystic adenoid carcinoma in 1 case. Anastomotic reconstruction was performed by interrupted 4-0 absorbable sutures (monofilament material). RESULTS: All the resections were complete (R0). Postoperative mortality was 3.6%. The rate of major complications was 10.7% (1 myocardial infarction, 1 anastomotic stenosis requiring dilatation and 1 anastomotic fistula). Among the 23 patients with non-small-cell lung cancer (18 men and 5 women; mean age 58 ± 12 years), 8 were Stage I, 9 were Stage II and 6 were Stage IIIa. At a mean follow-up of 46 months, the recurrence rate was 32%. There were 2 loco-regional recurrences. No endobronchial or perianastomotic recurrence occurred. The 3- and 5-year overall and disease-free survival rates of patients with non-small-cell lung cancer were 76.3% and 55.1% and 68.7% and 62.9%, respectively. CONCLUSIONS: A Y-sleeve resection with reimplantation of the upper load bronchus is a technically feasible and oncologically adequate operation.

Bronchoscopic treatment of emphysema: an update.

Chronic obstructive pulmonary disease (COPD) is the major causes of disability and mortality. The efficacy of maximal medical treatment, although effective at the early stages of the disease, becomes limited when extensive alveolar destruction is the main cause of respiratory failure. At this stage of the disease more aggressive options, when feasible, should be considered. Lung transplantation and lung volume reduction surgery (LVRS) are currently available for a selected group of patients. Endoscopic alternatives to LVRS have progressively gained acceptance and are currently employed in patients with COPD. They promote lung deflation searching the same outcome as LVRS in terms of respiratory mechanics, ameliorating the distressing symptom of chronic dyspnea by decreasing the physiological dead space.

Naive CD4+ T Cells Carrying a TLR2 Agonist Overcome TGF-ß-Mediated Tumor Immune Evasion.

TLR agonists are effective at treating superficial cancerous lesions, but their use internally for other types of tumors remains challenging because of toxicity. In this article, we report that murine and human naive CD4+ T cells that sequester Pam3Cys4 (CD4+ TPam3) become primed for Th1 differentiation. CD4+ TPam3 cells encoding the OVA-specific TCR OT2, when transferred into mice bearing established TGF-ß-OVA-expressing thymomas, produce high amounts of IFN-γ and sensitize tumors to PD-1/programmed cell death ligand 1 blockade-induced rejection. In contrast, naive OT2 cells without Pam3Cys4 cargo are prone to TGF-ß-dependent inducible regulatory Foxp3+ CD4+ T cell conversion and accelerate tumor growth that is largely unaffected by PD-1/programmed cell death ligand 1 blockade. Ex vivo analysis reveals that CD4+ TPam3 cells are resistant to TGF-ß-mediated gene expression through Akt activation controlled by inputs from the TCR and a TLR2-MyD88-dependent PI3K signaling pathway. These data show that CD4+ TPam3 cells are capable of Th1 differentiation in the presence of TGF-ß, suggesting a novel approach to adoptive cell therapy.

Long-segment pulmonary artery resection to avoid pneumonectomy: long-term results after prosthetic replacement.

OBJECTIVES: Resection of a long pulmonary artery (PA) segment infiltrated by tumour and reconstruction by conduit interposition or wide patch is a challenging but feasible option to avoid pneumonectomy. Our goal was to report the long-term results of our experience with this type of operation using various techniques and materials. METHODS: Between 1991 and 2015, 24 patients underwent sleeve resection of a long PA segment or extended resection (>2.5 cm) of 1 aspect of the circumference of the PA associated with lobectomy for centrally located lung cancer. Materials used for conduit reconstruction (20 patients) included pulmonary vein in 12 patients, autologous pericardium in 4, porcine pericardium in 3 and bovine pericardium in 1. Patches used in 4 patients consisted of porcine pericardium (2 patients) and pulmonary vein (2 patients). RESULTS: Twenty-three patients underwent left upper lobectomy without associated bronchoplasty. One patient underwent bronchovascular left upper sleeve lobectomy. The postoperative morbidity rate was 29.1%. No complications related to the reconstructive procedure occurred. There were no postoperative deaths. Complete patency of the reconstructed PA was shown in all patients by postoperative contrast computed tomography performed every 6 months. Pathological tumour stage ranged from I to IIIA. Five-year overall survival and disease-free survival rates were 69.9% and 52.7%, respectively, at a median follow-up of 41 months. CONCLUSIONS: Resection of the long PA segment followed by conduit or wide patch reconstruction is a feasible, safe and effective option to avoid pneumonectomy. Different biological materials can be used to provide adequate tissue characteristics; the choice is made on a case-by-case basis. Long-term results confirm the oncological reliability of this operation.