Loco-Regional Anesthesia for Pain Management in Robotic Thoracic Surgery.

Robotic thoracic surgery is a prominent minimally invasive approach for the treatment of various thoracic diseases. While this technique offers numerous benefits including reduced blood loss, shorter hospital stays, and less postoperative pain, effective pain management remains crucial to enhance recovery and minimize complications. This review focuses on the application of various loco-regional anesthesia techniques in robotic thoracic surgery, particularly emphasizing their role in pain management. Techniques such as local infiltration anesthesia (LIA), thoracic epidural anesthesia (TEA), paravertebral block (PVB), intercostal nerve block (INB), and erector spinae plane block (ESPB) are explored in detail regarding their methodologies, benefits, and potential limitations. The review also discusses the imperative of integrating these anesthesia methods with robotic surgery to optimize patient outcomes. The findings suggest that while each technique has unique advantages, the choice of anesthesia should be tailored to the patient's clinical status, the complexity of the surgery, and the specific requirements of robotic thoracic procedures. The review concludes that a multimodal analgesia strategy, potentially incorporating several of these techniques, may offer the most effective approach for managing perioperative pain in robotic thoracic surgery. Future directions include refining these techniques through technological advancements like ultrasound guidance and exploring the long-term impacts of loco-regional anesthesia on patient recovery and surgical outcomes in the context of robotic thoracic surgery.

Robotic surgery for thymic cysts: clinical features, management, and results of a multicentric study.

Thymic cysts are rare, radiological diagnosis is often incidental, and cysts seldom assume clinical relevance for symptoms of compression. Thymoma were occasionally found inside both complex and simple thymic cysts. Given the challenges in accurately clinical diagnosing and since the occasionally discovering of thymoma inside both complex and simple thymic cysts, the management of thymic cysts remains controversial. Advancements in surgical tools such as robotics, applied to thymic conditions, could potentially transform the approach to thymic cysts. We report one the largest multicentric series of thymic cysts surgically treated with robotic approach, focusing on preoperative findings and surgical results. Cases were gathered from three Italian thoracic surgery centers with homogeneous clinical practice, significant experience in thymic neoplasms, and thoracic robotic skilled. Surgical intervention was indicated for patients with radiological diagnosis of thymic cysts under the following circumstances: the presence of symptoms, concurrent myasthenia gravis, cysts growing in follow-up, and the complexity of the cyst with suspicion of neoplasm. Data were collected and matched according to postoperative and pathological features to identify potential prognostic factors. Population include 57 patients, 29/28 male/female ratio with mean age of 59.46 ± 11.67 years. The average size of the thymic cysts was 29.14 ± 24.53 ranged between 3 and 150 mm. All patients undergone CT scan and mean of values of density was 25.82 ± 11-82 Hounsfield. Surgical procedures were robotic approach in all case including total/extended thymectomy 35 (61.4%) and cyst resection/partial thymectomy 22 (38.6%). There were no mortality or recurrence. Major complications rate was 5.3%. No correlations were observed between preoperative features and complication. Pathological examination revealed microfoci of thymic tumor in four cases. Robot-assisted surgery for thymic cysts showed excellent early clinical outcomes with low rate of postoperative complications also in case of large lesion. Thymic cysts should not be underestimated due to the risk of coexistent thymic neoplasm.

Surgery for Non-Small Cell Lung Cancer in the Personalized Therapy Era.

Lung cancer remains one of the tumours with the highest incidence and the poorestprognosis, with an estimated incidence of more than 220,000 cases with 135,000 cancerrelateddeaths annually in the United States [1,2].[...].

External Validation of a Prognostic Score for Survival in Lung Carcinoids.

Background: A prognostic score including T-dimension, age, histology and lymph node ratio was previously proposed in absence of an external validation dataset. The aim of the current study was to validate the proposed prognostic score using an independent dataset. Methods: Data of patients with lung carcinoids, who underwent surgical resection and lymphadenectomy in five institutions from 1 January 2005 to 31 December 2019, were retrospectively analyzed. Two risk groups were created based on the following data: age, histology, node ratio and pT for disease-free survival (DFS); age, sex, node ratio and pT for overall survival (OS). The previously proposed score was validated, identifying two groups of patients: a high risk (HRG) and low risk (LRG) group. Results: The final analysis was conducted on 283 patients. Regarding DFS, 230 (81.3%) patients were assigned to the LRG and 53 (18.7%) to the HRG. Considering OS, 268 (94.7%) were allocated in the LRG and 15 (5.3%) in the HRG. The 5-year DFS was 92.7% in the LRG vs. 67% in the HRG (p < 0.001) while the 5-year OS was 93.6% in the LRG vs. 86.2% in the HRG (p = 0.29) with clear curve separation. Conclusion: Our analysis confirmed the validity of the composite score for DFS in lung carcinoids. Regarding OS, statistical significance was not reached because of a low number of deaths and patients in the HRG.

Lymphadenectomy for lung carcinoids: Which factors may predict nodal upstaging? A multi centric, retrospective study.

OBJECTIVE: To investigate risk factors for nodal upstaging in patients with lung carcinoids and to understand which type of lymphadenectomy is most appropriate. METHODS: Data regarding patients with lung carcinoids, who underwent surgical resection and lymphadenectomy in five institutions from January 1, 2005 to December 31, 2019, were collected and retrospectively analyzed. Clinical and pathological tumor characteristics were correlated to analyze lymph node upstaging. RESULTS: The analysis was conducted on 283 patients. Pathology showed 230 typical and 53 atypical carcinoids. Nodal and mediastinal upstaging occurred in 33 (11.6%) and 16 (5.6%) patients, respectively. At the univariable analysis, nodal upstaging was significantly correlated with central location (p = 0.003), atypical histology (p < 0.001), pT dimension (p = 0.004), and advanced age (p = 0.043). The multivariable analysis confirmed atypical histology (odds ratio [OR]: 11.030; 95% confidence interval [CI]: 4.837-25.153, p < 0.001) and central location (OR: 3.295; 95% CI: 1.440-7.540, p = 0.005) as independent prognostic factors for nodal upstaging. Atypical histology (p < 0.001), pT dimension (p = 0.036), number of harvested lymph node stations (p = 0.047), and type of lymphadenectomy (p < 0.001) correlated significantly with mediastinal upstaging. The multivariable analysis confirmed atypical histology (OR: 5.408; 95% CI: 1.391-21.020, p = 0.015) and pT (OR: 1.052; 95% CI: 1.021-1.084, p = 0.001) as independent prognostic factors. CONCLUSION: Atypical histology, dimension, and central location are associated with a high-risk for occult hilo-mediastinal metastases, and mediastinal radical dissection may predict nodal upstaging. Thus, we suggest radical mediastinal lymph node dissection in high-risk tumors, reserving sampling, or lobe-specific dissection in peripheral, small typical carcinoids.

Continuous Erector Spinae Plane Block as Postoperative Analgesic Technique for Robotic-Assisted Thoracic Surgery: A Case Series.

INTRODUCTION: The erector spinae plane block (ESPB) is a recently implemented analgesic technique initially reported for thoracic analgesia and subsequently adopted for both intra- and postoperative pain management. Thoracic surgery is among the most painful surgical procedures, even when conducted with minimally invasive approach. Robotic-assisted thoracic surgery (RATS) challenges the traditional analgesic regimens as one of its aims is to decrease the patient's length of stay (LOS) whilst achieving optimal postoperative pain management. Furthermore, there is lots of growing evidence on the impact of poorly controlled postoperative pain (PP) on the development of chronic post-surgical pain (CPSP). In these case series, we aim to describe our preliminary experience of postoperative pain management with continuous ESPB in the field of RATS. CASE SERIES PRESENTATION: In eight consecutive patients undergoing elective RATS procedure, we performed the ESPB after surgery with an initial bolus of local anesthetic followed by catheter insertion for continuous infusion. The infusion of local anesthetic lasted for the first two postoperative days. The effectiveness of the ESPB was evaluated through serial pain assessment with numeric rate scale (NRS) score, both at rest and during movement every 6 hours. Any analgesic rescue drug prescription was reported. We noted that the ESPB strongly reduced the prescription of opioids and of rescue analgesic. In our series, only one patient needed opioids during the first two postoperative days, and no rescue analgesic administration was noted in the remaining cases. CONCLUSION: We report a small but promising experience regarding postoperative pain management with continuous ESPB performed after RATS. We implemented the ESPB before surgery. Larger studies on postoperative pain management with continuous regional blocks in thoracic surgery are warranted.

Which Is the Best Treatment in Recurrent Thymoma? A Systematic Review and Meta-Analysis.

BACKGROUND: Optimal recurrent thymoma management remains arguable because of limited patient numbers, and relatively late and variable recurrence patterns. Given the absence of high-quality evidence and relatively small study cohorts, we performed a quantitative meta-analysis to determine the outcome of surgical and non-surgical approaches assessing the five-year overall survival (5y overall survival (OS)) in patients with recurrent thymoma. METHODS: We performed a comprehensive literature search and analysis according to PRISMA guidelines of studies published from 1 January 1980 until 18 June 2020 from PubMed/MEDLINE, EMBASE, and Scopus. We included studies with the cohorts' superior to 30 patients describing recurrent thymoma treatment, comparing surgical and non-surgical approaches reporting survival data. RESULTS: Literature search revealed 3017 articles. Nine studies met all inclusion criteria and were selected for the meta-analysis. The recurrences were local/regional in 73-98% of cases and multiple in 49-72%. After treatment, 5y OS ranged from 48-77% and 10y OS from 37-51%. The quantitative meta-analysis showed a better outcome comparing surgical vs other treatments. Two studies showed statistically significant risk differences in the 5y OS favoring complete resection. After pooling results of seven studies using the random model, the combined 5y OS risk difference was 0.39, with lower and upper limits of 0.16 and 0.62, respectively (p = 0.001), and a moderate heterogeneity among studies (p = 0.098, I2 = 43.9%). Definitive conclusions could not be drawn regarding the prognostic impact of myasthenia gravis, histology, and patterns of relapse reported in literature. CONCLUSIONS: Surgical treatment after thymoma recurrence is associated with a significant better 5y OS; therefore, surgical resection should be preferred in all technically feasible cases.

Management of pulmonary ground-glass opacities: a position paper from a panel of experts of the Italian Society of Thoracic Surgery (SICT).

OBJECTIVES: A significant gap in our knowledge of how to manage pulmonary ground-glass opacities (GGOs) still exists. Accordingly, there is a lack of consensus among clinicians on this topic. The Italian Society of Thoracic Surgery (Società Italiana di Chirurgia Toracica, SICT) promoted a national expert meeting to provide insightful guidance for clinical practice. Our goal was to publish herein the final consensus document from this conference. METHODS: The working panel of the PNR group (Pulmonary Nodules Recommendation Group, a branch of the SICT) together with 5 scientific supervisors (nominated by the SICT) identified a jury of expert thoracic surgeons who organized a multidisciplinary meeting to propose specific statements (n = 29); 73 participants discussed and voted on statements using a modified Delphi process (repeated iterations of anonymous voting over 2 rounds with electronic support) requiring 70% agreement to reach consensus on a statement. RESULTS: Consensus was reached on several critical points in GGO management, in particular on the definition of GGO, radiological and radiometabolic evaluation, indications for a non-surgical biopsy, GGO management based on radiological characteristics, surgical strategies (extension of pulmonary resection and lymphadenectomy) and radiological surveillance. A list of 29 statements was finally approved. CONCLUSIONS: The participants at this national expert meeting analysed this challenging topic and provided a list of suggestions for health institutions and physicians with practical indications for GGO management.

Complications in Idiopathic Pulmonary Fibrosis: Focus on Their Clinical and Radiological Features.

Idiopathic pulmonary fibrosis (IPF) is a fibrotic lung disease with uncertain origins and pathogenesis; it represents the most common interstitial lung disease (ILD), associated with a pathological pattern of usual interstitial pneumonitis (UIP). This disease has a poor prognosis, having the most lethal prognosis among ILDs. In fact, the progressive fibrosis related to IPF could lead to the development of complications, such as acute exacerbation, lung cancer, infections, pneumothorax and pulmonary hypertension. Pneumologists, radiologists and pathologists play a key role in the identification of IPF disease, and in the characterization of its complications-which unfortunately increase disease mortality and reduce overall survival. The early identification of these complications is very important, and requires an integrated approach among specialists, in order to plane the correct treatment. In some cases, the degree of severity of patients having IPF complications may require a personalized approach, based on palliative care services. Therefore, in this paper, we have focused on clinical and radiological features of the complications that occurred in our IPF patients, providing a comprehensive and accurate pictorial essay for clinicians, radiologists and surgeons involved in their management.

Current Practices in the Management of Pulmonary Ground-Glass Opacities: A Survey of SICT Members.

BACKGROUND: Several gray areas and controversies exist concerning the management of pulmonary ground-glass opacities (GGOs), and there is a lack of consensus among clinicians on this topic. One of the main aims of the Italian Society of Thoracic Surgery is to promote education and research, so we decided to perform a survey on this topic to estimate current trends in practice in a large sample of thoracic surgeons. METHODS: A total of 160 thoracic surgeons responded, namely, completed our questionnaire (response rate, 53%; 160 of 302). The survey was composed of 36 questions divided into six subsections: (1) demographic characteristics of the respondents; (2) terminology and taxonomy; (3) radiologic and radiometabolic evaluation; (4) diagnostic approach and indications for surgery; (5) surgical management; and (6) radiologic surveillance. RESULTS: We observed some divergence of opinion regarding the definition of mixed GGOs, the role of 18F fluorodeoxyglucose positron emission tomography and computed tomography scans, indications for nonsurgical biopsy, intraoperative techniques for localizing GGOs, indications for surgery, extension of lung resection and lymph node dissection according to the radiologic scenario, use of intraoperative frozen section analysis, and radiologic surveillance of pure GGOs. CONCLUSIONS: This topic warrants more investigation in the future. An upcoming consensus conference of Italian Society of Thoracic Surgery experts (also open to experts in other specialties) could provide updated indications for GGO management based on the literature, expert opinions, and the results of the present survey.

Surgical Resection for Pulmonary Carcinoid: Long-Term Results of Multicentric Study-The Importance of Pathological N Status, More Than We Thought.

BACKGROUND: Histological subdivision into typical (TC) and atypical (AC) is crucial for treatment and prognosis of lung carcinoids but can be also very challenging, even for experts. In this study, we aimed to strengthen or reduce the prognostic value of several pathological, clinical, or per-operative factors some of which are still controversial. METHODS: We retrospectively reviewed clinical records related to 195 patients affected by TC (159) or AC (36) surgically treated between 2000 and 2014, in three different centers. Survival and subtypes comparison analyses were performed to identify potential prognostic factors. RESULTS: TCs showed a lower rate of nodal involvement than ACs (N0 = 94.9%; N1 = 1.9%; N2 = 3.2% in typical and N0 = 63.8%; N1 = 16.6%; N2 = 19.4% in atypical carcinoids, respectively, p < 0.0001). Long-term oncological results of resected carcinoids were significantly better in TCs than ACs with higher 5- and 10-year overall survival rates (97.2 and 88.2% vs. 77.9 and 68.2%, respectively; p = 0.001) and disease-free survival rates (98.2 and 90.3% in typical and 80.8 and 70.7% atypical carcinoids, respectively; p = 0.001). Risk factors analysis revealed that AC subtype [HR 4.33 (95% CI 1.72-8.03), p = 0.002], pathological nodal involvement [HR 3.05 (95% CI 1.77-5.26), p < 0.0001], and higher SUVmax [HR 4.33 (95% CI 1.03-7.18), p = 0.002] were independently and pejoratively associated with overall survival. Factors associated with a higher risk of recurrence were AC subtype [HR 6.13 (95% CI 1.13-18.86), p = 0.002]; nodal involvement [HR 5.48 (95% CI 2.85-10.51), p < 0.0001]; higher Ki67 expression level [HR 1.09 (95% CI 1.01-1.20), p = 0.047]; and SUVmax [HR 1.83 (95% CI 1.04-3.23), p = 0.035]. CONCLUSION: Surgery for lung carcinoids allows satisfactory oncological results which mainly depend on carcinoid subtype dichotomy, pathological nodal status, and SUVmax.

Control of major pulmonary artery bleeding with a gelatin matrix-thrombin solution: a retrospective analysis.

BACKGROUND: Intraoperative pulmonary artery (PA) bleeding is common during thoracic surgery. We investigated the efficacy of the gelatin matrix-thrombin solution FloSeal (Baxter International, Deerfield, IL, USA) for control of major PA bleeding. METHODS: Retrospective data were collected on all intraoperative PA injuries during open or minimally invasive lobectomy or pneumonectomy between January 2000 and January 2014. Patients received either 4/0 prolene sutures (Standard) or the gelatin matrix-thrombin solution, plus sutures as needed (Matrix), with at least 6-month follow-up. Endpoints included time to hemostasis, total blood loss, transfusion and complications. RESULTS: Of 2809 procedures, 39 (1.4%) had intraoperative PA injury, of which 21 received standard care and 18 the gelatin matrix-thrombin solution. Hemostasis was achieved in all Standard group patients after 2 minutes, and after 5 minutes in Matrix patients. Additional sutures were required in 4 (19.0%) Standard group patients. Three (16.7%) Matrix patients had a second solution application, while 17 (77.8%) received precautionary sutures. Mean blood loss on postoperative day 1 was 836.1±186.1 mL and 957.1±163.0 mL in the Matrix and Standard groups, respectively (P=0.003). Four (22.2%) Matrix patients received postoperative transfusions versus eight (38.0%) Standard patients (P=0.02). Two Standard and no Matrix patients underwent surgical revision. There were no complications and no mortalities. CONCLUSIONS: Our analysis suggests that the gelatin matrix-thrombin solution is safe and effective for the control of major bleeding following intraoperative PA injury, and may improve outcomes. Further prospective studies are required to confirm our findings.

Endoscopic stenting for double bronco-pleural fistula after lobectomy.

Bronchial fistula is one of the most serious complications after pulmonary resection. It presents a challenge in terms of treatment, with a high risk of perioperative mortality. We describe a patient who underwent a right upper lobectomy and systematic hilar-mediastinal lymphadenectomy for lung adenocarcinoma complicated by 2 bronchopleural fistulas. The lesions were sited at the upper lobar stump and the pars membranacea of the intermediate bronchus. The patient was successfully treated by placement of an endobronchial prosthesis (initially a self-expanding prosthesis and subsequently, a Dumon prosthesis) and a pleural chest drain, to avoid a potential right pneumonectomy.

Long-term results after treatment for recurrent thymoma: a multicenter analysis.

OBJECTIVES: The treatment for recurrent thymoma remains a very controversial issue. This study aims to investigate the long-term outcomes in patients with relapse according to treatment strategies and clinicopathological features. METHODS: We retrospectively analyzed the database of three tertiary centers of thoracic surgery with the aim of reviewing the clinical records of 81 patients who experienced a recurrent thymoma after radical thymectomy, in the period between January 2001 and June 2013. The staging of both primitive and recurrent thymomas were based on the surgical and pathological criteria described by Masaoka. Experienced pathologists reassessed independently the histology of the initial thymoma and its relapse, according to the WHO classification. To the purposes of this study R+ resection or thymic carcinoma were considered as exclusion criteria. The overall outcome for long-term (5 years and 10 years) survival and disease-free survival after initial thymectomy and after treatment of recurrent thymoma were analyzed using standard statistics. RESULTS: The population was gender balanced (41 M, 40 F), mean age: 46.4 ± 12.3 years. Fifty-four patients (66.7%) were affected by myasthenia gravis, while the other 14 by other paraneoplastic conditions. Surgery was performed in 61 patients (75.3%,), and radiotherapy and/or chemotherapy in 14 patients (17.3%). The mean follow-up duration after recurrence onset was 66.3 ± 56.4 months. Adjuvant therapy had no effect on prolonging the disease-free survival: no differences were found when investigating the administration of adjuvant chemotherapy (no CHT = 91.5 ± 76.4 months versus yes CHT=64.0 ± 41.3) and radiotherapy (no RT=86.2 ± 72.8 months versus yes RT= 93.0 ± 62.3; p = 0.8). Relapses were mostly local (mediastinum: 15 cases, pleura: 44 cases); hematogenous distant recurrences were observed in 15 cases (lung: 12; liver: 1; bone: 2 cases). An upgrade in the WHO class (defined as the "migration" of WHO class at initial thymectomy to more aggressive WHO class assigned at thymic recurrence resection) was found in 25/61 cases (40.9%), but this phenomenon apparently did not influence patient's prognosis. Overall, the 5- and 10-year survival rates after the initial thymectomy were 94.8% and 71.7%, respectively, while the 5- and 10-year survival rates after the treatment of the recurrence at the thymic level were 73.6% and 48.3%, respectively (82.4% at 5 years and 65.4% at 10 years when a R0-re-resection was obtained). The analysis on the trends of disease-free survival indicated that the site of recurrence (hematogenous diffusion) seems to be associated to a higher risk of re-relapse (p = 0.01). CONCLUSIONS: Even following a thymectomy performed with radical intent, thymoma may recur several years later, usually as a locoregional relapse. A rewarding long-term survival may be expected after treatment, especially when a re-resection (radical) is performed (82.4% at 5 years). An histopathological "WHO upgrade" (from "low-risk" WHO classes at thymectomy to "high-risk classes" at relapse) may be observed in a remarkable percentage of patients (nearly 40% in this series), but this phenomenon seems to be not correlated with any worsening of the prognosis.

Is sleeve lobectomy comparable in terms of short- and long-term results with pneumonectomy after induction therapy? A multicenter analysis.

BACKGROUND: Sleeve lobectomy (SL) is considered a valid therapeutic option in untreated, centrally located non-small cell lung cancer (NSCLC) even in patients "fit" for pneumonectomy (PN). Nevertheless, SL feasibility and long-term results after induction therapy (IT) have been only rarely investigated. We herein report the results of a multicenter retrospective study on NSCLC patients who underwent PN or SL after IT for locally advanced NSCLC. METHODS: From January 1992 to January 2012, 119 consecutive patients (94 males, 25 females) underwent in three tertiary referral centers either SL (bronchial, arterial, or both) or PN for locally advanced NSCLC after IT (chemotherapy alone or combined chemoradiotherapy). The indication for SL was based on technical feasibility. Clinical and pathologic variables were retrospectively reviewed, and treatment results were assessed and compared in both groups. Survival was calculated by Kaplan-Meier method and compared by the log-rank test as well the Cox regression model. RESULTS: Sleeve lobectomy was performed in 51 patients and PN, in 68 patients. Thirty-day mortality and morbidity rates were 3.9% and 9.8% for SL and 2.9% and 22.1% for PN, respectively. Five-year survival rates were 53.8% after SL and 43.1% after PN, respectively (p = 0.28). Overall recurrence rate was 42.8% after SL and 47.0% after PN (p = 0.34); relapse was locoregional in 22.4% of SL cases and 12.1% after PN, respectively (p = 0.011). The Cox analysis suggested pN status and right side as independent risk factors for death in the SL group (hazard ratio, 1.96; 95% confidence interval, 1.12 to 3.44; p = 0.018; and hazard ratio, 2.96; 95% confidence interval, 1.13 to 8.66; p = 0.047, respectively). As well, pN status and right side were a strong predictor of relapse (hazard ratio, 2.33; 95% confidence interval, 1.17 to 4.64; p = 0.016; and hazard ratio, 2.96; 95% confidence interval, 1.13 to 8.66; p = 0.046, respectively) in SL patients. CONCLUSIONS: For locally advanced NSCLC, SL represents a safe and effective surgical option when compared with PN even after IT, with substantially comparable early and long-term results. Nevertheless, further investigations on a large cohort of patients are needed.

Thymectomy in myasthenia gravis: proposal for a predictive score of postoperative myasthenic crisis.

OBJECTIVES: Thymectomy plays an important role in patients with myasthenia gravis (MG). This study aimed to explore predictors of postoperative myasthenic crisis (POMC) after thymectomy and to define a predictive score of respiratory failure. METHODS: The clinical data of 177 patients with MG undergoing thymectomy from January 1995 to December 2011 were retrospectively reviewed. The following factors were analysed in relation to the occurrence of myasthenic crisis: gender, age, body mass index (BMI), anti-acetylcholine receptor-antibody level, bulbar symptoms, comorbidities, duration of symptoms, Osserman-stage, Myasthenia Gravis Foundation of America (MGFA) stage, history of myasthenic crisis, use of immoglobulins or plasmapheresis, kind of therapy, spirometric and blood gas parameters, histology, kind of surgery, non-myasthenic complications and duration of intubation. RESULTS: Twenty-two patients experienced postoperative respiratory failure after thymectomy. Univariate analysis revealed a correlation with age >60 years (odds ratio (OR) = 1.79, 95% confidence interval (CI) = 1.04-6.78; P = 0.040); Osserman-stage (IIB- OR = 5.16, 95% CI = 1.10-24.18; P = 0.037, III-IV- OR = 8.75, 95% CI = 1.53-50.05; P = 0.015); bulbar symptoms (OR = 7.42, 95% CI = 1.67-32.84; P = 0.008); BMI >28 (OR = 3.99, 95% CI = 1.58-10.03; P = 0.003); preoperative plasmapheresis (OR = 2.97, 95% CI = 1.18-14.04; P = 0.021); duration of symptoms >2 years (OR = 4.00, 95% CI = 1.09-14.762; P = 0.036); extended surgery (OR = 2.52, 95% CI = 1.02-6.22; P = 0.045); lung (OR = 4.05, 95% CI = 1.44-11.42; P = 0.008), pericardial (OR = 3.78, 95% CI = 1.45-9.82; P = 0.006) or pleural resection (OR = 3.23, 95% CI = 1.30-8.03; P = 0.012); Vital Capacity % <80% (OR = 0.20, 95% CI = 0.05-0.82; P = 0.025) and PaCO2 >40 mmHg (OR = 3.76, 95% CI = 1.12-12.68; P = 0.032). Multivariate logistic regression analysis showed that Osserman-stage (IIB- OR = 5.69, 95% CI = 1.09-29.69; P = 0.039 (III-IV- OR = 11.33, 95% CI = 1.67-76.72; P = 0.013), BMI >28 (OR = 3.65, 95% CI = 1.10-12.15; P = 0.035), history of myasthenic crisis (OR = 24.10, 95% CI = 2.34-248.04; P = 0.007), duration of symptoms >2 years (OR = 5.94, 95% CI = 1.12-31.48; P = 0.036) and lung resection (OR = 8.48, 95% CI = 2.18-32.97; P = 0.002) independently predict POMC. Excluding history of preoperative myasthenic crisis (statistically associated with Osserman-stage), we built a scoring system according to the OR of Osserman-stage (I-IIA, IIB, III-IV), BMI (<28, ≥ 28), duration of symptoms (<1, 1-2, >2 years) and association with a pulmonary resection. This model helped in creating four classes with increasing risk of respiratory failure (Group I, 6%; Group II, 10%; Group III, 25%; Group IV, 50%). CONCLUSIONS: Our model facilitates the stratification of patient risk and prediction of the occurrence of POMC. Moreover, it could help to guide the anaesthesiologist's decision on the duration of intubation. Further studies based on larger series are needed to confirm these preliminary data.

Post-operative rehabilitation for surgically resected non-small cell lung cancer patients: serial pulmonary functional analysis.

INTRODUCTION: Post-operative pulmonary rehabilitation in patients who have undergone surgery for lung cancer is a subject of open debate. Clinical practice in this setting is based on the results of observational trials, such as the one described here. Prospective randomized controlled trials have been registered and recruitment is ongoing. METHODS: From 2005 to 2008, 110 patients with surgical non-small cell lung cancer were entered into a post-operative inpatient pulmonary rehabilitation programme for 3 weeks. All patients were evaluated for pulmonary function after surgery (time 0; T0) and at the end of pulmonary rehabilitation programme (time 1; T1). Statistical analysis focused on improvement in pulmonary function parameters and physical performance in the 6-min walking test (6MWT). Mixed models multiple linear regression was used to identify parameters related to the primary end-points of this research. RESULTS: Patients' mean age was 70.1 years (standard deviation (SD) 8.5 years); male/female ratio 73/37. A total of 94 patients underwent lobectomy, 8 underwent pneumonectomy, and the remaining 8 underwent bilobectomy. Among the analysed parameters a significant improvement could be detected only with regards to the 6MWT (257.4 (SD 112.2) at T0 and 382.8 (SD 11.09) at T1). CONCLUSION: Post-operative pulmonary rehabilitation in patients with surgical non-small cell lung cancer is effective in terms of exercise tolerance.