Comparison of two surgical approaches for the treatment of primary spontaneous pneumothorax*.

AIM: The authors report a retrospective study on surgical treatment of primary spontaneous pneumothorax (PSP). Surgical approaches by Videoassisted axillary mini-thoracothomy (VAMT) and three-port VATS (t-VATS) are compared. Mean post-operative stay (MPS) and ipsilateral recurrence rate (IRR) are assessed. Secondary endpoints were about complications, early post-operative pain and long term neurologic symptoms. PATIENTS AND METHODS: From January 2009 to December 2011 we consecutively observed 85 cases of PSP. Treatment was represented by surgery in 52 patients: the approach was by VAMT in 39 instances and t-VATS in 13. Median follow up was 30 months. RESULTS: Patients submitted to surgery had a MPS of 6.62 ± 1.5 days for VAMT and 6.69 ± 3.4 days for t-VATS (p=0,94). The IRR was 0% in both surgical approaches, comparing to 7,2% for the group of patients treated by simple drainage. Complications were observed in VAMT group: 2 conversions to thoracothomy for technical difficulties (extensive pleural adherences) and one case of re-thoracothomy for hemothorax. Mean Visual Analogic Scale (VAS) score for early post-operative pain was: 2.10±0.71 for VAMT and 1.92±0.64 for t-VATS, p=0.42 at t-student test. Paresthesia complain rate was 33.3% (VAMT) vs 30.7% (t-VATS) for moderate symptoms (p=0.72 at chi square test). The remaining patients complained only slight symptoms or no symptoms at all. CONCLUSIONS: Our experience suggested that both surgical approaches to PSP are safe and effective. No differences were found for early post-operative pain and long term paresthesia rate, between the two approaches. No recurrence occurred during follow up.

Efficacy and safety of fibrin sealant patch in the treatment of air leakage in thoracic surgery.

AIM: Air leakage represents a major problem in lung surgery. Absorbable fibrin sealant patch (AFSP), a collagen sponge coated with human fibrinogen and thrombin, can be used as an adjunct to primary stapling or suturing. This study compared the efficacy of AFSP with manual suturing after primary stapling. METHODS: This was a prospective, multicenter, randomized study. Patients undergoing lobectomy, bilobectomy, anatomical segmentectomy for lung cancer or wedge resection for pulmonary metastasis with air leakage grade 1 or 2 according to Macchiarini scale after stapler suture were randomized to receive AFSP or standard surgical treatment (ST). The primary endpoint was the reduction of intraoperative air leakage intensity. Duration of postoperative air leakage and number of days until removal of last chest drain were secondary endpoints. Safety was recorded for all patients. RESULTS: A total of 346 patients were enrolled in 14 centres, 179 of whom received AFSP and 167 ST. Intraoperative air leak intensity was reduced in 90.5% of AFSP patients and 82% of ST patients (P=0.03). A significant reduction in postoperative air leakage duration was observed in the AFSP group (P=0.0437). The median number of days until removal of last drainage was 6 (3-37) in the AFSP group and 7 (2-27) in the ST (P=0.38). Occurrence of adverse events was comparable in both groups. CONCLUSION: AFSP was more efficacious than standard ST as an adjunct to primary stapling in reducing intraoperative air leakage intensity and duration of postoperative air leakage in patients undergoing pulmonary surgery. AFSP was well tolerated.

Physiological effects of a lung-recruiting strategy applied during one-lung ventilation.

BACKGROUND: One-lung ventilation (OLV) affects respiratory mechanics and ventilation/perfusion matching, reducing functional residual capacity of the ventilated lung. While the application of a lung-recruiting manoeuvre (RM) on the ventilated lung has been shown to improve oxygenation, data regarding the impact of RM on respiratory mechanics are not available. METHODS: Thirteen patients undergoing lung resection in lateral decubitus were studied. During OLV, a lung-recruiting strategy consisting in a RM lasting 1 min followed by the application of positive end-expiratory pressure 5 cmH(2)O was applied to the ventilated lung. Haemodynamics, gas exchange and respiratory mechanics parameters were recorded on two-lung ventilation (TLV(baseline)), OLV before and 20 min after the RM (OLV(pre-RM), OLV(post-RM), respectively) and TLV(end). Haemodynamics parameters were also recorded during the RM. RESULTS: The PaO(2)/FiO(2) ratio was 358+/-126 on TLV(baseline); it decreased to 235+/-113 on OLV(pre-RM) (P<0.01) increased to 351+/-120 on OLV(post-RM) (P<0.01 vs. OLV(pre-RM)), and remain stable thereafter. During the RM, CI decreased from 3.04+/-0.7 l/m(2) OLV(pre-RM) to 2.4+/-0.6 l/m(2) (P<0.05), and returned to baseline on OLV(post-RM) (3.1+/-0.7 l/m(2), NS vs. OLV(pre-RM)). The RM resulted in alveolar recruitment and caused a significant decrease in static elastance of the dependent lung (16.6+/-8.9 cmH(2)O/ml OLV(post-RM) vs. 22.3+/-8.1 cmH(2)O/ml OLV(pre-RM)) (P<0.01). CONCLUSIONS: During OLV in lateral decubitus for thoracic surgery, application to the dependent lung a recruiting strategy significantly recruits the dependent lung, improving arterial oxygenation and respiratory mechanics until the end of surgery. However, the transient haemodynamic derangement occurring during the RM should be taken into account.

[Autofluorescence bronchoscopy in early diagnosis of pulmonary carcinoma]. / Broncoscopia ad autofluorescenza nell'anticipazione diagnostica del carcinoma polmonare.

AIM: Autofluorescence bronchoscopy (AFB) has been proposed to widen traditional white light bronchoscopy (WLB) possibilities of early diagnosis of neoplastic and preneoplastic lesions of the tracheo-bronchial mucosa in high risk groups. The authors report their study on AFB with the aim of establishing its role in the early diagnosis of bronchogenic carcinoma and its positive predictive value (PPV) compared and associated to WLB. METHODS: From May 2002 to May 2004 we performed WLB and AFB in 213 patients (177 males, 36 females), mean age 63.7 years (range 18-84 years), who were divided into 2 main groups (group A: patients at risk for bronchogenic carcinoma, n=82; group B: patients to be operated on for bronchogenic carcinoma, n=131). In total, 237 WLB-AFB were performed (101 in group A, 136 in group B) and 77 biopsies for pathological examination. RESULTS: The 2 tools (WLB and AFB) were concordant in 156 (66%) and discordant in 81 (34%) cases. Considering the biopsies performed, we obtained a PPV of 26% for lesions visible with WLB, of 40% for those visible with AFB, of 38% for those visible with the association of both. In group A, in 56 patients of the follow-up subgroup, we found 2 dysplastic areas and 1 carcinoma in situ. In group B there was a discordant extension of the pathologic area visible with WLB and with AFB in 30 cases which was positive in 18 of them at histological examination. CONCLUSIONS: In our experience, AFB has revealed to be a valid tool for both early diagnosis of neoplastic recurrences or a second primary lung neoplasia in patients in follow-up after resection and preoperative evaluation of resection margins in patients candidate to surgery. More studies are needed to widen its indications in the early diagnosis in high risk groups, to improve its potentialities and optimize its learning curve in order to establish the procedural guide lines.

[Minimally invasive thoracic surgery versus standard surgery]. / Chirurgia toracica mininvasiva versus chirurgia standard.

Advances in technology, with the availability of optics and minitelevision cameras and improved endoscopic instrumentation (especially endo-stapler devices), have allowed the surgeon to obtain a superior panoramic view of the thoracic cavity and an optimal surgical manuvrability. This has determined the development, besides the traditional thoracotomic approach, of minimally invasive techniques of video-assisted thoracic surgery (VATS). An auxiliary mini-thoracotomic approach and the magnification of the operating theatre, which allows the surgeon to accomplish difficult manoeuvres under diret view, have progressively extended the indications of this procedure: at first used for the treatment of pneumothorax and pleural effusions, it is now employed in biopsy or atypical resection of pulmonary nodules, lung cancer staging and diagnostic-therapeutical procedures of mediastinal diseases, major pulmonary resections (lobectomy and pneumonectomy) and lung volume reduction surgery for emphysema (LVRS). The Authors review minimally invasive techniques of video-assisted thoracic surgery (VATS), compared to the traditional surgical ones, for the treatment of various thoracic diseases.

Endothoracic nodules in patients who under-went nephrectomy for renal cell carcinoma. Results of surgical resection.

AIM: A review of our experience with surgical resection of endothoracic nodules in patients who underwent nephrectomy for renal cell carcinoma (RCC) is presented, to evaluate the incidence of metastases in our series and the effectiveness and the opportunity of surgical treatment in this sort of patients. METHODS: Between January 1988 and January 2002, 41 consecutive patients (33 men, 8 women) underwent resection for suspected endothoracic metastases from RCC; 1 more male patient for metastases from an occult renal cancer. Mean age was 62 y (range: 43-80 y). Mean time between nephrectomy and 1st pulmonary resection in 41 patients was 29 mo (range: 0-120 mo). Nineteen patients had solitary lesions, 11 multiple unilateral and 12 bilateral. Antero-lateral thoracotomy was performed in 37 patients, median sternotomy in 1, simultaneous bilateral thoracotomy (clam-shell) in 2, sterno-laparotomy in 1, thoracofrenolaparotomy in 1. Wedge excision was performed in 36 patients, lobectomy with lymphadenectomy in 5, mediastinal limphadenectomy in 1. Six patients had repeat resection for recurrent metastases. RESULTS: Only 24 patients (57%) had histologic diagnosis of pulmonary metastases from RCC; 11 (26%) had benign lesions; 7 (17%) primary lung cancer. Mean follow-up was 25 mo (range: 1-91 mo). Overall, 4-y survival was 50%. Patients with solitary metastasis had a lower survival than those with 4 and more lesions. CONCLUSION: The evidence of pulmonary nodules in patients submitted to nephrectomy for RCC is not necessarily indicative of metastatic disease. Pulmonary resection for RCC metastases, even bilateral and recurrent, may help prolong survival in selected patients.

A nodular pulmonary lesion due to Linguatula serrata in an HIV-positive man.

A coin-shaped pulmonary lesion was accidentally detected in a 42-year-old, HIV-seropositive man residing in Bari (Apulia, Southern Italy) during a routine X-ray examination. A lung cancer was suspected, obliging physicians to investigate surgically. After thoracotomy a lung nodule, 1.8 cm in diameter, was excised and submitted for histological examination. Histological analysis revealed a nodular infarctual lesion containing a larva of Pentastomida. Despite the poor state of preservation of the parasite it was possible to recognise some morphological characteristics which enabled the parasite to be identified as Linguatula serrata (Pentastomida, Porocephalida). This is the first case reported in Europe in the lung in a living man due to this parasite, the few others occurring in autopsy reports. No evident correlations were found in the present case between HIV-seropositivity and the development of the parasitosis. The importance of lung nodules caused by metazoan invertebrates is emphasised: even though they are rare in man, they are regularly mistaken for cancer at X-ray examination.

[The one-time surgical repair of postintubation esophagotracheal fistulae]. / Riparazione chirurgica in tempo unico di fistole esofagotracheali post-intubazione.

Personal experience in the treatment of the tracheal-esophageal non-neoplastic fistula is reported. In the last years, three cases of FTE, concerning some cannula tracheal-stomachal beare patients from 14, 2, 1 months have been examined. In two cases the patients were in spontaneous ventilation, on the contrary a mechanical ventilation was employed in the third. In two patients the fistular way was located correspondingly of the decubitus point of the tracheal stomachal cannula, on the membranaceous pars, and it was not associated with concomitant tracheal stenosis. The first stage of the treatment was removal of the nasogastric probe, supporting the decubitus phenomenon subtending the establishment and the extension of the FTE, then the preparation of a gastrostomy to assure the drainage of secretions under the fistula and a jejunum anastomosis to allow a suitable feeding and recovery of the patients. In these three cases the restoring operation was accomplished by a cervicotomy with a direct opening of the fistula, a suture of the esophageal wall, a suture of the membranaceous pars on the healthy tissue and then a protection of these sutures by interposition, between trachea and esophagus, of the prethyroid muscles transposed and fixed to the prevertebral band. In two cases the post-operative course did not present complications, while the patients kept in assisted ventilation during the postoperative course showed a relapse of the FTE on the twelfth day and then the progressive establishment of a septic state and the exitus on the twentieth day. It is underlined how the success of the reparation of the fistula is largely conditioned by the respiratory autonomy of the patient that guarantees the recurrence of decubitus and infection phenomena causing the lesion.

Primary bronchial amyloidosis. A case report.

A case of primary bronchial amyloidosis in a 58-year old patient, with haemoptysis, cough, purulent sputum and fever, is described. Bronchoscopy showed nodules and yellow wax plaques in the lower lobar bronchi. Histology of bioptic specimens showed the amyloidosic nature of the lesions. The search of other localizations was negative.

[Lung resections for cancer in the elderly]. / Resezioni polmonari per cancro nell'anziano.

BACKGROUND: The purpose of this study is to investigate the value of surgical treatment for lung cancer in the elderly. Results are compared with findings in younger patients operated on during the same period (1985-1990). METHODS: 137 patients 70 years of age or older (range: 70 yrs-87 yrs) (group A) underwent surgical resection [pneumonectomy in 19 (13.8%), lobectomy or bilobectomy in 84 (61.3%), segmentectomy or wedge resection in 22 (16%)]. In group B (younger patients) 561 were treated by pneumonectomy in 156 (27.8%), lobectomy or bilobectomy in 294 (52.4%) and segmentectomy or wedge resection in 64 (11.4%). RESULTS: The overall 2-year survival rate was 64.6% in group A and 61.4% in B. The 5-year survival rate was 36.2% (group A) and 43.2% (group B). CONCLUSIONS: These data suggest that advanced age should not be a contraindication to curative pulmonary resections. More attention must be paid to pre-codiseases of the increasing risk of postoperative complications.

[Multiplane transesophageal echocardiography in the study of expansive mediastinal processes compressing the right heart: a report of clinical cases]. / Ecocardiografia transesofagea multiplanare nello studio dei processi espansivi del mediastino comprimenti il cuore destro: descrizione di casi clinici.

In order to assess the role of multiplane transesophageal echocardiography in detecting mediastinal masses and in evaluating the manifestations of cardiac compression due to tumoral growth, 3 cases of patients with right ventricular outflow obstruction are presented. In each of these patients transesophageal echocardiography provided an accurate evaluation of the hemodynamic consequences of the tumoral process.