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INTRODUCTION: The Nuss procedure for pectus excavatum requires that the sternal elevation be maintained by indwelling metal bars that are traditionally removed approximately 3 y after the repair. METHODS: A retrospective cohort study was conducted of all patients who underwent primary Nuss repair from 2007 to 2018 in two institutions and had a follow-up of at least 24 mo. Pectus bars had been left in place beyond 3 y in patients concerned over possible recurrence after bar removal. Structured interviews were held to assess pain, chest tightness, or other discomfort, and any adverse events related to pectus bars. Results were compared between patients in whom pectus bars were removed after 3 y (standard group) and those in whom bars were left in place longer (extended bar duration group). RESULTS: Two hundred and thirty-one patients (91% males, mean age 23.9 ± 8.3, mean Haller index 4.9 ± 2.3) were included. Bar duration was 30.6 ± 6.6 mo in the standard group (51 patients) versus 69.1 ± 26.3 mo in the extended group (180 patients). Some discomfort was reported by 81.6% in the standard group versus 62.9% in the extended group (P = 0.033), and discomfort occurring at least monthly or more often was only reported by 30% in the standard versus 30.3% in the extended group (P = 1.000). Quality of life improved in 92.6% of the standard group versus 94.7% of the extended group (P = 1.000). No significant adverse events were reported in either group. CONCLUSIONS: Our data suggest that an extended bar duration after the Nuss repair may not cause any adverse event nor negatively affect quality of life.
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Tórax em Funil , Parede Torácica , Masculino , Humanos , Adolescente , Adulto Jovem , Adulto , Feminino , Estudos Retrospectivos , Qualidade de Vida , Resultado do Tratamento , Procedimentos Cirúrgicos Minimamente Invasivos/métodosRESUMO
BACKGROUND: The Nuss procedure is the primary treatment for pectus excavatum (PE), but patient expectations are not always met. In our unit, our standard approach in the last few years has been the routine application of two bars instead of one. We aimed to retrospectively assess the impact of this approach on patient satisfaction, quality of life (QoL) and safety. METHODS: A retrospective study included 182 patients over 16 years old who underwent the Nuss procedure for PE between January 2007 and September 2021. Patients were categorized into one-bar or two-bar correction groups. Propensity score matching (PSM) was used, resulting in 30 patients in each group. Primary endpoints were QoL and cosmetic satisfaction, while secondary endpoints included complications and recurrence. RESULTS: After PSM, both groups showed similar general characteristics. Patients treated with two bars reported fewer psychological complaints post-surgery (93.3% vs. 73.3%, p = 0.031). There were no significant differences in QoL improvement (96.7% in both groups, p = 0.197), perioperative complications (p = 0.771) or recurrence (one patient in the one-bar group, p = 1.000). CONCLUSIONS: Our study reveals that patients undergoing the Nuss Procedure for PE with two bars exhibit comparable clinical outcomes and QoL to those with one bar. However, patients with two bars may have higher levels of psychological well-being and satisfaction, indicating potential benefits associated with this approach. These findings suggest potential advantages of the two-bar approach, but further research with larger sample sizes is warranted to confirm these observations.
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OBJECTIVES: Inherent technical aspects of pulmonary lobectomy by video-assisted thoracoscopic surgery (VATS) may limit surgeons' ability to deal with factors predisposing to complications. We analysed complication rates after VATS lobectomy in a prospectively maintained nationwide registry. METHODS: The registry was queried for all consecutive VATS lobectomy procedures from 49 Italian Thoracic Units. Baseline condition, tumour features, surgical techniques, devices, postoperative care, complications, conversions and the reasons thereof were detailed. Univariable and multivariable regressions were used to assess factors potentially linked to complications. RESULTS: Four thousand one hundred and ninety-one VATS lobectomies in 4156 patients (2480 men, 1676 women) were analysed. The median age-adjusted Charlson index of the patients was 4 (interquartile range 3-6). Grade 1 and 2 and Grade 3-5 complications were observed in 20.1% and in 5.8%, respectively. Ninety-day mortality was 0.55%. The overall conversion rate was 9.2% and significantly higher in low-volume centres (<100 cases, P < 0.001), but there was no significant difference between intermediate- and high-volume centres under this aspect. Low-volume centres were significantly more likely to convert due to issues with difficult local anatomy, but not significantly so for bleeding. Conversion, lower case-volume, comorbidity burden, male gender, adhesions, blood loss, operative time, sealants and epidural analgesia were significantly associated with increased postoperative morbidity. CONCLUSIONS: VATS lobectomy is a safe procedure even in medically compromised patients. An improved classification system for conversions is proposed and prevention strategies are suggested to reduce conversion rates and possibly complications in less-experienced centres.
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Complicações Intraoperatórias/epidemiologia , Pneumonectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Cirurgia Torácica Vídeoassistida/métodos , Idoso , Feminino , Hospitais/estatística & dados numéricos , Humanos , Pulmão/cirurgia , Neoplasias Pulmonares/cirurgia , Masculino , Pessoa de Meia-Idade , Pneumonectomia/efeitos adversos , Pneumonectomia/estatística & dados numéricos , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Cirurgia Torácica Vídeoassistida/efeitos adversos , Cirurgia Torácica Vídeoassistida/estatística & dados numéricosRESUMO
EBUS-TBNA is gaining widespread acceptance as a minimally invasive procedure for mediastinal staging and re-staging of lung cancer, diagnosis of lung tumors adjacent to large airways and characterization of both malignant and benign lymphadenopathy. The aim of this article is to describe the appropriate setting and practical aspects of the procedure that may help at the start of a new EBUS-TBNA program to improve patient safety, comfort and procedural yield according to operator experience, procedure aim, and institutional needs.
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The traditional approach to thymectomy requires median sternotomy based on the assumption that it is the best means to achieve adequate resection margins, complete removal of the thymus and clearance of the anterior mediastinal fat. However, in recent years, VATS thymectomy has been gaining acceptance as a means to achieve adequate oncologic results and symptomatic improvement of myasthenic symptoms with less impact on the patient. We have adopted a flexible approach based on the location of the tumor and on whether the patient has myasthenia gravis (MG) or not when planning minimally invasive VATS thymectomy. A preferential approach from the left side is chosen for clinical stage I-II thymomas located on the left side or on the midline in patients without MG, and a bilateral approach (uniportal VATS on the right side and three-portal VATS on the left side) for MG patients with or without thymoma in order to achieve complete clearance of the anterior mediastinal fat on both sides. Such techniques are herewith clearly illustrated in hope that surgeons wishing to endeavor in such an effort will be facilitated.
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BACKGROUND: Multi-institutional studies of endobronchial-ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging in lung cancer are scarce. It is unclear if the high diagnostic performance of EBUS-TBNA reported by experts' guidelines can be generally achieved. METHODS: This is a retrospective study performed in five tertiary referral centers of thoracic surgery in Italy, to assess the EBUS-TBNA diagnostic performance in patients with non-small cell lung cancer (NSCLC). Patient inclusion criteria were: both genders; >18 years old; with suspect/confirmed NSCLC; undergoing EBUS-TBNA for mediastinal node enlargement at computed tomography (size >1 cm, ≤3 cm) and/or pathological uptake at positron emission tomography. Altogether we included 485 patients [male, 366; female, 119; median age, 68 years (IQR, 61-74 years)] undergoing mediastinal staging between January 2011 and July 2016. All EBUS-TBNAs were performed by experienced bronchoscopists, without pre-defined quality standards. Depending on usual practice in each center, EBUS-TBNA was done under conscious sedation, with 21- or 22-Gauge (G) needle, and specimen preparation was cell-block, or cytology slides, or core-tissue. Sampling was classified inadequate in absence of lymphocytes, or when sample was insufficient. We analyzed the EBUS-TBNA procedural steps likely to influence the rate of adequate samplings (diagnostic yield). RESULTS: EBUS-TBNA sensitivity, negative predictive value (NPV) and accuracy respectively were 90%, 78% and 93% in the whole cohort. At multivariate analysis, use of 21-G needle was associated with better diagnostic yield (P<0.001). Center and specimen processing technique were not independent factors affecting EBUS-TBNA diagnostic yield. CONCLUSIONS: In this multicentric study, EBUS-TBNA was a highly sensitive and accurate method for NSCLC mediastinal node staging. Results indicate better performance of EBUS-TBNA with 21-G needle, and suggest that specimen processing technique could be chosen according to the local practice preference.
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Is sampling really effective in staging non-small cell lung cancer? The aim of the study was to assess if systematic nodal dissection is necessary in order to stage non-small cell lung cancer correctly or whether mediastinal lymph node sampling can be used and whether in selected cases it could replace systematic nodal dissection for the treatment of lung cancer. A prospective study was conducted in 94 patients affected by clinically resectable non-small cell lung cancer (stages I-IIIB) who were surgically treated by the same team of surgeons. During surgery mediastinal lymph node sampling was done first and then another surgeon completed the systematic nodal dissection and performed the lung resection. One hundred and ninety-three mediastinal nodal stations were investigated using the American Thoracic Society lymph node map to identify them. On analysing the 193 mediastinal nodal stations investigated, it emerged that in 181 cases (94%) mediastinal lymph node sampling and systematic nodal dissection yielded the same histopathological findings, whereas in 12 cases (6%) there was no agreement between the two techniques. The negative predictive value of mediastinal lymph node sampling was 92.8% (103/111). The results of the study show no statistical difference between mediastinal lymph node sampling and systematic nodal dissection in staging non-small cell lung cancer. However, it is possible that in a limited percentage of cases a nodal station could be understaged and thus the surgical resection could prove incomplete if mediastinal lymph node sampling alone is performed. Moreover, in those cases where mediastinal lymph node sampling detects N2 disease and systematic nodal dissection has not been completed, the intervention cannot be considered radical.
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Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/secundário , Neoplasias Pulmonares/patologia , Linfonodos/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Humanos , Neoplasias Pulmonares/cirurgia , Metástase Linfática , Mediastino , Estadiamento de Neoplasias , Estudos ProspectivosRESUMO
The main indications for cervical mediastinoscopy are preoperative staging of lung cancer and diagnostic biopsy of mediastinal mass (lymphoma, sarcoidosis, tuberculosis etc.). We undertook a retrospective review of our experience of mediastinal exploration by cervical media-stinoscopy: 253 mediastinoscopies were performed on 252 patients (195 male and 57 female; mean age 53 years, range 14-88 years) between 1995 and June 2003. Four extended mediastinoscopies were performed and 1 patient had a re-mediastinoscopy following a non-diagnostic procedure. 319 lymph nodal stations were investigated in 253 procedures. We observed no mortality, while 2 patients had major bleeding (0.7%), with the need for open surgical treatment in order to achieve haemostasis. The median length of hospital-stay was one day, with discharge in the first postoperative day. 69 out of 170 patients, who eventually resulted to be affected by a histologically proven lung cancer, had a negative mediastinoscopy. Fifteen of them resulted N2 at the time of surgery: 8 patients with a false negativity in a biopsied station (4 in station 4R and 4 in station 7), while 7 cases showed infiltration in stations which were not sampled (5 in station 5, 1 in station 8 and 1 in station 7, the latter being the only one in which a standard cervical mediastincoscopy could have been able to stage it correctly). So, having observed 61 true negatives and 8 false-negatives in the sampled stations, in our experience the negative predictive value of cervical mediastinoscopy was 88.4%, with 78.2% of patients correctly staged without using other diagnostic tools. In conclusion, mediastinoscopy is an important procedure for the diagnostic biopsy of mediastinal mass and a useful tool in preoperative staging of lung cancer, especially if associated with chest CT-scan and Positron Emission Tomography (PET). In our experience, the spreading of PET does not lead to a reduction of cervical mediastinoscopies, both for the contemporary introduction of new chemotherapeutic preoperative protocols and, above all, for the not negligible incidence of false-positive results using PET, suggesting that media-stinoscopy should always be performed in patients affected by a PET-positive mediastinal growth.
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Neoplasias Pulmonares/patologia , Mediastinoscopia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Mediastinoscopia/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
OBJECTIVE: To evaluate the short-term and the long-term results of bronchoplastic resections (BR) performed for central carcinoid tumors (CCT). METHODS: Retrospective study of patients who underwent BR for a CCT between 1966 and 2003. RESULTS: BRs were performed in 25 patients out of 92 (27%) who were resected for CCT. Median age was 37 years. All patients were symptomatic. Preoperative bronchoscopy was diagnostic in 15 patients. The bronchoplasties performed were: 11 sleeve lobectomies, 1 sleeve segmentectomy, 8 wedge lobectomies, 4 flap lobectomies and 1 wedge segmentectomy. There were 22 typical and 3 atypical carcinoids without nodal metastasis. No major complications or mortality occurred. One patient with a typical carcinoid developed pretracheal metastatic adenopathy 19 years after resection. No recurrence or stenosis has occurred at the sites of bronchoplasty so far. Three patients died of unrelated disease. Overall the 10-, 15- and 20-year survival rates were 100, 100 and 71%. CONCLUSIONS: Bronchoplastic resections are the treatment of choice for CCT. Short- and long-term results are excellent. Life-long follow-up is necessary, however, due to the possibility of late recurrence.
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Broncoscopia/métodos , Tumor Carcinoide/cirurgia , Neoplasias Pulmonares/cirurgia , Adulto , Idoso , Brônquios/patologia , Brônquios/cirurgia , Tumor Carcinoide/patologia , Feminino , Humanos , Pulmão/patologia , Pulmão/cirurgia , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Lipoblastoma is a rare benign tumor arising from embryonic fat; it occurs mainly in the extremities and almost exclusively in infants and children younger than 3 years. We present a case of giant mediastinal lipoblastoma in a 16-month-old boy who presented with acute respiratory distress. The mass was completely excised through a left posterolateral thoracotomy. The postoperative course was uneventful, and the pathologic final diagnosis was lipoblastoma. Although extremely rare, mediastinal lipoblastoma can be life threatening; therefore, it should be included in the differential diagnosis of mediastinal mass in younger subjects.