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.

mRNA markers of breast cancer nodal metastases: comparison between mammaglobin and carcinoembryonic antigen in 248 patients.

Histological detection of axillary lymph node metastases is still the most valuable prognostic parameter for breast cancer, but about 30% of node-negative patients relapse within five years, suggesting that current methods are inadequate for identifying metastatic disease. More sensitive, PCR-based methods for the detection of metastatic cells are now available, enabling the amplification of cancer cell-specific mRNA messages by the RT-PCR assay. An ideal tumour marker, consistently expressed in tumour samples and not at all in normal lymph nodes, remains to be identified. The present study first investigated the expression of seven mRNA markers, CEA, CK19, c-Met, mammaglobin, MUC-1, beta1-->GalNAc-T and p97, selected on the basis of their previously reported specificity for breast cancer cells. Eighteen lymph nodes were examined from patients without tumours. Only mammaglobin mRNA and CEA mRNA were not expressed in normal nodes. All of the other markers showed a band of expression in 17%-55% of cases, indicating that they are not breast cancer-specific. CEA mRNA and mammaglobin mRNA expression could be detected in 15/20 (75%) and 19/20 (95%) primary breast carcinomas, respectively. The expression of mammaglobin mRNA and CEA mRNA was then compared in axillary lymph nodes from 248 consecutive breast cancer patients, 89 with histologically documented lymph node metastasis and 159 without histological evidence of metastatic disease. Ninety-seven per cent of the patients with histologically involved nodes showed expression of mammaglobin mRNA, whereas CEA mRNA was expressed in 79% of these cases. In the group of patients with histologically negative lymph nodes, 46 (29%) and 32 (20%) were found to be positive for mammaglobin and CEA expression, respectively, indicating the presence of metastases not detected by routine histological examination of one lymph node section. These results show that both mammaglobin RT-PCR and CEA RT-PCR are useful tools for the detection of breast cancer metastases in axillary lymph nodes. The detection sensitivity of the mammaglobin RT-PCR is far superior to that of the CEA RT-PCR, allowing the diagnosis of occult metastases in nearly one-third of cases.

[Surgical treatment of isolated adrenal metastasis from lung carcinoma]. / Trattamento chirurgico delle metastasi surrenaliche isolate da carcinoma polmonare.

A surgical treatment of patients with lung cancer non-microcitoma and isolated adrenal metastasis has been reported in literature although limited in number and follow up. The Authors report 12 cases of patients operated for lung cancers non-microcitoma and isolated adrenal metastasis. One patients was lost in the follow up, two patients died 3 and 6 months after the adrenalectomy. The other patients are alive after 88, 39, 36, 17, 13 months after the adrenalectomy. Four of these patients are also disease free. Other 4 patients, more recently operated, are alive and disease free after 3, 3, 9 and 9 months after the adrenalectomy. The Authors believe that a surgical treatment is justified in these patients, considering the results of the series reported in literature and also their own results.

[Hemoperitoneum secondary to aneurysm of the pancreatico-duodenal artery: report of a clinical case]. / Emoperitoneo da rottura di un aneurisma dell'arteria pancreatico--duodenale: a proposito di un caso clinico.

Pancreaticoduodenal artery (PD A) aneurysms are rare, with a reported incidence of 2% among all splanchnic artery aneurysms. Most of these lesions are undetectable until symptoms of rupture occur. In similar cases (65%), PDA rupture is usually associated with a high mortality rate, with fatal bleeding into the retroperitoneal space, intraperitoneal cavity or gastrointestinal tract. Clinical picture without rupture also has been reported (35%) and is often associated with atypic abdominal signs and symptoms or diagnosed incidentally on radiology studies. The Authors report a case of octogenarian patient with ruptured PDA aneurysm and bleeding into the retroperitoneal space presenting with stable clinical condition. Surgical treatment was performed successfully after radiological diagnosis of retroperitoneal haematoma with good outcome. Patients presenting catastrophic clinical condition need rapid resuscitation and emergency laparotomy: control of the bleeding site may be successful and aetiologycal diagnosis delayed after perioperative angiography. Further laparotomy is mandatory for a definitive treatment such as PDA obliteration or resection. An alternative therapy is the transcatheter embolization. In patients with relatively stable condition, radiological study is stressed. Anyway, the aneurysm should be obliterated whenever possible to avoid rebleeding or local complications such as erosion of the neighboring structure. In conclusion, an appropriate and early treatment lead to a good outcomes.

[Control of postoperative pain with intrapleural analgesia]. / Controllo del dolore postoperatorio con analgesia intrapleurica.

INTRODUCTION: Personal experience in the treatment of postoperative pain using intrapleural analgesia applied on 50 patients chosen at random in a group of 90 after thoracotomy is reported. METHODS: At the end of operation a peridural catheter for continuative infusion was applied in the paravertebral socket by direct transfixion of chest wall. A local anaesthetic has been given (75 mg of bupivacaine 0.50%) through the catheter at 8 hours interval for three times at the most. The degree of analgesia has been valued immediately before and after medicine administration and during the 8 hours interval by recording the cardiocirculatory and haemogasanalytical parameters. The measurement of pain intensity has been achieved by visual analogous just an hour after operation and subsequently every 4 hours during the first post operative day and every 8 hours during the following days. RESULTS: Most of the examined patients (90%), reported a remarkable attenuation of pain, valued by achromatic grey test after 4 hours since the first giving. The catheter has always been removed during the 8th postoperative day and it did not cause intrapleural complications. The method used warrants a good level of analgesia, improving the respiratory per-formance and giving a rapid mobilization, essential items in the reduction of immediate post operative complications. CONCLUSIONS: The results confirm the validity of this treatment in the pain control of thoracothomized patients with a positive answer in 45 out of 50 examined patients without remarkable complications.

[Endobronchial foreign bodies: surgical indications]. / Indicazioni chirurgiche nei corpi estranei endobronchiali.

Removal of foreign bodies from the tracheobronchial tree is generally possible by bronchoscopy. Seldom requested is a thoracotomy, to be considered an "ultima ratio" for cases with asphyxia, with an acute or chronic obstructive pulmonary infection, for cases-finally-of very little foreign body in a peripheral location. We collected in the past fifteen patients who had a thoracotomy for a tracheobronchial foreign body: extensive description is given of our most recent case.

[Quality of life after pulmonary resection for bronchogenic carcinoma. Evaluation of a group of patients surviving more than five years]. / La qualità di vita dopo resezione polmonare per carcinoma broncogeno. Valutazione su un campione di pazienti sopravvissuti oltre i cinque anni.

The method of guided-interview on selected questionnaires was employed for the assessment of quality of life in patients radically resected for lung cancer. A selection of thirty patients was done in a group of 151 long-term survivors non treated by adjuvant therapy. An assessment protocol and personal results were discussed.

[Preoperative and immediate postoperative respiratory therapy in patients with pulmonary resection]. / La fisiokinesiterapia respiratoria nella preparazione all'intervento e nel trattamento postoperatorio immediato dei pazienti sottoposti a resezione polmonare.

Twenty patients with a resectable lung cancer and with a low respiratory function were included in this study. During the preoperative period all patients underwent a physiokinesic preparation in view of some improvement of their ventilation performances. Methodology as well as results are reported good response to the program, better post-operative functional recovery and absence of complications were observed in this group of patients.

[Role of video-thoracoscopy in the diagnostic specification of thoraco-pulmonary diseases]. / Ruolo della videotoracoscopia nella precisazione diagnostica delle affezioni toraco-polmonari.

Video-thoracoscopy can be used for diagnostic purposes when the other non-invasive methods are not satisfactory for an accurate histological diagnosis, in lung and pleural pathology. Cases observed in last six months and subject to surgery are discussed.

[Chest drainage combined with intracavitary therapy in neoplastic pleural effusion: comparison of three different protocols]. / Il drenaggio toracico associato alla terapia endocavitaria nei versamenti pleurici neoplastici: confronto di tre diverse metodiche.

Twenty-eight patients with malignant pleural effusion observed in a two year period were treated with intrapleural instillation of different substances: Tetracycline, Corynebacterium parvum and Beta-Interferon. Different results were observed: complete responsiveness (no recurrence of pleural effusion within three months); partial responsiveness (recurrence of moderate pleural effusion within one month after drainage removal); insufficient responsiveness (recurrence of massive effusion within one month). Among patients treated with Tetracycline seven complete, five partial and one insufficient responses were observed. Instillation of Corynebacterium parvum allowed two complete, two partial and three insufficient responses. Finally, in the group treated with Beta-Interferon complete responsiveness was obtained in just one patient, partial responsiveness in three, while the treatment was insufficient in the last two. These results suggest pleural drainage is the best treatment in patients with malignant pleural effusion, however, the association of Tetracycline instillation allows better results.

[Neoplastic involvement of pulmonary fissures. Diagnostic possibility of high resolution x-ray computed tomography]. / Atteinte néoplasique des scissures pulmonaires. Possibilité diagnostique de la tomodensitométrie en haute résolution.

Acknowledging fissure invasion by pulmonary tumors located in contact with or in the vicinity of a fissure is an important piece of information for the therapeutic choice, especially in patients whose functional respiratory impairments are a contraindication of pneumonectomy. Fifteen patients with pulmonary neoplasms adjacent to a fissure were studied with standard computed tomography (10 mm sections), completed by high-resolution CT. The findings of the CT studies were compared with those operative reports. On surgery, the oblique fissure was infiltrated in 12 patients, unharmed in 2 others, while the horizontal fissure was infiltrated in 3 patients. Standard CT allowed diagnosing the involvement of the oblique fissure in 4 patients. Thin sections with high-resolution reconstruction algorithms allowed detecting the involvement of the oblique fissure in 13 cases, including one false-positive result. On thin sections, the fissures appear as well-delineated, dense lines. This allows an accurate study of the relationships between the tumor and the fissure, thus increasing the sensitivity of CT for the detection of tumoral extension across the fissures. The orientation of the horizontal fissure, which is almost parallel to the plane of section, makes the study of its relationships with an adjacent mass difficult, even in high-resolution CT.

[Neoplastic involvement of pulmonary fissures. Usefulness of high resolution CT]. / Coinvolgimento neoplastico delle scissure polmonari. Possibilità della TC ad alta risoluzione.

In order to plan an adequate treatment, it is very important to recognize the transfissural spread of lung cancer near a pleural fissure, especially in the patients who cannot bear pneumonectomy because of impaired pulmonary function. Fifteen patients with lung cancer near a fissure were examined by means of conventional CT (10 mm-thick slices) followed by high-resolution CT (HRCT). The results obtained with both techniques were compared with surgical findings. At surgery, major fissure involvement was seen in 12 cases, minor fissure was involved in 3, and 2 patients were normal. In 4 cases fissural involvement was correctly demonstrated by conventional CT scans. Neoplastic involvement of the major fissure was identified in 13 cases by HRCT scans, with only 1 false positive. Pleural fissures appear as thin and sharp lines on HRCT scans. Thus, the relationship of lung cancers to fissures is better identified and the accuracy of the method in defining neoplastic spread is higher. However, the relationship of a neoplastic mass to the minor fissure is difficult to evaluate, because the fissure is roughly parallel to the scanning plane.

Elevation of glutathione transferase activity in human lung tumor.

Glutathione transferase activity in the cytosolic fractions of human lung tumors was found to be significantly higher than that present in the corresponding non-tumor cytosolic fractions. The relative activities of 'cationic', 'near-neutral' and 'acidic' glutathione transferases of both tumor and non-tumor cytosols were estimated after isoelectric focusing. More than 90% of activity in both tumor and non-tumor cytosols was found to be associated with the 'acidic' (pI 4.6) activity peak. In the chromatogram of tumor tissues the activity associated with the 'acidic' peak was found to be increased in comparison with non-tumor tissues. When the protein fractions associated with the 'acidic' peak of both tumor and non-tumor tissues were tested against the antibodies raised against human placenta transferase (transferase pi) a continuous precipitin line was obtained. An increased amount of immunoreactive glutathione transferase was also found in tumor cytosols as compared with non-tumor cytosols. Thus, our studies indicate that the predominant glutathione transferase of human lung appears to be electrophoretically and immunologically very similar or identical to transferase pi and that the elevation of transferase activity measured in the lung tumor cytosols was mainly due to increased quantity of this isoenzyme.