Experimental left pneumonectomy in pigs: procedure and management.

BACKGROUND: Because there is no detailed description of procedures and perioperative management of major pulmonary resections in swine, we reviewed our experience to delineate the most effective practice in performing left pneumonectomy. MATERIALS AND METHODS: Analysis of 11 consecutive left pneumonectomies. Animal data, operative reports, anesthesia records, and perioperative facts were evaluated. Follow-up information until postoperative day 60, methods of care-taking, therapy administration, and all the stabling aspects were systematically assessed. The investigation was aimed at highlighting those procedural steps or details which make the difference in optimizing the available resources (animals, instruments, and personnel). No statistical analysis was performed considering data characteristics and the descriptive nature of information. RESULTS: Surgery requires a median time of 2 h and 16 min; two operators and one anesthesiologist represent the basic team. Circulators' number depends on goals to accomplish. The most straightforward procedure requires careful dissection of the pulmonary ligament (limited view), pulmonary veins (low variability), pulmonary artery (delicate), and finally bronchus (no variability observed). The key factors for good anesthesia management have been identified: sedation by caregivers, preoxygenation before induction of general anesthesia, high respiratory rates with low tidal volume after pneumonectomy, and noninvasive ventilation after extubation. Antibiotic prophylaxis has been performed. Postoperative care must be continuous until animals are able to stand up, afterward "preventive noncurative," and always animal friendly. Ideas for minimally stressful therapy administration are helpful. CONCLUSIONS: After the delineation of this methodology, the compliance to a routine practice allowed us to reduce time, stress, and cost; quality and quantity of possible research increased.

Therapeutic options in locally advanced thyroid carcinoma. Our experience.

INTRODUCTIONS: Thyroid cancer is the most common endocrine malignancy with an incidence equal to 1% of all malignant tumors. Prognostic factors affecting survival are manifold, including in several classifications (AMES, AGES, CORN and TNM). In this sense, the invasion of adjacent structures is one of the most important variables. The authors describe the experience of a single center in surgical treatment of advanced thyroid cancer. MATERIALS AND METHODS: Between 1986 and 2010 , 1565 patients were undergoing surgery with thyroid cancer. In particular, 1403 interventions were made for differentiated cancer, 97 for medullary carcinoma, 25 for insular carcinoma, 29 for anaplastic carcinoma, 2 for plasmacytoma, and 7 for lymphoma and 2 for angiosarcoma. Among these 896 showed invasion of adjacent structures and / or distant metastases. RESULTS: There were no perioperative deaths or major complications. Surgical procedures consisted of: 13 loboistmectomy, 519 total thyroidectomy (TT), 325 TT with lymphadenectomy of the central compartment, 7 TT with radical lymphectomy, 621 TT with functional lymphectomy, 6 TT with breast lumpectomy, 5 TT with with video-assisted lung metastasectomy, 16-TT with resection and tracheal anastomosis, 6 TT with laryngotracheal resection, 3 TT with laryngectomy, 4 TT with trachetomy, 28 TT with respiratory stent placement, 12 tracheotomy. At present, 1328 patients were free of disease, while 104 showed recurrence. Total of 133 deaths were recorded, all linked to disease relapse. DISCUSSION: The role of surgery in the treatment of advanced thyroid cancer is still undeniable. In the presence of extracapsular trespassing, in fact, the adoption of interventions demolition permits long-term survival, given the lack of aggressiveness of the tumor differentiated representing the majority of cases. The aim of surgical radicalization addition, even in the presence of distant metastases, it is justified by the possibilities offered by the therapeutic radioiodine treatment, which is not feasible in the presence of significant amounts of thyroid tissue which picks. In the presence of undifferentiated tumors, finally, endoscopic or surgical treatment may be indicated by simple purpose of palliation of respiratory symptoms.

[Management of spontaneous pneumothorax: nationwide fact-finding survey among Italian thoracic surgery units]. / Trattamento dello pneumotorace spontaneo. Indagine conoscitiva nazionale nelle strutture di Chirurgia Toracica.

Spontaneous pneumothorax, in both the primary and secondary variants, is a relatively frequent disease, occurring at all ages. Management of spontaneous pneumothorax is not standardised. Furthermore, few attempts have been made in the literature to codify the diagnostic workup and treatment. The aim of the present study is to report the results of a nationwide fact-finding survey, focused on current practice in the management of spontaneous pneumothorax by thoracic surgeons. A questionnaire, consisting of items in 6 major areas, was prepared and e-mailed to 49 thoracic surgery units in Italy. Thirty-five centres responded. The results (collected in a database presented at the XXX Congress of the Italian Society of Thoracic Surgeons in October 2006) show agreement on some questions (surgical indications, thoracoscopy as the first-choice surgical technique, use of mechanical staplers...) and a great variability of ideas and attitudes on others (CT scanning in primary spontaneous pneumothorax, definition of persistent air-leak, clamping of the chest tube before removal, pleurodesis techniques, postoperative chest X-ray schedule...). It is the authors' opinion that further work is needed in order to achieve a greater measure of agreement in the management of primary and secondary pneumothorax.

Effectiveness and predictability of pleurodesis with the Tachosil® surgical patch compared with talc poudrage: an experimental study.

OBJECTIVES: The human fibrinogen/thrombin surgical patch is proposed for videothoracoscopic pleurodesis after recurrent observation in routine clinical practice of site-specific pleuro-pulmonary adhesions. METHODS: A total of 36 experimental videothoracoscopies were performed on 18 pigs, all of which underwent a bilateral sequential procedure. The right or left side was casually approached and two 4.8 × 4.8 cm Tachosil® patches were placed over the dorsal lung surface in the highest antigravitary position through a double-port thoracoscopy. The contralateral side was subsequently entered by a single-port thoracoscopy to perform talc poudrage in accordance with current recommendations (1 g/18 kg). Thoracoscopy and autopsy were performed after 60 days to evaluate the outcome. Pleurodesis was graded on a predefined three-tier scale (none-moderate-firm); specimens were then submitted to the pathologist. The statistical analyses performed were: frequencies distribution, variables association test and hypothesis testing using binomial distribution. RESULTS: Pleurodesis was firm in 15/18 cases (P = 0.004), moderate in 2/18, and none in 1/18 cases with the sealant matrix. Talc pleurodesis was firm in 7/18 cases and moderate in 11/18. No surgical, medical, behavioural or growth disorders were recorded. There was complete correspondence between lung surface covered by the sealant patch and pleural adhesion topography (P < 0.001) and no other sites of adhesion were found at autopsy, whereas talc effect was commonly found to produce random pleural cavity obliteration, most frequently in declivous places, with inhomogeneous pleural adhesion for tissue density and rough/smooth outline (P < 0.001). The pathologist disclosed that talc creates a variable and unpredictable inflammatory background, sometimes severe, with the development of many granulomas. Fibrin sealant patch pleurodesis is caused by connective tissue irrespective of the pleural and pulmonary anatomy. CONCLUSIONS: The fibrin sealant patch is effective in producing localized pleurodesis in swine. The morphology and topography of the adhesions, 2 months after the patch placement, are consistent and more predictable than after talc poudrage. The latter causes a diffuse pleurodesis which is not predictable, with a predominantly gravitational location and produces a much more serious inflammatory response.

Baseline and post-surgery endothelial progenitor cell levels in patients with early-stage non-small-cell lung carcinoma: impact on cancer recurrence and survival.

OBJECTIVES: Endothelial progenitor cells (EPCs) are believed to play a role in promoting abnormal vascularization in neoplastic sites. We measured the number of circulating EPCs in treatment-naïve patients with early non-small-cell lung cancer (NSCLC) and healthy controls. The prospective influence of baseline and post-surgery EPC levels on cancer recurrence and survival was investigated. METHODS: Circulating EPCs were quantified by FACS analysis in 34 patients with Stage I-II NSCLC and 68 healthy age- and sex-matched controls. Measurement of EPCs was repeated 48 h after thoracic surgery and at the hospital discharge. Cancer recurrence and survival was evaluated after 446 ± 106 days of follow-up (range 182-580 days). RESULTS: The base 10 logarithmic [log] number of circulating EPCs was comparable between patients with NSCLC and controls [mean ± standard deviation (SD): 2.3 ± 0.32 vs 2.3 ± 0.26 n/ml, P = 0.776]. In regression analysis, smoking status [standardized coefficient beta (ß) = -0.26, 95% confidence interval (CI) for B -0.29/-0.03, P = 0.014] and systolic blood pressure [ß = -0.23, 95% CI for B -0.011/-0.001, P = 0.018] were independent predictors of the number of EPCs, irrespective of the NSCLC status. The mean number of EPCs did not change after surgical treatment. However, a post-surgery EPC increase was observed in 44% patients. Patients with a 48 h post-surgery EPC increase had a higher rate of cancer recurrence/death than patients with either stable or decreased post-surgery EPC levels [hazard ratio (HR) 4.4, 95% CI 1.1-17.3; P = 0.032], irrespective of confounders. CONCLUSIONS: Circulating EPC levels are comparable between patients with early-stage NSCLC and healthy controls. Overall, surgical cancer resection was not associated with a significant early EPC change. However, an early post-surgery EPC increase is able to predict an increased risk of cancer recurrence and death.

Left main bronchus resection and reconstruction. A single institution experience.

BACKGROUND: Left main bronchus resection and reconstruction (LMBRR) is a complex surgical procedure indicated for management of inflammatory, benign and low grade malignant lesions. Its application provides maximal parenchymal sparing. METHODS: Out of 98 bronchoplastic procedures performed at the Authors' Institution in the 1995-2011 period, 4 were LMBRR. Indications were bronchial carcinoid in 2 cases, inflammatory pseudotumor in 1 case, TBC stricture in 1 case. All patients underwent preoperatively a rigid bronchoscopy to restore the airway lumen patency. At surgery a negative resection margin was confirmed by frozen section in the neoplastic patients. In all patients an end-to-end bronchial anastomosis was constructed according to Grillo. RESULTS: There were neither mortality nor major complications. Airway lumen was optimal in 3 patients, good in 1. CONCLUSION: LMBRR is a valuable option for the thoracic surgeon. It maximizes the parenchyma-sparing philosophy, broadening the spectrum of potential candidates for cure. It remains a technically demanding procedure, to be carried out by an experienced surgical team. Correct surgical planning affords excellent results, both in the short and long term.

Multiple pleuropericardial implants of thymoma after videothoracoscopic resection.

The case of a 49-year-old man with multiple pleuropericardial implants of B2 thymoma is reported. Two years earlier, the patient had undergone left videothoracoscopic (VATS) resection of a 6-cm thymoma in another hospital. The operative report describes a technically correct procedure with morcellation of the lesion within a retrieval thoracoscopic bag. Through a standard thoracotomy, 11 implants were resected with macroscopically complete tumor removal. The origin of cell spillage was ascribed to manipulation of the thymoma during VATS resection.