Surgical management of post-transplant bronchial stenoses: a single-center experience.

PURPOSE: Bronchial stenoses are challenging complications after lung transplantation and are associated with high rates of morbidity and mortality. We report a series of patients who underwent bronchoplasty or sleeve resection for bronchial stenoses that did not resolve with endoscopic treatment after lung transplantation. METHODS: Between 1995 and 2020, 497 patients underwent lung transplantation at our Institution. 35 patients (7.0%) experienced bronchial stenoses with a median time from transplantation of 3 months. Endoscopic management was effective in 28 cases (5.6%) while 1 patient required re-transplantation. Six patients (1.2%) underwent bronchoplasty or sleeve resection. RESULTS: The procedures of the six patients who underwent bronchoplasty or sleeve resection were as follows: lower sleeve bilobectomy (n = 3), wedge bronchoplasty of the bronchus intermedius (n = 1), isolated sleeve resection of the bronchus intermedius (n = 1), and isolated sleeve resection of the bronchus intermedius (n = 1), associated with a middle lobectomy. All patients were discharged after a median time of 11 days. At a median of 12 months from surgery, two patients remain alive with a preserved pulmonary function. Four patients died after a median time of 56 months from bronchoplasty of causes that were not related to surgery. CONCLUSIONS: Bronchial reconstructions are challenging procedures that can be performed in highly specialized centers. Despite this, they can be considered a good strategy to obtain a definitive resolution of stenosis after lung transplantation.

Predictors of behaviour in solitary fibrous tumours of the pleura surgically resected: Analysis of 107 patients.

OBJECTIVES: Gold standard therapy for solitary fibrous tumour of the pleura is complete surgical resection. Aims of this retrospective study are to evaluate oncological and surgical outcomes and to verify the clinical reliability of prognostic scores presented in literature. METHODS: Study population: 107 patients surgically treated between 1972 and 2018. Male/female ratio: 1/2.45; median age at surgery: 60 years (range, 19-80); peduncle lesions 69.8%; visceral pleura origin 72.9%; benign histology 73.8%; median diameter 8 cm (range 1 to 35, 27 cases giant [≥15 cm]). RESULTS: After a median follow up of 7 years, 12 patients had recurrence. By multivariate analysis, malignant histology (P = .03; HR, 4.17; 95% CI, 1.15-15.06), origin from parietal pleura (P = .03; HR, 3.90; 95% CI, 1.08-14.09), England (P = .002; HR, 1.98; 95% CI, 1.28-3.07), Diebold (P = .008; HR, 1.96; 95% CI, 1.20-3.22) and Tapias (P = .003; HR, 1.75; 95% CI, 1.20-2.53) scores were found independent significant predictors of relapse. Giant tumours were associated with open surgery (P = .003), origin from parietal pleura (P = .011) and intraoperative bleeding (P > .001). Overall 10-year disease-free survival (DFS) rate was 81%. Predictors of worst DFS were parietal pleura origin (P = .002), malignant histology (P = .006) and all the prognostic scores. CONCLUSIONS: Malignant histology and origin from parietal pleura were significant predictors of tumour recurrence and worst DFS. The use of current scoring systems can help to predict clinical behaviour. Patients with higher risk of relapse can benefit from closer follow up, prolonged over 10 years.

Multi-risk assessment in mountain regions: A review of modelling approaches for climate change adaptation.

Climate change has already led to a wide range of impacts on our society, the economy and the environment. According to future scenarios, mountain regions are highly vulnerable to climate impacts, including changes in the water cycle (e.g. rainfall extremes, melting of glaciers, river runoff), loss of biodiversity and ecosystems services, damages to local economy (drinking water supply, hydropower generation, agricultural suitability) and human safety (risks of natural hazards). This is due to their exposure to recent climate warming (e.g. temperature regime changes, thawing of permafrost) and the high degree of specialization of both natural and human systems (e.g. mountain species, valley population density, tourism-based economy). These characteristics call for the application of risk assessment methodologies able to describe the complex interactions among multiple hazards, biophysical and socio-economic systems, towards climate change adaptation. Current approaches used to assess climate change risks often address individual risks separately and do not fulfil a comprehensive representation of cumulative effects associated to different hazards (i.e. compound events). Moreover, pioneering multi-layer single risk assessment (i.e. overlapping of single-risk assessments addressing different hazards) is still widely used, causing misleading evaluations of multi-risk processes. This raises key questions about the distinctive features of multi-risk assessments and the available tools and methods to address them. Here we present a review of five cutting-edge modelling approaches (Bayesian networks, agent-based models, system dynamic models, event and fault trees, and hybrid models), exploring their potential applications for multi-risk assessment and climate change adaptation in mountain regions. The comparative analysis sheds light on advantages and limitations of each approach, providing a roadmap for methodological and technical implementation of multi-risk assessment according to distinguished criteria (e.g. spatial and temporal dynamics, uncertainty management, cross-sectoral assessment, adaptation measures integration, data required and level of complexity). The results show limited applications of the selected methodologies in addressing the climate and risks challenge in mountain environments. In particular, system dynamic and hybrid models demonstrate higher potential for further applications to represent climate change effects on multi-risk processes for an effective implementation of climate adaptation strategies.

Is chest tube capnography effective in differentiating between true and false air leaks after minimally invasive thoracic surgery?

OBJECTIVE: Air leak (AL) is the most frequent adverse event after thoracic surgery. When AL occurs, the concentration of the principal gas in the pleural space should be similar to that of air exhaled. Accordingly, we tried to develop a new method to identify AL by analyzing pCO2 levels in the air flow from the chest drainage using capnography. METHODS: This is a prospective observational study of 104 patients who underwent VATS surgery between January 2020 and July 2021. Digital drainage systems were used to detect AL. RESULTS: Eighty-two patients (79%) had lung resection. Among them, 19 had post-operative day 1 air leaks (median 67 ml/min). AL patients had higher intrapleural CO2 levels (median 24 mmHg) (p < 0.001). Median chest drainage duration was 2 days (range 1.0-3.0). Univariable logistic regression showed a linear and significant association between intrapleural CO2 levels and AL risk (OR 1.26, 95% CI 1.17-1.36, p < 0.001, C index: 0.94). The Univariable Gamma model demonstrated that an elevation in CO2 levels was linked to AL on POD1 (with an adjusted mean effect of 7.006, 95% CI 1.59-12.41, p = 0.011) and extended duration of drainage placement (p < 0.001). CONCLUSIONS: Intrapleural CO2 could be an effective tool to assess AL. The linear association between variables allows us to hypothesize the role of CO2 in the identification of AL. Further studies should be performed to identify a CO2 cutoff that will standardize the management of chest drainage.

Learning from the COVID-19 pandemic in Italy to advance multi-hazard disaster risk management.

COVID-19 challenged all national emergency management systems worldwide overlapping with other natural hazards. We framed a 'parallel phases' Disaster Risk Management (DRM) model to overcome the limitations of the existing models when dealing with complex multi-hazard risk conditions. We supported the limitations analysing Italian Red Cross data on past and ongoing emergencies including COVID-19 and we outlined three guidelines for advancing multi-hazard DRM: (i) exploiting the low emergency intensity of slow-onset hazards for preparedness actions; (ii) increasing the internal resources and making them available for international support; (iii) implementing multi-hazard seasonal impact-based forecasts to foster the planning of anticipatory actions.

Sublingual Sufentanil in Pain Management After Pulmonary Resection: A Randomized Prospective Study.

BACKGROUND: Successful postoperative pain management after major lung resection surgery is mostly achieved through intravenous administration of analgesic drugs. This study explored the use of sublingual sufentanil cartridges (Zalviso) as a noninvasive alternative to postoperative analgesia. METHODS: From July 2019 to April 2020, patients who underwent major thoracoscopic lung resection surgery were randomly allocated to receive either intravenous pain management, or patient-controlled analgesia by the Zalviso system. Pain assessment scores were collected for a 72-hour time window, and requests for additional medication due to insufficient pain control were recorded. RESULTS: Of the 80 patients enlisted, 40 were assigned to the Zalviso group and 40 to the control group. The groups were not statistically different from each other. The difference in the mean pain scores reported was statistically significant in the first 24 hours in favor of the Zalviso group (P = .046), and the need for additional pain medication was significantly higher in the control group (P = .004). CONCLUSIONS: Patient-controlled analgesia using sublingual sufentanil cartridges can provide effective pain relief for patients undergoing video-assisted thoracic surgery and can reduce the need for additional medication, offering a noninvasive alternative to traditional intravenous therapy.

Comparison of operative and postoperative characteristics and outcomes between thoracoscopic segmentectomy and lobectomy for non-small-cell lung cancer: a propensity score matching study from the Italian VATS Group Registry.

OBJECTIVES: Only few studies compared the surgical morbidity and mortality of thoracoscopic segmentectomy versus lobectomy for non-small-cell lung cancer, in particular, by relating the segmental resections with the corresponding anatomical lobes. METHODS: We enrolled a total of 7487 patients who underwent VATS lobectomy (7269) or segmentectomy (218) from January 2014 to July 2019. A propensity score matching approach was used to account for potential confounding factors between the 2 groups. After matching, 349 lobectomies and 208 segmentectomies were included in the analysis. We analysed the operative and postoperative outcomes of video-assisted anatomical segmentectomy compared with video-assisted lobectomy and, in details, the results of segmentectomy with its corresponding lobectomy in a large cohort of patients from the Italian VATS Group Registry. RESULTS: The overall conversion rate to thoracotomy was not statistically different between the groups (27 patients 8% vs 7 patients 3%, P = 0.1). The lobectomy group had a greater number of resected lymph nodes (median 11 vs 8, P = 0.006). No significant differences were detected in 30-day mortality (1.4%, 5 patients vs 0.9%, 2 patients), overall complications (18%, 62 patients vs 14%, 29 patients) and prolonged air leakage (31 patients, 9% vs 12 patients, 6%) between lobectomy and segmentectomy, respectively. No statistical differences were found regarding the median duration of drainage (3.2 days, P = 1) and the overall median length of hospital stay (6.4 days, P = 0.1) between the 2 groups. In the context of segmentectomy versus corresponding lobectomy, the right upper lobectomy compared with right upper segmentectomy showed a higher number of resected lymph nodes (P = 0.027). No statistical differences were reported in terms of conversion rate and postoperative complication and mortality. CONCLUSIONS: Segmentectomy could be considered a safe procedure without significant differences compared to thoracoscopic lobectomy in terms of postoperative morbidity and mortality.

Sarcopenia as a Predictor of Short- and Long-Term Outcomes in Patients Surgically Treated for Malignant Pleural Mesothelioma.

Surgery for malignant pleural mesothelioma (MPM) should be reserved only for patients who have a good performance status. Sarcopenia, a well-known predictor of poor outcomes after surgery, is still underinvestigated in MPM. The aim of this study is to evaluate the role of sarcopenia as a predictor of short-and long-term outcomes in patients surgically treated for MPM. In our analysis, we included patients treated with a cytoreductive intent in a multimodality setting, with both pre- and post-operative CT scans without contrast available. We excluded those in whom a complete macroscopic resection was not achieved. Overall, 86 patients were enrolled. Sarcopenia was assessed by measuring the mean muscular density of the bilateral paravertebral muscles (T12 level) on pre-and post-operative CTs; a threshold value of 30 Hounsfield Units (HU) was identified. Sarcopenia was found pre-operatively in 57 (66%) patients and post-operatively in 61 (74%). Post-operative sarcopenic patients had a lower 3-year overall survival (OS) than those who were non-sarcopenic (34.9% vs. 57.6% p = 0.03). Pre-operative sarcopenia was significantly associated with a higher frequency of post-operative complications (65% vs. 41%, p = 0.04). The evaluation of sarcopenia, through a non-invasive method, would help to better select patients submitted to surgery for MPM in a multimodality setting.

Computed Tomography and Spirometry Can Predict Unresectability in Malignant Pleural Mesothelioma.

Preoperative identification of unresectable pleural mesothelioma could spare unnecessary surgical intervention and accelerate the initiation of medical treatments. The aim of this study is to determine predictors of unresectability, testing our impression that the contraction of the ipsilateral hemithorax is often associated with exploratory thoracotomy. Between 1994 and 2020, 291 patients undergoing intended macroscopic complete resection for mesothelioma after chemotherapy were retrospectively investigated. Eligible patients (n = 58) presented a preoperative 3 mm slice-thickness chest computed tomography without pleural effusion or hydropneumothorax. Lung volumes (segmented using a semi-automated method), modified-Response Evaluation Criteria in Solid Tumors (RECIST) measurements, and spirometries were collected after chemotherapy. Multivariable analysis was performed to determine the predictors of unresectability. An unresectable disease was found at the time of operation in 25.9% cases. By multivariable analysis, the total lung capacity (p = 0.03) and the disease burden (p = 0.02) were found to be predictors of unresectability; cut-off values were <77.5% and >120.5 mm, respectively. Lung volumes were not confirmed to be associated with unresectability at multivariable analysis, probably due to the correlation with the disease burden (p < 0.001; r = -0.4). Our study suggests that disease burden and total lung capacity could predict MPM unresectability, helping surgeons in recommending surgery or not in a multimodality setting.

Relapse Patterns and Tailored Treatment Strategies for Malignant Pleural Mesothelioma Recurrence after Multimodality Therapy.

To date, there have been no established therapies for recurrent malignant pleural mesothelioma (MPM) after multimodality treatment. Aims of this retrospective study are to analyze the recurrence pattern, its treatment and to identify the predictors of best oncological outcomes for relapsed MPM, comparing extrapleural pneumonectomy (EPP) vs. pleurectomy/decortication (PD). Study population: 94 patients with recurrence of MPM after multimodality treatment underwent macroscopic complete resection (52.1% with EPP and 47.9% with PD) between July 1994 and February 2020. Distant spread was the most frequent pattern of recurrence (71.3%), mostly in the EPP group, while the PD group showed a higher local-only failure rate. Post-recurrence treatment was administered in 86.2%, whereas best supportive care was administered in 13.8%. Median post-recurrence survival (PRS) was 12 months (EPP 14 vs. PD 8 months, p = 0.4338). At multivariate analysis, predictors of best PRS were epithelial histology (p = 0.026, HR 0.491, IC95% 0.263-0.916), local failure (p = 0.027, HR 0.707, IC95% 0.521-0.961), DFS ≥ 12 months (p = 0.006, HR 0.298, IC95% 0.137-0.812) and post-recurrence medical treatment (p = 0.046, HR 0.101, IC95% 0.897-0.936). The type of surgical intervention seems not to influence the PRS if patients are fit enough to face post-recurrence treatments. In patients with a prolonged disease-free interval, in the case of recurrence the most appropriate treatment seems to be the systemic medical therapy, even in the case of local-only relapse.

Extracorporeal membrane oxygenation in lung transplantation: Indications, techniques and results.

The use of extracorporeal membrane oxygenation (ECMO) in the field of lung transplantation has rapidly expanded over the past 30 years. It has become an important tool in an increasing number of specialized centers as a bridge to transplantation and in the intra-operative and/or post-operative setting. ECMO is an extremely versatile tool in the field of lung transplantation as it can be used and adapted in different configurations with several potential cannulation sites according to the specific need of the recipient. For example, patients who need to be bridged to lung transplantation often have hypercapnic respiratory failure that may preferably benefit from veno-venous (VV) ECMO or peripheral veno-arterial (VA) ECMO in the case of hemodynamic instability. Moreover, in an intra-operative setting, VV ECMO can be maintained or switched to a VA ECMO. The routine use of intra-operative ECMO and its eventual prolongation in the post-operative period has been widely investigated in recent years by several important lung transplantation centers in order to assess the graft function and its potential protective role on primary graft dysfunction and on ischemia-reperfusion injury. This review will assess the current evidence on the role of ECMO in the different phases of lung transplantation, while analyzing different studies on pre, intra- and post-operative utilization of this extracorporeal support.

Video-assisted left lower lobectomy with intrapericardial pulmonary vein isolation.

The thoracoscopic approach to lobectomy is now the gold standard in cases of pulmonary malignancies because it is associated with a significant reduction in both  postoperative hospital stay and pain. Even in cases of complex resection, as in the case reported here, the procedure can be performed safely after careful pre-operative planning.  This video tutorial describes our technique for the intrapericardial isolation of the left inferior pulmonary vein in a patient affected by a left lower lobe metastasis from a colonic carcinoma.  The lesion was retracting the inferior vein to such an extent that an intrapericardial approach was required in order to obtain a radical resection. The operation was carried out using a 3-port technique to allow for safe and unhindered manipulation of the hilar structures and the parenchyma. The pericardial sac was easily opened and the feasibility of the procedure was readily confirmed.  The patient made an uneventful recovery; specifically, we did not record any arrhythmia or hemodynamic instability. She was discharged home on the 4th postoperative day.

Selecting sustainable alternatives for cruise ships in Venice using multi-criteria decision analysis.

The rapid growth of cruise ship tourism increases the use of historic port cities as strategic hubs for cruise ship operators. Benefits derived from increased tourism for the municipality and cruise ships are often at odds with the environmental and social impacts associated with continued historical port use. This study illustrates the use of Multi-Criteria Decision Analysis (MCDA) for weighing of various criteria and metrics related to the environment, economy, and social sustainability for the selection of a sustainable cruise line route. Specifically, MCDA methodology was employed in Venice, Italy to illustrate its application. First, the four most representative navigational route projects among those presented to local authorities were assessed based on social, economic, and environmental considerations. Second, a pool of experts representing the local authority, private port businesses, and cruise line industry were consulted to evaluate the validity and weight assignments for the selected criteria. Finally, a sensitivity analysis was employed to assess the robustness of the recommendations using an evaluation of weight changes and their effects on the ranking of alternative navigational routes. The results were presented and discussed in a multi-stakeholder meeting to further the route selection process.