Digital air leak monitoring after lobectomy for primary lung cancer in patients with moderate COPD: can a fast-tracking algorithm reduce postoperative costs and complications?

AIM: Prolonged air leaks remain one of the most important complication after pulmonary resection. The aim of this study was to test a new fast-track chest tube removal protocol using a new drainage system, which digitally records postoperative air leaks, compared to the traditional one, with subjective visual air leak assessment. METHODS: Patients with moderate COPD undergoing lobectomy for primary lung cancer at the Department of Thoracic Surgery of the University of Torino were randomised in two groups with different chest drainage systems and different removal protocols: in Group A the drainage was removed after digitally recordered measurement of air leaks; in Group B the tube was removed according to the air leaks visualization by bubbling in the water column. The following variables were evaluated: first and second drainage removal day; overall hospital length of stay; overall hospitalization costs. RESULTS: First and second drainages were removed sooner in those patients with the digital drainage system. An earlier drainage removal is associated with significative reduction in hospital length of stay and overall hospitalization costs. CONCLUSION: The digital and continuous air leak measurement reduces the hospital length of stay by a more accurate and reproductive air leaks measurement. Further studies are mandatory to corroborate our preliminary results.

Recurrence of thymoma: analysis of clinicopathologic features, treatment, and outcome.

OBJECTIVE AND METHODS: This study reports clinicopathologic features, treatment, and outcome of 30 recurrent thymomas out of 266 totally resected thymomas. RESULTS: The mean disease-free interval to recurrence was 86 months. Recurrence occurred less frequently and after a longer disease-free interval after resection of encapsulated versus invasive thymomas. The presence of associated myasthenia gravis did not affect recurrence proportion, disease-free interval, or survival after recurrence. A local recurrence occurred in 11 patients, 17 patients had a distant recurrence, and the extent of the recurrence could not be determined in 2 cases. Surgical treatment of the recurrent tumor was attempted in 16 cases, and a total resection was possible in 10 cases; exclusive radiotherapy was done in 11 cases. Overall 5- and 10-year survivals were 48% and 24%, respectively. In a univariate analysis, survival was significantly better in the presence of a local recurrence and in case of a total resection of the recurrent tumor. The use of adjuvant therapy after the resection of the initial thymoma had no effect on reducing the incidence of recurrence, in prolonging the disease-free interval, or in improving survival after the development of the recurrence. In a multivariate survival analysis, significant prognostic factors were the presence of a local recurrence and total resection of the recurrent tumor. CONCLUSIONS: Surgical resection is recommended in patients with recurrent thymoma. Local recurrence and total resection of the recurrent tumor are associated with excellent prognosis. A poor prognosis may be anticipated in the presence of distant recurrence and when radical surgical treatment is not done.

Thymoma: results of 241 operated cases.

Clinical and histopathological aspects of 241 thymomas were reviewed. One hundred sixty of the patients with thymoma had myasthenia gravis and 15 had other autoimmune diseases; 55% of the thymomas were encapsulated and 45% invasive. Operation was radical resection in 87.5% of the patients, subtotal resection with residual tumor in 8.7%, and simple biopsy in 3.7%. A tumor relapse was observed in 24 patients (10%): 2 (1.5%) of 133 with encapsulated thymomas and 22 (20.4%) of 108 with invasive thymomas; among these patients, a relapse was found in 20.6% of the patients who received radiotherapy postoperatively and in 24.6% who did not. Adverse prognostic factors were clinical stage IVa (multiple pleural nodes), not feasible resection (for technical reasons), inoperable tumor relapse, and association with one of the following autoimmune diseases: pure red cell aplasia, hypogammaglobulinemia, and lupus erythematosus. Conversely, myasthenia gravis is now a curable disease; it contributes to early discovery of associated thymoma, thus allowing a better survival for patients with thymoma who have myasthenia gravis compared with patients with thymoma but without myasthenia gravis (p less than 0.05). Postoperative radiotherapy does not seem necessary after removal of encapsulated thymomas, but it is advisable in case of invasive thymomas, regardless of the extent of the resection.

Combined radiosurgical treatment of Pancoast tumor.

Operative technique and long-term results of 60 consecutive patients with Pancoast tumor treated with combined radiosurgical treatment were evaluated. External radiation therapy was administered preoperatively in a dose of 30 Gy in 50 patients. Operation was considered radical (R0) in 36 patients (60%). A microscopic invasion of the margin of resection (R1) was observed in 5 patients (8.3%). In 19 patients (31.6%) the operation was considered presumably not radical (R2). Three patients died in the postoperative period (5%). Fourteen major postoperative complications occurred in 13 patients (21%). Seven patients had recurrence of pain postoperatively. Overall 3- and 5-year actuarial survival rates were 34% and 17.4%, respectively. The corresponding figures for the R0 and combined R1-R2 groups were 45.8% and 23.5% (R0), and 11.4% (R1-R2; no 5-year survivors were observed in this group) (p < 0.025). Median survivals in the R0 and combined R1-R2 patients were 19 and 7 months, respectively. Different median survivals for the patients with residual tumor were as follows: intervertebral foramina, 5 months; subclavian artery (isolated), 9 months; subclavian artery (in association), 7 months; brachial plexus, 4 months; and vertebral body, 7 months. We conclude that combined radiosurgical treatment represents a valuable therapeutic option in the treatment of Pancoast tumor. In case of residual tumor a poor outcome may usually be anticipated, but in the majority of these patients the operation permits good control of the pain.

Postoperative pain and superficial abdominal reflexes after posterolateral thoracotomy.

BACKGROUND: Posterolateral thoracotomy can produce stretching of/or damage to the intercostal nerves and their branches. To assess intercostal nerve impairment after operation, we measured the superficial abdominal reflexes, which are mediated, at least in part, by the most inferior intercostal nerves. METHODS: Using electrophysiologic techniques, we made recordings from the left and right abdominal walls to study the responses evoked by mechanical stimulation of the skin after operation. In addition, we assessed postoperative pain intensity according to a numeric rating scale and recorded postoperative opioid dose. RESULTS: We found that the patients with complete disappearance of the superficial abdominal reflexes experienced more severe postoperative pain than those in whom the reflexes were maintained. Moreover, opioid treatment was less effective in the patients with no reflexes postoperatively. CONCLUSIONS: Our findings show a strict correlation between pain intensity after posterolateral thoracotomy and absence of abdominal reflexes. We suggest that the higher pain intensity together with the absence of reflexes may be due to intercostal nerve impairment, be it anatomic or functional, and thus to a larger neuropathic component of postoperative pain. This finding may be used as a predictor of patients with high analgesic requirements.

Solitary fibrous tumour of the pleura: surgical treatment.

OBJECTIVE: Solitary fibrous tumours (SFT) of the pleura are rare tumours originated from the mesenchimal tissue underlying the mesothelial layer of the pleura. This tumours present unpredictable clinical course probably related to their histological and morphological characteristics. METHODS: Twenty-one patients affected by SFT of the pleura were referred to us for surgical resection from September 1984 to April 2000. They were 15 males and six females with median age of 51 (range 15--73) years. Nine patients (43%) were symptomatic and predominant clinical symptoms or signs were dyspnoea (19%), coughing (14.3%), chest pain (28.5%), finger clubbing (14.3%) and hypoglycaemia (14.3%). Hypoglycaemia was related to a pathological incretion of insulin-like growth factor 2 by the tumour. Chest radiograph and computed tomography of the chest revealed intra-thoracic homogeneous sharply delineated round or lobulated mass sometimes associated with ipsilateral pleural effusion (19%) or causing pulmonary atelectasis with opacification of the complete hemithorax (19%). Surgical excision required 14 posterolateral thoracotomies, six anterior thoracotomies and one video-assisted thoracoscopy. Thirteen tumours arose from visceral pleura and wedge resection was performed, seven tumours arose from parietal pleura and extrapleural resection was carried out without any chest-wall resection, one tumour growth within the upper left lobe and required lobectomy. Tumours weighted from 22 to 1942 g and measured from 22x12x8 to 330x280x190 mm. At cut section seven cases (34%) revealed focal necrosis and hemorrhagic zones and on light microscopy six cases (28.5%) were characterized by high mitotic count: characteristics related with uncertain clinical behaviour. Immuno-histochemical reactions were in all cases positive for CD34. RESULTS: In all our patients resections were complete. Paraneoplastic syndromes like hypoglycaemia and clubbing receded after surgery. No intraoperative or perioperative medical or surgical complications occurred. Median chest-drain duration timed 3 (range 2--5) days and median hospital stay was 5 (range 4--7) days. Perioperative mortality rate was 0%. Median follow-up was 68 (range 2--189) months: during this period patients were submitted to chest X-ray with 6-months interval to evaluate possible local recurrence. Only one patient experienced tumour recurrence after 124 months follow-up: the tumour was suspected after observation of finger clubbing. The tumour was detected and excised by redo-thoracotomy. CONCLUSIONS: Surgical resection of benign solitary fibrous tumours is usually curative, but local recurrences can occur years after seemingly adequate surgical treatment. Malignant solitary fibrous tumours generally have a poor prognosis. Clinical follow-up and radiological follow-up are indicated for both benign and malignant solitary fibrous tumours.

Thymectomy in myasthenia gravis. Results of 662 cases operated upon in 15 years.

The results of thymectomy in the treatment of myasthenia gravis (MG) are reviewed in the light of a personal series of 662 MG patients, operated upon during the last 15 years. In 500 MG patients without thymoma, the following results have been achieved: remission 37.9%, improvement 49.4%, unchanged or worse 7.4%, dead 5.2%. There is no sex prevalence and the remission rate is higher in patients under 40 years of age (P less than 0.01), with mild disease (P less than 0.05), with a MG duration of less than 1 year (P less than 0.05) and with a follow-up length of between 5 and 10 years (P less than 0.01). No correlations are found between outcome and thymic histology. The results of 162 MG patients with thymoma are: remission rate 15.7%, improvement 60.3%, unchanged or worse 3.7% and dead 20.1%. The remission rate is higher with mild symptoms (P less than 0.05) and when the tumour is encapsulated (P less than 0.02). The postoperative mortality is 0.8% (none in the last 5 years) for non-thymomatous MG and 4.9% for thymomatous MG (2 of 8 patients died of pancytopaenia and 1 of pulmonary embolism).

The significance of associated pre-invasive lesions in patients resected for primary lung neoplasms.

OBJECTIVE: To evaluate the prevalence and clinico/prognostic significance of the presence of pre-invasive lesions in patients resected for primary lung neoplasm. METHODS: From 1993 to 2002, 1090 patients received resection for primary lung carcinomas. Of these, 73 presented an associated pre-invasive lesion in the surgical specimen distant from the primary tumour. Classification of pre-invasive lesions included Atypical Adenomatous Hyperplasia (AAH); Carcinoma In Situ (CIS) either diffuse or at the bronchial resection margin; Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH). Correlation between the presence of pre-invasive lesion and the following variables were calculated by logistic regression analysis: sex, age, median tumour size, histology, histologic differentiation, histologic evidence of invasiveness (vascular and perineural invasion), peritumoural lymphocytic infiltrate, pTNM, lobe location, history of previous malignancy. Survival rates were computed using Kaplan-Meier method and survival differences with the total patient population of resected lung carcinomas were tested using the log-rank method. RESULTS: There were 28 AAH, 42 CIS (5 at the bronchial resection margin) and 3 DIPNECH. Histology of the primary tumor included bronchioloalveolar carcinoma (9 patients), adenocarcinoma (19), squamous cell carcinoma (39), typical carcinoid tumour (3) and adenosquamous carcinoma (3). Overall prevalence of pre-invasive lesion was 6.7%. A strong correlation was found between the presence of AAH and the co-existence of either adenocarcinoma, bronchioloalveolar carcinoma or mixed adenocarcinoma-containing tumours (P = 0.00002) between CIS and squamous cell carcinoma (P = 0.009) and between DIPNECH and carcinoid tumours (P = 0.001). No significant correlation was found between the presence of any type of pre-invasive lesion and sex, age, median tumour size, histologic differentiation, histologic evidence of invasiveness, pTNM, lobe location and history of previous malignancy or the probability to develop a second primary lung carcinoma in the remaining lobe(s) after resection. Survival rates in the patients with AAH and CIS were not significantly different from those of patients without pre-invasive lesion (P = 0.3 and P = 0.1). CONCLUSIONS: Associated pre-invasive lesions in patients resected for primary lung neoplasms are not infrequent. AAH is associated with adenocarcinoma, CIS with squamous cell carcinoma, DIPNECH with typical carcinoid tumours. Our experience indicates that in these patients histology, stage distribution and survival do not differ from the total population of resected patients with lung tumors.

Videothoracoscopy and video-assisted small thoracotomy for the treatment of pulmonary malignancies.

Video-assisted thoracic surgical procedures continue to be performed with increased frequency; the role of this new technique in the treatment of pulmonary malignancies or metastatic mediastinal adenopathies is not yet defined. Out of a series of 100 consecutive video-assisted thoracic operations, 22 patients resulted affected by a malignancy in the lung or in the subcarinal lymphnodes: six patients had a primary lung cancer and were operated with a video-assisted small thoracotomy of 5 cm (three lobectomy and three segmentectomy) because of a very poor respiratory reserve. Nine patients received a video-assisted wedge resection of a nodule resulted at the frozen section a metastasis of a carcinoma: a small thoracotomy of 8 cm was made and a hand entered the thoracic cage to obtain a careful palpation of the entire lung; five patients had enlarged lymphnodes only in posterior and inferior mediastinum, inaccessible by cervical mediastinoscopy or anterior mediastinotomy: thoracoscopic exploration obtained a useful mediastinal nodal sampling for these adenopathies. In selected cases video-assisted thoracic surgery can be used for resection or assessment of thoracic malignancies.

Successful management of hemorrhage from the pulmonary artery stump after lobectomy for bronchogenic carcinoma.

Pulmonary bleeding from the arterial stump following lung resection is a life-threatening complication requiring immediate surgical correction. Predisposing conditions are almost always represented by bronchopleural fistula and empyema. The operation often represents a major challenge to the thoracic surgeon, because of the choice of the most appropriate surgical access, the optimal technique to control the bleeding, as well as to treat the associated bronchopleural fistula. We present a case of successful treatment of hemorrhage from the pulmonary artery stump associated with BPF and empyema following lobectomy for bronchogenic carcinoma. A standard postero-lateral thoracotomy using the previous incision was used with adequate exposure of the source of bleeding and the bronchopleural fistula.

Hemangioma of the rib. A case report.

A case of hemangioma of the left twelfth rib is presented. clinical presentation, radiologic appearance and differential diagnosis with other vascular tumors of the bone are discussed, along with a review of the literature.

Bronchial carcinoid associated with Cushing's syndrome.

Bronchial carcinoid is the most frequent cause of Cushing's syndrome due to ectopic ACTH production. The authors report a case of bronchial carcinoid which diagnosis was difficult because of the presence of pulmonary mycosis, that determined a hypercorticosuprarenalism. Medical treatment with octreotide, ketoconazolo and mitotane was useless, and bilateral suprarenalectomy was performed. A scintigraphy with raced somatostatin revealed a left lung area capting radiation. A CT scan of the thorax revealed a lesion of the lingula and the patient underwent an atypical lung resection with complete solution of the symptom. The problems of diagnosis and treatment of neuroendocrine tumors of the lung are discussed and the importance of SSA in the diagnostic procedure is pointed out.

Right post pneumonectomy pleural empyema caused by an esophagopleural fistula due to an esophageal carcinoma.

A case report of a patient with pleural empyema resulting from esophagopleural fistula following perforation of squamous cell carcinoma of the esophagus is presented. The patient had previously received a right pneumonectomy for bronchogenic carcinoma with the adjunct of postoperative radiotherapy. Description of the case, differential diagnosis and therapy of esophagopleural fistulas (EPF) as well as a review of the Literature is described and discussed.

Preoperative concurrent radiation therapy and cisplatinum continuous infusion in IIIa (N2) non small cell lung cancer. A pilot study.

From April 1991 to September 1993, 18 patients affected by a presumed operable IIIa (N2) non small cell lung cancer (NSCLC) with histologically confirmed bulky mediastinal metastases, received preoperative concurrent radiation therapy and continuous infusion of cisplatinum (CDDP). The radiotherapy consisted of 2 Gy given 5 days a week for a total dose of 50 Gy; CDDP was administered by means of a central catheter and a portable pump at the daily dose of 6 mg/m2 given on the same days as the radiation therapy (total dose: 150 mg/m2). Two weeks after the end of the treatment, the patients were reevaluated: 5 patients had either local or distant disease progression, the other 13 were submitted to thoracotomy: 12 received a complete resection and 1 patient underwent only a mediastinal lymphadenectomy, because pneumonectomy was impossible due to lack of respiratory function. No histological evidence of cancer cells was observed in the specimens of 6 patients (33%). Radiological response rate was 61% (11/18); resection rate was 66% (12/18) and complete resection rate was 61% (11/18). There was one postoperative death (5%). The 3 year actuarial survival rate is 63.6% for the patients who received a resection with a median survival time of 18 months. All non operated patients died within one year. Combined preoperative treatment was well tolerated. Better results were achieved in patients with squamous cell carcinoma who had a complete resection following a total tumor sterilization with radio-chemotherapy.

Results of surgical resection of stage IIIa (N2) non small cell lung cancer, according to the site of the mediastinal metastases.

Out of a series of 1563 consecutive patients submitted to thoracotomy for lung cancer between 1980 and 1990, 278 patients underwent a resection for a non small cell lung cancer (NSCLC) with mediastinal node metastases (N2). Selection of cases for surgery was carried out using CT from 1983 and mediastinoscopy for the patients with mediastinal lymph nodes larger than 1.5 cm from 1985: all patients with positive mediastinoscopy were excluded from thoracotomy, but 10 cases underwent a resection after neoadjuvant radio-chemotherapy. The surgical procedures were pneumonectomy (106), lobectomy (146) and atypical resection (8) with ipsilateral mediastinal lymphadenectomy. Resection was complete in 236 patients (84.8%) and incomplete in 42 patients (15.2%). Postoperative mortality was 3.2%. Almost all patients received radiotherapy after surgery. Actuarial 5-year survival was 13.7% for the entire group and 18.5% for the patients who underwent curative resection; no patients survived 5 years after palliative resection (p < 0.05). There were no differences with regard to prognosis according to the histology of the tumors and to surgical procedures. A better prognosis is associated with: completeness of resection, involvement of only one level, low T classification. Five-year survival rate of patients with metastases only in upper mediastinum was 25%; on the contrary 5-year survival rate of patients with metastases in the lymph nodes of the lower mediastinum was only 8% (p < 0.05). In our opinion better results among the patients with metastases in the upper mediastinum depends on the selection obtained with mediastinoscopy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Post-traumatic right diaphragmatic hernia. Description of a clinical case]. / Ernia diaframmatica destra post-traumatica. Descrizione di un caso clinico.

The paper reports a case of chronic right posttraumatic diaphragmatic hernia which was brought to the authors' attention due to onset of intestinal subocclusion. Surgery was performed using thoracotomy with reduction of the ilial loops in the abdomen and suture of the diaphragmatic breech; a laparotomic route was used to resect a tract of ischemic small intestine using a termino-terminal anastomosis. The authors discuss the etiopathogenetic, diagnostic and therapeutic problems in the light of data reported in the literature.

[Benign fibrous mesothelioma of the pleura]. / Il mesotelioma fibroso benigno della pleura.

The authors report 4 cases of patients with benign fibrous mesothelioma of the pleura, an extremely rare pathology (not more than 500 cases reported to date in the literature), and discuss biological behaviour, diagnosis and surgical treatment. Benign fibrous mesothelioma is generally diagnosed by chance during chest x-ray given that it is paucisymptomatic; diagnostic procedures include thoracic CT (which may be supplemented by transthoracic needle biopsy) and bronchoscopy. Treatment is surgical and consists of exeresis of the neoplasia; prognosis is excellent and cases are reported in the literature of 24-year follow-up without recurrence. Lastly, the authors underline the importance of modern immunohistochemical techniques which help the surgeon to formulate a precise diagnosis and to differentiate benign fibrous mesothelioma.

[Askin's tumor in a young adult: a rare occurrence. Apropos one case observed]. / Il tumore di Askin in un giovane adulto: una rara evenienza. A proposito di un caso osservato.

Askin's tumour is a rare malignant small cell neoplasia of the thoracic wall; it most often effects females during childhood and is characterised by limited survival. The authors report a recent case of Askin's tumour in a young adult male. The case was characterised by multiple recidivation but a long survival. The authors discuss its diagnosis and treatment.

[Post-traumatic hernia of the diaphragm]. / Le ernie post-traumatiche del diaframma.

The paper reports the series of post-traumatic hernias of the diaphragm observed during the period between 1954 and June 1992. This group of 77 patients (59 males and 18 females) were aged between 6 and 75 years old. Both acute and chronic hernias were reported; in 60 cases the diaphragmatic lesion was on the left, in 9 cases on the right, and there were 8 cases of laceration to both hemidiaphragms. The most frequently herniated organ was the stomach, followed by the transverse colon and spleen. With regard to the access route used, the authors draw attention to the fact that during the first twenty years of the series thoracotomies were prevalently used, whereas during the last decade laparotomy has been used in cases of early post-traumatic hernia, thoracotomy in cases of chronic post-traumatic hernia or if there is suspected damage to organs and intrathoracic structures.

[PT (INR) in extractive dental surgery in patients treated with oral anticoagulants]. / PT (INR) nella chirurgia dentaria estrattiva in pazienti trattati con anticoagulanti orali.

The authors report their actual behaviour in dental extractive surgery with regard to patients subjected to oral anticoagulant therapy. They analyze the hospital ambulatory casistry treated, formulate some considerations and conclude confirming their behaviour supported by the results obtained.