Could fluorescence-guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment summary.

BACKGROUND: Indocyanine green fluorescence vision is an upcoming technology in surgery. It can be used in three ways: angiographic and biliary tree visualization and lymphatic spreading studies. The present paper shows the most outstanding results from an health technology assessment study design, conducted on fluorescence-guided compared with standard vision surgery. METHODS: A health technology assessment approach was implemented to investigate the economic, social, ethical, and organizational implications related to the adoption of the innovative fluorescence-guided view, with a focus on minimally invasive approach. With the support of a multidisciplinary team, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaires and self-reported interviews, considering the dimensions resulting from the EUnetHTA Core Model. RESULTS: From a systematic search of literature, we retrieved the following studies: 6 on hepatic, 1 on pancreatic, 4 on biliary, 2 on bariatric, 4 on endocrine, 2 on thoracic, 11 on colorectal, 7 on urology, 11 on gynecology, 2 on gastric surgery. Fluorescence guide has shown advantages on the length of hospitalization particularly in colorectal surgery, with a reduction of the rate of leakages and re-do anastomoses, in spite of a slight increase in operating time, and is confirmed to be a safe, efficacious, and sustainable vision technology. Clinical applications are still presenting a low evidence in the literature. CONCLUSION: The present paper, under the patronage of Italian Society of Endoscopic Surgery, based on an HTA approach, sustains the use of fluorescence-guided vision in minimally invasive surgery, in the fields of general, gynecologic, urologic, and thoracic surgery, as an efficient and economically sustainable technology.

The endogenous oxytocin after manipulative osteopathic treatment in full-term pregnant women.

OBJECTIVE: The aim of this study is to assess whether the touch of osteopathic manipulative treatment (OMT) can affect the endogenous production of oxytocin in full-term pregnant women and the assessment of well-being following the treatment. PATIENTS AND METHODS: In this study have been enrolled 57 pregnant women at full-term pregnancy (37th-41st week) for evaluation of the concentration of salivary oxytocin 2 minutes before and 2 minutes after a single session of OMT by an osteopath lasting for 30 minutes. Pre-OMT and post-OMT saliva samples were collected with the use of Salivette® salivary swabs. 7 salivary swabs were excluded from the analysis. 50 samples were analyzed with an appropriate ELISA kit. RESULTS: The mean OT salivary concentration pre-OMT was 89.98±16.39, and post-OMT was 100.60±19.13 tends to increase with p=0.0000051. In multivariate analysis, two subgroups show interesting data in the mean difference in OT salivary concentration post-OMT: women with painful contractions (p=0.06) and women under 35 years (p=0.09). CONCLUSIONS: The results of this study demonstrate that the effectiveness of OMT-increasing endogenous oxytocin is statistically significant in full-term pregnant women. The sensation of well-being found in most women indicates that there has been a predominantly central rather than peripheral oxytocin release after OMT.

Typical and atypical carcinoid tumours: 20-year experience with 89 patients.

AIM: The aim of this study was to conduct a retrospective clinical and pathological analysis of the authors' 20-year experience on treatment of typical and atypical carcinoid tumours. METHODS: A retrospective clinical and pathological analysis was conducted on 89 patients treated for bronchial carcinoid neoplasms at the Division of Thoracic Surgery, Hospital of Florence (Italy) between January 1986 and January 2006. They were 47 male (52.8%) and 42 female patients, age ranging from 22 to 77 years (average: 55.5 years). Diagnosis was made with radiological methods such as plain chest roentgenography, computed tomography (CT), and bronchoscopy. On the basis of bronchoscopic findings 63 carcinoids (70.8%) were centrally located and 26 (29.2%) were classified as peripheral. In 38 cases of central lesion the diagnosis was obtained by endobronchial biopsy. A correct pathological diagnosis was obtained before surgery in 58 patients; in the others resected cases the correct diagnosis was determined by intraoperative histology during surgery. All operation were performed through a thoracotomy, with sparing muscle in last ten years. Surgical procedures utilized were lobectomy, pneumonectomy, segmentectomy, wedge resections, sleeve resections and bronchoplastic procedures. A radical mediastinal lymphadenectomy was performed in every operation. RESULTS: There were 63 (70.8%) typical carcinoid (TC) and 26 (29,2%) atypical carcinoid (AC). No operative or postoperative mortality was seen. Ten patients (11.7%) experienced complications: 4 prolonged air leaks, 2 bleeding requiring re-operation, 1 chylothorax, 1 pulmonary embolism, 2 late cicatricial bronchial stenosis after sleeve lobectomy treated successfully by laser therapy. Four patients (4.5%) were treated with endoscopy plus surgery. In all that patients a Laser Nd-YAG coagulation and excision of the lesion was performed. Four patients (4.5%) were treated only with endoscopy, overall because of bad general condition. On the basis of the hystopatological documentation of all patients operated before 1999 (60 patients) the authors observed that in 4 cases (6.6%) the diagnosis has changed from AC to TC while only 1 case (1.6%) of AC was classified as TC with new criterias. During median 122-month follow-up 7 relapses (8.2%) were diagnosed in operated patients; recurrent cancer developed preferentially in AC (N=4, 16.6%) than TC (N=3, 4.9%). The overall survival at 10 and 15 years was 92% and 82% respectively. CONCLUSIONS: Anatomical resection, including formal lobectomy (or pneumonectomy when indicated) and radical mediastinal lymphadenectomy, should be performed in carcinoid tumours.

Thoracoscopic localization techniques for patients with solitary pulmonary nodule: radioguided surgery versus hookwire localization.

AIM: The aim of this study is to compare 2 different methods for localization of peripheral pulmonary lesions requiring thoracoscopic resection: radioguided surgery (still considered an innovative method) and computed tomography-guided hookwire localization. METHODS: Thirty randomized patients (21 males and 9 females), ranging from 21-74 years, average age 56.3 years) with solitary pulmonary nodule (SPN) were enrolled in this prospective study. Inclusion criteria was: a maximum nodule diameter of less than 3 cm and a maximum distance from the visceral pleura of 3 cm. The patients were subdivided into 2 equal groups and one of the 2 different methods for diagnosing SPN was applied. Group A received a thoracoscopy using the scinti-probe technique and group B received a thoracoscopy aided by a hooked needle. RESULTS: The frozen section revealed a primitive pulmonary tumor in 13 cases, intestinal adenocarcinoma metastasis in 3 cases and renal cancer metastasis in 1 case. The remaining 13 cases were pathologically benign: sarcoidosis in 6 cases, hamartochondroma in 3 cases, scleroanthracosis in 2 cases and tuberculoma in 2 cases. CONCLUSION: On the basis of our experience, the conclusion is drawn that this methods has been proven efficacious in the diagnosis of SPN, and video-assisted thoracoscopy allows for the removal of pulmonary nodules without complications.

Gastropleural fistula as complication of postpneumonectomy empyema.

A 54-year-old woman underwent a left pneumonectomy for monolateral congenital pulmonary cysts, complicated by a pleural empyema without bronchial fistula, in the late postoperative period. The pleural empyema was evacuated and managed by means of a small thoracic drainage. Three months after discharge the patient noticed the presence of ingesta in the pleural washing fluid. Diagnostic and operative procedures in this rare case of non malignant, non traumatic gastropleural fistula are described.

Combined approach to intrathoracic lesions invading the spinal cord.

The treatment of intrathoracic lesions invading the spine has two main issues: the surgical route to be preferred and the incidence of complications following the operation. As a matter of fact surgical treatment, performed in two stages, has a higher risk of cord accidents. Some authors have proposed a combined thoraco-vertebral surgical route which allows the exposition of both the spine and the chest. We experienced the utility of such a surgical approach in the treatment of two endothoracic lesions invading the thoracic spine and requiring the stabilization of the rachis. Satisfactory results were achieved without morbidity.

Gamma probe-guided thoracoscopic surgery of small pulmonary nodules.

Video-assisted thoracic surgery (VATS) is an interesting and emerging procedure for the diagnosis and treatment of peripheral pulmonary nodules. We developed a new radioguided surgical technique for the detection during VATS of pulmonary nodules smaller than 2 cm, situated deep in the lung parenchyma and neither visible nor palpable with endoscopic instruments. The procedure is divided into two phases. Two hours before surgery 0.3 ml of a solution composed of 0.2 mL of 99mTc-labeled human serum albumin microspheres (5-10 MBq) and 0.1 mL of non-ionic contrast is injected into the lesion under CT guidance. Then the patient is submitted to VATS. During thoracoscopy a collimated probe of 11 mm diameter connected to a gamma ray detector is introduced via an 11.5 mm trocar and the pleural surface of the suspected area is scanned. A hot spot indicates the presence of the radiolabeled nodule and hence the area to be resected. We treated 39 patients with small pulmonary nodules (mean size, 8.3 mm; range, 4-19 mm). The patients were 27 men and 12 women (mean age, 60.8 years; range, 13-80 years). Nineteen patients had a history of synchronous or metachronous malignancy. In all cases the nodule was detected and resected and the resection margins were pathologically free of tumor. Histological examination showed 21 benign and 18 malignant lesions (7 metastases and 11 primary lung cancers). Nine patients with a frozen section-based histopathological diagnosis of lung cancer without functional contraindications underwent a completion lobectomy by open surgery in the same surgical session. In conclusion, the radiolocalization of small pulmonary nodules by gamma probe during VATS is a safe and easy procedure, with fewer complications and a lower failure rate than other localization techniques.

[Diagnosis and treatment of pleuro-pericardial cysts. Role of videosurgery]. / Diagnosi e trattamento delle cisti pleuro-pericardiche. Ruolo della videochirurgia.

BACKGROUND: The pericardial cysts are benign "tumors" of the antero-inferior mediastinum, most often asymptomatic, which diagnosis is radiologic and incidental. When cysts are symptomatic and/or diagnosis is difficult, any resort to invasive diagnostic examinations and surgical ablation is suitable. METHODS: From January 1993 to January 1994 five patients with pericardial cyst have been treated. Three patients were symptomatic: two suffering from cardiac arrhythmia and one had cough with dyspnea. In three cases the lesion had a typical location and typical radiological patterns, and diagnosis was made by chest X-ray, confirmed by computed tomography (CT). In one case chest X-ray and CT didn't allow a sure diagnosis (differential diagnosis with Morgagni's diaphragmatic hernia), and in another case all examinations suggested a relapsing pleural effusion. RESULTS: All patients underwent ablation of the cyst by VATS; no complications were observed and patients left the hospital, on average, after 2 days (range 1-3). CONCLUSIONS: VATS, thanks to its low invasiveness, may be considered the method of choice for the diagnosis of atypical lesions and/or treatment of symptomatic cysts.

Endothoracic sonography with color Doppler availability during video assisted thoracic surgery (videothoracoscopic operative staging with ultrasound color Doppler) for lung cancer staging.

BACKGROUND: The preoperative staging of lung cancer can be problematical when we attempt to evaluate T factor (T2-T3 versus T4) and N factor (N0 versus N1-N2). In some cases, radiology tests (CT scan, magnetic resonance imaging) cannot entirely dispel the possibility that the mediastinal structures have been infiltrated. N factor is evaluated mainly by dimensional criteria. However, mediastinoscopy and mediastinotomy do not allow the full exploration of all mediastinal mode stations. METHOD: Starting in 1995, we submitted 10 consecutive patients to videothoracoscopic operative staging with ultrasound color Doppler (VOS-USCD). In five cases, preoperative staging showed possible infiltration of the pulmonary artery (T4). In nine cases, we found involvement of the mediastinal nodes, seven patients were N2, and two were N3. Videothoracoscopy was performed under general anesthesia using a double-lumen endotracheal tube. The videothoracoscope and sonographic probe were inserted via three thoracoports placed in the axillary triangle. RESULTS: Following the results of VOS-USCD, the staging and subsequently the therapeutic program were modified in seven of 10 cases (70%). CONCLUSIONS: Our preliminary experience indicates that VOS-USCD should be applied to the diagnosis of patients in stage IIIA (N2) and that it is particularly valuable for patients in stage IIIB.