Medical thoracoscopy without pleural fluid: How I do it.

Thoracoscopy is a commonly used minimally invasive procedure in the field of interventional pulmonology. While medical thoracoscopy is the widely preferred modality, modifications to the technique and expansion in the scope of its utility have always challenged the conventional approach. We describe a modified technique of medical thoracoscopy in absence of pleural effusion also known as dry thoracoscopy under sedation and local anaesthesia.

Diagnostic Accuracy of Pleural Fluid Cytology, Carcinoembryonic Antigen and C-Reactive Protein Together in Patients With Pulmonary Metastases and Malignant Pleural Effusion.

BACKGROUND/AIM: Pleural effusion (PE) has a heterogeneous aetiology, and differential diagnosis between benign and malignant disease may require invasive procedures in up to 60% of cases. The sensitivity of pleural cytology is limited, and several strategies have been tested to reduce the need of invasive diagnostic approaches. The aim of this study was to evaluate the usefulness of pleural fluid cytology, compared to, and combined with, carcinoembryonic antigen (CEA), C reactive protein (CRP), and lactate dehydrogenase (LDH) assay of pleural fluid (PF) in patients with a history of cancer, exudative non-purulent PE, and suspicion of malignant PE on imaging studies. PATIENTS AND METHODS: The medical records of 40 patients with pulmonary metastases and malignant PE, and 57 controls with benign exudative PE were reviewed. All the patients underwent pleural cytology and CEA, CRP, and LDH assay before VATS-guided biopsy. RESULTS: The sensitivity and specificity were 55.0% and 98.2% (cytology), 35.0% and 98.2% (CEA), 92.5% and 71.9% (CRP), 70.0% and 54.4% (LDH). The multivariate analysis excluded LDH, and the final AUC (cytology+CEA+CRP) was 0.894. CONCLUSION: In all patients with a history of cancer and PE of uncertain origin, the combination of PF cytology plus pleural CEA and CRP assay together should be suggested to recognize malignant plural effusion (MPE), minimising the use of unnecessary invasive investigations.

Outcome of laparoscopic gastric bypass in obese and diabetic patients: when surgery fails.

BACKGROUND: The beneficial effects of bariatric surgery on diabetes and obesity have been widely demonstrated in the literature. The aim of our study was to evaluate the rate of failure of laparoscopic gastric bypass both in terms of weight loss and metabolic remission after one follow-up year. METHODS: A longitudinal, multicenter prospective study was carried out on 771 patients affected by pathological obesity. The following parameters were recorded for each patient before surgery: anthropometric, metabolic, social, smoking habits and previous failure of other bariatric procedures. After 1 follow-up year, final weight, final Body Mass Index (BMI), final percentage of lost excess body weight and percentage of lost BMI were evaluated. RESULTS: Statistical analysis showed a correlation between BMI>50 kg/m2, presence of metabolic syndrome, presence of diabetes, gastric pouch volume greater than 60 mL and failure of weight loss outcome. Statistical analysis of metabolic failure has recognized a high preoperative glycated hemoglobin percentage (HbA1c%) value as a statistically significant negative predictive factor. CONCLUSIONS: Bariatric Surgery is the most effective treatment for weight loss and metabolic improvement. However, in our study, surgery did not achieve the expected outcome in patients with specific metabolic, anthropometric and surgical characteristics (BMI>50 kg/m2, presence of metabolic syndrome, presence of T2DM with high preoperative HbA1c% level and gastric pouch volume greater than 60 mL).

Analysis of Factors Affecting Short-term Results in Elderly Patients Undergoing Elective Surgical Resection for Stage I-II Colon Cancer.

AIM: The aim of this study was to analyze the influence of comorbidities and to compare the short-term results of elective surgical resection of stage I-II colon adenocarcinoma in elderly (≥65 years) versus younger patients. PATIENTS AND METHODS: Two groups of sex-matched younger and older patients were compared: Group A: N=36, median age 58 (range=43-65) years; and group B: N=67, median age 73 (range=66-86) years. RESULTS: Overall, 71 out of 103 (68.9%) patients had one or more comorbidities. A greater number of older patients had an American Society of Anesthesiologists (ASA) score >2 (p=0.004) and were on multiple medications (polypharmacy) (p=0.016), but the distribution of the other parameters was similar (p≥0.05). Intra- and postoperative complications in group A vs. B occurred in 25.0% vs. 26.9%, and 47.2% vs. 64.2%, respectively (p≥0.05). CONCLUSION: Elderly patients with colon cancer scheduled to elective surgical resection should not be considered at increased risk of intra- or short-term postoperative complications with respect to younger patients. However, they require careful individual preoperative evaluation because they are usually polypharmacy users and have a higher ASA score.

Preoperative Predictive Factors of Successful Weight Loss and Glycaemic Control 1 Year After Gastric Bypass for Morbid Obesity.

BACKGROUND: Gastric bypass (GBP) is one of the most effective surgical procedures to treat morbid obesity and the related comorbidities. This study aimed at identifying preoperative predictors of successful weight loss and type 2 diabetes mellitus (T2DM) remission 1 year after GBP. METHODS: Prospective longitudinal study of 771 patients who underwent GBP was performed at four Italian centres between November 2011 and May 2013 with 1-year follow-up. Preoperative anthropometric, metabolic and social parameters, the surgical technique and the previous failed bariatric procedures were analyzed. Weight, the body mass index (BMI), the percentage of excess weight lost (% EWL), the percentage of excess BMI lost (% BMIL) and glycated haemoglobin (HbA1c) were recorded at follow-up. RESULTS: Univariate and multivariate analysis showed that BMI <50 kg/m(2) (p = 0.006) and dyslipidaemia (p = 0.05) were predictive factors of successful weight loss. Multivariate analysis of surgical technique showed significant weight loss in patients with a small gastric pouch (p < 0.001); the lengths of alimentary and biliary loops showed no statistical significance. All diabetic patients had a significant reduction of HbA1c (p < 0.001) after surgery. BMI ≥ 50 kg/m(2) (p = 0.02) and low level of preoperative HbA1c (p < 0.01) were independent risk factors of T2DM remission after surgery. CONCLUSIONS: This study provides a useful tool for making more accurate predictions of best results in terms of weight loss and metabolic improvement.

Incidentally discovered asymptomatic splenic hamartoma with rapidly expansive growth: a case report.

Splenic hamartoma (SH) is a very rare benign vascular lesion, usually asymptomatic. Although infrequent, it must be differentiated from malignant lesions, such as lymphoma or metastases, or other vascular neoplasms of the spleen. We present the case of a solid lesion of the spleen discovered incidentally in a 42-year-ol women, characterized by an unusual rapid expansive growth during four-month follow-up. The lesion, isoechoic and close to the hilum, was initially suspected to be an accessory spleen, measuring 3.5 cm in size. Four months later, magnetic resonance imaging revealed a 9-cm expansive nonhomogeneous mass in the antero-superior margin of the spleen, dislocating the stomach. The lesion exhibited central necrosis with hyper- and hypointense signal both in T1 and T2-weighted images. Due to the risk of spontaneous rupture and because malignancy could not be ruled out, the patient underwent hand-assisted laparoscopic splenectomy. Macroscopically, the spleen measured 15×12×4 cm and weighed 890 g. Cut sections revealed a single nodule of dark-red tissue sized 8.5 cm. The lesion exhibited a network of irregularly arranged and tortuous vascular channels lined by endothelium similar to splenic sinus lining cells, surrounded by aggregates of lymphocytes and macrophages resembling the pulp cords. On immunohistochemical staining the tissue was CD34 - and CD8 + and the final diagnosis was SH. In conclusion, when SH is suspected and malignancy cannot be ruled out, hand-assisted splenectomy should be considered the procedure of choice. Partial splenectomy should be preferred in children, to avoid potential risks of total splenectomy.

Serum N-telopeptide of type I collagen and bone alkaline phosphatase and their relationship in patients with non-small cell lung carcinoma and bone metastases. Preliminary results.

Lung cancer represents the most common malignancy in Western countries and the presence of bone metastasis (BMs) may significantly worsen the prognosis. Several urinary and serum markers are altered in patients with BMs from non-small cell lung cancer (NSCLC). The aim of this study was to assess the usefulness of two serum markers of bone remodeling in patients with NSCLC and BMs. Thirty-five patients (24 men, 11 women, median age 63 years, range 51-72 years) with NSCLC were examined. There were 16 patients with confirmed BMs (Group A), and 19 age-matched (63.5±4.9 vs. 63.7±4.4 years; p=0.88) patients without BMs (Group B). Serum levels of bone resorption marker cross-linked amino-terminal telopeptide of type I collegen (NTx), and bone formation marker bone alkaline phosphatase (BAP) were measured in both groups by enzyme-linked immunosorbent assay. Both NTx (33.5±7.2 vs. 25.6±3.1 nM bone collagen equivalent, BCE/l) and BAP (51.7±6.0 vs. 40.7±7.3 U/l) serum levels were significantly (p<0.001) different between groups (A vs. B). Using a cut-off value of 30 nM BCE/l (TNx) and 50 U/l (BAP), the sensitivity was 56.2% and 37.5%, respectively (Odds ratio, OR=0.47, 95% confidence interval, CI 0.11-1.91, p=0.48), while the specificity was 89.5% and 84.2% (OR=0.62, 95% CI 0.09-4.26, p=0.50), respectively. No correlation was found between age and both NTx (R=-0.34, p=0.08) and BAP (R=-0.10, p=0.61) among patients with BMs. In conclusion, in patients with NSCLC and BMs both NTx and BAP are specific markers of bone remodeling, but their usefulness is limited in early diagnosis of metastatic disease.

Hypoxemia and hypoventilation syndrome improvement after laparoscopic bariatric surgery in patients with morbid obesity.

BACKGROUND: The objective of this study was to evaluate the relationship between oxygen partial pressure (pO(2)), awake oxymetric saturation (SpO(2)), body mass index (BMI), and percentage of excess weight loss (EWL) in extremely severe obesity (BMI >50 kg m(-2)) and hypoxemia, before and after laparoscopic Roux-en-Y gastric bypass. PATIENTS AND METHODS: A group of 11 obese patients aged 41.2 + or - 10.2 years (4 men, 7 women, median BMI=52.3 kg/m(2), range 50.2-57.1) were prospectively enrolled in the study. BMI, arterial blood gas measurements, and spirometry were obtained before and after (6 and 12 months) surgery. RESULTS: The main preoperative parameters were SpO(2)=88.3 + or - 3.9%, predicted forced vital capacity (FVC)=84.5 + or - 8.3%, predicted forced expiratory volume exhaled in one second (FEV1)=79.9+/-10.1%. No relationship (p>0.01) was found between BMI, SpO(2), and FEV1. A significant correlation between SpO(2) and both paO(2) (R=0.74, p=0.009) and EWL (R=-0.75, p=0.008) was found. Three, 6, and 12 months after surgery EWL was 18.9%, 26.4%, and 39.6% (p<0.001), respectively. At one-year follow-up SpO(2), FVC, and FEV1 were 96.2 + or - 3.2% (p<0.001), 112.3 + or - 9.9% (p<0.001), and 101.6 + or - 18.8% (p=0.003), respectively. CONCLUSION: In patients with extremely severe obesity, bariatric surgery may improve significantly both SpO(2) and spirometric parameters, and EWL represents the factor that impacted the results.

Anesthetic management of morbidly obese and super-morbidly obese patients undergoing bariatric operations: hospital course and outcomes.

BACKGROUND: Although the implications for the anesthetic and perioperative care of severely obese patients undergoing weight loss operations are considerable, current anesthetic management of super-obese (SO) patients (BMI > or =50 kg/m(2)), including super-super-obese (BMI > or =60) derives from experience with morbidly obese (MO) patients (BMI 40-49.9 kg/m(2)). We compared anesthetic and perioperative data of SO patients and MO patients undergoing weight loss operations to evaluate if anesthetic management influenced outcome. METHODS: A retrospective analysis was performed on data from 150 consecutive patients (119 MO, 31 SO) undergoing bariatric surgery between May 2000 and March 2005. Data analyzed included preoperative anesthetic assessment, anesthetic management, postoperative care, and intra- or postoperative complications. RESULTS: There were no differences in anesthetic management or in postoperative course or outcome between MO and SO patients. Intraoperative surgical complications occurred in 26% (n=8) in the SO group and 14% (n=15) in the MO group (P<0.01). CONCLUSIONS: No differences in outcome occurred between MO and SO patients undergoing bariatric operations under similar anesthetic management. Anesthesia for weight loss surgery can be safely performed on SO patients with the understanding that these patients are not at risk per se due to their higher BMI. The degree of obesity influenced only the incidence of intraoperative surgical complications.