Intraoperative ventilatory leak: Real-time guidance for management of air leak in lung cancer patients undergoing VATS lobectomy.

BACKGROUND: Persistent air leak (PAL) is a common complication after video-assisted thoracoscopic surgery (VATS) lobectomy. We aimed to evaluate whether the intraoperative quantitative measurement of air leaks using a mechanical ventilation test could predict PAL and identify those patients needing additional treatment for the prevention of PAL. METHODS: This was an observational, retrospective, single-center study that included 82 patients who underwent VATS lobectomy with a mechanical ventilation test for VL. Only 2% of patients who underwent lobectomy surgery had persistent air leaks. RESULTS: At the end of lobectomy performed in patients with non-small cell lung cancer, the lung was reinflated at a 25-30 mmH2O pressure and ventilatory leaks (VL) were calculated and in relation to the entity of the air leaks, we evaluated the most suitable intraoperative treatment to prevent persistent air leaks. CONCLUSION: VL is an independent predictor of PAL after VATS lobectomy; it provides a real-time intraoperative guidance to identify those patients who can benefit from additional intraoperative preventive interventions to reduce PAL.

One-lung ventilation in obese patients undergoing thoracoscopic lobectomy for lung cancer.

BACKGROUND: We evaluated the safety and feasibility of one-lung ventilation in obese patients undergoing thoracoscopic lobectomy and whether obesity affected peri- and postoperative outcomes. METHODS: This was a retrospective single center study including consecutive patients undergoing thoracoscopic lobectomy between October 2019 and February 2022. Obese patients were statistically compared to a control group to evaluate any differences in relation to one-lung ventilation and peri- and postoperative outcomes. RESULTS: Our study population included 111 patients; of these, 26 (23%) were included in the obese group, while 85 (77%) were included within the nonobese group. To obtain one-lung ventilation in nonobese patients, a double-lumen tube was more frequently used than a single-lumen tube with bronchial blocker (61% vs. 39%; p = 0.02), while in obese patients a single-lumen tube with bronchial blocker was used more than a double-lumen tube (81% vs. 19%, p = 0.001). Intergroup comparison showed that a double-lumen tube was the preferred method in nonobese patients, while a single-lumen tube with bronchial blockers was the strategy of choice in obese patients (p = 0.0002). Intubation time was longer in the obese group than in the nonobese group (94.0 ± 6.1 vs. 85.0 ± 7.0 s; p = 0.0004) and failure rate of first attempt at intubation was higher in the obese group (23% vs. 5%; p = 0.01). Obesity was not associated with increased intra-, peri- and postoperative complications and/or mortality. CONCLUSIONS: One-lung ventilation is a feasible and safe procedure also in obese patients and obesity did not negatively affect peri- and postoperative outcomes after lung resection.

Noninvasive positive pressure ventilation in the assessment of extrinsic tracheal stenosis.

In patients with extrinsic tracheal stenosis caused by a mediastinal mass, an airway stent is a palliative measure to relieve airway obstruction. However, the self-expanding force of the stent may be insufficient to force a rigid stenosis. Our goal was to report a simple strategy to indirectly estimate the rigidity of the stenosis and predict airway patency after inserting the stent. Before the procedure, the inspiratory and expiratory flows and their ratio were evaluated under spontaneous breathing and after positive pressure ventilation generated by a facial mask. In patients with stenosis successfully treated with a stent (n = 11), we found significant changes in expiratory (2.3 ± 0.7 vs 2.8 ± 0.7; p = 0.03) and inspiratory (1.5 ± 0.6 vs 2.5 ± 0.9; p = 0.001) flows and a reduction of their ratio (1.4 ± 0.3 vs 1.1 ± 0.2; p = 0.01) whereas no significant changes were observed in patients (n = 2) whose stent failed to force the stenosis. In these cases, a tracheostomy was performed to assure ventilation. Our simple strategy may help physicians predict airway patency after stenting or plan alternative treatments in patients with rigid stenosis difficult to force by stenting.

In-hospital mortality in non-variceal upper gastrointestinal bleeding Forrest 1 patients.

OBJECTIVE: Non-variceal upper gastrointestinal bleeding (NVUGIB) is recognized world-wide as a common cause of emergency hospitalization, and it often represents a life-threatening event. The purpose of this prospective study was to assess in-hospital mortality in NVUGIB Forrest 1 patients admitted to the emergency unit owing to active bleeding. MATERIAL AND METHODS: We enrolled all patients consecutively admitted to the emergency unit for NVUGIB, acutely bleeding at endoscopy (spurting or oozing). Demographic characteristics, clinical and biochemical parameters, endoscopic findings and treatments were evaluated. RESULTS: Of a total of 142 patients (98 M (69%), mean age+/-SD=66+/-14 years), spurting (16 (11.3%)) and oozing (126 (88.7%)) were identified. All patients received endoscopic treatment within 6 h of admission and were managed according to the guidelines. Seventeen (12%) patients suffered rebleeding, 4 patients (2.8%) required surgery to stop the bleeding, and 8 (5.6%) died during hospitalization (4 within 5 days and the remainder within 24 days of admission) - 3 as a consequence of bleeding (2.1%) and 5 of non-surgical complications (3.5%). Cox regression analysis showed that the lesions in more than one segment of the esophagogastroduodenal tract (p=0.008, hazard ratio (95% CI)=7.623 (1.680-34.600)) and the number of blood units transfused during the first 48 h of hospitalization (p=0.038, 2.075 (1.041-4.135)) were predictive of in-hospital death. CONCLUSIONS: In Forrest 1 patients given rapid endoscopic treatment, in-hospital mortality seems to be related to the contemporaneous presence of bleeding and non-bleeding lesions in more than one segment of the esophagogastroduodenal tract and the number of blood units transfused during the first 48 h of hospitalization.