The Overweight Paradox: Impact of Body Mass Index on Patients Undergoing VATS Lobectomy or Segmentectomy.

The aim of this study was to assess the impact of BMI on perioperative outcomes in patients undergoing VATS lobectomy or segmentectomy. Data from 5088 patients undergoing VATS lobectomy or segmentectomy, included in the VATS Group Italian Registry, were collected. BMI (kg/m2) was categorized according to the WHO classes: underweight, normal, overweight, obese. The effects of BMI on outcomes (complications, 30-days mortality, DFS and OS) were evaluated with a linear regression model, and with a logistic regression model for binary endpoints. In overweight and obese patients, operative time increased with BMI value. Operating room time increased by 5.54 minutes (S.E. = 1.57) in overweight patients, and 33.12 minutes (S.E. = 10.26) in obese patients (P < 0.001). Compared to the other BMI classes, overweight patients were at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications. In the overweight range, a BMI increase from 25 to 29.9 did not significantly affect the length of stay, nor the risk of any complications, except for renal complications (OR: 1.55; 95% CI: 1.07-2.24; P = 0.03), and it reduced the risk of prolonged air leak (OR: 0.8; 95% CI: 0.71-0.90; P < 0.001). 30-days mortality is higher in the underweight group compared to the others. We did not find any significant difference in DFS and OS. According to our results, obesity increases operating room time for VATS major lung resection. Overweight patients are at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications following VATS resections. The risk of most postoperative complications progressively increases as the BMI deviates from the point at the lowest risk, towards both extremes of BMI values. Thirty days mortality is higher in the underweight group, with no differences in DFS and OS.

Cost analysis of pulmonary lobectomy procedure: comparison of stapler versus precision dissection and sealant.

OBJECTIVE: We aimed to evaluate the direct costs of pulmonary lobectomy hospitalization, comparing surgical techniques for the division of interlobar fissures: stapler (ST) versus electrocautery and hemostatic sealant patch (ES). METHODS: The cost comparison analysis was based on the clinical pathway and drawn up by collecting the information available from the Thoracic Surgery Division medical team at Mantova Hospital. Direct resource consumption was derived from a previous randomized controlled trial including 40 patients. Use and maintenance of technology, equipment and operating room; administrative plus general costs; and 30-day use of postsurgery hospital resources were considered. The analysis was conducted from the hospital perspective. RESULTS: On the average, a patient submitted to pulmonary lobectomy costs €9,744.29. This sum could vary from €9,027 (using ES) to €10,460 (using ST). The overall lower incidence (50% vs 95%, P=0.0001) and duration of air leakage (1.7 days vs 4.5 days, P=0.0001) in the ES group significantly affects the mean time of hospital stay (11.0 days vs 14.3 days) and costs. Cost saving in the ES group was also driven by the lower incidence of complications. The main key cost driver was staff employment (42%), then consumables (34%) and operating room costs (12%). CONCLUSION: There is an overall saving of around €1,432.90 when using ES patch for each pulmonary lobectomy. Among patients undergoing this surgical procedure, ES can significantly reduce air leakage incidence and duration, as well as decrease hospitalization rates. However, further multicenter research should be developed considering different clinical and managerial settings.

Pleurodesis with Thulium Cyber Laser versus talc poudrage: a comparative experimental study.

Sclerosing fluids to achieve pleurodesis could be hardly replaced for bed-side procedures, but other devices may be successfully applied during thoracoscopy. Thulium Cyber Laser was experimented for this purpose and compared to talc poudrage. Twenty pigs underwent operative videothoracoscopy (VATS). Ten models were subjected to double-port VATS and parietal pleura photoevaporation using Thulium Cyber Laser™ (TCL) 150 W 2010 nm on the posterior third of three ribs; the pleural surface was homogeneously treated inside the target perimeter. The remaining ten pigs underwent uniportal thoracoscopy; talc poudrage was performed using the current clinical practice dosage (1 g/18 kg) with accurate talc powder spread over the whole pleural surface. All models were followed up for 60 days. Pleurodesis firmness was graded on a three-tier scale (none-moderate-firm) and site-matching topographical expectancy was evaluated. TCL produced pleurodesis in all models: 7/10 were firm and 3/10 moderate. Talc poudrage pleurodesis was firm in 4/10 and moderate in 6/10. Pleural adhesions were found exclusively in the treated area after laser treatment, while talc created a wide spectrum of effects, most commonly anarchic jagged adhesions obliterating less than 50 % of the pleural cavity (7/10), mostly declivous. The pathologist found more aggressive inflammation (sometimes severe) in the talc group. Expected localized pleurodesis was always registered in laser group (10/10), while talc poudrage was found poorly effective if consistent pleurodesis is expected in an apico-dorsal position (2/10). Laser pleurodesis appears more homogeneous, qualitatively not inferior, and topographically more predictable than talc pleurodesis. Parietal photoevaporation seems effective and the localized pleurodesis is reproducible.

Minimally invasive thoracoscopic technique for cardiac resynchronization therapy.

Outcome of surgical left ventricular (LV) lead placement is not well defined in patients with failed percutaneous cardiac resynchronization therapy. An extended experience with epicardial LV lead placement is here reported, describing the minimally invasive procedure performed at our institution using a thoracoscopic surgical approach.

Correlation of computed tomography densitometry and pathological grading of emphysema with the variation of respiratory function after lobectomy for lung cancer.

The presence of emphysema may lead to an underestimation of postoperative respiratory function after lobectomy when evaluated by standard functional assessment. The aim of the study was to assess the correlation between computed tomography (CT) densitometry, pathological grading of emphysema and variation of pulmonary function after lobectomy for lung cancer. Forty-one patients entered the study. Respiratory function was assessed preoperatively and after a mean period of 4.04 months following surgery. Postoperative function remained unchanged or increased after surgery in nine patients (Group A). In the remaining 32 patients (Group B) postoperative function was reduced after surgery. Preoperative forced expiratory volume in 1 s (FEV(1))% was 68.5+/-13.1% in Group A and 91.7+/-21.0% in Group B. CT densitometry of the lobe to be resected was -877.8+/-57.6 HU in Group A and -827.5+/-64.4 HU in Group B. Pathological grading of emphysema of the resected lobe (range 0-10) was 4.1+/-2.2 in Group A and 3.1+/-1.2 in Group B. A significant correlation was observed (Spearman rank correlation) between the variation of FEV(1) and preoperative FEV(1) (P=0.003; r=-0.455), CT quantitative assessment (P=0.036; r=-0.430) and pathological grading (P=0.008; r=0.673). Patients with a higher degree of emphysema had a lower reduction of respiratory function after lobectomy and CT densitometry and pathological grading of emphysema correlated with the variation in respiratory function.

Prognostic factors and analysis of S100a4 protein in resected pulmonary metastases from renal cell carcinoma.

BACKGROUND: This study analyzes our experience with pulmonary resection for metastases from renal cell carcinoma. The goals were to search for factors influencing prognosis and to investigate the presence and the prognostic value of S100A4 protein in lung metastases and corresponding primary renal tumors. METHODS: Sixty-five patients underwent surgical resection for renal and pulmonary lesions between 1992 and 2007. S100A4 protein expression was immunohistochemically examined in the peritumoral infiltrate of 64 lesions (32 metastases and the 32 corresponding primary carcinomas). RESULTS: Overall 3-, 5-, and 10-year survival rates were 58, 46, and 25%, respectively. Univariate analysis revealed that surgical radicality (p = 0.0039) and stratification into groups according to the International Registry of Lung Metastases classification (p = 0.0137) were prognostic factors. Multivariate analysis confirmed that this classification was a significant prognostic factor (p = 0.01). All metastases and the corresponding primary carcinomas expressed S100A4 protein. Twenty-one metastases (66%) had weak expression and 11 (34%) had strong expression. Twelve (37.5%) primary lesions had weak expression and 20 (62.5%) had strong expression. The 5-year survival rate for patients with strong expression in primary carcinoma was 41%, significantly lower than that of patients with weak expression (78%; p = 0.05). CONCLUSIONS: Pulmonary resection in metastatic renal cell carcinoma results in long-term survival. Complete resection and stratification into groups according to the International Registry of Lung Metastases classification were prognostic factors. Overexpression of S100A4 protein in primary tumors was correlated with a poor prognosis. If confirmed in larger studies this finding could be used to schedule adjuvant treatments in patients undergoing nephrectomy for renal cell carcinoma.