The Use of Exogenous Lung Surfactant (Poractant Alfa) in Acute Respiratory Failure by Drowning.

Drowning is an acute respiratory failure as a result from immersion or submersion of the airways in a liquid medium (predominantly water). Inhalation of water causes severe lung damage due to the destruction of pulmonary surfactant, resulting in decreased lung elasticity, alveolar collapse, alteration of ventilation-perfusion ratio, intrapulmonary blood shunting, hypoxia, acute lung injury, and Acute Respiratory Distress Syndrome (ARDS). Poractant alfa (Curosurf®), a natural surfactant effective in the treatment of newborn respiratory distress, has been used in various forms of ARDS, but in drowning syndromes, experience is still poor. We describe a series of nine clinical cases of drowning, six adults and three children, treated in our Intensive Care Unit (ICU) with endobronchial administration of poractant alfa. After 24 and 48 hours of administration in all cases, there was an improvement in arterial blood gas analysis (ABG) parameters and imaging. All patients were discharged without clinical consequences.

Pharyngo-oesophageal perforation following anterior cervical discectomy and fusion: management and results.

OBJECTIVES: Pharyngo-oesophageal perforation is a rare, life-threatening complication of anterior cervical discectomy and fusion surgery; its management remains poorly defined. We reviewed our experience to understand the treatment of this dreadful complication. METHODS: Data regarding the demographics, clinical course, diagnosis, management and outcomes of 15 cases of pharyngo-oesophageal perforations in 14 patients were collected during the period from 2003 to 2016. RESULTS: Pharyngo-oesophageal perforation occurred at a median of 32 days (range 1 day-102 months) after anterior cervical discectomy and fusion surgery. Clinical manifestations included neck abscesses and cutaneous fistulas (10 cases), cervical swelling (two cases), salivary leakage from cervicotomy (two cases), dysphagia, halitosis and regurgitation (one case). In all cases, conservative management was utilized. Two patients affected by minor external fistulas were successfully managed conservatively. In 13 cases, the following surgery was performed: (i) radical bone debridement, total or partial removal of spine fixation devices, autologous bone graft insertion or plate/cage replacement in one case each; (ii) anatomical suture of the fistula; or (iii) suture line reinforcement with myoplasty (in 11/13 cases). Perforation recurred in three cases. One patient underwent reoperation. The other two patients were treated conservatively At a median follow-up of 82 months (range 1-157 months), all patients exhibited permanent resolution of the perforation. CONCLUSIONS: Patients with minimal leaks in the absence of systemic infection can be managed conservatively. For cases of large fistulas with systemic infection, we recommend partial or total removal of the fixation devices, direct suture of the oesophageal defect and coverage with tissue flaps.

Ex vivo pulmonary nodule detection with miniaturized ultrasound convex probes.

BACKGROUND: The intraoperative localization of small and deep pulmonary nodules is often difficult during minimally invasive thoracic surgery. We compared the performance of three miniaturized ultrasound (US) convex probes, one of which is currently used for thoracic endoscopic diagnostic procedures, for the detection of lung nodules in an ex vivo lung perfusion model. METHODS: Three porcine cardiopulmonary blocks were perfused, preserved at 4°C for 6 h and reconditioned. Lungs were randomly seeded with different patterns of echogenicity target nodules (9 water balls, 10 fat, and 11 muscles; total n = 30). Three micro-convex US probes were assessed in an open setting on the pleural surface: PROBE 1, endobronchial US 5-10 MHz; PROBE 2, laparoscopic 4-13 MHz; PROBE 3, fingertip micro-convex probe 5-10 MHz. US probes were evaluated regarding the number of nodules localized/not localized, the correlation between US and open specimen measurements, and imaging quality. RESULTS: For detecting target nodules, the sensitivity was 100% for PROBE 1, 86.6% for PROBE 2, and 78.1% for PROBE 3. A closer correlation between US and open specimen measurements of target diameter (r = 0.87; P = 0.0001) and intrapulmonary depth (r = 0.97; P = 0.0001) was calculated for PROBE 1 than for PROBES 2 and 3. The imaging quality was significantly higher for PROBE 1 than for PROBES 2 and 3 (P < 0.04). CONCLUSIONS: US examination with micro-convex probes to detect pulmonary nodules is feasible in an ex vivo lung perfusion model. PROBE 1 achieved the best performance. Clinical research with the endobronchial US micro-convex probe during minimally invasive thoracic surgery is advisable.

Results of left thoracoscopic Collis gastroplasty with laparoscopic Nissen fundoplication for the surgical treatment of true short oesophagus in gastro-oesophageal reflux disease and Type III-IV hiatal hernia.

OBJECTIVES: Controversy exists regarding surgery for true short oesophagus (TSOE). We compared the results of thoracoscopic Collis gastroplasty-laparoscopic Nissen procedure for the treatment of TSOE with the results of standard laparoscopic Nissen fundoplication. METHODS: Between 1995 and 2013, the Collis-Nissen procedure was performed in 65 patients who underwent minimally invasive surgery when the length of the abdominal oesophagus, measured intraoperatively after maximal oesophageal mediastinal mobilization, was ≤1.5 cm. The results of the Collis-Nissen procedure were frequency-matched according to age, sex and period of surgical treatment with those of 65 standard Nissen fundoplication procedures in patients with a length of the abdominal oesophagus >1.5 cm. Postoperative mortality and morbidity were evaluated according to the Accordion classification. The patients underwent a timed clinical-instrumental follow-up that included symptoms assessment, barium swallow and endoscopy. Symptoms, oesophagitis and global results were graded according to semi-quantitative scales. The results were considered to be excellent in the absence of symptoms and oesophagitis, good if symptoms occurred two to four times a month in the absence of oesophagitis, fair if symptoms occurred two to four times a week in the presence of hyperaemia, oedema and/or microscopic oesophagitis and poor if symptoms occurred on a daily basis in the presence of any grade of endoscopic oesophagitis, hiatal hernia of any size or type, or the need for antireflux medical therapy. The follow-up time was calculated from the time of surgery to the last complete follow-up. RESULTS: The postoperative mortality rate was 1.5% for the Collis-Nissen and 0 for the Nissen procedure. The postoperative complication rate was 24% for the Collis-Nissen and 7% for Nissen (P = 0.001) procedure. The complication rate for the Collis-Nissen procedure was 43% in the first 32 cases and 6% in the last 33 cases (P < 0.0001). The median follow-up period was 96 months. The results were: excellent in 27% of Collis-Nissen and 29% of Nissen; good in 64% of Collis-Nissen and 55% of Nissen; fair in 3% of Collis-Nissen and 11% of Nissen and poor in 6% of Collis-Nissen and 5% of Nissen (P = 0.87). CONCLUSIONS: In patients affected by a TSOE, the Collis-Nissen procedure may achieve equally satisfactory results as the standard Nissen procedure in uncomplicated patients. CLINICAL REGISTRATION NUMBER: NCT02288988.

Surgery for Type III-IV hiatal hernia: anatomical recurrence and global results after elective treatment of short oesophagus with open and minimally invasive surgery.

OBJECTIVES: Type III-IV hiatal hernia (HH) is associated with a true short oesophagus in more than 50% of cases; dedicated treatment of this condition might be appropriate to reduce the recurrence rate after surgery. A case series of patients receiving surgery for Type III-IV hernia was examined for short oesophagus, and the results were analysed. METHODS: From 1980 to 1994, 60 patients underwent an open surgical approach, and the position of the oesophago-gastric junction was visually localized; from 1995 to 2013, 48 patients underwent a minimally invasive approach, and the oesophago-gastric junction was objectively localized using a laparoscopic-endoscopic method. The patients underwent a timed clinical-instrumental follow-up that included symptoms assessment, barium swallow and endoscopy. The results were considered to be excellent in the absence of symptoms and oesophagitis; good, if symptoms occurred two to four times a month in the absence of oesophagitis; fair, if symptoms occurred two to four times a week in the presence of hyperaemia, oedema and/or microscopic oesophagitis; and poor, if symptoms occurred on a daily basis in the presence of any grade of endoscopic oesophagitis, HH of any size or type, or the need for antireflux medical therapy. The follow-up time was calculated from the time of surgery to the last complete follow-up. RESULTS: Among the open surgery patients, 78% underwent abdominal fundoplication, 10% the Belsey Mark IV procedure, 8% laparotomic Collis-Nissen fundoplication and 3% the Pearson operation. Among the minimally invasive surgery patients, 44% underwent a laparoscopic floppy Nissen procedure and 56% a left thoracoscopic Collis-laparoscopic Nissen procedure. The postoperative mortality and complication rates were 1.6% (1/60) and 15% for open surgery and 4.1% (2/48) and 12.5% for minimally invasive surgery. A total of 105 patients were followed up for a median period of 96 months. Five relapses occurred after open surgery (5/59, 8%) and two after minimally invasive surgery (2/46, 4%). Among the 105 patients, excellent, good, fair and poor outcomes were observed in 38%, 44%, 9% and 9%, respectively. CONCLUSIONS: These data suggested that the selective treatment of short oesophagus in association with a Type III-IV hernia reduced the anatomical recurrence rate and achieved satisfactory outcomes. CLINICALTRIALSGOV ID: NCT01606449.

Collis-Nissen gastroplasty for short oesophagus.

The Collis-Nissen procedure is performed for the surgical treatment of 'true short oesophagus'. When this condition is strongly suspected radiologically, the patient is placed in the 45° left lateral position on the operating table with the left chest and arm lifted to perform a thoracostomy in the V-VI space, posterior to the axillary line. The hiatus is opened and the distal oesophagus is widely mobilized. With intraoperative endoscopy, the position of the oesophago-gastric junction in relationship to the hiatus is determined and the measurement of the length of the intra-abdominal oesophagus is performed to decide either to carry out a standard anti-reflux procedure or to lengthen the oesophagus. If the oesophagus is irreversibly short ('true short oesophagus'), the short gastric vessels are divided and the gastric fundus is mobilized. An endostapler is introduced into the left chest. The left thoracoscopic approach is suitable to control effectively the otherwise blind passage of the endostapler into the mediastinum and upper abdomen (if a second optic is not used). The tip of the stapler is clearly visible while 'walking' on the left diaphragm. The Collis gastroplasty is performed over a 46 Maloney bougie. A floppy Nissen fundoplication and the hiatoplasty complete the procedure.

Esophagogastric metaplasia relates to nodal metastases in adenocarcinoma of esophagus and cardia.

BACKGROUND: Immunohistochemical profiles of esophageal and cardia adenocarcinoma differ according to the presence or absence of Barrett's epithelium (BIM) and gastric intestinal metaplasia (GIM) in the fundus and antrum. Different lymphatic spreading has been demonstrated in esophageal adenocarcinoma. We investigated the correlation among the presence or absence of intestinal metaplasia in the esophagus and stomach and lymphatic metastases in patients who underwent radical surgery for esophageal and cardia adenocarcinoma. METHODS: The mucosa surrounding the adenocarcinoma and the gastric mucosa were analyzed. The BIM+ patients underwent subtotal esophagectomy and gastric pull up, and the BIM- patients underwent esophagectomy at the azygos vein, total gastrectomy, and esophagojejunostomy. The radical thoracic (station numbers 2, 3, 4R, 7, 8, and 9) and abdominal (station numbers 15 through 20) lymphadenectomy was identical in both procedures except for the greater curvature. RESULTS: One hundred ninety-four consecutive patients were collected in three major groups: BIM+/GIM-, 52 patients (26.8%); BIM-/GIM-, 90 patients (46.4%); BIM-/GIM+, 50 patients (25.8%). Two patients (1%) were BIM+/GIM+. A total of 6,010 lymph nodes were resected: 1,515 were recovered in BIM+, 1,587 in BIM-/GIM+, and 2,908 in BIM-/GIM- patients. The percentage of patients with pN+ stations 8 and 9 was higher in BIM+ (p=0.001), and the percentage of patients with pN+ perigastric stations was higher in BIM- (p=0.001). The BIM-/GIM- patients had a number of abdominal metastatic lymph nodes higher than did the BIM-/GIM+ patients (p=0.0001). CONCLUSIONS: According to the presence or absence of BIM and GIM in the esophagus and cardia, adenocarcinoma correspond to three different patterns of lymphatic metastasization, which may reflect different biologic and carcinogenetic pathways.

The frequency of true short oesophagus in type II-IV hiatal hernia.

OBJECTIVES: The misdiagnosis of short oesophagus may occur on recurrence of the hernia after surgery for type II-IV hiatal hernia (HH). The frequency of short oesophagus in type II-IV hernia is undefined. The aim of this study was to assess the frequency of true short oesophagus in patients undergoing surgery for type II-IV hernia. METHODS: Thirty-four patients with type II-IV hernia underwent minimally invasive surgery. After full isolation of the oesophago-gastric junction, the position of the gastric folds was localized endoscopically and two clips were applied in correspondence. The distance between the clips and the diaphragm (intra-abdominal oesophageal length) was measured. When the intra-abdominal oesophagus was <1.5 cm after oesophageal mobilization, the Collis procedure was performed. After surgery, patients underwent a follow-up, comprehensive of barium swallow and endoscopy. RESULTS: After mediastinal mobilization (median 10 cm), the intra-abdominal oesophageal length was >1.5 cm in 17 patients (4 type II, 11 type III and 2 type IV) and ≤ 1.5 cm in 17 patients (13 type III and 4 type IV hernia). No statistically significant differences were found between patients with intra-abdominal oesophageal length > or ≤ 1.5 cm with respect to symptoms duration and severity. Global results (median follow-up 48 months) were excellent in 44% of patients, good in 50%, fair in 3% and poor in 3%. HH relapse occurred in 3%. CONCLUSIONS: True short oesophagus is present in 57% of type III-IV and in none of type II HHs. The intraoperative measurement of the submerged intra-abdominal oesophagus is an objective method for recognizing these patients.