Is chest tube capnography effective in differentiating between true and false air leaks after minimally invasive thoracic surgery?

OBJECTIVE: Air leak (AL) is the most frequent adverse event after thoracic surgery. When AL occurs, the concentration of the principal gas in the pleural space should be similar to that of air exhaled. Accordingly, we tried to develop a new method to identify AL by analyzing pCO2 levels in the air flow from the chest drainage using capnography. METHODS: This is a prospective observational study of 104 patients who underwent VATS surgery between January 2020 and July 2021. Digital drainage systems were used to detect AL. RESULTS: Eighty-two patients (79%) had lung resection. Among them, 19 had post-operative day 1 air leaks (median 67 ml/min). AL patients had higher intrapleural CO2 levels (median 24 mmHg) (p < 0.001). Median chest drainage duration was 2 days (range 1.0-3.0). Univariable logistic regression showed a linear and significant association between intrapleural CO2 levels and AL risk (OR 1.26, 95% CI 1.17-1.36, p < 0.001, C index: 0.94). The Univariable Gamma model demonstrated that an elevation in CO2 levels was linked to AL on POD1 (with an adjusted mean effect of 7.006, 95% CI 1.59-12.41, p = 0.011) and extended duration of drainage placement (p < 0.001). CONCLUSIONS: Intrapleural CO2 could be an effective tool to assess AL. The linear association between variables allows us to hypothesize the role of CO2 in the identification of AL. Further studies should be performed to identify a CO2 cutoff that will standardize the management of chest drainage.

A strange case of pleuritic pain in the third trimester of pregnancy.

Pulmonary sequestration is an uncommon congenital malformation of the lung, generally diagnosed in childhood or adolescence, corresponding to dysplastic lung tissue not communicating with the rest of vascular or bronchial lung system but receiving an arterial blood supply from systemic arteries. Currently, surgical resection is usually indicated in order to prevent or treat related symptoms or complications, although controversy exists regarding its use in asymptomatic patients and adults. We present the case of a 32-year-old pregnant woman with acute chest pain and vomiting diagnosed with intralobar sequestration at 32+2 weeks of gestation and treated with pulmonary lobectomy after giving birth by cesarean section at 33+0 weeks of gestation.

Sublingual Sufentanil in Pain Management After Pulmonary Resection: A Randomized Prospective Study.

BACKGROUND: Successful postoperative pain management after major lung resection surgery is mostly achieved through intravenous administration of analgesic drugs. This study explored the use of sublingual sufentanil cartridges (Zalviso) as a noninvasive alternative to postoperative analgesia. METHODS: From July 2019 to April 2020, patients who underwent major thoracoscopic lung resection surgery were randomly allocated to receive either intravenous pain management, or patient-controlled analgesia by the Zalviso system. Pain assessment scores were collected for a 72-hour time window, and requests for additional medication due to insufficient pain control were recorded. RESULTS: Of the 80 patients enlisted, 40 were assigned to the Zalviso group and 40 to the control group. The groups were not statistically different from each other. The difference in the mean pain scores reported was statistically significant in the first 24 hours in favor of the Zalviso group (P = .046), and the need for additional pain medication was significantly higher in the control group (P = .004). CONCLUSIONS: Patient-controlled analgesia using sublingual sufentanil cartridges can provide effective pain relief for patients undergoing video-assisted thoracic surgery and can reduce the need for additional medication, offering a noninvasive alternative to traditional intravenous therapy.

Video-assisted thoracoscopic lobectomy after neoadjuvant chemotherapy for non-small cell lung cancer: a multicenter propensity-matched study.

BACKGROUND: The role of video-assisted thoracoscopic surgery for the treatment of non-small-cell lung cancer after neoadjuvant chemotherapy remains controversial. The aim of this study is to demonstrate the reliability of video-assisted lobectomy compared to the open approach by evaluating perioperative and long-term outcomes. METHODS: In this retrospective, multicentric study from January 2010 to December 2018, we included all patients with non-small-cell lung cancer who underwent lobectomy through the video-assisted or open approach after neoadjuvant chemotherapy. The perioperative outcomes, including data concerning the feasibility of the surgical procedure, the occurrence of any medical and surgical complications and long-term oncological evidence, were collected and compared between the two groups. To minimize selection bias, propensity score matching was performed. RESULTS: A total of 286 patients were enrolled: 193 underwent thoracotomy lobectomy, and 93 underwent VATS lobectomy. The statistical analysis showed that surgical time (P < 0.001), drainage time (P < 0.001), days of hospitalization (P < 0.001) and VAS at discharge (P = 0.042) were lower in the VATS group. The overall survival and disease-free survival were equivalent for the two techniques on long-term follow-up. CONCLUSIONS: VATS lobectomy represents a valid therapeutic option in patients affected by non-small-cell lung cancer after neoadjuvant chemotherapy. The VATS approach in our experience seems to be superior in terms of the perioperative outcomes, while maintaining oncological efficacy.

Comparison of operative and postoperative characteristics and outcomes between thoracoscopic segmentectomy and lobectomy for non-small-cell lung cancer: a propensity score matching study from the Italian VATS Group Registry.

OBJECTIVES: Only few studies compared the surgical morbidity and mortality of thoracoscopic segmentectomy versus lobectomy for non-small-cell lung cancer, in particular, by relating the segmental resections with the corresponding anatomical lobes. METHODS: We enrolled a total of 7487 patients who underwent VATS lobectomy (7269) or segmentectomy (218) from January 2014 to July 2019. A propensity score matching approach was used to account for potential confounding factors between the 2 groups. After matching, 349 lobectomies and 208 segmentectomies were included in the analysis. We analysed the operative and postoperative outcomes of video-assisted anatomical segmentectomy compared with video-assisted lobectomy and, in details, the results of segmentectomy with its corresponding lobectomy in a large cohort of patients from the Italian VATS Group Registry. RESULTS: The overall conversion rate to thoracotomy was not statistically different between the groups (27 patients 8% vs 7 patients 3%, P = 0.1). The lobectomy group had a greater number of resected lymph nodes (median 11 vs 8, P = 0.006). No significant differences were detected in 30-day mortality (1.4%, 5 patients vs 0.9%, 2 patients), overall complications (18%, 62 patients vs 14%, 29 patients) and prolonged air leakage (31 patients, 9% vs 12 patients, 6%) between lobectomy and segmentectomy, respectively. No statistical differences were found regarding the median duration of drainage (3.2 days, P = 1) and the overall median length of hospital stay (6.4 days, P = 0.1) between the 2 groups. In the context of segmentectomy versus corresponding lobectomy, the right upper lobectomy compared with right upper segmentectomy showed a higher number of resected lymph nodes (P = 0.027). No statistical differences were reported in terms of conversion rate and postoperative complication and mortality. CONCLUSIONS: Segmentectomy could be considered a safe procedure without significant differences compared to thoracoscopic lobectomy in terms of postoperative morbidity and mortality.

Extracorporeal membrane oxygenation in lung transplantation: Indications, techniques and results.

The use of extracorporeal membrane oxygenation (ECMO) in the field of lung transplantation has rapidly expanded over the past 30 years. It has become an important tool in an increasing number of specialized centers as a bridge to transplantation and in the intra-operative and/or post-operative setting. ECMO is an extremely versatile tool in the field of lung transplantation as it can be used and adapted in different configurations with several potential cannulation sites according to the specific need of the recipient. For example, patients who need to be bridged to lung transplantation often have hypercapnic respiratory failure that may preferably benefit from veno-venous (VV) ECMO or peripheral veno-arterial (VA) ECMO in the case of hemodynamic instability. Moreover, in an intra-operative setting, VV ECMO can be maintained or switched to a VA ECMO. The routine use of intra-operative ECMO and its eventual prolongation in the post-operative period has been widely investigated in recent years by several important lung transplantation centers in order to assess the graft function and its potential protective role on primary graft dysfunction and on ischemia-reperfusion injury. This review will assess the current evidence on the role of ECMO in the different phases of lung transplantation, while analyzing different studies on pre, intra- and post-operative utilization of this extracorporeal support.

Primary Hodgkin lymphoma of the lung arising with hemoptysis and pulmonary consolidation: a case report.

Classic Hodgkin lymphomas are neoplasms originating from lymphoid tissue. Primary extra-nodal classic Hodgkin lymphoma (PE-cHL) of the lung is rare. A 37-years-old Caucasian male was referred to our hospital for recurrent episodes of hemoptysis, cough and bronchitis. A computed tomography (CT) scan showed a massive left upper lung consolidation, which was positive at the positron emission tomography (PET) scan. After several inconclusive tests and no benefit from medical therapies, the patient underwent a left upper lobectomy; pathology report showed a classical type Hodgkin lymphoma with no lymph-nodes involvement. Four cycles of adjuvant chemotherapy were administered with no toxicity. At the last follow up 14 months after surgery, the patient is alive and free from disease. Primary extra-nodal classical Hodgkin lymphoma of the lung is a rare entity, but it should be considered as a differential diagnosis in young patients with pulmonary consolidation even without systemic symptoms.

Predictors of behaviour in solitary fibrous tumours of the pleura surgically resected: Analysis of 107 patients.

OBJECTIVES: Gold standard therapy for solitary fibrous tumour of the pleura is complete surgical resection. Aims of this retrospective study are to evaluate oncological and surgical outcomes and to verify the clinical reliability of prognostic scores presented in literature. METHODS: Study population: 107 patients surgically treated between 1972 and 2018. Male/female ratio: 1/2.45; median age at surgery: 60 years (range, 19-80); peduncle lesions 69.8%; visceral pleura origin 72.9%; benign histology 73.8%; median diameter 8 cm (range 1 to 35, 27 cases giant [≥15 cm]). RESULTS: After a median follow up of 7 years, 12 patients had recurrence. By multivariate analysis, malignant histology (P = .03; HR, 4.17; 95% CI, 1.15-15.06), origin from parietal pleura (P = .03; HR, 3.90; 95% CI, 1.08-14.09), England (P = .002; HR, 1.98; 95% CI, 1.28-3.07), Diebold (P = .008; HR, 1.96; 95% CI, 1.20-3.22) and Tapias (P = .003; HR, 1.75; 95% CI, 1.20-2.53) scores were found independent significant predictors of relapse. Giant tumours were associated with open surgery (P = .003), origin from parietal pleura (P = .011) and intraoperative bleeding (P > .001). Overall 10-year disease-free survival (DFS) rate was 81%. Predictors of worst DFS were parietal pleura origin (P = .002), malignant histology (P = .006) and all the prognostic scores. CONCLUSIONS: Malignant histology and origin from parietal pleura were significant predictors of tumour recurrence and worst DFS. The use of current scoring systems can help to predict clinical behaviour. Patients with higher risk of relapse can benefit from closer follow up, prolonged over 10 years.