Left atrial size predicts the onset of atrial fibrillation after major pulmonary resections.

OBJECTIVES: Atrial fibrillation (AF) is a frequent complication after pulmonary resections. Notwithstanding prevention and early treatment it may show a negative impact on the outcome. We assessed the role of echocardiographic variables to predict the onset of this complication. METHODS: One-hundred and thirty-four patients were prospectively evaluated: 72 (53.7%) (Group I) underwent lobectomy or pneumonectomy; 62 (46.3%) receiving minor thoracic procedures were included in Group II. Previous AF was the only exclusion criteria. All patients preoperatively underwent bidimensional echocardiography. Demographics, type of resection, histology, staging, diagnosis of chronic obstructive pulmonary disease , induction chemotherapy, smoking history, magnesium levels, other cardiologic diseases, electrocardiographic and echocardiographic findings (atrial and ventricular diameters, left atrial area, left ventricular ejection fraction and diastolic dysfunction) were assessed. RESULTS: Preoperative variables did no't show any statistically significant difference between the groups. In 21 patients (15.7%) AF was observed 3.7 ± 1.8 days after surgery. All AF episodes occurred in Group I. Three patients (2.2%) with AF died during the postoperative course. The left atrial diameter and area were significantly enlarged in patients with AF (P = 0.001 and P < 0.0002); 18 AF episodes (86%) occurred in patients with atrial enlargement. At univariate analysis low postoperative magnesium levels, LV diastolic dysfunction, left atrial antero-posterior diameter >40 mm, left atrial area above 20 mm(2) and extended resections were statistically significant. At multivariate analysis only left atrial area enlargement was an independent predictive prognostic factor for postoperative AF. CONCLUSIONS: Echocardiographic left atrial size evaluation may be useful to predict the onset of postoperative AF in patients undergoing lobectomy and pneumonectomy.

Anterior approach to the thoracic spine.

An anterior approach affords the spine surgeon excellent visualization and access to the anterior thoracic spine, the vertebral bodies, intervertebral disks, spinal canal, and nerve roots. This approach is currently used in the surgical treatment of thoracic disk disease, vertebral osteomyelitis or discitis, fractures and tumors of the vertebral bodies, allowing for proper decompression of neural elements and spine stabilization. Over a 10-year period in a single institution, a total of 142 patients with a mean age of 49.6 years underwent anterior thoracic exposure of the spine. The indication for surgery was trauma fracture in 20 patients, malignancy in 35, degenerative disease in 29 and correction of scoliosis in 58. Surgical approaches were determined based on the location and length of spinal involvement, including cervico-thoracic approach (15) thoracotomic approach (85) video-assisted thoracoscopy (10) and thoracolumbar exposure (32). Mean operative time was 334 min (range from 256 to 410 min). There was no perioperative mortality. Thirty-one patients (21.8%) developed postoperative complications. The anterior approach to the thoracic spine is safe and effective and even the presence of complications can be appropriately managed. An adequate preoperative evaluation stratifying the risk and instituting measures to reduce it, accurate surgical planning and careful surgical technique are key to yielding a good outcome and to reduce the risk of complications.

Thymoma and thymic carcinoma.

Thymoma and thymic carcinoma are an extremely heterogeneous group of neoplastic lesions with an exceedingly wide spectrum of morphologic appearances. They show different presentations with a variable and unpredictable evolution ranging from an indolent non-invasive attitude to a highly infiltrative and metastasising one. Prognosis can be predicted on the basis of a number of variables, mainly staging, the WHO histological pattern and diameter of the tumour. Complete surgical resection is certainly the gold standard to achieve cure. However, especially in patients with lesions at advanced stage, complete resection may be difficult and recurrence often occurs; at these stages, disease-free long-term survival may be difficult to be accomplished. Chemo- and radiotherapy protocols have been designed to complete surgical treatment and improve results in inoperable patients as well, based on the reported sensitivity of thymic tumours to these treatment modalities. The integration of clinical staging and histology, with the new histogenetic morphological classification, has contributed to design multimodality treatment protocols that help to improve prognosis. Induction therapy can now be applied before surgery in patients with tumours considered inoperable, improving resectability and outcome without adding morbidity and mortality to the surgical procedure. This newly developed approach helps to reduce the recurrence rate and to ameliorate disease-free survival. New therapies are now being evaluated as for many other tumours; however, they still need confirmation in prospective randomised studies. In the future, integrated treatment modality should be incorporated in a standardised approach that goes from a careful assessment of histology, staging and lymph node status, and a constructive and non-empirical co-operation between medical and radiation oncologists, pathologists and thoracic surgeons.

Thoracoscopic resection of mediastinal bronchogenic cysts in adults.

OBJECTIVE: Bronchogenic cysts are uncommon congenital anomalies of foregut origin usually located within the mediastinum and the lung and rarely diagnosed in adults. Surgical excision is recommended to establish diagnosis based on histologic examination, alleviate symptoms if present, and prevent future complications. Thoracoscopic approach is becoming the primary therapeutic option. METHODS: Between January 1995 and July 2008, 30 patients with mediastinal bronchogenic cyst (MBC) underwent thoracoscopic operation (19 male, 11 female with a mean age of 39 years, range 19-59 years). Symptoms were present in 11 patients (37). RESULTS: The cysts averaged 5.2 cm in their greatest diameter (range 3-10.5 cm). In two cases thoracoscopy was converted to thoracotomy because of major pleural adhesions. There were no operative deaths and no intra-operative complications. Postoperative course was uneventful in all cases and the 28 patients who underwent thoracoscopy were discharged after a mean of 3.7 days (range 2-5 days). CONCLUSIONS: Considering the low conversion and complication rate, thoracoscopic excision of bronchogenic mediastinal cyst should be considered the primary therapeutic option.

Long-term Doppler echocardiographic evaluation of the right heart after major lung resections.

OBJECTIVE: The effects of major lung resections on cardiac function in the medium and long term have not been thoroughly evaluated. We have studied right heart function with serial Doppler echocardiography in patients undergoing lobectomy and pneumonectomy during 4 years of follow-up after surgery. METHODS: Thirty-six patients undergoing lobectomy and 15 receiving pneumonectomy were evaluated with one- and two-dimensional Doppler standard transthoracic echocardiography before surgery and 1 week, 3 months, 6 months, 1 year, and 4 years postoperatively. We have studied the right midventricular diastolic diameter (RVDD), the right ventricle free wall thickness, the tricuspid valve insufficiency (TVI) and regurgitation jet (TRJ), and the pulmonary artery systolic pressure (PASP). RESULTS: None of the patients died within the first postoperative year. After lobectomy there were no significant modifications of any variable at any time. RVDD progressively increased after pneumonectomy (26.5+/-2.2mm preoperatively vs 34.3+/-7.6 at 4 years; p<0.001). Four years after surgery all patients undergoing pneumonectomy had moderate TVI while only 55% of patients receiving lobectomy showed it (low grade in 50% and moderate in 5%). In this group of patients PASP increased from 26.1+/-2.6 mmHg preoperatively to 34.3+/-7.6 mmHg at 4 years (p<0.00001). CONCLUSIONS: Right ventricle modifications are clearly evident after pneumonectomy and even if they do not show a clear clinical impact they should not be neglected.

Pleurodesis with an autologous blood patch to prevent persistent air leaks after lobectomy.

OBJECTIVE: Air leakage after pulmonary lobectomy is a well-known problem often contributing to extended hospitalization. Many techniques have been proposed to prevent and treat air leakage, but none have been proved incontrovertibly effective. We evaluated the role of an autologous blood patch after pulmonary lobectomy. METHODS: Twenty-five patients with air leaks on the sixth postoperative day after lobectomy were enrolled in this study. They were randomly assigned to 2 groups: group A (12 patients), with 50 mL of autologous blood infused in the pleural cavity; and group B (13 patients), with 100 mL of blood infused. These 2 groups were retrospectively compared with the last 15 patients showing the presence of air leaks for at least 6 days (group C) (in this group the duration of leakage after the sixth postoperative day was compared). We recorded the duration of posttreatment air leaks and hospitalization. RESULTS: Air leaks stopped 2.3 +/- 0.6 days after the procedure in group A, 1.5 +/- 0.6 days after the procedure in group B, and after 6.3 +/- 3.7 days in group C. The air leakage disappeared within 72 hours in all patients in groups A and B. There was a statistically significant difference in the duration of drainage between groups A and B (P = .005), groups A and C (P = .0009), and groups B and C (P = .0001), showing the effectiveness of an autologous blood patch, particularly with 100 mL of blood. CONCLUSIONS: Management of air leaks after lobectomy with an autologous blood patch is easy, safe, and effective, and does not add costs. It may become the gold standard treatment early in the postoperative course.

Successful treatment with one-way endobronchial valve of large air-leakage complicating narrow-bore enteral feeding tube malposition.

Tracheopulmonary intubation is the most common misplacement site for narrow-bore feeding tube and it might be associated with severe pleuro-pulmonary complications. A 38-year-old female with a severe bilateral pneumonia and acute respiratory insufficiency was admitted in the ICU, intubated, and mechanically ventilated. Few hours after the insertion of a narrow-bore feeding tube the patient's oxygen saturation dropped with hypotension and tachycardia. A large left-side hydropneumothorax developed requiring a chest tube. Air-leakage was important and bronchoscopic implant of one-way endobronchial valve was accomplished. Immediate and substantial decrease of air-leakage was observed, and it completely stopped after 5 days; as soon as the patient was extubated. Endobrochial one-way valve, specifically designed for bronchoscopic lung volume reduction, resulted in being safe and effective to control a significant and prolonged air-leakage due to a malposition of a narrow-bore feeding tube.

Laminin alpha2 chain-positive vessels and epidermal growth factor in lung neuroendocrine carcinoma: a model of a novel cooperative role of laminin-2 and epidermal growth factor in vessel neoplastic invasion and metastasis.

Capillaries expressing the laminin alpha2 chain in basement membranes may be considered early developing vessels in normal and neoplastic human tissues. Therefore, we investigated whether up-regulation of this extracellular matrix protein favors transendothelial migration of neoplastic cells and then metastasis. In lung small and large cell neuroendocrine carcinomas, which exhibit a stronger metastatic tendency among carcinomas, laminin alpha2 chain-positive vessels were more numerous than in carcinoid tumors and supraglottis, breast, and lung non-small cell carcinomas, suggesting a direct relationship between these vessels and metastasis. In vitro studies showed that epidermal growth factor (EGF) induced a more efficient migration of the AE-2 lung neuroendocrine carcinoma cell line through the purified laminin alpha2 chain rather than through the laminin beta1 chain and fibronectin. AE-2 cells constitutively expressed all EGF receptors and the alpha6beta1 integrin, which is one of the laminin alpha2 chain receptors. EGF up-regulated alpha6beta1 expression in several tumors. In this regard, we show that EGF increased the chemo-kinetic migration of AE-2 cells through EAHY endothelial monolayers, which was inhibited by the anti-alpha6 integrin chain monoclonal antibody. These data indicate that laminin alpha2 chain and alpha6beta1 may be mutually involved in EGF-dependent migration of AE-2 cells and that laminin alpha2 chain-positive vessels may favor metastasis of EGF-dependent tumors.

Operative endoscopy of the airway with the old-fashioned esophageal dilators.

Bronchial dilation is usually required to treat a number of disorders; the most frequent are complications after airway surgery, including lung transplantation, stenosis after radiotherapy, and compression by an extraluminal mass. The procedure is performed by forcing the tip of a rigid bronchoscope through the stenosis using barrels of increasing size; however, when there is a clear discrepancy between the caliber of the rigid instrument and the stenosis, the first step may be difficult. In such cases, we have successfully employed two types of old-fashioned esophageal dilators rescued from the armamentarium of our endoscopy unit.

Operative and non-operative treatment of benign subglottic laryngotracheal stenosis.

OBJECTIVE: Surgery is the first line of treatment for laryngotracheal stenosis; Montgomery tube or permanent tracheostomy have been so far the only alternatives. Nd-YAG laser resection and indwelling endotracheal stents have rarely been used in subglottic stenosis for anatomic and technical reasons. We have used the latter approach to optimize the timing of surgery or to achieve palliation without tracheostomy. METHODS: Between 1991 and 2001 we have treated 18 patients with subglottic stenosis (10 males, 8 females; age range 14-78, mean 34). The upper margin of the stricture was 2mm to 1cm below the vocal cords; the stenotic segment extended from 1.5 to 5 cm. Three patients had tracheostomy done elsewhere. Four patients (Group I) had laser and stenting by a Dumon prosthesis as the only treatment; six had laser and stenting (#4) followed after 1-6 months by laryngotracheal resection (Group II); eight had surgery alone (Group III). RESULTS: In Group I, one patient required repositioning of the stent and in two the stent was removed; two patients died of their underlying disease; at a follow-up of 2-9 years all living patients did well but required permanent aerosolized therapy and periodical bronchoscopy. In Group II, we had two wound infections due to airway colonization by staphylococcus aureus. In Group III, two patients developed anastomotic postoperative stenosis, treated by laser (#2) and stenting (#1), and one patient with previous tracheostomy had a wound infection. Overall, in the 14 surgical patients (Groups II and III) stenosis occurred in 14.2% and infection in 21.3%. After a follow up of 15 months to 12 years, all surgical patients breathe and speak well. CONCLUSIONS: Laser resection and endoluminal stenting can be a viable alternative to surgery or optimize the timing of operation in patients with subglottic stenosis.

Bullectomy is comparable to lung volume reduction in patients with end-stage emphysema.

OBJECTIVES: Emphysema is one of the most prevalent disabling diseases, not modified by current medical treatment and physical rehabilitation. Lung transplantation is an effective clinical option in end-stage emphysema but it is available only for a limited number of patients. Bullectomy and lung volume reduction represent other surgical options to improve symptoms and exercise tolerance in selected patients. Both procedures allow the removal of the area of emphysematous lung resulting in improvement in chest wall mechanics, ventilation/perfusion ratio and re-expansion and better function of the residual lung. There is some evidence that in patients with end-stage emphysema bullectomy and lung volume reduction work in the same manner and yield similar functional results. METHODS: We compared and analyzed retrospectively two groups of patients with end-stage emphysema who underwent bullectomy or lung volume reduction. Over the last 5 years 20 patients with end-stage emphysema presenting with bullae underwent thoracoscopic bullectomy (Group I). During the same period of time 18 patients with end-stage non-bullous emphysema underwent thoracoscopic unilateral lung volume reduction. Pre-operative baseline respiratory function data, peri-operative data, and functional results recorded at 6 and 12 months were compared and analyzed. RESULTS: Both groups were homogeneous in terms of age, degree of respiratory derangement and severity of emphysema. Complication rate and peri-operative data were similar in the two groups. Improvement in symptoms, respiratory function and exercise tolerance was comparable. CONCLUSIONS: Our experience supports the hypothesis that the physiopathological basis of respiratory improvement after bullectomy and lung volume reduction surgery in patients with end-stage emphysema is the same, although the exact mechanism remains incompletely understood.