Intraoperative Management of Hypercapnia With an Extracorporeal Carbon Dioxide Removal Device During Giant Bullectomy.

Extracorporeal CO2-removal devices have been introduced in clinical practice to provide protective and ultraprotective ventilation strategies in different settings to avoid retention of carbon dioxide. The need to facilitate lung-protective ventilation is required not only for the treatment of acute respiratory distress syndrome but also in thoracic surgery during complex operations, especially in respiratory compromised patients. This report describes a case of giant bullectomy for vanishing lung syndrome in which intraoperative hypercapnia secondary to protective ventilation was managed with a CO2-removal device (Decap-Hemodec s.r.l., Salerno, Italy). To the best of our knowledge, this is the first report in the literature of the intraoperative use of the Decap system for giant bullectomy.

Pulmonary Metastases from NSCLC and MPLC (Multiple Primary Lung Cancers): Management and Outcome in a Single Centre Experience.

BACKGROUND: This is an institutional review of surgical management of second pulmonary tumours in patients with history of Non-small Cell Lung Cancer (NSCLC) resection according to The American College of Chest Physicians' (ACCP) revision to the Martini and Melamed's criteria for the classification of multiple primary lung cancers (MPLC). METHODS: All patients who underwent iterative pulmonary resections for pulmonary metastasis (Group A) or MPLC (Group B) between 2006 and 2012 were reviewed and their survivals compared accordingly. The main criteria of insertion in Group B were different histology and the same histology with disease-free interval ≤ 4 years; we excluded loco-regional recurrence in nodes and/or on bronchial stump. RESULTS: Group A: Twenty patients; Disease free time (DFT) after first operation was 15.2 months (range 2-44). One, two and three years overall survival after second resection was 74%, 29%, 14% respectively. Group B: Thirty-six patients. One, two and three years overall survival was 94%, 81%, and 69% respectively. No statistical differences on outcome were found between the two groups in spite of the apparent worse survival rate for Group A (p=.197). CONCLUSIONS: A further resection for additional nodules, whether designated as intrapulmonary metastases or second primary NSCLC, can be an appropriate curative strategy in selected patients with unimpaired respiratory function and no evidence of distant metastatic disease. The site, the extent of the second resection, the histology and even the stage are unlikely to be related to survival.

Tracheo-bronchoplastic procedures for NSCLC: single-centre experience.

BACKGROUND: The purpose of this study was to assess operative mortality, morbidity, and long-term results of the totality of sleeve resections performed at our institutions over the last eight years, including sleeve lobectomies (SL), carinoplasties with total lung sparing (CP) and sleeve pneumonectomies (SP). METHODS: A retrospective review of all the patients who underwent a tracheo-bronchial resection for bronchial cancer between 2004 and 2012 was undertaken. Bronchial sleeve resections and combined bronchial and vascular sleeve resections were described. RESULTS: The resulting group studied was 22 patients. SL and SP had a perioperative mortality rate of 7.1% and 28.5% respectively; morbidity rates were 21.4% for SL and 42.8% for SP. Global one-year and three-year survival was 75% and 63% respectively. One-year survival was 84% for SL and 53% for SP; three-year survival rate was 65% and 35% respectively (p=0.24). The absence of nodal metastatic involvement was associated with a better outcome with a three-year survival rate of 69% in the N0 group vs a 36% rate in the N+ group. CONCLUSIONS: Sleeve resection procedures achieved satisfactory local control of the tumour in our experience even in patients with preoperative contraindication to pneumonectomy, with acceptable mortality and morbidity rates.

Accuracy of transthoracic ultrasound for the prediction of chest wall infiltration by lung cancer and of lung infiltration by chest wall tumours.

BACKGROUND: We wanted to determine the accuracy of transthoracic ultrasound in the prediction of chest wall infiltration by lung cancer or lung infiltration by chest wall tumours. METHODS: Patients having preoperative CT-scan suspect for lung/chest wall infiltration were prospectively enrolled. Inclusion criteria for lung cancer were: obliteration of extrapleural fat, obtuse angle between tumour and chest wall, associated pleural thickening. The criteria for chest wall tumours were: rib destruction and intercostal muscles infiltration with extrapleural fat obliteration and intrathoracic extension. Lung cancer patients with evident chest wall infiltration were excluded. Transthoracic ultrasound was preoperatively performed. Predictions were checked during surgical intervention. RESULTS: Twenty-three patients were preoperatively examined. Sensitivity, specificity, positive and negative predictive values of transthoracic ultrasound were 88.89%, 100%, 100% and 93.3%, respectively. Youden index was used to determine the best cut-off for tumour size in predicting lung/chest wall infiltration: 4.5cm. At univariate logistic regression, tumour size (<4.5 vs ≥ 4.5cm) (p=0.0072) was significantly associated with infiltration. CONCLUSIONS: Transthoracic ultrasound is a useful instrument for predicting neoplastic lung or chest wall infiltration in cases of suspect CT-scans and could be used as part of the preoperative workup to assess tumour staging and to plan the best surgical approach.

Synchronous thymoma and lung adenocarcinoma treated with a single mini-invasive approach.

A 75 year-old man with a lesion in the middle lobe of the lung was discovered to also have, during the follow-up period, a mass in the mediastinum, diagnosed as a multi-thymic cyst. Both pathologies were successfully treated with a single surgical approach by video-assisted thoracoscopy. We performed a middle VATS lobectomy with complete lymphadenectomy followed by radical thymectomy without additional incision. The postoperative course was uneventful.

Surgery for non-small cell lung cancer in younger patients: what are the differences?

BACKGROUND: Non-small cell lung cancer (NSCLC) in young adults is uncommon. The objective of this study was to evaluate the clinicopathological characteristics, outcomes and prognosis of people younger than 50 years old treated surgically for NSCLC. METHODS: A retrospective study was conducted using the institutional database of four thoracic surgery units to collect patients with NSCLC younger than 50 years who had undergone surgery. These patients were compared with older patients (>75-years) operated in the same institutions and in the same period. RESULTS: We identified 113 young patients and 347 older patients. Younger patients were more likely to be female, non-smokers, with fewer comorbidities. Younger patients were more likely to be symptomatic at the time of diagnosis. Risk factors for poor prognosis in younger patients were T-stage, and disease-free-interval less than 548 days. Kaplan-Meier analysis showed a lower five-year survival in older patients compared with the younger ones (66% vs 38%, p=0.001). CONCLUSIONS: In conclusion NSCLC in younger patients has some distinct clinicopathological characteristics. The overall-survival of young patients is better than in older patients. Young patients receive more complete and aggressive treatment that could explain better survival. Further prospective studies with larger patient populations are required, to clarify the biological and genetic variance of NSCLC in younger patients.

Video-assisted thoracoscopic lobectomy for non-small cell lung cancer: a morbidity limiting approach in a patient on chronic hemodialysis and double agent antiplatelet therapy.

Patients with end-stage renal disease on hemodialysis undergoing surgery for lung cancer represent a high-risk group because of electrolyte imbalance, anemia, hemodynamic instability, bleeding tendency, and immunocompromised state. We describe a patient on hemodialysis with three lung adenocarcinoma of the right lower lobe as an incidental finding during the clinical course of a myocardial infarction treated with drug-eluting stent implantation and double-agent antiplatelet therapy. Considering patient comorbidities, we decided to perform a right lower lobectomy and complete lymph node dissection by a minimally invasive technique. In our experience, the thoracoscopic approach allowed us to perform lobectomy with complete lymph nodes dissection without morbidity. The use of ultrasound scalpel permits a complete lymph node dissection minimizing bleeding even in a double antiplatelet therapy patient.

Three-dimensional surgical simulation-guided navigation in thoracic surgery: a new approach to improve results in chest wall resection and reconstruction for malignant diseases.

OBJECTIVES: Oncological surgery of the chest wall should be performed to achieve free margins of at least 2 cm for metastasis or 4 cm for primary tumours. When the lesion is not visible or palpable, difficulty in identification may lead to a larger incision and a resection wider than is necessary. METHODS: We report three cases of non-palpable metastatic chest wall lesions in which the preoperative surgical planning and the intraoperative identification of the tumour, and thus the subsequent chest wall reconstruction, was supported using computer-based surgery. RESULTS: The application of high-resolution three-dimensional imaging technology and navigational systems is used in preoperative surgical planning to provide virtual simulations of a patient's skeletal changes and new soft tissue profile. Intraoperatively, a mobile navigation probe was used to identify the lesion, matching surgical landmarks and the preoperative computed tomography imaging, achieving the radical resection of the tumour with correct but not excessive surgical margins. Two patients underwent partial sternectomy followed by sternal allograft reconstruction. The third patient underwent chest wall resection followed by reconstruction using titanium bars and vicryl mesh. In all cases, the postoperative period was uneventful. After a follow-up period of 13.9 and 8 months, respectively, all patients are disease free, without complications. CONCLUSIONS: Application of navigation technology in thoracic surgery should be encouraged because it is easy to use and requires a limited learning curve.

Thoracoscopic resection of a giant mediastinal parathyroid cyst.

Parathyroid cysts are a rare situation, unusually in the mediastinum. The preoperative diagnosis could be more difficult in some atypical topographies and imaging characteristics in particular in case of huge mediastinal cyst. In the following years traditionally, in case of intrathoracic parathyroid cysts, sternotomy or thoracotomy have been the preferred approaches. We report a case of an older patient with a huge mediastinal parathyroid cyst removed successfully using videothoracoscopy.

Recurrent primary cardiac osteosarcoma: a case report and literature review.

Primary malignant cardiac tumors are very rare. Among malignant tumors, sarcomas occupy first place. In particular, primary cardiac osteosarcoma is extremely rare. To the best of our knowledge, only 42 cases have been reported worldwide. Cardiac malignant tumors usually require complex operations due to the difficulty in completely removing the tumor with acceptable free surgical margins and because of the proximity to vital structures. The current multimodality treatment strategies for cardiac sarcoma are still suboptimal, and surgery in particular frequently has unsatisfactory results. We report a case of recurrent primary cardiac osteosarcoma in a young male who underwent trans-sternal right pneumonectomy and a wide resection of the left and right atrium followed by reconstruction with heterologous pericardium under extracorporeal circulation. The patient died 6 months after the operation due to local and systemic disease recurrence.

Sternal resection and reconstruction for local recurrence of breast cancer using the sternal allograft transplantation technique.

Sternal involvement in patients with breast cancer is relatively rare and its treatment is still controversial. Surgery is usually indicated in cases of single metastases in a multimodality protocol. Partial or complete sternectomy associated or not with the resection of surrounding tissues is the technique of choice to obtain safety margins and radical treatment of the disease. The most challenging part of the operation is the reconstruction of the anterior chest wall in order to avoid secondary complications and respiratory failure. In the last few years, different techniques and materials have been used to reconstruct the sternum. We report our experience in two patients with recurrent breast cancer using the sternal allograft technique to replace the sternum after partial sternectomy. The use of a sternal-allograft provides excellent functional and cosmetic results without complications during the follow-up period. The implantation technique is simple and reproducible.

Desmoid tumour of the thoracic outlet in a 70 year-old man successfully removed through cervico-thoracic Dartevelle approach.

Desmoid tumours have a strong tendency for local invasion and recurrence. A 70 year-old male presented with cervical and left shoulder pain associated with a supraclavicular mass. The computed-tomography showed an expansive lesion measuring 10 cm × 6 cm × 5.5 cm in the left supraclavicular space. At magnetic resonance imaging the subclavian vessels and the brachial plexus were dislocated anteriorly but not infiltrated. An incisional biopsy suggested a desmoid tumour. An anterior cervicothoracic approach was used to remove the tumour. The chest wall was reconstructed with titanium bars and a polytetrafluoroethylene-patch. The clavicle was fixed using a titanium clip. The post-operative course was uneventful. The patient was treated with adjuvant radiation therapy. After six months the patient is in good clinical condition free from disease recurrence. In conclusion, desmoid tumour of the thoracic outlet is a challenging situation. Wide radical resection should be attempted whenever possible. The Dartevelle approach gives an optimal surgical field with direct control of vessels and nerve roots facilitating tumour dissection and radical resection en-bloc with the chest wall. The chest wall reconstruction with titanium bars and clips is a simple and effective method to guarantee good respiratory function and to stabilise the shoulder girdle.

Paraneoplastic dermatomyositis as presentation of thymic carcinoma.

Thymic carcinomas are very rare and heterogeneous groups of anterior mediastinum neoformations with an extremely aggressive behavior. Often, the diagnosis is made in the advanced stages. Paraneoplastic syndromes associated with thymic carcinoma are extremely rare. We report a case of a 64-year-old man presenting with early stage thymic carcinoma which was discovered because of associated paraneoplastic dermatomyositis. The dermatomyositis disappeared completely after radical resection of the tumor. After 20-month follow-up, the patient is in good clinical condition without recidivism of disease.

A massive post-sternotomy sternal defect treated by allograft sternal transplantation.

We report a case of a patient with complete sternal destruction after cardiac surgery, who underwent total sternal replacement with sternal allograft, titanium bars, and screws.

Can topical application of tranexamic acid reduce blood loss in thoracic surgery? A prospective randomised double blind investigation.

OBJECTIVE: The systemic or topical use of antifibrinolytic agents is effective in reducing postoperative bleeding and blood product transfusion in cardiac surgery. We sought to study the effect of the topical application of tranexamic acid into the pleural space to reduce postoperative bleeding after lung surgery. METHODS: This was a prospective randomised double blind placebo controlled investigation. From May-2010 to February-2012, 89-patients, scheduled for pulmonary resection, were randomly allocated to one of the two study groups. Group-A received 5 g of tranexamic-acid in 100 ml of saline solution. Group-B received 100 ml of saline solution as placebo. RESULTS: The blood loss in the first 12-h was significantly less in group-A. The same trend was observed in the first 24-h but without reaching a true statistical significance. The mean volume of blood transfusion was statistically lower in group-A. The analysis between post-operative haemoglobin concentration, haematocrit, platelet-count, international-normalised-ratio, fibrinogen and partial-thromboplastin-time of both groups was not statistically significant. CONCLUSION: In our experience, the topical use of tranexamic-acid after lung surgery reduces postoperative bleeding and blood transfusion volume. The topical administration of tranexamic-acid is safe without increasing the risk of post-operative complications related to pharmacological side-effects.

Accuracy of transthoracic ultrasound for the detection of pleural adhesions.

OBJECTIVES: In the era of minimally invasive surgery, preoperative detection of pleural adhesions can be very useful for the assessment of surgical approach, because pleural adhesions are the main contraindication to video-assisted thoracoscopy. The aim of this study was to assess the sensitivity and specificity of transthoracic ultrasound in the detection of pleural adhesions prior to thoracic surgery. METHODS: From February 2010 to January 2011, 142 consecutive patients (male, 98; female, 44; age range, 36-83 years, mean age, 63.4 years) undergoing surgical thoracic intervention (except for pneumothorax) were preoperatively scanned by two different surgeons. According to thoracic wall projections of lung segments, we created a nine-region topographic map, in which every pulmonary area was scanned to assess the presence or the absence of 'gliding sign' (lesion-by-lesion analysis). During operations the surgeon, blinded to the prediction, confirmed or excluded each suspected adhesion or documented other adhesions not previously identified. RESULTS: A total of 1192 predictions were made. Ultrasound predictions were confirmed 1124 times and refuted 68 times. Sensitivity was 80.6% (95% confidence interval, 0.740-0.872) and specificity 96.1% (95% confidence interval, 0.949-0.973). The positive predictive value was 73.2% and the negative predictive value was 97.4%. CONCLUSIONS: Transthoracic ultrasound is an effective method for predicting pleural adhesions before thoracic surgery in experienced hands. Its safety, feasibility and low cost make it a useful method for the planning of minimally invasive surgical interventions.

Allogenic sternal transplant after sternectomy for metastasis of ovarian carcinoma.

Sternal metastasis from ovarian carcinoma is extremely rare. We report a case of a young woman in whom a single metastasis at the level of the upper portion of the sternum developed. Surgical excision of the sternum was performed with replacement by a sternal allograft stabilized by titanium plates and transosseous high-tension sutures. With this simple and reproducible technique, we obtained a stable and dynamic reconstruction of the sternoclavicular joints and shoulder girdle. The use of a sternal allograft provides excellent functional and cosmetic results. The implantation technique is simple and reproducible.

Surgical results and long-term follow-up of T(4)-non-small cell lung cancer invading the left atrium or the intrapericardial base of the pulmonary veins.

Patients with locally advanced non-small cell lung cancer infiltrating the left atrium (LA) or the intrapericardial base of the pulmonary veins (PVs) are generally not considered good candidates for surgery because of the poor long-term survival. In the last 10 years, 31 consecutive patients with non-small cell lung cancer directly invading the LA or the intrapericardial base of the PVs underwent surgery. Pneumonectomy was the operation performed most frequently. In-hospital mortality was 9.7% and overall morbidity was 52%. One-, 2- and 3-year survival rates were 64, 46 and 30%, respectively with a mean survival of 22 months. The systemic recurrence of disease was the major cause of death at follow-up. At statistical analyses, the N-factor and the type of operation were related to poor long-term survival. In these patients, surgery could be performed with an acceptable operative mortality and morbidity. Surgery should be considered whenever a complete resection is technically possible. A careful preoperative evaluation is mandatory to select good candidates for surgery.

Pleuropneumonectomy for stage IVa thymoma: delayed metastatic spread after multimodality treatment.

We report a case of a caucasic woman aged 55, carrying a Masaoka stage IVa thymoma, initially not suitable to surgical treatment. After induction chemotheraphy, she underwent a radical resection of the mediastinal mass combined with left pleuro-pneumonectomy. After being disease-free for 5 years, the patient first developed a splenic recurrence, then an abdominal metastasis, both treated by surgery. To date she is alive and disease-free, 10 years after the first operation. The patient underwent multimodal treatment only after the first surgical operation, while the recurrences were only treated surgically. The exceptional nature of our case lies mainly in the site of the metastases (first the spleen, then the omentum), then in the long disease-free period, and in the final outcome which was beyond all expectations.

Right pneumonectomy for T4 non-small cell lung cancer invading intrapericardial pulmonary vein in a patient with a right aortic arch.

A 59 year-old man with a right-sided aortic arch who had a T4 right lung cancer invading the proximal superior pulmonary vein underwent an intrapericardial-pneumonectomy with partial left atrium resection and a radical lymphadenectomy. The presence of a right-sided aortic arch required particular attention during dissection of the lymph nodes. This is the first case of a right-pneumonectomy for T4-lung cancer in a patient with a right-sided aortic arch.