Effectiveness of home-based preoperative pulmonary rehabilitation in COPD patients undergoing lung cancer resection.

OBJECTIVE: To investigate the effectiveness of a home-based preoperative rehabilitation program for improving preoperative lung function and surgical outcome of patients with chronic obstructive pulmonary disease (COPD) undergoing lobectomy for cancer. METHODS: This was a prospective, observational, single-center study including 59 patients with mild COPD who underwent lobectomy for lung cancer. All patients attended a home-based preoperative rehabilitation program including a minimum of 3 sessions each week for 4 weeks. Each session included aerobic and anaerobic exercises. Participants recorded the frequency and the duration of exercise performed in a diary. The primary end point was to evaluate changes in lung function including predicted postoperative (PPO) forced expiratory volume in 1 second (FEV1), 6-minute walking distance test (6MWD), PPO diffusing capacity for carbon monoxide (DLCO) %, and blood gas analysis values before and after the rehabilitation program. Postoperative pulmonary complications were recorded and multivariable analysis was used to identify independent prognostic factors (secondary end point). RESULTS: All patients completed the 4-week rehabilitation program. Thirteen of 59 (22%) patients (Group A) performed <3 sessions per week (mean sessions per week: 2.3±1.3); 46 of 59 (78%) patients (Group B) performed ⩾3 sessions per week (mean sessions per week: 3.5±1.6). The comparison of PPO FEV1% and 6MWD before and after rehabilitation showed a significant improvement only in Group B. No significant changes in PPO DLCO% or in blood gas analysis values were seen. Nine patients presented postoperative pulmonary complications, including atelectasis (n = 6), pneumonia (n = 1), respiratory failure (n = 1), and pulmonary embolism (n = 1). Group A presented higher number of postoperative pulmonary complications than Group B (6 vs 3; p = 0.0005). Multivariate analysis showed that the number of weekly rehabilitation sessions was the only independent predictive factor (p = 0.001). CONCLUSIONS: Our simple and low-cost rehabilitation program could improve preoperative clinical function in patients with mild to moderate COPD undergoing lobectomy and reduce postoperative pulmonary complications. All patients should be motivated to complete at least 3 rehabilitation sessions per week in order to obtain significant clinical benefits. Our preliminary results should be confirmed by larger prospective studies.

Effects of a high-intensity pulmonary rehabilitation program on the minute ventilation/carbon dioxide output slope during exercise in a cohort of patients with COPD undergoing lung resection for non-small cell lung cancer.

OBJECTIVE: Preoperative functional evaluation is central to optimizing the identification of patients with non-small cell lung cancer (NSCLC) who are candidates for surgery. The minute ventilation/carbon dioxide output (VE/VCO2) slope has proven to be a predictor of surgical complications and mortality. Pulmonary rehabilitation programs (PRPs) could influence short-term outcomes in patients with COPD undergoing lung resection. Our objective was to evaluate the effects of a PRP on the VE/VCO2 slope in a cohort of patients with COPD undergoing lung resection for NSCLC. METHODS: We retrospectively evaluated 25 consecutive patients with COPD participating in a three-week high-intensity PRP prior to undergoing lung surgery for NSCLC, between December of 2015 and January of 2017. Patients underwent complete functional assessment, including spirometry, DLCO measurement, and cardiopulmonary exercise testing. RESULTS: There were no significant differences between the mean pre- and post-PRP values (% of predicted) for FEV1 (61.5 ± 22.0% vs. 62.0 ± 21.1%) and DLCO (67.2 ± 18.1% vs. 67.5 ± 13.2%). Conversely, there were significant improvements in the mean peak oxygen uptake (from 14.7 ± 2.5 to 18.2 ± 2.7 mL/kg per min; p < 0.001) and VE/VCO2 slope (from 32.0 ± 2.8 to 30.1 ± 4.0; p < 0.01). CONCLUSIONS: Our results indicate that a high-intensity PRP can improve ventilatory efficiency in patients with COPD undergoing lung resection for NSCLC. Further comprehensive prospective studies are required to corroborate these preliminary results.

Effects of a high-intensity pulmonary rehabilitation program on the minute ventilation/carbon dioxide output slope during exercise in a cohort of patients with COPD undergoing lung resection for non-small cell lung cancer / Efeitos de um programa de reabilitação de alta intensidade no comando VE/VCO2 durante exercício em um grupo de pacientes submetidos à ressecção para câncer de pulmão de células não pequenas

ABSTRACT Objective: Preoperative functional evaluation is central to optimizing the identification of patients with non-small cell lung cancer (NSCLC) who are candidates for surgery. The minute ventilation/carbon dioxide output (VE/VCO2) slope has proven to be a predictor of surgical complications and mortality. Pulmonary rehabilitation programs (PRPs) could influence short-term outcomes in patients with COPD undergoing lung resection. Our objective was to evaluate the effects of a PRP on the VE/VCO2 slope in a cohort of patients with COPD undergoing lung resection for NSCLC. Methods: We retrospectively evaluated 25 consecutive patients with COPD participating in a three-week high-intensity PRP prior to undergoing lung surgery for NSCLC, between December of 2015 and January of 2017. Patients underwent complete functional assessment, including spirometry, DLCO measurement, and cardiopulmonary exercise testing. Results: There were no significant differences between the mean pre- and post-PRP values (% of predicted) for FEV1 (61.5 ± 22.0% vs. 62.0 ± 21.1%) and DLCO (67.2 ± 18.1% vs. 67.5 ± 13.2%). Conversely, there were significant improvements in the mean peak oxygen uptake (from 14.7 ± 2.5 to 18.2 ± 2.7 mL/kg per min; p < 0.001) and VE/VCO2 slope (from 32.0 ± 2.8 to 30.1 ± 4.0; p < 0.01). Conclusions: Our results indicate that a high-intensity PRP can improve ventilatory efficiency in patients with COPD undergoing lung resection for NSCLC. Further comprehensive prospective studies are required to corroborate these preliminary results.

RESUMO Objetivos: A avaliação funcional pré-operatória é fundamental para otimizar a seleção dos pacientes para cirurgia torácica para tratamento do CPCNP. Uma alta inclinação VE/VCO2 se mostrou um preditor de complicações cirúrgicas e de aumento da mortalidade. Programas de reabilitação pulmonar (PRP) demonstraram aumentar os parâmetros funcionais e os desfechos de curto prazo em pacientes com DPOC submetidos à ressecção pulmonar. O impacto dos PRP na inclinação VE/VCO2 não foi totalmente investigado. Métodos: Avaliamos retrospectivamente 25 pacientes com DPOC consecutivos submetidos aos efeitos de um programa de reabilitação pulmonar de alta intensidade (PRP) na inclinação VE/VCO2. Resultados: Não foram observadas variações significativas nos principais parâmetros espirométricos após o programa de reabilitação de três semanas (pré-reabilitação VEF1 versus pós-reabilitação VEF1 %prev: 61,5 ± 22,0% para 62,0 ± 21,1%, ns; pré-reabilitação DLCO para pós-reabilitação DLCO %prev: 67,2 ± 18,1% para 67,5 ± 13,2%, ns). Por outro lado, o pico de VO2 e a inclinação VE/VCO2 melhoraram significativamente após PRP (pico de VO2 pré-reabilitação para pico de VO2 pós-reabilitação: 14,7 ± 2,5 para 18,2 ± 2,7 mL/kg/min, p < 0,0000001; inclinação pré-reabilitação VE/VCO2 para pós-reabilitação inclinação VE/VCO2: 32,0 ± 2,8 para 30,1 ± 4,0, p<0,01). Conclusão: Documentamos o benefício no desempenho físico de um treinamento de três semanas em um grupo de pacientes com DPOC com um comprometimento funcional notável em parâmetros de esforço. Dados adicionais e mais abrangentes são necessários para esclarecer os mecanismos fisiológicos.

Benefits of Pulmonary Rehabilitation in Idiopathic Pulmonary Fibrosis: A CASE REPORT.

CLINICAL CASE: We describe the case of a 50-y-old man with idiopathic pulmonary fibrosis (IPF) who underwent pulmonary rehabilitation (PR). The 8-wk training program, including resistance training and aerobic exercises, was conducted 3 d/wk under physiotherapist supervision. Clinical and functional assessment was performed prior to and following the program. At the end of the training program, meaningful improvements in primary outcomes, including spirometry values and exertional parameters, were noted. DISCUSSION: Pulmonary rehabilitation may represent a valid treatment in the management of symptoms in patients with IPF. Although the current guidelines for diagnosis and management of IPF recommend the use of PR programs, patients are not routinely referred to PR centers and exercise training for these patients is not standardized. SUMMARY: Idiopathic pulmonary fibrosis is a progressive and fatal disease characterized by the loss of lung function, which results in a severe impairment of daily activities. Prospective studies testing the effectiveness of PR programs in larger cohorts of patients are still lacking. Furthermore, a standardization of pulmonary training programs should be developed to better understand the benefit of PR.

Bilateral simultaneous VATS for complete resection of bilateral posterior mediastinal bronchogenic cyst: A case report.

INTRODUCTION: The mediastinal bronchogenic cysts represents 50%-60% of mediastinal cysts and rarely occurs in the posterior mediastinum. The final surgical resection is indicated for symptomatic patients and is recommended for some asymptomatic patients in order to establish the diagnosis and to avoid any subsequent complications. CASE PRESENTATION: We report a case of 17 years-old male suffering from bronchogenic cysts of the mediastinum. The patient was admitted to our hospital complaining with dry chough and dyspnea; CT scan showed a cystic mass in posterior mediastinum. To achieve a correct diagnosis and to prevent the risk of complications, a complete surgical resection was performed by using bilateral simultaneous VATS. DISCUSSION: Bronchogenic cysts manifest as solitary or multiple lesions, majority of which are located in the mediastinum while sometimes can occur in the lung parenchyma. They are usually asymptomatic and casually discovered at chest X-ray or CT scan. The most common complications are infections, pneumothorax and hemoptysis. The complete surgical resection is the only radical and definitive treatment of the bronchogenic mediastinal cysts. VATS permits good exposure of the thoracic cavity including the mediastinum and better evaluation of the anatomic relationship. The absence of intra and postoperative complications, the reduction of pain in the early postoperative period demonstrate the security of this approach. CONCLUSION: Bilateral simultaneous VATS for resection of bilateral posterior mediastinal bronchogenic cyst may be a useful approach. In our case no intra and post-operative complications occurred and patient discharged home on 4 rd day.

Spirometry in elderly laryngectomized patients: A feasibility study.

BACKGROUND: Laryngeal cancer is the second most common respiratory neoplasm after lung cancer. Laryngectomy is a well established treatment for larynx cancers which involve relevant anatomic alterations. Spirometry is an essential investigation tool for diagnosis and severity of respiratory diseases, difficult to perform in laryngectomees. METHODS: 43 consecutive laryngectomized patients were enrolled from July 2014 to March 2015. Patients fulfilling inclusion criteria underwent spirometry at baseline assessment and after two days. During the examination, the spirometer was placed directly on the stoma of the patient, through mouthpiece "Spirometry Filter 74". RESULTS: At baseline, 26 eligible laryngectomees correctly performed the spirometry test with mouthpiece adhering to the stoma; 4 patients refused to perform the second spirometry after 2 days. The feasibility of spirometry examination in these patients was 100% despite difficulties in the execution of the test. The Pearson coefficient of reproducibility for FEV1, FVC and Tiffeneau Index was, respectively, 0.98, 0.94 and 0.77. DISCUSSION: Spirometry in laryngectomee patients is a feasible procedure for assessment of respiratory function; despite technical difficulties in the execution of the test, our results underline the reproducibility and repeatability of the spirometry. In conclusion, when performed within dedicated respiratory pathophysiology unit, spirometry is a reliable tool in the assessment and follow up of laryngectomees.

Integrated therapeutic approach to giant solitary fibrous tumor of the pleura: report of a case and review of the literature.

The fibrous tumors of the pleura are rare primary tumors, accounting for 5% of malignant pleural neoplasms, which generally originate from sub-mesothelial mesenchymal tissue of the visceral pleura. These tumours generally exhibit clinical benign behavior although 12% of solitary fibrous tumors can be malignant and have worse outcomes. These tumors are considered "giant" when the lesion > 15 cm. Surgical treatment is the best choice for both benign and malignant neoplasms. We retrospectively analyzed the main case series of giant fibrous tumors of the pleura. In addition we report our experience of a 76-year-old woman treated by pre-surgical embolization involving implantation of vascular plugs. Surgery was successfully carried out without complications; imaging and functional assessment 6 months post intervention demonstrated both the absence of recurrence and improvement of lung function parameters.

Preoperative high-intensity training in frail old patients undergoing pulmonary resection for NSCLC.

Thoracic surgery remains the better therapeutic option for non-small cell lung cancer patients that are diagnosed in early stage disease. Preoperative lung function assessment includes respiratory function tests (RFT) and cardio-pulmonary exercise testing (CPET). Vo2 peak, FEV1 and DLCO as well as recognition of performance status, presence of co-morbidities, frailty indexes, and age predict the potential impact of surgical resection on patient health status and survival risk. In this study we have retrospectively assessed the benefit of a high-intensity preoperative pulmonary rehabilitation program (PRP) in 14 patients with underlying lung function impairment prior to surgery. Amongst these, three patients candidate to surgical resection exhibited severe functional impairment associated with high score of frailty according CHS and SOF index, resulting in a substantial mortality risk. Our observations indicate that PRP appear to reduce the mortality and morbidity risk in frail patients with concurrent lung function impairment undergoing thoracic surgery. PRP produced improvement of VO2 peak degree and pulmonary function resulting in reduced postoperative complications in high-risk patients from our cases. Our results indicate that a preoperative training program may improve postoperative clinical outcomes in fraillung cancer patients with impaired lung function prior to surgical resection.

Single port VATS resection of a sessile solitary fibrous tumour of the visceral pleura. A case report.

UNLABELLED: The solitary fibrous tumour of the visceral pleura is a rare neoplasm that derives from mesenchymal cells adjacent to the mesothelial tissue of pleura. Surgical resection is the treatment of choice in benign lesions and healing resulting in half of malignant. Local recurrence can occur in malignant cases, but it is very rare in solitary benign tumors. It may be a result of an incomplete or conservative surgery, lack of identification of a tumor during the operation or a growth of a synchronous neoplasm independent from that removed. Surgical resection is also burdened with some difficulty as the size of the tumor, the relationship with the adjacent structures and identification of the vascular peduncle. We report a case of 72 years-old male with a sessile left solitary fibrous tumour of the visceral pleura. The mass of 10 x 7 x 5 cm was attached, thanks to large planting base, to lateral basal segment of left lower lobe. The patient was treated by single port video assisted approach with a 4 cm skin incision. This case, in our knowledge, represents the first resection by single port VATS of a sessile SFTP with a large plating base and, more generally, the third SFTP resection treated by single portal access. KEY WORDS: Solitary fibrous tumour, Uniportal VATS.

Lung and Nodal Involvement in Nontuberculous Mycobacterial Disease: PET/CT Role.

INTRODUCTION: Systematic use of (18)F-FDG PET/CT has the potential to simultaneously assess both pulmonary and lymph node involvement in nontuberculous mycobacterial (NTM) lung infection. OBJECTIVE: The aim of the study was to evaluate the role of (18)F-FDG PET/CT in the assessment of both mediastinal lymph nodes and lung involvement in NTM patients compared with active tuberculosis (TB) patients. METHODS: 26 patients with pulmonary NTM disease were selected; six consecutive patients had undergone (18)F-FDG PET/CT and data was compared with 6 active TB patients. RESULTS: NTM exhibited different radiological lung patterns with an average SUV max value at PET/CT scan of 3,59 ± 2,32 (range 1,14 to 9,01) on pulmonary lesions and a mean value of SUV max 1,21 ± 0,29 (range 0,90 to 1,70) on mediastinal lymph nodes. Pulmonary lesions in TB showed an average SUV max value of 10,07 ± 6,45 (range 1,20 to 22,75) whilst involved mediastinal lymph nodes exhibited a mean SUV max value of 7,23 ± 3,03 (range 1,78 to 15,72). CONCLUSIONS: The differences in PET uptake in a broad range of lung lesions and lymph nodes between NTM and M. tuberculosis patients suggest a potential role for PET/CT scan in the diagnosis and management of pulmonary mycobacterial disease.

Diathermy haemorrhoidectomy: reasons for a therapeutic choice.

BACKGROUND: Diathermy haemorrhoidectomy is an effective technique for the management of 2nd, 3rd and 4th degree haemorrhoids. The anal cushions are excised by use of diathermy without ligature of the vascular pedicles. The aim of the present study is to evaluate the efficacy and tolerability of this technique. METHODS: Between September 1999 and September 2003, 84 patients with 2nd, 3rd, and 4th degree haemorrhoids underwent diathermy haemorrhoidectomy. Patients were discharged the same day or the day after. All the patients were asked to complete two questionnaires one on the level of pain they experienced and the other on their expectation of pain. Patients were followed-up for 1 to 4 years (range 12-48 months, mean 20.5). RESULTS: The average pain severity score on a visual analogue scale (0-10) was 3.06 +/- 0.38 and consistently lower than expected. The majority of patients returned to their usual daily activities within 4 days and all of them returned to work within 11 days. A mild residual secretion persisted for 4 to 5 weeks. None of our patients experienced postoperative haemorrhage, complete stenosis or sphincteric disturbances. CONCLUSIONS: Diathermy haemorrhoidectomy appears to be a safe, low cost and effective technique for the treatment of haemorrhoids. It is well tolerated by patients.

Plasma levels of t-PA and PAI-1 correlate with the formation of experimental post-surgical peritoneal adhesions.

This study has evaluated whether systemic changes of plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) parallel the adhesions development and whether they could be used as predictors of adhesion risk. This has been studied in an animal model of post-surgical peritoneal adhesion by monitoring for 10 days the plasma and tissue levels of t-PA and PAI-1. The results showed that both tissular and plasmatic levels of t-PA were decreased in concomitance with the development of peritoneal adhesions. In contrast, PAI-1 was found increased into the tissue and into the plasma samples of the rats taken at 5 and 10 days time points. Inflammatory mediators such as ICAM-1, VCAM-1, and IL-6 within the peritoneal lavage fluid also correlated with the adhesion formation process. In conclusion, post-surgical peritoneal adhesions provide alterations of local inflammatory components and local and systemic fibrinolytic components, possibly with PAI-1 quenching t-PA. This may have potential for the identification of high-risk patients.

Iatrogenic splenic injuries.

Inadvertent intraoperative injuries to the spleen by the surgical team represent an underestimated complication of many abdominal procedures. Surgical reports often lack the necessary details and frequently a clear justification as why a splenectomy was indicated is not provided. The wide variability of the incidence reported in literature makes it is difficult to evaluate the morbidity and mortality associated to these injuries and to assess the early and late consequences of this complication, although it is still possible to infer some of the reasons for these inconsistencies and to roughly estimate both clinical and socio-economical effects of this injury. Given the degree of uncertainty on the incidence of iatrogenic and traumatic splenic injuries and on the immediate and long-term sequelae suffered by asplenic patients, we thought that a multicentric prospective study was warranted. We are therefore announcing the start of a study involving several Institutions within the Regione Campania, aimed at obtaining an unbiased estimate of the incidence of these injuries, together with the extent and severity of their long-term complications. We also aim to help promoting a more effective prevention.