Management of COVID-19 related tracheal stenosis: The state of art.

Tracheal stenosis (TS) is a debilitating disease promoted by pathologic narrowing of the trachea. The acute respiratory distress syndrome caused by COVID-19 has been demonstrated to trigger enhanced inflammatory response and to require prolonged invasive mechanical ventilation as well as high frequency of re-intubation or emergency intubation, thus increasing the rate and complexity of TS. The standard-of-care of COVID-19-related tracheal complications has yet to be established and this is a matter of concern. This review aims at collecting latest evidence on this disease, providing an exhaustive overview on its distinctive features and open issues, and investigating different diagnostic and therapeutic strategies to handle COVID-19-induced TS, focusing on endoscopic versus open surgical approach. The former encompasses bronchoscopic procedures: electrocautery or laser-assisted incisions, ballooning dilation, submucosal steroid injection, endoluminal stenting. The latter consists of tracheal resection with end-to-end anastomosis. As a rule, traditionally, the endoscopic management is restricted to short, low-grade, and simple TS, whereas the open techniques are employed in long, high-grade, and complex TS. However, the critical conditions or extreme comorbidities of several COVID-19 patients, as well as the marked inflammation in tracheal mucosa, have led some authors to apply endoscopic management also in complex TS, recording acceptable results. Although severe COVID-19 seems to be an issue of the past, its long-term complications are still unknown and considering the increased rate and complexity of TS in these patients, we strongly believe that it is worth to focus on it, attempting to find the best management strategy for COVID-19-related TS.

Post-intubation iatrogenic tracheobronchial injuries: The state of art.

Iatrogenic tracheobronchial injury (ITI) is an infrequent but potentially life-threatening disease, with significant morbidity and mortality rates. Its incidence is presumably underestimated since several cases are underrecognized and underreported. Causes of ITI include endotracheal intubation (EI) or percutaneous tracheostomy (PT). Most frequent clinical manifestations are subcutaneous emphysema, pneumomediastinum and unilateral or bilateral pneumothorax, even if occasionally ITI can occur without significant symptoms. Diagnosis mainly relies on clinical suspicion and CT scan, although flexible bronchoscopy remains the gold standard, allowing to identify location and size of the injury. EI and PT related ITIs more commonly consist of longitudinal tear involving the pars membranacea. Based on the depth of tracheal wall injury, Cardillo and colleagues proposed a morphologic classification of ITIs, attempting to standardize their management. Nevertheless, in literature there are no unambiguous guidelines on the best therapeutic modality: management and its timing remain controversial. Historically, surgical repair was considered the gold standard, mainly in high-grade lesions (IIIa-IIIb), carrying high morbi-mortality rates, but currently the development of promising endoscopic techniques through rigid bronchoscopy and stenting could allow for bridge treatment, delaying surgical approach after improving general conditions of the patient, or even for definitive repair, ensuring lower morbi-mortality rates especially in high-risk surgical candidates. Our perspective review will cover all the above issues, aiming at providing an updated and clear diagnostic-therapeutic pathway protocol, which could be applied in case of unexpected ITI.

Tracheal stenting on venovenous ECMO with a dual lumen right atrium-to-pulmonary artery cannula in a COVID-19 patient with an inferior vena cava filter.

A 47-year-old man, with no medical history, was diagnosed with severe COVID-19 ARDS and pulmonary embolism. Venovenous extracorporeal membrane oxygenation (ECMO) was required for impossibility to deliver protective ventilation. The patient was weaned from ECMO after clinical improvement. An inferior vena cava filter was then positioned to prevent embolization from a persistent left femoral deep venous thrombosis. Two days after the ECMO removal, a large lesion of the tracheal posterior wall was diagnosed. Tracheal stenting was deemed necessary. ECMO support was then re-established, to safely perform the bronchoscopic procedure. Due to the presence of the inferior vena cava filter, the patient was cannulated via the right internal jugular vein with a double lumen ProtekDuo cannula. The patient was then weaned from ECMO support and invasive ventilation. The tracheal stent was removed after 40 days, showing a full recovery of the tracheal lesion. The patient was discharged home in good condition.

Radical thymectomy versus conservative thymomectomy in the surgical treatment of thymic malignancies.

BACKGROUND: Complete thymectomy is recommended for thymic malignancies to reduce local recurrence and the likelihood of the long-term development of myasthenia gravis (MG). Thymus-conserving surgery (thymomectomy) seems to yield similar results, but evidence is still limited. The objective of this study was to assess if the oncological outcome, in terms of overall survival (OS) and disease-free survival (DFS), are comparable between radical thymectomy vs. conservative thymomectomy patients, and to assess if the outcome of the video-assisted thoracoscopic surgery (VATS) approach was similar to open surgery approach. METHODS: We retrospectively analyzed 157 consecutive patients with either resectable thymoma or thymic carcinoma from two Italian centers (Humanitas Research Hospital, Milan, and Humanitas Gavazzeni, Bergamo) between 1997 and 2013 who underwent thymomectomy or extended thymectomy with the VATS or open approach; the patients with Miastenia Gravis underwent radical thymectomy. The patients were followed through physical examinations and phone interviews. RESULTS: Thymomectomy and thymectomy were performed on 86 (54.8%) and 71 (45.2%) patients, respectively. Prognostic factors and comorbidities were comparable in the two groups. The median follow-up was 77 months. Cox proportional hazards model revealed that Masaoka advanced stage and thymic carcinoma of WHO classification were independent predictive factors for overall survival, but that the extent of surgery and the approach used (minimally invasive versus open) were not. Notably, five- and ten-year survival rates were similar in the two groups. CONCLUSIONS: In our experience, radical thymectomy and conservative thymomectomy did not differ in terms of disease-free and overall survival rates. In nonmyasthenic patients with early-stage resectable thymic malignancy, minimally invasive thymomectomy provided equivalent results to open thymectomy. Our results should be interpreted with caution due to the retrospective nature of the study. Well-designed, adequately-powered studies should be very welcome to increase the quantity and the quality of clinical evidence before incorporating this procedure in future guidelines.

From full thoracotomy to uniportal video-assisted thoracic surgery: lessons learned.

Over the last two decades, conventional video-assisted thoracic surgery (VATS) has established itself as the preferred approach for almost all thoracic surgical procedures. The procedure provides a safe and easy approach with undisputed patient benefit at a cost acceptable to the healthcare system all over the world, in large hospitals as well as underprivileged rural areas. VATS has effectively addressed the patients' right to less scarring, trauma (both of access and intrathoracic manipulation), medication, pain, hospitalization, and early return home and work. These improvements have been further stressed by the introduction of uniportal VATS (uniVATS). Single port surgery is a very exciting new modality in the field of minimal access surgery which aims at further reducing scars of standard vats and towards an hypothetical prospective of scarless surgery.

Multicentric study of endobronchial ultrasound-transbronchial needle aspiration for lung cancer staging in Italy.

BACKGROUND: Multi-institutional studies of endobronchial-ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging in lung cancer are scarce. It is unclear if the high diagnostic performance of EBUS-TBNA reported by experts' guidelines can be generally achieved. METHODS: This is a retrospective study performed in five tertiary referral centers of thoracic surgery in Italy, to assess the EBUS-TBNA diagnostic performance in patients with non-small cell lung cancer (NSCLC). Patient inclusion criteria were: both genders; >18 years old; with suspect/confirmed NSCLC; undergoing EBUS-TBNA for mediastinal node enlargement at computed tomography (size >1 cm, ≤3 cm) and/or pathological uptake at positron emission tomography. Altogether we included 485 patients [male, 366; female, 119; median age, 68 years (IQR, 61-74 years)] undergoing mediastinal staging between January 2011 and July 2016. All EBUS-TBNAs were performed by experienced bronchoscopists, without pre-defined quality standards. Depending on usual practice in each center, EBUS-TBNA was done under conscious sedation, with 21- or 22-Gauge (G) needle, and specimen preparation was cell-block, or cytology slides, or core-tissue. Sampling was classified inadequate in absence of lymphocytes, or when sample was insufficient. We analyzed the EBUS-TBNA procedural steps likely to influence the rate of adequate samplings (diagnostic yield). RESULTS: EBUS-TBNA sensitivity, negative predictive value (NPV) and accuracy respectively were 90%, 78% and 93% in the whole cohort. At multivariate analysis, use of 21-G needle was associated with better diagnostic yield (P<0.001). Center and specimen processing technique were not independent factors affecting EBUS-TBNA diagnostic yield. CONCLUSIONS: In this multicentric study, EBUS-TBNA was a highly sensitive and accurate method for NSCLC mediastinal node staging. Results indicate better performance of EBUS-TBNA with 21-G needle, and suggest that specimen processing technique could be chosen according to the local practice preference.

Overview of uniportal video-assisted thoracic surgery (VATS): past and present.

Single incision video-assisted thoracic surgery (VATS), better known as uniportal VATS, has taken the world of thoracic surgery by storm over the previous few years. Through advances in techniques and technology, surgeons have been able to perform increasingly complex thoracic procedures utilizing a single small incision, hence avoiding the inherent morbidity of the standard open thoracotomy. This was a natural extension of what most recognize as the standard of care for early stage lung cancer, the VATS lobectomy, generally performed through a three- or four-incision technique. Improved camera optics have allowed the use of smaller cameras, making the uniportal approach technically easier. Improvement in articulating staplers and the development of other roticulator instruments have also aided working through a small single access point. The uniportal technique further brings the operative fulcrum inside the chest cavity, enabling better visualization, and creates working conditions similar to the open thoracotomy. Currently, uniportal VATS is being used for minor thoracic procedures and lung resections up to complex thoracic procedures typically requiring open approaches, such as chest wall resections, pneumonectomy, and bronchoplastic and pulmonary artery sleeve resections. Uniportal VATS is a clear advance in the field of general thoracic surgery and provides but a glimpse into the untold future.

Prognostic and diagnostic potential of local and circulating levels of pentraxin 3 in lung cancer patients.

There is a well-established link between inflammation and cancer of various organs, but little data are available on inflammation-associated markers of diagnostic and prognostic clinical utility in pulmonary malignancy. Blood samples were prospectively collected from 75 resectable lung cancer patients before surgery and in a cohort of 1,358 high-risk subjects. Serum levels of long pentraxin 3 (PTX3) were determined by high-sensitivity ELISA. PTX3 immunostaining was evaluated by immunohistochemistry in cancer tissue. Serum PTX3 levels in the high-risk population were not predictive of developing subsequent lung cancer or any other malignancy; however, serum PTX3 values in patients with lung cancer were significantly higher compared with cancer-free heavy smokers. With a cutoff of 4.5 ng/ml, specificity was 0.80, sensitivity 0.69, positive predictive value 0.15 and negative predictive value 0.98. The receiver operating curve (ROC) for serum PTX3 had an area under the curve (AUC) of 83.52%. Preoperative serum PTX3 levels in lung cancer patients did not correlate with patient outcome, but high interstitial expression of PTX3 in resected tumor specimens was a significant independent prognostic factor associated with shorter survival (p < 0.001). These results support the potential of serum PTX3 as a lung cancer biomarker in high-risk subjects. Furthermore, PTX3 immunohistochemistry findings support the role of local inflammatory mechanisms in determining clinical outcome and suggest that local expression of PTX3 may be of prognostic utility in lung cancer patients.

Long-Term Follow-up Results of the DANTE Trial, a Randomized Study of Lung Cancer Screening with Spiral Computed Tomography.

RATIONALE: Screening for lung cancer with low-dose spiral computed tomography (LDCT) has been shown to reduce lung cancer mortality by 20% compared with screening with chest X-ray (CXR) in the National Lung Screening Trial, but uncertainty remains concerning the efficacy of LDCT screening in a community setting. OBJECTIVES: To explore the effect of LDCT screening on lung cancer mortality compared with no screening. Secondary endpoints included incidence, stage, and resectability rates. METHODS: Male smokers of 20+ pack-years, aged 60 to 74 years, underwent a baseline CXR and sputum cytology examination and received five screening rounds with LDCT or a yearly clinical review only in a randomized fashion. MEASUREMENTS AND MAIN RESULTS: A total of 1,264 subjects were enrolled in the LDCT arm and 1,186 in the control arm. Their median age was 64.0 years (interquartile range, 5), and median smoking exposure was 45.0 pack-years. The median follow-up was 8.35 years. One hundred four patients (8.23%) were diagnosed with lung cancer in the screening arm (66 by CT), 47 of whom (3.71%) had stage I disease; 72 control patients (6.07%) were diagnosed with lung cancer, with 16 (1.35%) being stage I cases. Lung cancer mortality was 543 per 100,000 person-years (95% confidence interval, 413-700) in the LDCT arm versus 544 per 100,000 person-years (95% CI, 410-709) in the control arm (hazard ratio, 0.993; 95% confidence interval, 0.688-1.433). CONCLUSIONS: Because of its limited statistical power, the results of the DANTE (Detection And screening of early lung cancer with Novel imaging TEchnology) trial do not allow us to make a definitive statement about the efficacy of LDCT screening. However, they underline the importance of obtaining additional data from randomized trials with intervention-free reference arms before the implementation of population screening.

Radical surgery in an unusual case of thymoma with intraluminal growth into the superior vena cava and right atrium.

We report a very rare case of malignant invasive thymoma with intraluminal growth through the thymic veins into the superior vena cava (SVC), with intracardiac right atrium extension. A 44-year old female with SVC syndrome underwent a radical thymectomy with pericardiectomy and complete removal of the endovascular and endocardiac neoplastic thrombus by a longitudinal incision starting from the atrium and extending along the SVC. The left anonymous vein was sacrificed, and the SVC and atrium were repaired with a continuous 5-0 Prolene suture. The hospital stay was uneventful. Postoperatively, the patient received adjuvant chemoradiotherapy (three cycles of cisplatin, doxorubicin and cyclophosphamide and subsequent mediastinal irradiation with 50 Gy). Nine months after surgery, no recurrences were seen and the patient is still well. This thymoma presentation with intravascular growth without direct vascular wall infiltration, although very rare, is possible and the management may be challenging. In our case, a primary radical operation was considered mandatory due to the clinical symptoms and the risk of neoplastic embolization. The collection of other similar cases could better clarify the role of adjuvant therapy.

Pulmonary aspergilloma: clinical aspects and surgical treatment outcome.

Aspergillomas are fungal balls within lung cavities. The natural history is variable. Hemoptysis is a dangerous sequela. Medical therapy is ineffective because of the lack of a lesion blood supply. Randomized trials are lacking. Surgery should be the treatment of choice in cases of hemoptysis, and even in asymptomatic patients, if lung function is not severely compromised. Cavernostomy and cavernoplasty may be options for high-risk patients. Percutaneous therapy should be reserved for patients who are not fit for surgery. Bronchial artery embolization is appropriate for symptomatic patients not suitable for surgery. Embolization could be considered a preoperative and temporary strategy.

Caveats in using vacuum-assisted closure for post-pneumonectomy empyema.

OBJECTIVES: Vacuum-assisted closure (VAC) of chronic empyemas can potentially set challenging patients free of prolonged hospitalization by warranting outpatient care. We wanted to test this concept in post-pneumonectomy empyema patients. METHODS: Three patients with post-pneumonectomy bronchopleural fistula were subjected to open window thoracostomy (OWT) and subsequently to VAC. The BPFs were closed by endobronchial stents in 2 of the patients. The VAC system was applied at a median time of 35 days (range, 23-113) after pneumonectomy. The patients were scheduled for outpatient visits every three days with complete change of the VAC sponges. RESULTS: Hypotension and acute thoracic pain despite minimal suction applied to the VAC sponges were observed during treatment and eventually caused VAC discontinuation. In one patient, the sponges of the VAC system could not be directly removed through the OWT and careful dissection through VATS under deep sedation was needed. CONCLUSIONS: VAC can be of help to obliterate the post-pneumonectomy empyema cavity but its use can trigger clinically significant complications. Cautious monitoring of the VAC system must be exercised in the early period prior to discharging patients to the outpatient clinic.

Amplatzer device and vacuum-assisted closure therapy to treat a thoracic empyema with bronchopleural fistula.

We present a case of lower bilobectomy complicated by a large bronchopleural fistula and empyema 1 month after primary surgery. The patient was immediately treated with an open window thoracostomy. After surgical debridement, an Amplatzer Septal Occluder device (AGA Medical Corp, Plymouth, MN) was positioned to close the fistula. Thereafter, the thoracostomy rapidly and spontaneously closed with vacuum-assisted closure therapy.

Surgical procedures in the DANTE trial, a randomized study of lung cancer early detection with spiral computed tomography: comparative analysis in the screening and control arm.

BACKGROUND: The patient population derived from lung cancer screening programs with low-dose spiral computed tomography (LDCT) is different from the general population accessing thoracic surgical services. METHODS: Retrospective review of all surgical cases in the DANTE trial, a randomized study of lung cancer screening with LDCT. Patient characteristics, workup, procedures, resections for benign disease, complications, tumor features, and final outcomes have been analyzed in the LDCT and in the control arm. RESULTS: In the LDCT arm, 77 suspicious lesions were surgically managed in 72 patients. A benign lesion was diagnosed in 17 cases (22%). Major video-assisted thoracoscopic surgery resection was carried out in five lung cancer cases (7%) and segmentectomy in 11 (19%). Complete resection was achieved in 93%, and stage I rate was 73%. Two patients had a local recurrence after open lobectomy, and three had a resectable new primary. In the control group, 28 patients underwent 31 surgical procedures, in five cases (16%) for benign lesions. No major video-assisted thoracoscopic surgery resections were carried out. Resectability rate was 88%, and stage I rate was 52%. Five patients had a local recurrence and two had a second primary. CONCLUSIONS: Surgery for benign lesions is a relevant issue in screening-derived patients. Local control may be achieved by minimally invasive techniques or segmentectomy; however, developing the necessary skills requires an effort by the surgical team. Long-term survivors have a noticeable chance of developing second primary cancers or resectable recurrences and may benefit from a second resection.

A randomized study of lung cancer screening with spiral computed tomography: three-year results from the DANTE trial.

RATIONALE: Screening for lung cancer with modern imaging technology may decrease lung cancer mortality, but encouraging results have only been obtained in uncontrolled studies. OBJECTIVES: To explore the effect of screening with low-dose spiral computed tomography (LDCT) on lung cancer mortality. Secondary endpoints are incidence, stage at diagnosis, and resectability. METHODS: Male subjects, aged 60 to 75 years, smokers of 20 or more pack-years, were randomized to screening with LDCT or control groups. All participants underwent a baseline, once-only chest X-ray and sputum cytology examination. Screening-arm subjects had LDCT upon accrual to be repeated every year for 4 years, whereas controls had a yearly medical examination only. MEASUREMENTS AND MAIN RESULTS: A total of 2,811 subjects were randomized and 2,472 were enrolled (LDCT, 1,276; control, 1,196). After a median follow-up of 33 months, lung cancer was detected in 60 (4.7%) patients receiving LDCT and 34 (2.8%) control subjects (P = 0.016). Resectability rates were similar in both groups. More patients with stage I disease were detected by LDCT (54 vs. 34%; P = 0.06) and fewer cases were detected in the screening arm due to intercurrent symptoms. However, the number of advanced lung cancer cases was the same as in the control arm. Twenty patients in the LDCT group (1.6%) and 20 controls (1.7%) died of lung cancer, whereas 26 and 25 died of other causes, respectively. CONCLUSIONS: The mortality benefit from lung cancer screening by LDCT might be far smaller than anticipated.

Lung cancer screening with spiral CT: baseline results of the randomized DANTE trial.

BACKGROUND: Despite the high survival rates reported for screening-detected cases, the potential of screening of high-risk subjects for reducing lung cancer mortality is still unproven. We herewith present the baseline results of a randomized trial comparing screening for lung cancer with annual spiral computed tomography (CT) versus a yearly clinical review. METHODS: Male subjects, 60-74 years old, and smokers of 20+ pack-years were enrolled. All participants received a baseline medical examination, chest X-rays (CXR) and sputum cytology upon accrual. Subjects randomized in the spiral CT group received a spiral CT scan at baseline, then yearly for the following 4 years. For controls, a yearly clinical examination was scheduled for the following 4 years. RESULTS: 2472 subjects were randomized (1276 spiral CT arm, 1196 controls). Age, smoking exposure and co-morbid conditions were similar in the two groups. In the spiral CT group, 28 lung cancers were detected, 13 of which were visible in the baseline chest X-rays (overall prevalence 2.2%). Sixteen out of 28 tumours (57%) were stage I, and 19 (68%) were resectable. In the control group, eight cases were detected by the baseline chest X-rays (prevalence rate 0.67%), four (50%) were stage I, and six (75%) were resectable. CONCLUSIONS: Baseline lung cancer detection rate in the spiral CT arm was higher than in most published studies. The stage I detection rate was increased four-fold by spiral CT versus chest X-rays. However, more tumours in an advanced stage were also detected by CT. The high resection rate of screening-detected patients suggests a possible increase in cure rate. However, longer follow-up is required for definitive conclusions. This trial has been registered at www.Clinicaltrials.gov, registration No. NCT00420862.

Uniportal VATS wedge pulmonary resections.

Since 2000, 15 patients have undergone single port (uniportal) video-assisted thoracic surgery for wedge pulmonary resection either for diagnosis of interstitial lung diseases (10 patients) or for treatment of primary spontaneous pneumothoraces (5 patients). Diagnosis was obtained in all patients and no recurrences of pneumothorax were seen at follow-up. This initial experience shows that, for specific indications, uniportal video-assisted thoracic surgery for wedge pulmonary resections can be safe and effective.

Implementation of a user-friendly protocol for interpretation of air-leaks and management of intercostal chest drains after thoracic surgery.

We prospectively audited the implementation of a protocol for management of air-leaks and intercostal drains after thoracic surgical procedures. Out of the 99 patients who underwent thoracic surgical procedures during a 3-month period, 41 presented a postoperative air-leak on day 1. The protocol was strictly followed in 95% of the cases. The median drainage-time and hospital-stay were 3 and 4 days, respectively. The incidence of insertion of postoperative drains was 3%. Most of the nursing staff found the protocol user-friendly and easy to apply. A protocol for the management of postoperative air-leaks and intercostal drains can be implemented with high-compliance low complications.