Awake palliative thoracic surgery in a high-risk patient: one-lung, non-invasive ventilation combined with epidural blockade.

We report the case of a terminally ill cancer patient with recurrent pericardial and bilateral pleural effusions who was scheduled for video-assisted thoracoscopic surgery. The operation was performed with the patient awake under epidural anaesthesia. The patient's cough reflex in response to lung manipulation was successfully minimised by the inhalation of aerosolised lidocaine. Video-assisted thoracic surgery requires the exclusion of a lung from ventilation. In order to support one-lung spontaneous ventilation in this high-risk patient, we successfully used non-invasive bilevel positive airway pressure ventilation via a facemask. Based on this preliminary experience, we think that critically ill patients scheduled for palliative surgery can be successfully managed with the combination of minimally invasive surgical techniques and neuraxial block with non-invasive lung ventilation.

IIIB-T4 non-small cell lung cancer: indications and results of surgical treatment.

AIM: T4 non-small cell lung cancer (NSCLC) is commonly considered a contraindication to surgery, indeed chemo-radiotherapy achieves a poor survival rate. We have reviewed our experience with T4 NSCLC patients who underwent surgery with the aim of debating the indications and results of surgical treatment in this highly selected group of patients. METHODS: We investigated a cohort of 60 patients, 49 men and 11 women, who underwent surgery for NSCLC from January 1998 to December 2002 and whose pathological staging was T4N0-2M0. The median age was 65 years (range 46-82). The tumors were classified T4 for the following reasons: intralobar satellite metastasis in 24 cases, direct mediastinum invasion in 18 cases, malignant pleural effusion in 7 cases, involvement of the superior vena cava in 4 cases, marginal invasion of the vertebral body in 3 cases, involvement of the carena in 3 cases and invasion of the left atrium in 1 case. Thirteen patients had undergone neo-adjuvant chemotherapy while 39 underwent adjuvant therapies. RESULTS: Thirty-two patients resulted with N0 disease, 5 with N1 and 23 with N2 disease. Forty patients relapsed (27 systemic and 13 local relapses). The mean survival was 20 months. Of the examined parameters only metastatic nodal involvement was significantly associated with a worse prognosis (P=0.007). CONCLUSION: Surgery for T4 NSCLC may be effective in those patients without mediastinal (N2) lymph node involvement. The prognosis was neither affected by the subtype of T4 tumor nor by the use of adjuvant therapies and/or neoadjuvant chemotherapy but only by the N status. In the preoperative work-up, every possible effort should be made to achieve a careful evaluation of lymph-nodal status (primarily by mediastinoscopy and video operative staging).

A strategy for thoracoscopic resection of small pulmonary nodules.

BACKGROUND: Preoperative procedures are often necessary to localize pulmonary nodules during thoracoscopic resection in order to reduce the necessity of resorting to thoracotomy. The aim of this report is to describe the strategy we developed to limit preoperative techniques without reducing the thoracoscopic success rate of localization. METHODS: Between January 2000 and December 2003, 183 patients underwent video thoracoscopic resection of small pulmonary nodules. The patients were divided into two groups on the basis of the radiological features of the nodule. The subjects in group 1 were operated on directly, and endothoracic ultrasonography was performed when necessary. The subjects in group 2 underwent preoperative radionuclide labeling of the nodule. RESULTS: In group 1, 112 out of 119 nodules (94%) were localized. Twenty-five out of 32 lesions, neither visible nor palpable, were found by endothoracic ultrasonography. In group 2, we localized 62 out of 64 nodules (97%). CONCLUSIONS: Currently, we cannot completely avoid preoperative labeling techniques for thoracoscopic resection of small pulmonary nodules. However, correct patient selection may limit this necessity, without an increased conversion rate to thoracotomy, if endothoracic ultrasonography is available.

The utility of polyglactin-910 mesh in the plastic reconstruction of the chest wall after en-bloc resection.

From January 1991 to December 1994 the reconstruction of chest wall defects following en-bloc resection for 12 lung carcinomas involving the anterior chest wall, or requiring large chest wall resections, has included the use of a permeable and absorbable mesh of polyglactin-910. There was no operative mortality, and respiratory support was not required in any patient. There were no wound complications and the minor pulmonary problems were easily treatable. Hospitalization ranged from 7 to 15 days. The authors encourage the use of polyglactin-910 mesh in plastic reconstruction of the chest wall after en-bloc resections.

Treatment by VATS of giant bullous emphysema: results.

OBJECTIVE: In selected patients with giant bullous emphysema GBE and in those with specific complications, surgery may be the treatment of choice. METHODS: In the period January 1993-February 1996 we performed 34 VATS treatments in 29 patients affected by GBE. There were 22 (76%) males and 7 (24%) females, with a mean age of 54 years (range 24 74). In 23 cases, a pneumothorax (PNX) was present at admission, while 6 patients were treated by choice. Altogether. we performed 23 resections of sessile bullae (type 2 of Reid) by using a linear endoscopic stapling device (Endo-path 35 and 45 mm) and 11 ligatures of pedicled bullae (type 1 of Reid) by loop (Endo-loop 'PDS'). The mean number of charges for every treatment was 8 (range 4-21). The largest bullae were perforated and deprived of incarcerated air. They were then twisted on the axis perpendicular to the base in order to improve the manoeuvrability of the lesion and favour the correct placement of the Endo-path or Endo-loop. GBE was bilateral in 7 cases: one of these was treated bilaterally in the same surgical stage, other 4 were treated by staged operations. RESULTS: We experienced two conversions to open thoracotomy (one sessile giant bulla inside the fissura; 1 case of strong tuberculous pleural adhesions). Two patients, underwent a second operation by open thoracotomy because of a prolonged air leak. We have two peri-operative deaths, both to respiratory failure. Altogether, in 23 out of 29 (79%) cases VATS was effective and the mean hospital stay was 6 days (range 3-16). At a mean follow up of 16 months (range 1-36) no recurrence of PNX was observed. CONCLUSIONS: VATS may be considered as a suitable surgical technique to approach GBE and, in most cases, it is effective.

A pilot study of the role of TC-99 radionuclide in localization of pulmonary nodular lesions for thoracoscopic resection.

OBJECTIVE: Video-assisted thoracic surgery (VATS) is an interesting and emerging procedure for diagnosis and treatment of peripheral pulmonary nodules. However, thoracoscopy has limits in the detection of small nodules, below the pleural surface, deep in the lung parenchyma, which cannot be seen as much as palpated. Methods to localize such lesions, including the methylene blue injection or the introduction of a hooked-wire under the radiological vision, have some advantages but a lot of limitations. We are developing a new technique for the detection of pulmonary nodules smaller than 2 cm, deep in the lung parenchyma. METHODS: The technique consisted of a intra-lesional injection of 0.3 ml of solution of 99m Tc-labelled human serum albumin microspheres (5-10 MBq) under the CT-scan guide, 2 h before surgery. During thoracoscopy a 11 mm diameter-collimated probe connected to a gamma ray detector (Scinti Probe MR 100 - Pol. hi.tech., Aquila - Italy), is introduced by a 11.5 mm trocar and the pleural surface of the suspected area was scanned. A hot-spot indicated the presence of the injected nodule and as a consequence, the area to be resected. RESULTS: from June 1997 to June 1999 we treated 39 patients with small pulmonary nodules. The patients were 27 men and 12 women with a mean age of 60.8 years (range: 13-80). In 19 cases the anamnesis was positive for synchronous or metachronous malignant neoplasm. The mean surgical procedure length was 50 min (range 20-100 min). In all the cases the nodule was resected and the resection margins were pathologically free of tumour. The mean post-operative hospital stay was 3 days (range 2-6 days). Histological examination showed 21 benign lesions and 18 malignant lesions (seven metastases and 11 primary lung cancers). Nine pts with primary lung carcinoma underwent a completion lobectomy by open surgery. CONCLUSIONS: Radiolocalization by gamma-probe allows the detection and exeresis of small nodules in a easy and safe way. Future and predictable advances in radio-marked monoclonal antibodies, as well as in the development of endoscopic beta-detector probe, will offer a more effective method for detection of primary and metastatic tumours, targets of thoracoscopic resections.

Gamma probe-guided thoracoscopic surgery of small pulmonary nodules.

Video-assisted thoracic surgery (VATS) is an interesting and emerging procedure for the diagnosis and treatment of peripheral pulmonary nodules. We developed a new radioguided surgical technique for the detection during VATS of pulmonary nodules smaller than 2 cm, situated deep in the lung parenchyma and neither visible nor palpable with endoscopic instruments. The procedure is divided into two phases. Two hours before surgery 0.3 ml of a solution composed of 0.2 mL of 99mTc-labeled human serum albumin microspheres (5-10 MBq) and 0.1 mL of non-ionic contrast is injected into the lesion under CT guidance. Then the patient is submitted to VATS. During thoracoscopy a collimated probe of 11 mm diameter connected to a gamma ray detector is introduced via an 11.5 mm trocar and the pleural surface of the suspected area is scanned. A hot spot indicates the presence of the radiolabeled nodule and hence the area to be resected. We treated 39 patients with small pulmonary nodules (mean size, 8.3 mm; range, 4-19 mm). The patients were 27 men and 12 women (mean age, 60.8 years; range, 13-80 years). Nineteen patients had a history of synchronous or metachronous malignancy. In all cases the nodule was detected and resected and the resection margins were pathologically free of tumor. Histological examination showed 21 benign and 18 malignant lesions (7 metastases and 11 primary lung cancers). Nine patients with a frozen section-based histopathological diagnosis of lung cancer without functional contraindications underwent a completion lobectomy by open surgery in the same surgical session. In conclusion, the radiolocalization of small pulmonary nodules by gamma probe during VATS is a safe and easy procedure, with fewer complications and a lower failure rate than other localization techniques.

[Radioisotope methods and technics in obstetrical and gynecological diagnosis]. / Tecniche e metodiche radioisotopiche nella diagnostica ostetrica e ginecologica

Certain applications of radioisotopes to obstetric and gynaecological diagnosis are illustrated. Radioisotopes have been widely employed since the improvement in instrumental methods and the availability of short-life radioisotopes has removed the basic limitation which once prevented their use during the entire fecund period of the woman owing to the risk of radiation damage to the reproductive system. Particular attention is paid to the advances made in placental localization, in the study of thyroid and renal function in pregnancy, in the study of the diffusion of female genital tumours and relapses, and in early diagnosis of tumours of the uterus and ovaries. Dosimetric problems arising when using diagnostic techniques with radioisotopes in obstetrics and gynaecology are analysed.

[Possibilities of metabolic endoradiotherapy with P32 in the prevention of osseous metastases from breast neoplasms. Note II].

To reach a definitive conclusion on the value of using 32P in the prophylaxis of bone metastases in association with surgical and traditional radiotherapeutic treatment, observations should be extended to a much greater number of cases. This notwithstanding, the results obtained justify this methodology based on continuous sustained, internal irradiation which would seem to make possible a diminution in the frequency of bone metastases in the early years of a delay in their onset.

[Metabolic endoradiotherapy with P32 in skeletal metastases from breast neoplasms. Note I]. / La endoradiotherapia metabolica con 32P nelle metastasi scheletriche da neoplasia del seno. Nota 1

22 patients suffering from breast neoplasia with particularly painful bone metastasis were treated with radiophosphorus. Only occasionally was an evident recalcification condition encountered and survival, although exceptional in some cases, did not deviate from normal. On the basis, also, of clinical and experimental observations reported in the literature, it is held that the use of 32P in metabolic radiotherapy of bone metastases is worthwhile and is justified because of the encouraging successes obtained, especially in pain remission.

[Radiothermolumiscent dosimetry in plesioroentgenotherapy]. / Dosimetria a radiotermoluminescenza in plesioroentgenterapia

The employment of thermoluminescence dosimeters in the evaluation of X-rays emitted by a plesiotherapy apparatus was investigated. It was found that lithium fluoride microdosimeters gave good linearity of response in function of the energy involved. This response was also repeatable as required.

[Current trends in in the treatment of spontaneous pneumothorax]. / Orientamento attuale al trattamento del pneumotorace spontaneo.

In agreement with a number of published reports we state that video thoracoscopy is the best means for pnx classification (Vanderschueren RJA) and for the choice of its treatment. Video thoracoscopy and recent innovations in video-assisted thoracic surgery (VATS), together produce a significant improvement in the results. Between February 1992 and September 1994, we treated 143 pnx in 133 patients, 118 males, mean age 34 years (range 14-82); 5 of which undergoing a bilateral treatment and another 5 having to undergo a retreatment. On the basis of the endoscopic classification (Vanderschueren RJA), 26.1% of the cases fell into category I and 67.4% into the higher category, 6.5% presented enlarged bullous emphysema (GBE). Twenty-seven patients (20.3%), classified as category I at the first appearance of pnx, were treated by means of a chest tube thoracostomy. The remaining patients underwent surgical treatment: 106 treatments by VATS (74.1%) and 10 (7%) by an axillary thoracotomy. By VATS we performed: 77 ligature/resections of bullous lesions, 9 resections of pulmonary apex, 9 adhesiolysis, 7 GBE treatment by the "spaghetti technique", 2 coagulations of blebs, 1 suture and 1 parenchymal laceration repair by clips. No patients treated by a chest tube thoracostomy or who underwent thoracotomy presented recurrence at the follow-up (mean 33 months, range 15-46). We had a single complication (0.9%), 2 treatment conversions (1.9%) and in 3 patients (2.8%) a thoracotomy was necessary four days later. In thoracotomy we performed 5 resections of bullous lesions and 2 "capitonages" were effected in those patients treated in the first instance; 2 parenchyma tear repairs and 1 lobectomy in those patients treated after the failure of VATS.

[Diagnosis and treatment of pleuro-pericardial cysts. Role of videosurgery]. / Diagnosi e trattamento delle cisti pleuro-pericardiche. Ruolo della videochirurgia.

BACKGROUND: The pericardial cysts are benign "tumors" of the antero-inferior mediastinum, most often asymptomatic, which diagnosis is radiologic and incidental. When cysts are symptomatic and/or diagnosis is difficult, any resort to invasive diagnostic examinations and surgical ablation is suitable. METHODS: From January 1993 to January 1994 five patients with pericardial cyst have been treated. Three patients were symptomatic: two suffering from cardiac arrhythmia and one had cough with dyspnea. In three cases the lesion had a typical location and typical radiological patterns, and diagnosis was made by chest X-ray, confirmed by computed tomography (CT). In one case chest X-ray and CT didn't allow a sure diagnosis (differential diagnosis with Morgagni's diaphragmatic hernia), and in another case all examinations suggested a relapsing pleural effusion. RESULTS: All patients underwent ablation of the cyst by VATS; no complications were observed and patients left the hospital, on average, after 2 days (range 1-3). CONCLUSIONS: VATS, thanks to its low invasiveness, may be considered the method of choice for the diagnosis of atypical lesions and/or treatment of symptomatic cysts.

Technical review of the da Vinci surgical telemanipulator.

BACKGROUND: The da Vinci robotic surgical telemanipulator has been utilized in several surgical specialties for varied procedures, and the users' experiences have been widely published. To date, no detailed system technical analyses have been performed. METHODS: A detailed review was performed of all publications and patents about the technical aspects of the da Vinci robotic system. RESULTS: Published technical literature on the da Vinci system highlight strengths and weaknesses of the robot design. While the system facilitates complex surgical operations and has a low malfunction rate, the lack of haptic (especially tactile) feedback and collisions between the robotic arms remain the major limitations of the system. Accurate, preplanned positioning of access ports is essential. CONCLUSION: Knowledge of the technical aspects of the da Vinci robot is important for optimal use. We confirmed the excellent system functionality and ease of use for surgeons without an engineering background. Research and development of the surgical robot has been predominant in the literature. Future trends address robot miniaturization and intelligent control design.

Endothoracic sonography with color Doppler availability during video assisted thoracic surgery (videothoracoscopic operative staging with ultrasound color Doppler) for lung cancer staging.

BACKGROUND: The preoperative staging of lung cancer can be problematical when we attempt to evaluate T factor (T2-T3 versus T4) and N factor (N0 versus N1-N2). In some cases, radiology tests (CT scan, magnetic resonance imaging) cannot entirely dispel the possibility that the mediastinal structures have been infiltrated. N factor is evaluated mainly by dimensional criteria. However, mediastinoscopy and mediastinotomy do not allow the full exploration of all mediastinal mode stations. METHOD: Starting in 1995, we submitted 10 consecutive patients to videothoracoscopic operative staging with ultrasound color Doppler (VOS-USCD). In five cases, preoperative staging showed possible infiltration of the pulmonary artery (T4). In nine cases, we found involvement of the mediastinal nodes, seven patients were N2, and two were N3. Videothoracoscopy was performed under general anesthesia using a double-lumen endotracheal tube. The videothoracoscope and sonographic probe were inserted via three thoracoports placed in the axillary triangle. RESULTS: Following the results of VOS-USCD, the staging and subsequently the therapeutic program were modified in seven of 10 cases (70%). CONCLUSIONS: Our preliminary experience indicates that VOS-USCD should be applied to the diagnosis of patients in stage IIIA (N2) and that it is particularly valuable for patients in stage IIIB.