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Moretti M, De Giacomo T, Francioni F, Rendina EA, Venuta F, Mercadante E, Coloni GF. [Thoracoscopic esophagectomy for esophageal cancer. Personal experience]. MINERVA CHIR 2002; 57:111-5. [PMID: 11941285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Esophageal surgery was recently modified by minimally-invasive approach. Personal experience with the thoracoscopic technique for esophagectomy in patients with early stage esophageal cancer is described. METHODS. From 1996 to 2000 at the Department of Thoracic Surgery of the University of Rome "La Sapienza", 10 patients, 7 male and 3 female, underwent video-thoracoscopic esophagectomy for esophageal cancer. Median age was 64 years (range 53-72). With the patient in left lateral decubitus 4 ports were positioned between the 4th and 8th intercostal space. The thoracic esophagus was mobilized in the entire length and circumference with the connective tissue and peri-esophageal nodal stations. A cervicotomy followed by a median laparotomy for tubulization of the stomach was performed. RESULTS Nobody required conversion to thoracotomy. No complication or intraoperative death were observed. The median thoracic time was 110 minutes (range 55-165). No death within 30 days after discharge was recorded. One patient presented left vocal cord paralysis. In one case a recurrence in cervical anastomosis two months after the operation was observed. One patient died after 36 month for metastatic spread. Eight patients are alive with no evidence of disease, with median follow-up of 20 months. CONCLUSIONS In our experience, the video-toracoscopic approach is a viable and safe option for the treatment of early stage esophageal cancer. Low incidence of complications and local recurrence should encourage a most frequent use of this procedure.
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Venuta F, Rendina E, De Giacomo T, Moretti M, Mercadante E, Francioni F, Pugliese F, Coloni G. Bilateral sequential lung transplantation without sternal division. J Heart Lung Transplant 2002. [DOI: 10.1016/s1053-2498(01)00678-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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De Giacomo T, Rendina EA, Venuta F, Francioni F, Moretti M, Pugliese F, Coloni GF. Pneumoperitoneum for the management of pleural air space problems associated with major pulmonary resections. Ann Thorac Surg 2001; 72:1716-9. [PMID: 11722070 DOI: 10.1016/s0003-4975(01)03050-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of pneumoperitoneum to treat prolonged air leaks or space problems, or both, after pulmonary resection has been recently resurrected and used successfully. METHODS During the last 3 years, 14 patients experienced short-term pleural space problems associated with prolonged air leaks after pulmonary resection for lung cancer. All patients, under sedation and local anesthesia, had a mean of 2,100 mL of air injected under the diaphragm, using a Veres needle after a mean time of 7 days (range, 5 to 10 days) from the operation. In 3 patients talc slurry was added to help control the air leak. RESULTS No patients experienced complications during the induction of the pneumoperitoneum. No patients complained of dyspnea, although blood gas analysis showed a slight increment of carbon dioxide partial pressure (p < 0.0004). Obliteration of the pleural space was observed in all cases after a mean time of 4 days (range, 1 to 7 days). Air leaks stopped in all patients after a mean time of 8 days (range, 4 to 12 days). The mean postoperative hospital stay after lung resection was 18 days (range, 14 to 22 days). No patients had significant complications or long-term sequelae. We found that patients who had undergone induction chemotherapy had longer air leak durations than observed in noninduction patients (p = 0.03). CONCLUSIONS Our experience supports the use of postoperative pneumoperitoneum whenever a space problem associated with prolonged air leaks is present. The procedure is effective, safe, and easy to perform.
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Venuta F, Rendina EA, De Giacomo T, Mercadante E, Ciccone AM, Aratari MT, Moretti M, Coloni GF. Endoscopic treatment of lung cancer invading the airway before induction chemotherapy and surgical resection. Eur J Cardiothorac Surg 2001; 20:464-7. [PMID: 11509264 DOI: 10.1016/s1010-7940(01)00742-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Many patients with advanced lung cancer invading the airway require only palliation; however, induction chemotherapy and surgery may sometimes be considered. Preliminary endoscopic palliation may improve quality of life and functional status, allows better evaluation of tumor extension and contributes to prevent infectious complications. We reviewed our experience with preliminary laser treatment, induction chemotherapy and surgical resection in patients with lung cancer invading the airway. METHODS Twenty-one patients with stage IIIA and IIIB lung cancer presenting with an 80% unilateral airway obstruction were treated with laser resection, induction chemotherapy and surgery. Spirometry, arterial blood gas analysis, quality of life (QLQ-C30 score) and performance status were recorded before and after laser treatment and after chemotherapy. Complications during chemotherapy, surgical morbidity and mortality, and survival were also recorded. RESULTS No complications were observed after endoscopic treatment. FEV(1) significantly improved from 1.4+/-0.4 l/s to 2.2+/-0.7 l/s, as well as FVC (from 2+/-0.5 to 3.1+/-0.8 l), and remained stable after chemotherapy. The QLQ-C30 score significantly improved after laser treatment (from 45+/-4.8 to 31+/-2.5) as well as the Karnofsky status (from 76+/-5 to 90). One patient developed pneumonia during induction chemotherapy. Three patients were not operated on. We performed five pneumonectomies (one right tracheal sleeve pneumonectomy) and 13 lobectomies (five associated to a bronchial sleeve resection). One patient (5.5%) died after the operation. Four patients experienced minor postoperative complications. Three-year survival after the operation was 52%. CONCLUSIONS Preliminary endoscopic palliation of lung cancer invading the airway is feasible, improves evaluation and staging, helps to reduce the incidence of complications during induction chemotherapy without increasing surgical morbidity and mortality.
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Roberts PF, Venuta F, Rendina E, De Giacomo T, Coloni GF, Follette DM, Richman DP, Benfield JR. Thymectomy in the treatment of ocular myasthenia gravis. J Thorac Cardiovasc Surg 2001; 122:562-8. [PMID: 11547310 DOI: 10.1067/mtc.2001.116191] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Thymectomy is an effective and accepted treatment for myasthenia gravis, but thymectomy for ocular myasthenia gravis (Osserman stage I) is controversial. OBJECTIVE To assess the efficacy and propriety of thymectomy for the treatment of ocular myasthenia gravis. METHODS We conducted a review and follow-up of all patients who had thymectomy for the treatment of ocular myasthenia gravis between 1970 and 1998 at the University of California, Davis, Medical Center, and the University of Rome, "La Sapienza," Rome, Italy. Patient response to thymectomy was categorized as follows: cured, patients who became symptom-free and required no further medication; improved, patients who required less medication and whose symptoms were less severe; unchanged, patients whose symptoms and medications were the same; worse, patients who had more severe symptoms, needed more medication, or died. RESULTS Sixty-one patients (mean age 37 years; range 14-73 years) were followed up for a mean duration of 9 years (range 0.5-29 years). Ocular myasthenia gravis with mixed and cortical thymomas, stages I to IV, occurred in 12 patients, and ocular myasthenia without thymomas occurred in 49 patients. Transsternal thymectomy (n = 55) and transcervical thymectomy (n = 6) resulted in cure in 31 (51%) patients, improvement in 12 (20%) patients, no change in 16 (26%) patients, and worsening of symptoms (including 1 postoperative death) in 2 patients. Patient outcomes were statistically independent of the duration of preoperative symptoms (mean 9.5 months), patient age, or the presence or absence of thymoma. In patients with ocular myasthenia, 70% were cured or improved after thymectomy; in the subgroup of patients with ocular myasthenia and thymoma, 67% were cured or improved. CONCLUSION Thymectomy is an effective and safe treatment for patients with ocular myasthenia gravis.
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Mercadante E, De Giacomo T, Rendina EA, Venuta F, Moretti M, Aratari MT, Furio Coloni G. [Diagnostic delay in post-traumatic diaphragmatic ruptures]. MINERVA CHIR 2001; 56:299-302. [PMID: 11423797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Traumatic ruptures of the diaphragm are associated with closed chest and abdominal traumas, often the outcome of road accidents, with an incidence varying from 1 to 5% depending on the series. Diagnosis is frequently late if the possibility of breakages in two stages is also considered. This delay in diagnosis is encountered in a variable percentage of cases, between 9.5 and 60%. The clinical case of a post-traumatic ruptures of the diaphragm diagnosed 26 years after a car accident is described.
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Rocca GD, Coccia C, Pompei L, Ruberto F, Venuta F, De Giacomo T, Pietropaoli P. Hemodynamic and oxygenation changes of combined therapy with inhaled nitric oxide and inhaled aerosolized prostacyclin. J Cardiothorac Vasc Anesth 2001; 15:224-7. [PMID: 11312484 DOI: 10.1053/jcan.2001.21974] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate hemodynamic and oxygenation changes of combined therapy with inhaled nitric oxide (iNO) and inhaled aerosolized prostcyclin (IAP) during lung transplantation. DESIGN Prospective study. SETTING University hospital. PARTICIPANTS Ten patients scheduled for lung transplantation. INTERVENTIONS Ten patients, with a mean age of 38 years (range, 24 to 56 years), were scheduled for lung transplantation (2 single-lung transplantations and 8 double-lung transplantations). During first lung implantation with single-lung perfusion and ventilation, hemodynamic and oxygenation data were analyzed in 3 phases: (1) baseline, 5 minutes after pulmonary artery clamping; (2) inhaled NO phase, 15 minutes after inhaled NO administration (20 ppm) in 100% oxygen; and (3) IAP-inhaled NO phase, 15 minutes after combined administration of inhaled NO (20 ppm) and IAP (10 ng/kg/min) in 100% oxygen. MEASUREMENTS AND MAIN RESULTS During the inhaled NO phase, reductions of mean pulmonary arterial pressure (p < 0.05) and intrapulmonary shunt (p < 0.05) were noted. After the start of prostacyclin inhalation, a further decrease in mean pulmonary arterial pressure (p < 0.05) was observed. PaO2/FIO2 increased during the IAP-inhaled NO phase (p < 0.05), whereas intrapulmonary shunt decreased (p < 0.05). CONCLUSION This study confirms the action of inhaled NO as a selective pulmonary vasodilator during lung transplantation. Combined therapy with IAP and inhaled NO increases the effects on pulmonary arterial pressure and oxygenation compared with inhaled NO administered alone without any systemic changes.
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Venuta F, Rendina EA, De Giacomo T, Della Rocca G, Quattrucci S, Vizza CD, Ciccone AM, Mercadante E, Aratari MT, Rolla M, Cortesini R, Coloni GF. Improved results with lung transplantation for cystic fibrosis. Transplant Proc 2001; 33:1632-3. [PMID: 11267450 DOI: 10.1016/s0041-1345(00)02622-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Della Rocca G, Passariello M, Costa MG, Coccia C, Pompei L, Pierconti F, Venuta F, De Giacomo T, Pietropaoli P, Cortesini R. Volumetric monitoring in multiorgan donor and related lung transplant recipients. Transplant Proc 2001; 33:1637-9. [PMID: 11267452 DOI: 10.1016/s0041-1345(00)02624-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Rendina EA, Venuta F, De Giacomo T, Furio Coloni G. Stage IIIB non-small-cell lung cancer. CHEST SURGERY CLINICS OF NORTH AMERICA 2001; 11:101-19, viii. [PMID: 11253593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Highly selected patients with locally advanced non-small-cell lung cancer achieving cure do not contribute meaningfully to the overall prognosis of stage III. This finding is true particularly if clinicians rely on currently available therapeutic modalities (chemotherapy, radiation therapy, surgery) or refinements thereof. Understanding of the molecular biology continues to improve; it is more likely that in the new millenium, the real breakthroughs in staging and therapy for this high-risk, poor-prognosis group will come from the integration of molecular modalities in the clinical application.
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Landreneau RJ, De Giacomo T, Mack MJ, Hazelrigg SR, Ferson PF, Keenan RJ, Luketich JD, Yim AP, Coloni GF. Therapeutic video-assisted thoracoscopic surgical resection of colorectal pulmonary metastases. Eur J Cardiothorac Surg 2000; 18:671-6; discussion 676-7. [PMID: 11113674 DOI: 10.1016/s1010-7940(00)00580-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Careful patient selection is vital when video-assisted thoracoscopic surgical (VATS) therapeutic pulmonary metastasectomy of colorectal carcinoma is considered. Complete resection of all metastatic disease remains a vital concept. We reviewed our VATS experience for therapeutic metastasectomy of peripheral colorectal pulmonary metastases. METHODS Over 90 months, therapeutic VATS metastasectomy was accomplished upon 80 patients with colorectal metastases. Thin cut computed tomography (CT) was central in identifying lesions. The mean interval from primary carcinoma to VATS resection was 41 months (1-156 months; median, 33). A solitary lesion was resected in 60 patients and multiple (2-7) lesions resected in 20 patients. Statistics were obtained using the Student's t-test. RESULTS No operative mortality or major postoperative complications occurred. The hospital stay was 4.5+/-2. 2 days (range, 1-13). All lesions were resected by VATS, with four conversions to thoracotomy to improve the margins. The mean survival of patients with one lesion was 34.8 months compared with 26.5 months for patients with multiple lesions (P=0.37). The mean survival was 20.5 months when metastases occurred <3 years vs. 28.1 months for >3 years from primary carcinoma resection (P=0.20). Twenty-five (31%) patients are disease free; with a mean interval of 38.7 (3-84; median, 35) months. Sixty-nine percent (55/80) of patients developed a recurrence: 6/80 (8%) local; 19/80 (24%) regional (same hemithorax away from resection); and 30/80 (38%) distant. The overall survival at 1 year was 81.2%, 48.4% at 3 years and 30.8% at 5 years. CONCLUSIONS Therapeutic VATS resection of colorectal metastases appears efficacious. Preoperative CT can identify peripheral colorectal metastases amenable to VATS. Conversion to thoracotomy is indicated when none of the lesions identified by CT are found or when clear surgical margins are jeopardized.
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Venuta F, Rendina EA, Rocca GD, De Giacomo T, Pugliese F, Ciccone AM, Vizza CD, Coloni GF. Pulmonary hemodynamics contribute to indicate priority for lung transplantation in patients with cystic fibrosis. J Thorac Cardiovasc Surg 2000; 119:682-9. [PMID: 10733756 DOI: 10.1016/s0022-5223(00)70002-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Lung transplantation is a viable option for patients with cystic fibrosis. The current strategy of selection, based on spirometry and deterioration of quality of life, results in a high mortality on the waiting list. We reviewed the case histories of patients with cystic fibrosis accepted for lung transplantation to ascertain whether pulmonary hemodynamics could contribute to predict life expectancy. METHODS Forty-five patients with cystic fibrosis were accepted: 11 died on the waiting list (group I), 24 underwent transplantation (group II), and 10 are still waiting (group III). During evaluation we recorded spirometry, oxygen requirement, ratio of arterial oxygen tension to inspired oxygen fraction (PaO (2)/FIO (2)), arterial carbon dioxide tension (PaCO (2)), 6-minute walk test results, right ventricular ejection fraction, echocardiography, and pulmonary hemodynamics. We compared data from group I, II, and III patients. A comparison was also made within group II between the data collected at the time of evaluation and at the time of transplantation to quantify the deterioration during the waiting time. RESULTS The waiting time, spirometry, 6-minute walk test results, and right ventricular ejection fraction did not differ among the three groups. A statistically significant difference was found for PaO (2)/FIO (2), PaCO (2), mean pulmonary artery pressure, cardiac index, pulmonary arterial wedge pressure, and intrapulmonary shunt between groups I and II. Groups I and III showed statistically significant differences for mean pulmonary artery pressure, PaO (2)/FIO (2), and systemic vascular resistance indexed. No differences were observed between groups II and III. The comparison within group II showed a significant deterioration of pulmonary hemodynamics during the waiting time. CONCLUSIONS Pulmonary hemodynamics are worst in patients dying on the waiting list and deteriorate significantly during the waiting time. They may thus contribute to establish priority for lung transplantation in patients with cystic fibrosis.
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Della Rocca G, Coccia C, Pugliese F, Pompei L, Ruberto F, Costa MG, Venuta F, Rendina EA, De Giacomo T, Pietropaoli P, Gasparetto A. [Anesthesia in single and bilateral sequential lung transplantation. Lung Transplantation Group]. Minerva Anestesiol 2000; 66:183-93. [PMID: 10832267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Anesthesia for lung transplantation: intraoperative complications and long term results. METHODS 52 patients were scheduled for 16 single lung transplantations (SLT) (9 fibrosis and 7 emphysema) and 36 bilateral sequential lung transplantations (DLT) (4 bronchiectasis, 6 emphysema, 3 fibrosis, 22 cystic fibrosis and 1 pulmonary hypertension). Anesthesia was induced with propofol or midazolam, and fentanyl or alfentanil. As muscle relaxant vecuronium bromide was used. Anesthesia was maintained with isoflurane, fentanyl in boluses or sufentanil continuous infusion in O2 100%. Prostaglandin E1 (20-300 ng/kg/min), inhaled nitric oxide (10-40 ppm), dobutamine (5-15 mcg/kg/min), norepinephrine (0.05-3 mcg/kg/min) and ephedrine (5-10 mg per bolus) were used for hemodynamic management. In 2 patients inhaled areosolized prostacyclin were administered. RESULTS Mean pulmonary arterial pressure (mPA) and pulmonary vascular resistance (PVRI) increased after pulmonary artery clamping during first lung (mPA: 3347 nel DLT, 3643 nel SLT; PVRI; 375488 nel DLT, 377420 nel SLT) and second lung implantation (mPA: 3746; PVRI: 263553) and decreased after reperfusion of the first (mPA: 4737 nel DLT, 4329 nel SLT; PVRI: 488263 nel DLT, 420233 nel SLT) and the second lung (mPA: 4629; PVRI: 553260). Only in 9 cases (7 DLT and 2 SLT) C-P bypass was used. CONCLUSIONS With a strong drug support with pulmonary vasodilators, positive inotropic and systemic vasoconstrictor drugs, in most patients we transplanted C-P bypass can be avoided. Intraoperative deaths were not observed. Two years actuarial survival is 65% for DLT and 60% for SLT.
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Rendina EA, De Giacomo T, Venuta F, Ciccone AM, Coloni GF. Lung conservation techniques: bronchial sleeve resection and reconstruction of the pulmonary artery. SEMINARS IN SURGICAL ONCOLOGY 2000; 18:165-72. [PMID: 10657918 DOI: 10.1002/(sici)1098-2388(200003)18:2<165::aid-ssu10>3.0.co;2-m] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Bronchial and vascular reconstructive procedures are a technically feasible alternative to pneumonectomy and have the advantage of sparing functioning lung parenchyma. Between 1989 and 1999, we performed bronchovascular sleeve resection and reconstruction in 145 patients (109 men, 36 women; age range, 26 to 76 years, mean, 56 years) with non-small-cell lung cancer (NSCLCL). Forty-one patients had induction chemotherapy and 3 had pre-operative radiotherapy. Immediate and long-term postoperative evaluation included bronchoscopy, spirometry, electrocardiogram, Doppler echocardiography, and perfusion lung scans, computed tomography and, only recently, angio-magnetic resonance (MR) imaging. Follow-up ranged between 3 months and 10 years (mean, 3.7 years) and is complete for all patients. We report the results of this series and conclude that morbidity, mortality, and functional data indicate that bronchovascular reconstructions are equal to standard lobectomy in terms of pulmonary function. Long-term survival is comparable with that reported for standard resection (lobectomy-pneumonectomy). These findings suggest that even complex lung-sparing operations can be proposed as adequate procedures in the treatment of lung cancer as long as a complete anatomical resection is obtained.
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Venuta F, Rendina EA, De Giacomo T, Ciccone AM, Mercadante E, Coloni GF. Esophageal perforation after sequential double-lung transplantation. Chest 2000; 117:285-7. [PMID: 10631234 DOI: 10.1378/chest.117.1.285] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The authors report a case of esophageal perforation after sequential double-lung transplantation for bronchiectasis. This complication was probably related to the devascularization of the esophageal wall during pneumonectomy.
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Venuta F, Rendina EA, De Giacomo T, Coloni GF. Lung transplantation for emphysema. Monaldi Arch Chest Dis 1999; 54:506-9. [PMID: 10695321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
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Rocco G, Rendina EA, Meroni A, Venuta F, Della Pona C, De Giacomo T, Robustellini M, Rossi G, Massera F, Vertemati G, Rizzi A, Coloni GF. Prognostic factors after surgical treatment of lung cancer invading the diaphragm. Ann Thorac Surg 1999; 68:2065-8. [PMID: 10616978 DOI: 10.1016/s0003-4975(99)01121-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Diaphragmatic invasion from lung cancer (T3-diaphragm) is a rare occurrence reported to portend a poor prognosis. METHODS Fifteen patients with T3-diaphragm (14 males, 1 female; median age, 64 years) were surgically treated over a twenty-year period by en bloc resection (14 patients). One patient was only explored. Pathologic stage IIB (T3N0) was found in 11 patients. A partial infiltration of the diaphragm was observed in 3 patients, whereas full-depth invasion was found in 12. Diaphragmatic reconstruction was done primarily in 9 patients, and, by prosthetic material in 5. RESULTS Two patients are still alive without evidence of disease at 88, and, 114 months from surgery. Overall median survival was 23 months (range, 3 to 168). The actuarial 5-year survival was 20%, when all patients were considered, and, 27%, for T3N0 patients. Univariate analysis showed that prosthetic replacement of the muscle (p = 0.018) was significantly related to survival. CONCLUSIONS T3-diaphragm is best treated with en bloc resections with wide tumor-free margins and prosthetic replacement of the diaphragm.
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Rendina EA, Venuta F, De Giacomo T, Ciccone AM, Moretti M, Ruvolo G, Coloni GF. Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer. Ann Thorac Surg 1999; 68:995-1001; discussion 1001-2. [PMID: 10509997 DOI: 10.1016/s0003-4975(99)00738-9] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Lobectomy associated with reconstruction of the pulmonary artery (PA) is a technically feasible alternative to pneumonectomy in patients with lung cancer. However, concern about postoperative complications and long-term survival limited its acceptance so far. METHODS Between 1989 and 1996, we performed a PA reconstruction in 52 patients (41 men, 11 women; age range 35 to 75 years, mean 60 years) with lung cancer. Eleven patients had induction chemotherapy. We performed 15 PA sleeve resections, 34 PA reconstructions by a pericardial patch, and three PA reconstructions by a pericardial conduit, associated with a bronchial sleeve lobectomy or bilobectomy (33), or with standard lobectomy (19). Immediate and long-term postoperative evaluation included spirometry, echocardiography, perfusion lung scans, computed tomography, and PA angiography. The follow-up ranged between 27 and 96 months and is complete for all patients. RESULTS We had one specific postoperative complication (PA thrombosis) and no mortality. Perfusion scans and PA angiography were normal in all but the 1 patient having thrombosis. Mean forced expiratory volume (FEV) in 1 s and forced vital capacity (FVC) were, respectively, 72% and 80% preoperatively, 65% and 76% 1 month after surgery, and then they plateaued at 70% and 78% after 6 months. Echocardiography showed patterns in the normal range and normal estimates of PA pressures in all but 2 patients. Five-year survival was 38.3% for the entire group, 18.6% for stages IIIA and B, and 64.4% for stages I and II. CONCLUSIONS Morbidity, mortality, and functional data do not differ from what is currently reported for standard lobectomy. Long-term survival is in line with that reported for standard resection. These data support PA reconstruction as a viable option in the treatment of lung cancer.
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Venuta F, Rendina EA, Bufi M, Della Rocca G, De Giacomo T, Costa MG, Pugliese F, Coccia C, Ciccone AM, Coloni GF. Preimplantation retrograde pneumoplegia in clinical lung transplantation. J Thorac Cardiovasc Surg 1999; 118:107-14. [PMID: 10384193 DOI: 10.1016/s0022-5223(99)70149-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Retrograde pneumoplegia seems to improve early graft function in experimental and clinical lung transplantation. We evaluated the role of retrograde flushing in addition to antegrade pneumoplegia in clinical lung transplantation. METHODS Fourteen patients undergoing lung transplantation were randomized into 2 groups: in group I we performed antegrade pulmonary artery flushing with alprostadil (prostaglandin E1) and modified Euro-Collins solution at the time of retrieval. In group II additional retrograde flushing through the pulmonary veins was performed at the back table, before reimplantation. Hemodynamic variables, mean airway pressure, and blood gas analysis were monitored at different time points. Postoperative volumetric monitoring was performed to assess extravascular lung water. The reimplantation response was assessed by a radiographic score; extubation time and intensive care unit stay were recorded. RESULTS During retrograde flushing, blood and clots coming out from the pulmonary artery were observed; 2 lungs harvested from a donor with multiple bone fractures had fat emboli in the retrograde perfusate. Hemodynamic monitoring did not demonstrate any difference between the 2 groups. The ratio of arterial oxygen tension to inspired oxygen fraction, extravascular lung water, duration of intubation, and length of stay in the intensive care unit were improved in group II, but the differences did not reach statistical significance. Intrapulmonary shunt fraction was significantly improved in group II at each time point ( P =.02), as well as indexed alveolar-arterial oxygen tension gradient (P =.04), mean airway pressure (P =.04), and chest x-ray score ( P =.03). CONCLUSIONS Preimplantation retrograde flushing is not detrimental and helps to improve early graft function.
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Venuta F, Boehler A, Rendina EA, De Giacomo T, Speich R, Schmid R, Coloni GF, Weder W. Complications in the native lung after single lung transplantation. Eur J Cardiothorac Surg 1999; 16:54-8. [PMID: 10456403 DOI: 10.1016/s1010-7940(99)00141-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES Single lung transplantation is a viable option for patients with end-stage pulmonary disease; despite encouraging results, we observed serious complications arising in the native lung. We retrospectively reviewed 36 single lung transplants to evaluate the incidence of complications arising in the native lung, their treatment and outcome. METHODS Between 1991 and 1997, 35 patients received 36 single lung transplants for emphysema (16), pulmonary fibrosis (14), lymphangioleiomyomatosis (4), primary pulmonary hypertension (1) and bronchiolitis obliterans (1). The clinical records were reviewed and the complications related to the native lung were divided into early (up to 6 weeks after the transplant) and late complications. RESULTS Nineteen complications occurred in 18 patients (50%), leading to death in nine (25%). Early complications (within 6 weeks from the transplant) were bacterial pneumonia (1), overinflation (3), retention of secretions with bronchial obstruction and atelectasis (1), hemothorax (1), pneumothorax (1) and invasive aspergillosis (3); one patient showed active tuberculosis at the time of transplantation. Two patients developed bacterial pneumonia and invasive aspergillosis leading to sepsis and death. The other complications were treated with separate lung ventilation (1), bronchoscopic clearance (1), chest tube drainage (1) and wedge resection and pleurodesis (mechanical) by VATS (1). One patient with hyperinflation of the native lung eventually required pneumonectomy and died of sepsis. The patient with active tuberculosis is alive and well after 9 months of medical treatment. Late complications were recurrent pneumothorax (4), progressive overinflation with functional deterioration (2), aspergillosis (1) and pulmonary nocardiosis (1). Recurrent pneumothorax was treated with chest tube drainage alone (1), thoracoscopic wedge resection and/or pleurodesis (2) and pneumonectomy (1); hyperinflation was treated with thoracoscopic lung volume reduction in both cases; both patients with late infectious complications died. CONCLUSIONS After single lung transplantation, the native lung can be the source of serious problems. Early and late infectious complications generally result in a fatal outcome; the other complications can be successfully treated in most cases, even if surgery is required.
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De Giacomo T, Venuta F, Rendina EA, Della Rocca G, Ciccone AM, Ricci C, Coloni GF. Video-assisted thoracoscopic treatment of giant bullae associated with emphysema. Eur J Cardiothorac Surg 1999; 15:753-6; discussion 756-7. [PMID: 10431854 DOI: 10.1016/s1010-7940(99)00092-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Surgical treatment of bullous emphysema has received renewed attention because of recent advances in minimally invasive techniques. We describe our experience in the thoracoscopic management of patients with bullous emphysema over the last 5 years. METHODS Twenty-five patients (24 male, one female) with a mean age of 57 years with giant bullae associated with various degree of underlying emphysema, were operated on thoracoscopically at our Institution. The severity of the emphysema was classified according to the criteria of the American Thoracic Society: five patients were in stage I (FEV 1 > 50%), eight patients were in stage II (FEV1 35 to 49%) and 12 patients were in stage III (FEV1 < 35%). Nine patients underwent operation to treat complications related to bullae, 12 presented dyspnoea and four were asymptomatic. We performed 23 unilateral and two bilateral staged thoracoscopic procedures. RESULTS No intraoperative complications developed. Mean operative time was 107+/-25 min. No patient dead. Mean post-operative chest tube duration was 8+/-4.13 days and mean post-operative hospital stay was 11+/-5.76 days. The most frequent post-operative complication was air-leakage that in 12 patients lasted more than 7 days. Pulmonary function tests were obtained 3-6 months after the operation and statistical comparison between pre-operative and post-operative data was performed using Student's paired t-test. We observed best results in I and II stage patients, but also stage III patients experienced clinical improvement and better quality of life. CONCLUSIONS Our experience supports the safety and effectiveness of video-assisted thoracoscopy for the treatment of giant bullae. Minimally invasive approach is fully justified especially in the group of patients with severe impairment of lung function.
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De Giacomo T, Rendina EA, Venuta F, Ciccone AM, Coloni GF. Thoracoscopic resection of solitary lung metastases from colorectal cancer is a viable therapeutic option. Chest 1999; 115:1441-3. [PMID: 10334166 DOI: 10.1378/chest.115.5.1441] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The reported 5-year survival rate after pulmonary metastasectomy from colorectal carcinoma, usually accomplished through thoracotomy or median sternotomy, ranges from 9 to 47%. Video-assisted thoracoscopy (VAT) is employed routinely for many thoracic surgical procedures, but the main concern about this approach for resection of lung metastases is that VAT does not allow complete lung palpation to identify and remove metastases not detected by preoperative radiologic examinations. DESIGN In this study, we reviewed our experience with thoracoscopic resection of single peripheral lung metastases from colorectal carcinoma with potentially curative intent. PATIENTS AND INTERVENTIONS From July 1992 to September 1998, 24 patients (15 male, 9 female) with a mean age of 56 years, who previously had undergone resection for colorectal carcinoma and had a single limited and peripheral lung lesion identified by high-resolution CT, underwent thoracoscopic wedge resection of the lesions. RESULTS No intraoperative complications developed. Three patients had minor postoperative complications successfully treated. In one case, we found a benign lesion, and this patient was excluded from the analysis. In the remaining cases, metastases from colorectal cancer were confirmed. The median follow-up was 29 months, ranging from 3 to 67 months. Thirteen patients (56.5%) developed recurrence of the disease, and 5 of them (21.7%) had local recurrence. Cumulative 5-year survival estimated by Kaplan-Meier method was 49.5%, not really different from the data reported in the literature. CONCLUSIONS Thoracoscopic resection of single peripheral lung metastases from colorectal cancer with potentially curative intent seems effective and justified since the ultimate outcome of this highly selected group of patients seems to be not different from that obtained after a more invasive approach.
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Venuta F, Rendina EA, De Giacomo T, Della Rocca G, Antonini G, Ciccone AM, Ricci C, Coloni GF. Thymectomy for myasthenia gravis: a 27-year experience. Eur J Cardiothorac Surg 1999; 15:621-4; discussion 624-5. [PMID: 10386407 DOI: 10.1016/s1010-7940(99)00052-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Thymectomy is considered an effective therapeutic option for patients with myasthenia gravis (MG). We reviewed our 27-year experience with surgical treatment of MG with respect to long-term results and factors affecting outcome. METHODS Between 1970 and 1997, we performed 232 thymectomies for MG. Fifteen patients were lost to follow-up; the remaining 217 form the object of our study. Sixty-two patients (28.4%) had thymoma. Myasthenia was graded according to a modified Osserman classification: 51 patients (23.5%) were in class I, 81(37.3%) in class IIA, 52 (24%) in class IIB, 26 (12%) in class III and seven (3.2%) in class IV. Mean duration of symptoms before the operation was 12+/-10 months. Fifty-eight thymectomies for thymoma were performed through a median sternotomy and four through a clamshell incision. Forty-six thymectomies for non-thymomatous MG were performed through a standard cervicotomy, 101 procedures through a partial upper sternal-splitting incision and eight through a complete median sternotomy. RESULTS Operative mortality was 0.92% (two patients). After a mean follow-up of 119 months, 71% of all patients improved their clinical status (25% without medications and asymptomatic; 46% with a reduction of medications and/or clinically improved); 39 (18%) have a stable disease with no clinical modifications; 12 (5%) presented a deterioration of their clinical status with worse symptoms, required more medications, or both. Thirteen patients (6%) died because of MG (mean survival 34.3+/-3.6 months). The presence of a thymoma negatively influenced the prognosis. Younger patients showed a more favorable outcome as well as patients with a shorter duration of symptoms before the operation; patients with lower classes of myasthenia showed a higher rate of remission. CONCLUSIONS Thymectomy is effective in the management of patients with MG at all stages with low morbidity. Patients with thymoma present a less favorable outcome.
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Rendina EA, Venuta F, De Giacomo T, Ciccone AM, Ruvolo G, Coloni GF, Ricci C. Induction chemotherapy for T4 centrally located non-small cell lung cancer. J Thorac Cardiovasc Surg 1999; 117:225-33. [PMID: 9918961 DOI: 10.1016/s0022-5223(99)70416-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We used induction chemotherapy in a prospective, single-institution clinical trial intended to achieve resectability in patients with centrally located, unresectable T4 non-small cell lung cancer. Other types of IIIB disease were excluded. METHODS Between January 1990 and April 1996, we enrolled 57 patients with histologically confirmed non-small cell lung cancer. Eligibility criteria for T4 were clinical (superior vena cava syndrome, 9 patients), vocal cord paralysis (6 patients), dysphagia from esophageal involvement (1 patient), radiologic (computed tomography and magnetic resonance evidence of infiltration, 10 patients), bronchoscopic (tracheal infiltration, 11 patients), and thoracoscopic (histologically proven mediastinal infiltration, 20 patients). After 3 cycles of cisplatin (120 mg/m2), vinblastine (4 mg/m2), and mitomycin (2 mg/m2), patients were reevaluated. RESULTS Forty-two patients (73%; 36 men, 6 women; age range, 42-75 years; mean, 58 years) responded to therapy and underwent thoracotomy; 11 patients did not respond, and 4 patients had major toxicity. Thirty-six patients (63% of the entire group) had complete resection. We performed 4 exploratory thoracotomies, 6 pneumonectomies, 32 lobectomies (20 procedures were associated with reconstruction of hilar-mediastinal structures). Overall, 4 patients had no histologic evidence of disease. We had 2 bronchopleural fistulas with 1 death and 5 other major complications. Overall survival at 1 and 4 years is 61.4% and 19.5%, respectively. Forty-two patients (73%) underwent exploratory operation, with a 4-year survival of 25.9%; 36 patients (63%) had complete resection, with a 4-year survival of 30.5%. CONCLUSIONS Induction chemotherapy is effective for downstaging and surgical reconversion of centrally located T4 non-small cell lung cancer. Survival is promising, especially in patients whose disease becomes resectable.
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MESH Headings
- Adenocarcinoma/diagnosis
- Adenocarcinoma/drug therapy
- Adenocarcinoma/mortality
- Adenocarcinoma/pathology
- Adenocarcinoma/surgery
- Adult
- Aged
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Carcinoma, Non-Small-Cell Lung/diagnosis
- Carcinoma, Non-Small-Cell Lung/drug therapy
- Carcinoma, Non-Small-Cell Lung/mortality
- Carcinoma, Non-Small-Cell Lung/pathology
- Carcinoma, Non-Small-Cell Lung/surgery
- Carcinoma, Squamous Cell/diagnosis
- Carcinoma, Squamous Cell/drug therapy
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/surgery
- Chemotherapy, Adjuvant
- Cisplatin/administration & dosage
- Cisplatin/adverse effects
- Female
- Humans
- Lung Neoplasms/diagnosis
- Lung Neoplasms/drug therapy
- Lung Neoplasms/mortality
- Lung Neoplasms/pathology
- Lung Neoplasms/surgery
- Lymph Node Excision
- Male
- Middle Aged
- Mitomycin/administration & dosage
- Mitomycin/adverse effects
- Neoplasm Staging
- Pneumonectomy
- Preoperative Care/methods
- Prospective Studies
- Vindesine/administration & dosage
- Vindesine/adverse effects
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