Thoracoscopic pleural tent

Lung volume reduction has been performed in patients with advanced emphysema to relieve dyspnea and improve exercise tolerance. Median sternotomy and video-assisted thoracoscopy have been proposed as equally adequate approaches; however, prolonged postoperative air leakage is the most prevalent complication in all series. For this reason, on the basis of the experience achieved with the median sternotomy approach, buttressing of the suture line with different materials and techniques for space reduction have been proposed. We describe a technique to create a pleural tent after thoracoscopic volume reduction. The thoracoscopic creation of a pleural tent is feasible and results in a duration of postoperative air leaks and hospital stays similar to that achieved with stapler line buttressing.

Timing and priorities for cystic fibrosis patients candidates to lung transplantation

Bilateral lung transplantation is actually considered a valuable option for patients with endstage lung disease related to cystic fibrosis. Timing is crucial to transplant successfully as many patients as possible and it is mainly based on the progressive worsening of pulmonary function tests and quality of life. We reviewed the charts of all patients accepted for lung transplantation at our institution, in order to assess the role of several functional and demographic parameters; we compared the group of patients able to successfully wait for transplantation (Group A) with patients dying on the waiting list (Group B). Twenty-eight patients were accepted: 15 were successfully transplanted (2 at other institutions) (mean waiting time: 117 days), 7 died waiting (mean waiting time: 108 days) and 6 are still on the list. We recorded FEV-1, FVC, PaO2, PaCO2, supplemental O2 requirement, 6-minute walking test, right ventricular ejection fraction (RVEF) and cardio-pulmonary hemodynamics measured at right heart catheterization; we recorded also age at time of diagnosis and at time of evaluation, sex, weight and Schwachman score. These parameters were compared between Group A and B. Age at time of evaluation, sex, weight and Schwachman score did not present any difference between the two groups, as well as pulmonary function tests, PaO2, 6-minute walk test and RVEF. A statistically significant difference was found in terms of PaCO2 (43.9 +/- 9.3 in Group A vs 69.1 +/- 32.4 in Group B, heart rate at rest (102 +/- 21 vs 131 +/- 12) mean pulmonary artery pressure (20.6 +/- 2.9 vs 36 +/- 15.7), pulmonary vascular resistances (350 +/- 96 vs 460 +/- 119.4), cardiac index (3.2 +/- 0.6 vs 5.4 +/- 0.9). On the base of our initial experience we conclude that a careful evaluation of CF candidates for lung transplantation is recommended. A deterioration of pulmonary function tests and quality of life are useful parameters to accept patients in the waiting list; however priority should be attributed also on the base of cardio-pulmonary hemodynamics. A larger series of patients is required to draw definitive conclusions.

Lung transplantation for cystic fibrosis

Between November 1996 and November 1997 we have transplanted 13 patients with Cystic Fibrosis (CF). Bilateral Sequential Lung Transplantation (BSLT) was successfully performed in all patients; one patient died from pneumonia and sepsis in the postoperative period and 12 are alive and well after a follow-up ranging between 1 and 13 months. Blood gas analysis improved from mean values of PaO2: 56 mm/Hg (with oxygen) and PaCO2: 43 mm/Hg to mean values of PaO2: 85 mm/Hg and PaCO2: 37 mm/Hg. Pulmonary function tests also improved dramatically: FEV1 improved from 20% predicted to 98% predicted. FVC also improved from 39% to 100%. The quality of life markedly improved: the ideal body weight moved from about 84% to normal values within nine months, and the 6-minute walk-test improved after transplantation from a preoperative distance of 325 meters, to 600 meters after 6 months. In conclusion, our favorable experience with BSLT in CF patients emphasizes the importance of lung transplantation in these patients. Carefully selected and properly managed patients may benefit from transplantation in terms of quality and duration of life.

[Surgical endoscopy of the airways]

METHODS

Between April 1993 and April 1996, 146 endoscopic procedures were performed in 128 patients (144 with Nd:YAG laser) with benign or malignant obstructions of the airway. Removal of foreign bodies are not included in this series. Twenty resections were performed with the flexible fiberoptic bronchoscope under local anesthesia and 126 with the rigid tube under general anesthesia. Power settings were always between 20 and 35 Watts. Eighteen procedures were performed in emergency. Fifteen patients had a benign postintubation tracheal stricture (20 treatments-11 Dumon stents and 1 Montgomery tube). Eighty-two patients (90 treatments-12 stents) had malignant lesions of the airways (trachea 11, carina 2, RMB 22, LMB 27, TI 11, LULB 3, RULB 2, LILB 4). Laryngeal, tracheal or bronchial granulations were present in 19 patients (21 treatments). Other lesions were present in 11 patients (14 treatments-6 stents).

RESULTS

Major complications occurring during laser resections were bleeding (2), hypoxia (1) and cardiac arrhythmia (2); 2 patients died 24 hours after the procedure for cardio-respiratory failure. The airway calibre was improved in 100% of patients with benign lesions and 82.4% of patients with malignancy. In the latter group the trachea, main stem bronchi and truncus intermedius calibre was improved better than the lobar bronchi. All patients with malignancy underwent chemo-radiotherapy without respiratory distress.

CONCLUSIONS

Nd:YAG laser therapy is a safe and effective mean of releasing airway obstructions; indwelling stents contribute to further improve the results.

Technique to reduce air leaks after pulmonary lobectomy

OBJECTIVE

Patients undergoing pulmonary resections often present postoperative air leaks of varying magnitude and duration; this complication is more frequent with incomplete or absent interlobar fissures. Small leaks close spontaneously within 5-7 days; larger leaks may persist longer and could be associated with increased morbidity and prolonged hospitalization. We evaluated the role of different techniques to complete interlobar fissures before pulmonary lobectomy to prevent postoperative air leaks and reduce hospital stay and costs.

METHODS

A total of 30 patients undergoing pulmonary lobectomy for lung cancer and presenting incomplete interlobar fissures that needed to be opened both anteriorly and posteriorly were randomized into three groups. In Group I, fissures were created with a GIA stapler and buttressed with bovine pericardial sleeves. In Group II, we used TA 55 staplers alone; in Group III we used the 'old fashion' cautery, clamps and silk ties. The three groups were homogeneous for age, type of pulmonary resection and stage of the tumor. The duration of postoperative air leaks and hospital stay were compared with the one-way variance analysis.

RESULTS

Postoperative air leaks for Groups I, II and III persisted for 2 +/- 0.94, 5.3 +/- 2 and 5.3 +/- 1.7 days, respectively. Mean hospital stay was 4.4 +/- 0.96, 7.8 +/- 2.14 and 7.2 +/- 1.5, respectively. The difference between groups in terms of duration of postoperative air leaks and hospital stay was statistically significant (P = 0.0001).

CONCLUSIONS

The use of GIA staplers and pericardial sleeves to complete interlobar fissures for pulmonary lobectomy significantly reduces the duration of postoperative air leaks and hospital stay; no complications were associated with this technique.

Multimodality treatment of thymoma: a prospective study

BACKGROUND

Thymomas are a heterogeneous group of tumors. Treatment of invasive lesions is not well standardized. The aim of this study is to propose a clinicopathologically based protocol for multimodality therapy.

METHODS

Between 1965 and 1988, we operated on 83 patients with thymoma who did not receive standardized adjuvant therapy. In 1989, on the basis of the retrospective analysis of the data, we started a multimodality therapy protocol and used it for 65 patients. Twelve patients had medullary thymoma (11 stage I and 1 stage II), 13 had mixed type (6 stage I and 7 stage II), and 40 had cortical thymoma (4 stage I, 11 stage II, 12 stage III, and 13 stage IV). We considered three groups. Group I (n = 18 patients), benign thymoma, included stage I and II medullary and stage I mixed thymomas; radical resection with no adjuvant therapy was performed. Group II (n = 22), invasive thymoma, included stage I and II cortical and stage II mixed thymomas; postoperative chemotherapy plus radiotherapy was always administered. Group III (n = 25), malignant thymoma, comprised stage III and IV cortical thymomas and stage III mixed thymomas; resectable stage III lesions were removed, and highly invasive stage III and stage IV lesions underwent biopsy, neoadjuvant chemotherapy, and surgical resection; postoperative chemotherapy and radiotherapy was administered to all patients.

RESULTS

The 8-year survival rate for patients in stages I, II, III, and IV was 95%, 100%, 92%, and 68%, respectively. Patients with medullary thymoma had a 92% 8-year survival rate; those with mixed type, 100%; and those with cortical thymoma, 85%. Group I had an 8-year survival rate of 94%; group II, 100%; and group III, 76%. Survival was compared with that of patients operated on before 1989: differences were not significant for group I; survival improved in group II (100% versus 81%; p = not significant); and group III showed significant improvement (76% versus 43%; p < 0.049).

CONCLUSIONS

Multimodality treatment with neoadjuvant chemotherapy and adjuvant chemotherapy plus radiotherapy may improve the results of radical resection and the survival of patients with invasive and malignant thymoma.

Safety and efficacy of bronchovascular reconstruction after induction chemotherapy for lung cancer

OBJECTIVE

The aim of this study was to ascertain the safety and efficacy of bronchial sleeve resection and reconstruction of the pulmonary artery in patients who had undergone induction chemotherapy for lung cancer.

METHODS

Between January 1991 and July 1996, we operated on 68 patients who had received three cycles of cisplatin-based induction chemotherapy. In 27 of these cases, we performed a lobectomy (n = 25) or bilobectomy (n = 2) associated with reconstruction of the bronchus, the pulmonary artery, or both. In only five additional patients, pneumonectomy had to be carried out. Before chemotherapy, 14 patients were in stage IIIA and 13 were in stage IIIB. All patients in stage IIIB had T4 disease; no N3 cases were included. At thoracotomy, one patient had no evidence of tumor, six were in stage I, 13 were in stage II, six were in stage IIIA, and one was in stage IIIB. Sixteen patients had epidermoid carcinoma and 11 had adenocarcinoma.

RESULTS

Sixteen patients underwent bronchial sleeve resection; 11 had various types of pulmonary artery reconstruction, associated with the bronchial sleeve in eight cases. In 26 patients, resection was radical with histologically negative margins. Neither bronchial complications nor deaths occurred. One patient had empyema and two had wound infections. Mean chest tube duration was 6 days. After a postoperative follow-up of 4 to 69 months (mean 25 months), 14 patients are alive and free of disease, one is alive with disease, and 12 have died. There were no local recurrences. The 1- and 4-year survival rates are 78% and 39%, respectively.

CONCLUSIONS

Although it is technically demanding, lobectomy associated with bronchovascular reconstruction is feasible, with good immediate and long-term results, after induction chemotherapy.

Thoracoscopic staging of IIIB non-small cell lung cancer before neoadjuvant therapy

BACKGROUND

Bronchoscopy and imaging techniques are the most valuable tools for noninvasive staging of patients with locally advanced non-small cell lung cancer but their overall accuracy is not satisfactory. Neoadjuvant therapy protocols require strict criteria for patient selection and invasive staging should be carried out to establish standardized inclusion criteria and to homogenize posttreatment results. The aim of this prospective study was to evaluate the role of thoracoscopy in the assessment of the real extent of lung cancer in patients with the clinical suspicion of stage IIIB disease.

METHODS

From January 1993 to March 1996, we observed 64 patients with suspected IIIB non-small cell lung cancer. Forty-three patients were considered eligible for this study and were divided into three groups: group I, cytologically negative pleural effusion (n = 10); group II, computed tomographic suspicion of mediastinal infiltration (n = 30); and group III, contralateral lymphadenopathy not accessible by mediastinoscopy (n = 3).

RESULTS

No complications related to thoracoscopy occurred. Of 10 patients in group I, thoracoscopy up-staged the disease to IIIB in 6 (60%). Of 30 patients with suspicion of T4 (group II), thoracoscopy confirmed T4 in 15 patients (50%). Nine (30%) were downstaged to stage IIIA and 2 (6.6%) to stage II. In 4 patients (13.4%) thoracoscopy failed to yield definitive staging. In all 3 patients of group III, thoracoscopy confirmed stage IIIB.

CONCLUSIONS

Thoracoscopy proved adequate for correct staging in 39 of 43 patients (91%); therefore, it should be considered in the staging work-up of suspected stage IIIB patients.

Occult lung cancer in patients with bullous emphysema

BACKGROUND

The incidence of lung cancer is increased in patients with bullous emphysema.

METHODS

A series of 95 patients undergoing excision of bullous lung tissue was reviewed to determine the incidence and long term outcome of occult carcinoma present in the resected material.

RESULTS

Four patients (4.2%) had peripheral foci of large cell carcinoma in the resection specimen (three bullectomies and one lobectomy).

CONCLUSIONS

Resected bullous lung tissue should be carefully examined for areas of bronchogenic carcinoma. The results of incidental complete excision are favourable.

[The selection of patients who are candidates for lung transplantation]

From January 1991 to September 1993 we evaluated 49 patients (27 males and 22 females--mean age 42 years) with chronic respiratory failure as possible candidates for lung transplantation. 27 patients had idiopathic pulmonary fibrosis, 9 emphysema, 4 bronchiectasis, 3 cystic fibrosis, 3 primary pulmonary hypertension and 1 respectively lymphangiomatosis, thromboembolism and vanishing lung. 16 patients were considered suitable for single or double lung transplantation. 4 patients died waiting, 4 underwent single lung transplantation and 8 are still on the waiting list. The mean survival of patients in the waiting list was 145 days (52 for patients with idiopathic pulmonary fibrosis), ranging between 35 and 398 days.

[Video-assisted thoracoscopy in the treatment of recurrent pneumothorax]

Between April 1992 and May 1994, 45 patients with recurrent spontaneous pneumothorax underwent videoassisted thoracoscopy (group I). The mean chest tube duration, the length of hospital stay, the use of parenteral narcotics, the complications and the follow-up were analyzed and compared to the same data of a group of 21 patients previously treated by open approach between January 1991 and March 1993 (group II). Average age, sex and surgical indications distribution were comparable (group I: 36 males, 9 females, mean age 31.7 years; group II: 17 males, 4 females, mean age 31.5 years). Mean chest tube duration was lower in group I (group I 4.3 days vs group II 7.2 days), as was mean hospital stay (group I 4.6 days vs group II 10.3 days) and the necessity of parenteral narcotics for pain relief (group I 11% vs group II 66% of patients). No episodes of relapsing pneumothorax occurred in either group of patients after a mean follow-up of 12.4 months (range from 1-24 months) for group I and 30 months (range from 24-36 months) for group II. The incidence of minor complications was less in group I (4.4%) than group II (23.8%). Our early results in the treatment of recurrent spontaneous pneumothorax by videoassisted thoracoscopy have been encouraging and the merits of this approach make it preferable to thoracotomy.

Video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax

OBJECTIVE

To present our experience of video-assisted thoracoscopy in the treatment of recurrent spontaneous pneumothorax, and to compare the results with those of a historical control group treated by lateral thoracotomy.

DESIGN

Prospective evaluation with historical controls.

SETTING

Teaching hospital, Italy.

SUBJECTS

41 Patients with recurrent spontaneous pneumothorax, 20 of whom were treated by video-assisted thoracoscopy and 21 of whom underwent lateral thoracotomy (historical control group).

MAIN OUTCOME MEASURES

Duration of chest drainage, length of hospital stay, amount of narcotic analgesia required, postoperative complications, and recurrence during follow up.

RESULTS

The mean (range) duration of chest drainage in the group who underwent video-assisted thoracoscopy was 5 days (4-7) compared with 7 days (4-13) in the control group; the corresponding figures for length of hospital stay were 6 days (4-8) compared with 10 days (5-16). 3 Patients (15%) in the thoracoscopy group required parenteral narcotic analgesia compared with 14 (66%) in the control group, and 2 (10%) developed minor complications compared with 5 (24%). The mean length of follow up was 9 months (range 1-18) compared with 26 months (19-34), and no patient in either group developed a recurrence.

CONCLUSION

Our early results of treating recurrent spontaneous pneumothorax with video-assisted thoracoscopy have been encouraging, and we have adopted it in preference to lateral thoracotomy.

Preoperative chemotherapy and immunochemotherapy for locally advanced stage IIIA and IIIB non small cell lung cancer. Preliminary results

From January 1991 to November 1993, 110 patients with histologically confirmed stage IIIA and IIIB non-small cell lung cancer (NSCLC), were seen at our Institution. Our study was designed to evaluate whether redirection to surgery of otherwise unresectable patients may be obtained by preoperative therapy. Forty-nine patients were considered eligible for neoadjuvant treatment. Thirty-two (Group I) were treated with two or three cycles of cisplatin, vinblastine and mitomycin C and 17 (Group II) received two cycles of cisplatin, VP16, alpha 1 timosine and interferon. The overall response rate was 81.2% for Group I and 88.7% for Group II. Downstaging was predictive of resectability (P < 0.05). Forty-one patients (83.6%) underwent thoracotomy with 37 (75.5%) radical resections. Conservative techniques (bronchovascular reconstruction) (22 cases) were preferred over pneumonectomy (2 cases). The resectability rate was 84% for Group I and 87% for Group II (P = NS). Treatment-related complications were minor, with no deaths. Postoperative complications occurred in two cases in each group (7.4% and 14.3%). There was no histologic evidence of tumor in three patients. Two-year survival was 75% for Group I and 55% for Group II (P = NS). To date 35 patients who had complete resection are alive, and free of disease. We conclude that preoperative chemotherapy produces high response and resectability rates in both stage IIIA and IIIB unresectable NSCLC; radical resection using a conservative technique is possible in patients who are otherwise unresectable; no local recurrence occurred after radical resection; no significant differences were demonstrated between the two protocols.

Pancytopenia associated with thymoma resolving after thymectomy and immunosuppressive therapy. Case report

In a 43-year-old woman, pancytopenia accompanying thymoma persisted after thymectomy, requiring weekly blood transfusions, and did not respond to prednisone 50 mg/day. Cyclosporine 10 mg/kg/day plus prednisone 20 mg/day for a month gradually corrected the blood parameters. Thirty months later the patient is well and haematologically stable.

Comparative merits of thoracoscopy, mediastinoscopy, and mediastinotomy for mediastinal biopsy

Between April 1992 and April 1993, we performed fifty-four mediastinal biopsies in 51 patients with a mediastinal mass. Nine of these had lung cancer with mediastinal lymphadenopathy, and the remaining 42 had various primary mediastinal lesions. We have performed twenty video-assisted thoracic surgical procedure, twenty-six mediastinoscopies, and eight anterior mediastinotomies. In 3 patients the diagnosis was not obtained by mediastinoscopy, and video-assisted thoracoscopy was performed. We conclude that mediastinoscopy is indicated for the majority of lesions involving the peritracheal space. Restaging of lymphoma and highly infiltrative lesions are better managed by video-assisted thoracic surgery. Anterior mediastinotomy is indicated when feasible under local anesthesia for tumors infiltrating the anterior chest wall. In all other cases video-assisted thoracic surgery is preferable because it allows removal of large tissue biopsy specimens and even resection with wide surgical exposure and low operative trauma.

Reconstruction of the pulmonary artery in patients with lung cancer

Between March 1990 and December 1992, we performed 17 resections and reconstructions of the pulmonary artery (PA) in patients with lung cancer. Three patients with intrapericardial infiltration of the PA underwent left pneumonectomy and PA angioplasty through a median sternotomy during cardiopulmonary bypass. The first patient survived in excellent general health for 25 months and then died of brain metastases; the second died of bronchopneumonia on postoperative day 24; and the third died of generalized tumor spread after 3 months. Fourteen patients had extrapericardial infiltration of the PA. They underwent sleeve upper lobectomy and PA reconstruction instead of pneumonectomy. In 6 patients we performed a sleeve resection of the PA, and in 8, the vessel was reconstructed using a patch of autologous pericardium. Two minor postoperative complications occurred. Three patients died after 14, 15, and 20 months; the remaining 11 are alive and well 5 to 31 months after operation. We conclude that PA reconstruction associated with sleeve lobectomy is an advantageous alternative to pneumonectomy in select patients with lung cancer. Intraoperative indications, surgical technique, and perioperative management are crucial to achieve good results. Reconstruction of the main PA during cardiopulmonary bypass in association with left pneumonectomy can be performed successfully. The long-term results need further evaluation.