Surgical resolution of chronic thoracic pain stemming from a rare osteo-muscular conflict: A case report

INTRODUCTION

Chronic thoracic pain presents significant diagnostic and therapeutic challenges, particularly when arising from rare osteo-muscular conflicts. This report details a unique case of chronic pain due to an osteo-muscular conflict between the right tenth rib and the internal oblique muscle, highlighting the complexities involved in diagnosis and the potential for surgical resolution.

CASE PRESENTATION

A 33-year-old male with a decade-long history of chronic right hemithorax pain, unresponsive to conservative treatments, underwent diagnostic evaluation. Advanced imaging techniques, including a thoracic CT scan, revealed an ipodense area between the ninth and tenth ribs, suggesting an osteo-muscular conflict. Surgical intervention, specifically a partial costectomy of the right tenth rib, was pursued, resulting in significant symptom relief and improved quality of life.

CLINICAL DISCUSSION

This case underscores the importance of considering advanced diagnostic evaluations in persistent chronic pain cases and the effectiveness of targeted surgical interventions in resolving anatomical conflicts. It contributes to the body of knowledge on managing complex musculoskeletal conditions and underscores the need for personalized treatment approaches.

CONCLUSION

Surgical intervention in selected cases of chronic pain due to rare anatomical conflicts can offer significant relief and enhance patient outcomes. This case advocates for a nuanced approach to the diagnosis and treatment of chronic thoracic pain, emphasizing the role of advanced imaging and the potential benefits of surgical resolution.

CARE-radiology statement explanation and elaboration: reporting guideline for radiological case reports

Despite the increasing number of radiological case reports, the majority lack a standardised methodology of writing and reporting. We therefore develop a reporting guideline for radiological case reports based on the CAse REport (CARE) statement. We established a multidisciplinary group of experts, comprising 40 radiologists, methodologists, journal editors and researchers, to develop a reporting guideline for radiological case reports according to the methodology recommended by the Enhancing the QUAlity and Transparency Of health Research network. The Delphi panel was requested to evaluate the significance of a list of elements for potential inclusion in a guideline for reporting mediation analyses. By reviewing the reporting guidelines and through discussion, we initially drafted 46 potential items. Following a Delphi survey and discussion, the final CARE-radiology checklist is comprised of 38 items in 16 domains. CARE-radiology is a comprehensive reporting guideline for radiological case reports developed using a rigorous methodology. We hope that compliance with CARE-radiology will help in the future to improve the completeness and quality of case reports in radiology.

The SUPER reporting guideline suggested for reporting of surgical technique

Background

Existing reporting guidelines pay insufficient attention to the detail and comprehensiveness reporting of surgical technique. The Surgical techniqUe rePorting chEcklist and standaRds (SUPER) aims to address this gap by defining reporting standards for surgical technique. The SUPER guideline intends to apply to articles that encompass surgical technique in any study design, surgical discipline, and stage of surgical innovation.

Methods

Following the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network approach, 16 surgeons, journal editors, and methodologists reviewed existing reporting guidelines relating to surgical technique, reviewed papers from 15 top journals, and brainstormed to draft initial items for the SUPER. The initial items were revised through a three-round Delphi survey from 21 multidisciplinary Delphi panel experts from 13 countries and regions. The final SUPER items were formed after an online consensus meeting to resolve disagreements and a three-round wording refinement by all 16 SUPER working group members and five SUPER consultants.

Results

The SUPER reporting guideline includes 22 items that are considered essential for good and informative surgical technique reporting. The items are divided into six sections: background, rationale, and objectives (items 1 to 5); preoperative preparations and requirements (items 6 to 9); surgical technique details (items 10 to 15); postoperative considerations and tasks (items 16 to 19); summary and prospect (items 20 and 21); and other information (item 22).

Conclusions

The SUPER reporting guideline has the potential to guide detailed, comprehensive, and transparent surgical technique reporting for surgeons. It may also assist journal editors, peer reviewers, systematic reviewers, and guideline developers in the evaluation of surgical technique papers and help practitioners to better understand and reproduce surgical technique.

Trial Registration

https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/#SUPER.

Reporting guidelines for surgical technique could be improved: a scoping review and a call for action

OBJECTIVES

To identify reporting guidelines related to surgical technique and propose recommendations for areas that require improvement.

STUDY DESIGN AND SETTING

A protocol-guided scoping review was conducted. A literature search of MEDLINE, the EQUATOR Network Library, Google Scholar, and Networked Digital Library of Theses and Dissertations was conducted to identify surgical technique reporting guidelines published up to December 31, 2021.

RESULTS

We finally included 55 surgical technique reporting guidelines, vascular surgery (n = 18, 32.7%) was the most common among the clinical specialties covered. The included guidelines generally showed a low degree of international and multidisciplinary cooperation. Few guidelines provided a detailed development process (n = 14, 25.5%), conducted a systematic literature review (n = 13, 23.6%), used the Delphi method (n = 4, 7.3%), or described post-publication strategy (n = 6, 10.9%). The vast majority guidelines focused on the reporting of intraoperative period (n = 50, 90.9%). However, of the guidelines requiring detailed descriptions of surgical technique methodology (n = 43, 78.2%), most failed to provide guidance on what constitutes an adequate description.

CONCLUSION

Our study demonstrates significant deficiencies in the development methodology and practicality of reporting guidelines for surgical technique. A standardized reporting guideline that is developed rigorously and focuses on details of surgical technique may serve as a necessary impetus for change.

Diffuse Pulmonary Meningotheliomatosis: Clinic-Pathologic Entity or Indolent Metastasis from Meningioma (or Both)?

Pulmonary minute meningothelial-like nodules (MMNs) are common incidental findings in surgical specimens, consisting of tiny proliferation (usually no larger than 5-6 mm) of bland-looking meningothelial cells showing a perivenular and interstitial distribution, sharing morphologic, ultrastructural, and immunohistochemical profiles with meningiomas. The identification of multiple bilateral MMNs leading to an interstitial lung disease characterized by diffuse and micronodular/miliariform patterns radiologically allows the diagnosis of diffuse pulmonary meningotheliomatosis (DPM). Nevertheless, the lung is the most common site of metastatic primary intracranial meningioma, and differential diagnosis with DPM may be impossible without clinic-radiologic integration. Herein, we report four cases (three females; mean age, 57.5 years) fitting the criteria of DPM, all incidentally discovered and histologically evidenced on transbronchial biopsy (2) and surgical resection (2). All cases showed immunohistochemical expression of epithelial membrane antigen (EMA), progesterone receptor, and CD56. Notably, three of these patients had a proven or radiologically suspected intracranial meningioma; in two cases, it was discovered before, and in one case, after the diagnosis of DPM. An extensive literature review (44 patients with DPM) revealed similar cases with imaging studies excluding intracranial meningioma in only 9% (4 of 44 cases studied). The diagnosis of DPM requires close correlation with the clinic-radiologic data since a subset of cases coexist with or follow a previously diagnosed intracranial meningioma and, thus, may represent incidental and indolent metastatic deposits of meningioma.

An unexpected cause of recurrent pneumothorax

The thoracic district is the most frequent visceral location of synovial sarcoma, generally involving lung and pleura as a large solid mass. We present herein a 57-year-old man with recurrent pneumothorax and a localized bulla at the lingula. The lesion was excised by a Video-Assisted-Thoracoscopic-Surgery (VATS) wedge resection and surprisingly consisted of a unilocular cyst with fibrous wall intermingled by a longitudinal proliferation of bland-looking, dense, monomorphic spindle cells diffusely expressing EMA, CD99, CD56 and focally staining with cytokeratins. Fluorescent in situ hybridization demonstrated the presence of SYT rearrangement and a diagnosis of pulmonary cystic monophasic synovial sarcoma was made. Only few similar cases have been reported in literature, mainly occurring in young male adults. A meticulous examination of all resected tissue from pneumothorax is the prerequisite to suspect this extremely challenging condition, while immuno-molecular studies are mandatory to achieve the correct diagnosis.

Totally thoracoscopic versus standard VATS lobectomies: perioperative differences

BACKGROUND

Minimally invasive surgery is considered the gold standard approach for early stage lung cancer. Techniques range from a standard three-port approach to uniportal lobectomies, with no technique emerging as superior thus far. We retrospectively compared the pain outcomes of a standard approach using a utility incision with a totally thoracoscopic technique.

METHODS

Between January 2015 and December 2019, 168 patients received a VATS lobectomy in our centers. Two groups were created, Group A (82 patients, totally thoracoscopic approach) and Group B (86 patients, standard approach with utility incision). Perioperative outcomes, such as operative time, complications, length of stay, perioperative and chronic pain using visual analog scale (VAS), and rescue doses of painkillers were examined. A one-way analysis of covariance (ANCOVA) was conducted to investigate the impact of surgical time and days of drainage on VAS score.

RESULTS

Pain was less on postoperative day (POD) 1 and 2 (p = 0.025 and p = 0.020, respectively) in Group A. No differences were found in the baseline and perioperative characteristics of the two groups, in the mean VAS score at 1 month (p = 0.429), 1 year (p = 0.561), doses of NSAIDs (p = 0.609), and chronic pain (3vs7 patients, p = 0.220). The ANCOVA test showed no significant effect of surgical time and days of drainage on VAS score (p > 0.05).

CONCLUSIONS

In our experience, a totally thoracoscopic approach may improve acute postoperative pain without compromising the oncological results of the procedure and the safety of the patients.

Expert consensus on resection of chest wall tumors and chest wall reconstruction

Chest wall tumors are a relatively uncommon disease in clinical practice. Most of the published studies about chest wall tumors are usually single-center retrospective studies, involving few patients. Therefore, evidences regarding clinical conclusions about chest wall tumors are lacking, and some controversial issues have still to be agreed upon. In January 2019, 73 experts in thoracic surgery, plastic surgery, science, and engineering jointly released the Chinese Expert Consensus on Chest Wall Tumor Resection and Chest Wall Reconstruction (2018 edition). After that, numerous experts put forward new perspectives on some academic issues in this version of the consensus, pointing out the necessity to further discuss the points of contention. Thus, we conducted a survey through the administration of a questionnaire among 85 experts in the world. Consensus has been reached on some major points as follows. (I) Wide excision should be performed for desmoid tumor (DT) of chest wall. After excluding the distant metastasis by multi-disciplinary team, solitary sternal plasmacytoma can be treated with extensive resection and adjuvant radiotherapy. (II) Wide excision with above 2 cm margin distance should be attempted to obtain R0 resection margin for chest wall tumor unless the tumor involves vital organs or structures, including the great vessels, heart, trachea, joints, and spine. (III) For patients with chest wall tumors undergoing unplanned excision (UE) for the first time, it is necessary to carry out wide excision as soon as possible within 1–3 months following the previous surgery. (IV) Current Tumor Node Metastasis staging criteria (American Joint Committee on Cancer) of bone tumor and soft tissue sarcoma are not suitable for chest wall sarcomas. (V) It is necessary to use rigid implants for chest wall reconstruction once the maximum diameter of the chest wall defect exceeds 5 cm in adults and adolescents. (VI) For non-small cell lung cancer (NSCLC) invading the chest wall, wide excision with neoadjuvant and/or adjuvant therapy are recommended for patients with stage T_3-4N_0-1M₀. As clear guidelines are lacking, these consensus statements on controversial issues on chest wall tumors and resection could possibly serve as further guidance in clinical practice during the upcoming years.

Evidence on reporting guidelines for surgical technique in clinical disciplines: a scoping review protocol

Background

The reporting of surgical techniques is of mixed quality, with most at a very minimal level. Reporting guidelines that could be applied to guide surgical technique reporting vary in methodology for development, discipline coverage, dimension coverage and detail requested. However, a scoping review that could indicate the gaps and efforts needed in surgical technique reporting guidelines is lacking and warranted. This study aims to design a methodological rigour protocol to guide the development of a scoping review of surgical technique reporting guidelines.

Methods

This protocol is designed following the 2020 manual proposed by the Joanna Briggs Institute. To further ensure the soundness of the protocol, we also included multidisciplinary professionals (including methodologists, clinicians, and journal editors) to refine the protocol.

Discussion

Seven key steps for developing the scoping review are identified and presented in detail, including (I) identifying the research questions; (II) inclusion criteria; (III) search strategy; (IV) source of evidence selection; (V) data extraction; (VI) analysis of the evidence; and (VII) presentation of the results. Guided by this protocol, the subsequent scoping review will inform us the overview of surgical technique reporting guidelines and precisely guide our direction and next steps in improving surgical technique reporting guidelines.

Trial registration

This protocol is not registered as the PROSPERO database only accepts registration of systematic review protocols while does not accept registration of scoping review protocols.

Developing the surgical technique reporting checklist and standards: a study protocol

BACKGROUND

Standardized and transparent reporting of surgical technique is the cornerstone of effective dissemination, implementation and improvement. However, current reporting of surgical techniques is inadequate. The existing guidelines potentially applied to guide surgical technique reporting are with a minimal highlight of the surgical technique, lack requirements explaining what extent and dimensions need to be described in detail, or are unlikely to extrapolate to a wide range of surgical techniques. This study aims to formulate a rigorous protocol to develop a surgical technique reporting checklist and standards (SUPER) that defines what a clear, comprehensive and detailed surgical technique report should be contained.

METHODS

This protocol is designed following the classic guidance for developing reporting guidelines recommended by the EQUATOR network.

RESULTS

The development team will consist of surgeons (~80%), methodologists, and journal editors. The draft checklist sources will include a scoping review of existing reporting guidelines related to surgical technique, surgical technique articles from 15 top journals published in the last year, and brainstorming by the multidisciplinary development team. The final SUPER checklist will be formed after three rounds of Delphi surveys, one round of face-to-face meeting, and a month-long pilot test. The SUPER checklist will be published as open-access and be used in combination with existing reporting guidelines related to surgical techniques (e.g., IDEAL). This protocol will steer the SUPER checklist's development, allowing us to further elaborate surgical technique reporting for all surgical specialties, and enabling a more favorable experience for surgeons, nurses, medical students, residents, editors, and reviewers.

TRIAL REGISTRATION

This trial is registered at the EQUATOR network on December 18th, 2020. Available at: https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/.

When the Diagnosis of Mesothelioma Challenges Textbooks and Guidelines

The diagnosis of malignant mesothelioma (MPM) does not pose difficulties when presenting with usual clinico-radiologic features and morphology. Pathology textbooks and national/international guidelines generally describe the findings of classic MPM, underlining common clinical presentation, the gold standard of sampling techniques, usual morphologic variants, immunohistochemical results of several positive and negative primary antibodies in the differential diagnosis, and the role of novel molecular markers. Nevertheless, MPM often does not follow the golden rules in routine practice, while the literature generally does not sufficiently emphasize unusual features of its manifestation. This gap may potentially create problems for patients in sustaining a difficult diagnosis of MPM in clinical practice and during legal disputes. Indeed, the guidelines accidentally tend to favor the job of lawyers and pathologists defending asbestos-producing industries against patients suffering from MPM characterized by uncommon features. The current review is aimed at underlining the wide spectrum of clinical and radiological presentation of MPM, the possibility to consistently use cytology for diagnostic intent, the aberrant immunohistochemical expression using so-called specific negative and positive primary antibodies, and finally proposing some alternative and more unbiased approaches to the diagnosis of MPM.

Pseudocarcinomatous Mesothelioma: A Hitherto Unreported Presentation closely simulating primary lung cancer

Malignant mesothelioma (MM) has a wide range of clinical, radiologic, and pathologic presentations, mimicking lung cancer or interstitial lung diseases when predominantly involving the lung parenchyma. The case herein refers to a 79-year-old man, active smoker without asbestos exposure, incidentally discovered to have a pulmonary nodule in the right upper lobe (1.5 cm). The lesion was misinterpreted as primary lung adenocarcinoma at the frozen section in light of the predominant lepidic growth pattern. Definitive examination confirmed neoplastic proliferation along alveolar structures. However, the unusual globous shape of tumor cells along the alveoli abruptly merging with normal pneumocytes prompted us to perform some immunostains that surprisingly revealed a mesothelial differentiation (positive staining with calretinin, cytokeratins (CK5/6), D2-40, and negativity with BRCA-associated protein 1 (BAP1), Thyroid Transcription Factor 1 [TTF-1], claudin-4, carcinoembryonic antigen [CEA], and napsin). MM represents the pathologic counterpart of so-called pseudomesotheliomatous carcinoma, since it appears as a localized pulmonary neoplastic nodule displaying a predominant lepidic growth pattern (pseudocarcinomatous mesothelioma). The challenging diagnostic features of this unique case and a review of similar cases in the literature are discussed.

Sleeve Lobectomy: To Wrap or Not to Wrap the Bronchial Anastomosis?

BACKGROUND

Bronchoplastic procedures have become the reference standard in the lung parenchyma-sparing treatment of centrally located bronchopulmonary tumors. Two schools of thought exist regarding performing a bronchial sleeve resection: those who wrap the anastomosis with a pedicled flap and those who leave the anastomosis unprotected. We performed a study comparing these 2 methods.

METHODS

This study was a retrospective multicenter observational analysis of 90 consecutive patients undergoing bronchial sleeve resections for neoplastic disease between June 2009 and July 2019. Group A (60 patients) underwent bronchial wrapping and group B (30 patients) did not undergo wrapping.

RESULTS

The only difference between group A, which had 5 patients (8.3%), and group B, which had 10 patients (33.3%), regarding general characteristics was the presence of diabetes (P = .003). There were no differences in surgical, postoperative, and follow-up characteristics. There was no statistically significant difference between groups (group A, 9 patients [15%]; and group B, 6 patients [20%]) in terms of anastomotic complications at 1 year (P = .425). Diabetes was an independent predictive factor for anastomotic complications at 1 year (P = .035). The number of postoperative complications (P < .001) was an independent risk factor for length of hospital stay.

CONCLUSIONS

We found no differences between groups in terms of postoperative complications and length of hospital stay, which confirmed previous reports that sleeve resections may be performed safely without bronchial wrapping.

Three-chamber chest drain system in the COVID-19 era: is there a risk of further transmission?

We discuss the hypothesis that common Chest Drain Systems collected to a COVID-19 patient, could be a possible source of contamination for health care staff in a Thoracic Surgery ward and we propose an alternative way to minimize this further risk of transmission.

Mucinous Adenomyomatous Pulmonary Hamartoma: Clinicopathologic, Immunohistochemical, and Molecular Features of 6 Cases

Pulmonary hamartoma (PH) may show various combinations of mesenchymal tissues with entrapment of respiratory epithelium. An uncommon variant of PH prevalently consisting of smooth muscle with mucinous proliferation has been reported in literature under several definitions as sporadic reports. We collected a series of 6 leiomyomatous PH associated with mucinous growth from consultation files (3 cases) and multicentric revision of archival files among 128 consecutive surgically resected PH. The lesions have a prevalence for male gender (5:1) and lower lobes (5:1), with a mean age at diagnosis of 61 years. All cases were incidentally disclosed in asymptomatic patients and had an indolent behavior. At histology, 2 cases consisted uniquely of smooth muscle and 4 also showed mature adipose tissue. The mucinous proliferation consisted of a monotonous growth of columnar cells lacking p63-positive basal cells and expressing pan-CKs, MUC5A, and CK7, but negative with TTF-1, napsin, MUC1, MUC2, MUC6, CK20, and CDX2. Smooth muscle was negative with hormonal receptors. Molecular analysis using a multiplex gene panel did not reveal gene mutations, while ALK, BRAF, and ROS1 were negative. In conclusion, we describe a small series of uncommon PH with prevalent leiomyomatous mesenchymal component associated with a mucinous growth (mucinous adenomyomatous hamartoma). Despite the lack of basal cells coating mucinous proliferation and irregular architecture, the favorable outcome and lack of molecular alterations most likely lay for a benign/low-grade tumor. Pathologists should be aware of this unusual occurrence to prevent a diagnosis of overt malignancy, particularly in frozen section, small biopsy, and cytology.

Sleeve lobectomy compared with pneumonectomy for operable centrally located non-small cell lung cancer: a meta-analysis

Background

The purpose of this meta-analysis was to evaluate evidence comparing sleeve lobectomy (SL) and pneumonectomy (PN) in the treatment of non-small cell lung cancer (NSCLC).

Methods

The English literature search was undertaken in January 2018 and included studies dating back to 1996. Comparative studies were identified, evaluating survival, local recurrence, and distant recurrence rates, operative mortality, 30-day mortality, as well as complications. A pooled odds ratio (OR) and 95% confidence intervals (95% CI) were calculated with either the random or fixed-effect model.

Results

A total of 27 studies were identified, with publication dates between 1996 and 2018. These 27 studies included a total of 14,194 patients: 4,145 treated with SL and 10,049 treated with PN. The overall survival was significantly higher in the SL group compared to the PN one at 1, 3, 5 years. In patients with N0 and N1 disease, 5-year survival rates following SL exceeded those following PN. There was no statistically significant difference in the 3-, 5-year overall survival of N2 patients, according to the extent of surgery. The PN group had a higher rate of operative mortality, 30-day mortality and distant recurrence incidence. However, no statistical difference in complications and local recurrence between SL and PN were observed.

Conclusions

SL is an effective treatment option for hilar NSCLC with improved long-term survival compared to PN, with no increase of recurrence rate or postoperative complications. Furthermore, N2 disease is an important factor related to survival, and lymph node downstaging is a favorable prognostic factor.

Intrapulmonary solitary fibrous tumour: a rare neoplasm of the lung and a challenging pre-operative diagnosis

BACKGROUND

Case report of a 78-year-old male who came to our observation for a growing pulmonary mass of the left upper lobe without a pre-operative diagnosis. Post-operative histopathology revealed an intrapulmonary Solitary Fibrous Tumour (SFT) of the lung.

CASE REPORT

The pulmonary lesion was an ovoid mass centrally located in the left upper lobe; it had been known and stable in size for two years; the last Chest Computed Tomography (CT) Scan highlighted a marked increase in maximum diameter (35 versus 22 mm) with contrast enhancement. In view of the growth of the lesion, the patient was referred for surgery after multidisciplinary team evaluation, although a pre-operative diagnosis had not been reached. The patient underwent Video-Assisted Thoracic Surgery (VATS) left upper lobectomy by a biportal approach. The pulmonary nodule consisted of a proliferation of bland-looking spindle cells intermingled with fibrotic stroma and alternating sclerotic and cellular areas. At immunohistochemistry, the spindle cells expressed CD34, bcl2 and CD99. A final diagnosis of intrapulmonary SFT was reached. The 36-month follow-up was negative for relapses.

CONCLUSIONS

Primary intrapulmonary SFTs are extremely rare neoplasms, generally with benign biological behaviour; surgical resection is safe and essential in order to be curative and can be achieved by a minimally invasive approach. Pre-operative diagnosis is challenging, due to aspecific clinical and radiological features.

KEY WORDS

Lung, Solitary Fibrous Tumour, Video-Assisted Thoracic Surgery Lobectomy.

Conversion due to vascular injury during video-assisted thoracic surgery lobectomy: A multicentre retrospective analysis from the Italian video-assisted thoracic surgery group registry

OBJECTIVES

Vascular injuries are among the most severe causes of unplanned conversion during VATS lobectomies. The study aimed to analyse the incidence of vascular injuries and their risk factors during VATS lobectomy.

METHODS

The Italian VATS lobectomy Registry was used to collect data from 66 Thoracic Surgery Units. From 2013 to October 2016 (out of more than 3,700 patients enrolled) only information from Units with an enrollment >100 VATS lobectomies were retrospectively analysed. Logistic regression analysis was performed on selected variables of the univariate analysis.

RESULTS

Ten institutions contributed a total of 1,679 patients. Vascular injuries leading to conversion occurred in 44 (2.6%) patients. Years of experiences were inversely related to the risk of vascular injuries. Univariate analysis showed age, gender, surgical activity, Charlson Index Score and number of resected lymph nodes like significantly associated variables. Multivariate analysis revealed that number of resected lymph nodes, VATS experience ratio (number of VATS lobectomies/total lobectomies performed in the same year at same centre), and surgical activity of the centre were significantly associated with the risk of conversion. Unplanned thoracotomy was correlated with postoperative morbidity.

CONCLUSION

Vascular injuries in VATS lobectomies represented a rare complication which could directly affect the postoperative outcomes. The predictive factors for conversion were multifactorial and depended on characteristics of centres and surgeons' seniority. Minimally invasive VATS lobectomy approaches did not influence the risk of vascular damages.

Less is more: lung-sparing direct repair of a traumatic rupture of the bronchus intermedius

Major trauma is one of the most common causes of death in the western world in the young population (15-25 years). Thoracic trauma represents 25% of traumatic deaths, and the incidence of tracheobronchial injuries in literature is lower than 5%. Nevertheless, airway injuries are life-threatening conditions. Here we present a case of a 25-year-old patient who underwent a severe motorcycle crash. The injury severity score (ISS) was 35 at admission to the hospital. A right middle bronchus laceration <2 cm involving the whole thickness of the wall of the bronchus intermedius was identified. An urgent right posterolateral thoracotomy was performed, and the lesion was directly repaired. A conservative intervention was the key to grant our patient a healthy life.

Video-assisted thoracoscopic surgery bronchial sleeve lobectomy

A sleeve lobectomy (SL) is considered a valid option instead of a pneumonectomy in patients affected by central non-small cell lung cancer (NSCLC). In the last few years, the improvement of video-assisted thoracoscopic surgery (VATS) has allowed experienced surgeons to carry out this challenging operation by a minimally invasive approach. A full pre-operative assessment enclosing a flexible fiber-optic bronchoscopy evaluation and a multidisciplinary team discussion of the clinical case must be accomplished. There is no strictly an indication for the number of thoracoscopic ports: VATS SL is reported from 1 to 3-4 incisions. A significant variability in the technique of the anastomosis is documented and depends on the personal use and ability of the surgeon. However the operational principles are the same of an open SL: free bronchial margins at the frozen section examination, tension-free anastomosis, avoid luminal disparity and en-bloc resection. Due to the extent of the tumour, VATS SL can be associated to other complex resections like arterioplasty, or double sleeve (bronchial and artery) mainly on the left side. A patient underwent a VATS SL must be enrolled in an enhanced recovery pathway (ERP): physiological rehabilitation is a key point to achieve good outcomes and avoid complications.

Novel double-stapling technique for distal oesophageal resection and oesophago-jejunal anastomosis

AIM

The restoration of the digestive tract by performing an esophago-jejunal anastomosis (EJA) is a crucial step of the total gastric and distal esophagus surgical resection for esophago-gastric junction (EGJ) cancer. We have already ideated and tested on a cadaver model an innovative technique which could be useful to minimize the risk of complications related to the phase of securing the anvil of the circular stapler prior to perform the EJA. This surgical technique was derived from the well-known "double-stapling Knight and Griffen" one that was described for the rectal resection. We used the following described technique in 20 patients with EGJ cancer and it is efficient, reliable, safe, easy to learn and easy to perform.

MATERIALS AND METHODS

From August 2014 to May 2015, 20 patients (14 male and 6 female) underwent surgery for esophagogastric junction cancer: In all patients a distal esophageal resection and total gastrectomy was performed. Through the trans-hiatal access, the free margins of the esophageal stump were suspended and the anvil of a circular stapler on a new dedicated and registered support bar was inserted into the lumen. Subsequently, the linear suturing stapler is closed over the bar and then fired to suture the distal stump of the esophagus; after the confirmation of a negative margin, the bar is retracted and the push-rod of the anvil is pulled out through the linear suture. Finally, the anastomosis is performed with the classic technique by using a circular stapler.

RESULTS

No postoperative mortality occurred; postoperative course has been uneventful for 18 patients. One patient developed anastomotic fistula that has been treated conservatively with endoscopic prothesis, removed after 20 days. One patient developed in 3 POD myocardial infarction Mean Hospital stay has been 14 days (range 7-20 days).

CONCLUSIONS

The aim of our new procedure is the insertion the anvil of a common circular stapler without handsewn securing; this is to reduce the technical difficulties related to the hand-sewn securing into a deep and narrow anatomic location, typical of the trans-hiatal approach.

KEY WORDS

Anastomosis, Oesophago-gastric junction cancer, Stapler, Trans-hiatal.

Surgery for non-small cell lung cancer in younger patients: what are the differences?

BACKGROUND

Non-small cell lung cancer (NSCLC) in young adults is uncommon. The objective of this study was to evaluate the clinicopathological characteristics, outcomes and prognosis of people younger than 50 years old treated surgically for NSCLC.

METHODS

A retrospective study was conducted using the institutional database of four thoracic surgery units to collect patients with NSCLC younger than 50 years who had undergone surgery. These patients were compared with older patients (>75-years) operated in the same institutions and in the same period.

RESULTS

We identified 113 young patients and 347 older patients. Younger patients were more likely to be female, non-smokers, with fewer comorbidities. Younger patients were more likely to be symptomatic at the time of diagnosis. Risk factors for poor prognosis in younger patients were T-stage, and disease-free-interval less than 548 days. Kaplan-Meier analysis showed a lower five-year survival in older patients compared with the younger ones (66% vs 38%, p=0.001).

CONCLUSIONS

In conclusion NSCLC in younger patients has some distinct clinicopathological characteristics. The overall-survival of young patients is better than in older patients. Young patients receive more complete and aggressive treatment that could explain better survival. Further prospective studies with larger patient populations are required, to clarify the biological and genetic variance of NSCLC in younger patients.

Non-small cell lung cancer in surgically treated women

AIM AND BACKGROUND

To determine whether female patients operated on for non-small cell lung cancer (NSCLC) have a survival advantage compared to male patients.

METHODS AND STUDY DESIGN

We analyzed data from 1,426 prospectively collected patients submitted to lung resection for NSCLC between 1999 and 2008.

RESULTS

Two groups, including 1,014 male and 412 female patients, were compared. Female patients were significantly younger, were more frequently asymptomatic, were less likely to be smokers, had better preoperative respiratory function, had a lower frequency of COPD, and were less commonly affected by cardiovascular comorbidity than men. Adenocarcinoma was more frequently present and early pathological stage (stage IA) more frequently detected in women at diagnosis. The operative mortality was significantly lower among women (1.6% vs 4.6%) (P = 0.012), and women underwent significantly more segmentectomies and fewer pneumonectomies (P = 0.001). The disease-related 5-year survival rate was significantly higher in women (66% vs 51%) (P = 0.0008). At univariate analysis the absence of symptoms at presentation, lower pathological stage, squamous cell type, and female gender were positive factors influencing long-term survival. At multivariate analysis low pathological stage, squamous cell type and female gender were confirmed as independent positive prognostic predictors. Women had a significant survival advantage irrespective of the histological subtype at pathological stage IA, IB, IIB and IIIA disease (P <0.05).

CONCLUSIONS

Female gender was confirmed to be a particular subset amongst patients affected by NSCLC and exerted a positive effect on disease-related survival of patients submitted to surgical resection. This important effect of gender should be cautiously kept in mind in analyzing the results of current and future trials for lung cancer therapy.

Double-stapling technique for transhiatal distal esophageal resection: feasibility test in a cadaver model

OBJECTIVES

To assess the feasibility of a new surgical technique for the resection of the distal third of the esophagus and/or cardias for neoplasm.

METHODS

This surgical technique consists of two steps: For this purpose we built a stainless steel support bar for the anvil that is thinner than the freespace of a standard linear suturing stapler (TATM). The support bar holds up a push rod that can be adapted to the hooking-unhooking of the anvil.

RESULTS

We performed our new technique on five cadavers. We did not encounter any difficulty during the procedures. We tested the anastomosis with hydropneumatic assessment without recording any leaks. The esophago-enteric anastomosis was then opened without finding any mechanical defects related to the procedure.

CONCLUSION

It can often be very difficult to fashion a safe hand-sewn pouch or a purse string around the anvil of an EEATM during the resection of the distal third of the esophagus or the cardias by a trans-hiatal approach. Moreover, there is no standardized procedure to minimize anastomotic leak. To avoid these mechanical problems we designed this innovative procedure, which is considered to be reproducible without significant training.

Non-small cell lung cancer in surgically treated women

Aim and background

To determine whether female patients operated on for non-small cell lung cancer (NSCLC) have a survival advantage compared to male patients.

Methods and study design

We analyzed data from 1,426 prospectively collected patients submitted to lung resection for NSCLC between 1999 and 2008.

Results

Two groups, including 1,014 male and 412 female patients, were compared. Female patients were significantly younger, were more frequently asymptomatic, were less likely to be smokers, had better preoperative respiratory function, had a lower frequency of COPD, and were less commonly affected by cardiovascular comorbidity than men. Adenocarcinoma was more frequently present and early pathological stage (stage IA) more frequently detected in women at diagnosis. The operative mortality was significantly lower among women (1.6% vs 4.6%) (P = 0.012), and women underwent significantly more segmentectomies and fewer pneumonectomies (P = 0.001). The disease-related 5-year survival rate was significantly higher in women (66% vs 51%) (P= 0.0008). At univariate analysis the absence of symptoms at presentation, lower pathological stage, squamous cell type, and female gender were positive factors influencing long-term survival. At multivariate analysis low pathological stage, squamous cell type and female gender were confirmed as independent positive prognostic predictors. Women had a significant survival advantage irrespective of the histological subtype at pathological stage IA, IB, IIB and IIIA disease (P <0.05).

Conclusions

Female gender was confirmed to be a particular subset amongst patients affected by NSCLC and exerted a positive effect on disease-related survival of patients submitted to surgical resection. This important effect of gender should be cautiously kept in mind in analyzing the results of current and future trials for lung cancer therapy.

Surgical results and long-term follow-up of T(4)-non-small cell lung cancer invading the left atrium or the intrapericardial base of the pulmonary veins

Patients with locally advanced non-small cell lung cancer infiltrating the left atrium (LA) or the intrapericardial base of the pulmonary veins (PVs) are generally not considered good candidates for surgery because of the poor long-term survival. In the last 10 years, 31 consecutive patients with non-small cell lung cancer directly invading the LA or the intrapericardial base of the PVs underwent surgery. Pneumonectomy was the operation performed most frequently. In-hospital mortality was 9.7% and overall morbidity was 52%. One-, 2- and 3-year survival rates were 64, 46 and 30%, respectively with a mean survival of 22 months. The systemic recurrence of disease was the major cause of death at follow-up. At statistical analyses, the N-factor and the type of operation were related to poor long-term survival. In these patients, surgery could be performed with an acceptable operative mortality and morbidity. Surgery should be considered whenever a complete resection is technically possible. A careful preoperative evaluation is mandatory to select good candidates for surgery.

Pleuropneumonectomy for stage IVa thymoma: delayed metastatic spread after multimodality treatment

We report a case of a caucasic woman aged 55, carrying a Masaoka stage IVa thymoma, initially not suitable to surgical treatment. After induction chemotheraphy, she underwent a radical resection of the mediastinal mass combined with left pleuro-pneumonectomy. After being disease-free for 5 years, the patient first developed a splenic recurrence, then an abdominal metastasis, both treated by surgery. To date she is alive and disease-free, 10 years after the first operation. The patient underwent multimodal treatment only after the first surgical operation, while the recurrences were only treated surgically. The exceptional nature of our case lies mainly in the site of the metastases (first the spleen, then the omentum), then in the long disease-free period, and in the final outcome which was beyond all expectations.

Giant mediastinal mature teratoma with increased exocrine pancreatic activity presenting in a young woman: a case report

Introduction

Mediastinal mature teratoma is a benign, slow-growing tumor typically affecting 20- to 40-year-old adults. Fluid examination from the cystic masses rarely shows enzymatic activity as we describe in this report.

Case presentation

We report a case of a giant mediastinal germ cell tumor (measuring 15 cm × 14 cm × 8 cm) detected in a 35-year-old Caucasian woman. Microscopic examination showed that the lesion resembled a mature cystic teratoma with areas of pancreatic tissue with mature ductal and acinar structures intermixed with islets of Langerhans. Fluid from the cysts in the mass was examined after removal showed amylase activity of 599 U/l despite normal serum levels. The post-operative period was free of complications, and the patient was discharged on post-operative day 10.

Conclusion

Complete surgical removal is the treatment of choice for mature cystic teratomas, with optimal results and acceptable surgical risk. Exocrine pancreatic function may be an aid to pre-operative or intra-operative diagnosis; however, these findings have no impact on survival or the therapeutic pathway.

Pulmonary artery leiomyosarcoma successfully treated by right pneumonectomy

A 79-year-old woman had a primary tumor of the pulmonary artery, which was initially diagnosed as chronic pulmonary thromboembolism. Multislice angio-computed tomography showed a solid mass in the right pulmonary artery. Radical resection of the tumor was achieved by right pneumonectomy via a transsternal transpericardial approach. The patient was alive and free of disease 36 months after surgery.

Unusual delayed presentation of post-traumatic intrapericardial hernia associated with intestinal occlusion

AIM

We report a case of a 64-year-old man, admitted to our department following the onset a few months earlier of canalization disorders and a sensation of retrosternal tension.

MATERIAL OF STUDY

Patient's history revealed blunt thoraco-abdominal trauma with multiple costal fractures 15 years earlier as a result of a road accident and a cholecystectomy at the age of 57. A barium meal revealed an intrapericardial displacement of some intestinal loops; as the patient suffered acute intestinal occlusion with severe abdominal pain associated with nausea and vomiting, we performed an emergency median xipho-umbilical laparotomy, making it possible to identify both the site of the retrosternal diaphragmatic laceration with intrapericardial colonic herniation and the true cause of the occlusion: an adhesion, caused by the previous cholecistectomy, which was strangulating a jejunal loop. After detaching the adhesion between the colon and the pericardium, the viscera were replaced in the abdominal cavity and the diaphragmatic opening was closed.

RESULTS

The post-operative period was uneventful; a barium enema demonstrated the abdominal dislocation of the viscera. No recurrence was detected during the 48 months of follow-up.

CONCLUSIONS

A rare pathological event, such as an intrapericardial diaphragmatic hernia, was combined with intestinal occlusion, initially attributed to a further complication of the hernia itself but in actual fact independent of the hernia and a consequence of a previous cholecystectomy.

Use of coagulant spray glue (Glubran 2) for aerostatic purposes in pulmonary parenchyma resections in pigs: a preliminary study

BACKGROUND

The aim of our study was to test the aerostatic validity of a cyan-acrylic glue (Glubran 2), applied by means of a spray catheter, on an experimental pig model.

MATERIALS AND METHODS

15 young pigs were divided into three study groups of 5 based on surgical techniques: (1) atypical pulmonary resection with mechanical suturing and reinforcement with continuous suturing; (2) resection of the pulmonary parenchyma with a cold scalpel, followed by local application of Glubran 2; (3) atypical pulmonary resection with mechanical suturing followed by application of Glubran 2.

RESULTS

The mean aerostasis time was calculated at 3.5 +/- 1.26 s. The histopathological analysis did not show any particular differences when comparing the effects of the treatments carried out with Glubran 2 spray glue and the standard treatments. No statistically significant differences were recorded in the short- and medium-term survival of pigs treated with Glubran 2 compared with the respective control groups.

CONCLUSIONS

The application of Glubran 2 spray on wounds caused by pulmonary resections in pigs proved to have a rapid and effective influence for the purposes of aerostasis without significant differences in air losses and survivals.