Pulmonary hypertension is associated with higher mortality in cystic fibrosis patients awaiting lung transplantation

AIM:Pulmonary hypertension (PH) is frequently found in patients with advanced parenchymal lung diseases. In advanced stages, cystic fibrosis (CF) patients can develop PH and eventually cor pulmonale. Little is known about the prevalence of PH in CF patients and its impact on outcome. METHODS: We retrospectively studied a large cohort of CF patients evaluated for lung transplantation between 1995 and 2010. All the patients underwent right heart catheterization as part of the evaluation. We included 179 unique consecutive adult CF patients. Age was 24±9 years and 45.8% were women. RESULTS:Eighty-seven patients were transplanted (48.6%) and 65 died (36.3%) while waiting for LT. By right heart catheterization, 38.5% of the patients had PH (mean ≥25 mm Hg). PaCO2 (P=0.045) and forced vital capacity (P=0.023) were independent predictors of PH in CF patients. The median survival (free of lung transplantation) was 13.4 months. After adjusting for several covariates, the presence of PH significantly increased mortality (hazard ratio, HR) (P<0.001). Pulmonary vascular resistance was associated with mortality (P=0.03). When both PH and PVR were included in the model, only PH predicted mortality. CONCLUSION: Pulmonary hypertension of mild degree is frequently found in CF patients with advanced lung disease and its presence significantly worsens survival.

Extracorporeal circulatory support for lung transplantation: institutional experience

Lung transplantation (LT) represents the only available therapy for selected patients affected by end-stage pulmonary disease. Cardiopulmonary bypass (CPBP) is used, when required, during single and sequential double lung transplantation; however, it increases the risk of bleeding, early graft dysfunction, failure, and other potential side effects. We report our experience with 145 patients who underwent lung transplantations, among whom 34 required intraoperative CPBP. The indications for LT among these 34 patients were cystic fibrosis (n = 22), chronic obstructive pulmonary disease (n = 3), bronchiectasis (n = 2), primary pulmonary hypertension (n = 1), fibrosis (n = 2), pulmonary microlithiasis (n = 1), and retransplantation for obliterative bronchilitis (n = 3). CPBP was planned in 12 cases (group I) and unplanned in 22 (group II). The main reason for planning CPBP was primary and secondary pulmonary hypertension (mean pulmonary artery pressure >or=25 mm Hg). Acute right ventricular failure, hemodynamic instability, arterial desaturation, and increased pulmonary artery pressure were mandatory for unplanned CPBP. Among the 34 CPBP patients, the 30-day mortality rate was 35% (12/34) including 9 (70%) in group II (unplanned CPBP). The leading cause of death was multiorgan failure. The 1-year survival rates were 67% and 36%, and the 3-year survival rates were 47% and 18% for groups I and II, respectively. In conclusion, even if it represents a useful tool in the management of critical events, the use of unscheduled CPBP during LT procedures is associated with an increased postoperative morbidity and mortality.

Treatment of complex airway lesions after lung transplantation with self-expandable nitinol stents: early experience

Airway complications (AC) are considered a serious cause of morbidity after lung transplantation (LT). Mechanical dilatation, laser vaporization, and silicone stent placement usually solve it. However, the use of self-expandable metallic stents (SENS) may be indicated in selected cases. Ten lung transplant recipients with AC were treated with SENS. Six patients underwent LT for cystic fibrosis, 2 for idiopathic pulmonary fibrosis, 1 for bronchiectasis, and 1 for emphysema. All patients received at least 1 treatment attempt with dilatation and silicone stent placement. The indications for SENS placement were the presence of a tortuous airway axis with stenosis and malacia of the right main bronchus in 5 patients; a long stenosis of the main and intermediate right bronchus involving the upper lobe orifice in 3 patients; or malacia that could not be stabilized with silicone stents in 3 cases. In 1 patient the procedure was bilateral. Functional improvement was immediate with a mean forced expiratory volume at 1 second (FEV(1)) gain of 35%. No stent dislocation was observed. Symptoms did not occur again in 5 patients with previous recurrent episodes of pneumonia. One stenosis, which was due to the ingrowth of granulation tissue occurred at 6 months after the procedure, was successfully treated with mechanical dilatation and laser vaporization. The deployment of SENS in a selected group of patients with AC after LT was easy, safe, and effective.

Surgical treatment of redundancy after retrosternal esophagocoloplasty

Redundancy is a well-recognized complication of esophageal replacement with colonic interposition, occurring several years after surgery. In a small number of patients, symptoms are disabling and might require reoperation. This article describes the surgical treatment of a 54-year-old male presenting with severe dysphagia, malnutrition and recurrent aspiration pneumonia, progressively developed 30 years after esophageal replacement with retrosternal ileocolonic interposition for caustic strictures.

Preoperative anaemia does not affect the early postoperative outcome in patients with lung cancer

AIM

Several prognostic factors like age, gender, histology, stage, type of operation, associated disorders and administration of induction therapy have been evaluated to assess the risk of postoperative complications and outcome in patients with resectable lung cancer. Anemia is a frequent condition in this subset of patients being estimated up to 50%. The aim of this retrospective study was to evaluate the effect of preoperative anemia on early outcome after lung cancer resection.

METHODS

One-hundred thirty nine consecutive patients undergoing surgery for non small cell lung cancer were retrospectively considered. The mean age was 64.8+/-11.6 years. No patient received blood transfusions or administration of erythropoetin preoperatively. Overall, we performed 96 lobectomies, 14 pneumonectomies, 2 bilobectomies and 27 atypical resections. A subset of 27 patients (19.4%) (group I) had a preoperative value of Hb less than 12 g/dl (10.4+/-1.9 g/dL). Seven patients of them were stage IA (26%), 9 stage IB (33.3%), 2 stage IIA (7.4%), 6 stage IIB (22.2%), 2 stage IIIA (7.4%) and 1 stage IIIB (3.7%). Age, gender, stage, type of operation, induction chemotherapy, comorbidities were evaluated by univariate analysis comparing patients with and without preoperative anaemia. The two groups were homogenous regarding demographic characteristics.

RESULTS

Three patients (11.1%) in group I and 2 (1.8%) in group II required blood transfusions after surgery (P=0.01); 4 of them received pneumonectomy (P<0.0001). The overall morbidity was 17.9% (25/139); the most frequent complication was persistent air leakage, followed by retention of secretions. No statistically significant difference was observed between the 2 groups about early mortality (1 patient-3.7% in group I and 2 patients-1.8% in group II) and postoperative complications (5 patients-18.5% in group I and 20 patients-17.9% in group II).

CONCLUSION

Preoperative anaemia is not a risk factor for an increased rate of postoperative complications and should not be considered a contraindication to surgery.

Malignancies following lung transplantation

During the last 2 decades, long-term survival after lung transplantation has significantly improved. However, among the complications related to the continuous administration of immunosuppressive drugs, malignancy plays an important role. We retrospectively revisited our series of patients to report our experience. From January 1991 we performed 134 lung transplantations in 128 recipients (mean age, 33.4 +/- 13.5 years). In all patients the first-line immunosuppressive regimen was based on a calcineurin inhibitor (cyclosporine or tacrolimus), an antimetabolic agent (azathioprine), and steroids. Five patients (4.2%) developed malignancy and the mean time of occurrence after the transplantation was 46.4+/-23 months. The mean age was 41 +/- 16 years (P = not significant [ns]). The tumors were as follows: laryngeal cancer (radiotherapy), colon cancer (surgery plus adjuvant chemotherapy), gastric cancer (surgery plus adjuvant chemotherapy), endobronchial non-Hodgkin lymphoma (NHL) (endoscopic resection plus chemoradiotherapy), and cutaneous and visceral Kaposi's sarcoma (KS) (chemotherapy). All patients have reduced the dose of immunosuppressive drugs; in 1 of them, tacrolimus was changed to rapamycin. Two patients died because of neoplastic dissemination, another 1 due to obliterans bronchiolitis. The 2 patients with NHL and KS are alive at 6 and 9 months, respectively, without signs of recurrence. Malignancies after lung transplantation represent an important problem. A multidisciplinary approach is mandatory to obtain satisfactory results in terms of improved quality of life and long-term survival.

Incidence of fungal infections in a solid organ recipients dedicated intensive care unit

Invasive fungal infections are a significant cause of morbidity and mortality for patients undergoing solid organ transplantation. Our aim was to evaluate the incidence of invasive fungal infections in solid organ recipients within a dedicated intensive care unit (ICU).

MATERIALS AND METHODS

From May 2002 to May 2005, 278 patients undergoing solid organ transplantation (105 liver, 142 kidney, 20 lung, 2 combined liver-kidney, 9 combined pancreas-kidney) were admitted to our posttransplant intensive care unit. We retrospectively analyzed data obtained from the ICU stay. Fungal infection was defined by positivity of normally sterile biological samples and by elevated positivity of normally non sterile biological samples. We did not consider superficial fungal infections and asymptomatic colonizations.

RESULTS

Forty-six patients (16.5%) developed a fungal infection; at least one mycotic agent was isolated from each patient. Candida albicans was the most common pathogen, isolated from 71 % of infected patients (33 of 46). Infected patients showed a mortality rate of 35%, while that for non infected recipients was 3.5%. Total length of ICU stay was the most significant risk factor among infected patients (30.26 days vs 5.04 days P < .0001). Mean time between transplantation and first positive samples was 6.17 days (SD 8.88).

CONCLUSION

Fungal infections in solid organ transplant patients are a major issue because of their associated morbidity and mortality. Candida albicans was the most common pathogen and total length of ICU stay was the most important risk factor.

Lung cancer after treatment for non-Hodgkin lymphoma

AIM

Because of the improvement in treatment and survival of patients with lymphoma, late sequelae, including secondary cancers have been extensively studied. Lung cancer is one of the two most common solid tumors after Hodgkin's disease but fewer studies have been published about lung cancer after non-Hodgkin lymphoma (NHL).

METHODS

Over the last five years at our Institution we have observed 16 patients, 13 male and 3 female, with a mean age of 61 years, previously treated for NHL and lung cancer. Median latency between NHL and lung cancer was 7 years. In 6 patients (37.5%) the latency period was shorter than 5 years and 3 of them developed lung cancer within 2 years after the end of NHL therapy.

RESULTS

Ten patients underwent lung complete resection. Two, 3 and 5 year survival rate was respectively 52.7%, 26.3% and 13%. In contrast, the median survival of non surgical patients was 9 months. Comparison of survival between surgical and non-surgical group demonstrated a statistically significant better survival for surgically treated patients (P<0.04).

CONCLUSIONS

Surgery can improve survival in patients with history of NHL and lung cancer. Early diagnosis and treatment is crucial. NHL survivors should undergo careful follow-up and surveillance for secondary malignancy.

[Surgical treatment of iatrogenic perforations of the distal third of the esophagus. Personal experience]

AIM

The esophageal perforations are associated with a high mortality and morbidity when they are not diagnosed and treated quickly. The aim of our study is to analyze the treatment and prognosis of the distal iatrogenic esophageal perforations on the basis of time of onset, concomitant disease and size of perforations.

METHODS

The retrospective review was performed on 10 patients treated for distal iatrogenic esophageal perforations at our Institution from 1994 to 2003. The cause of perforations was: pneumatic dilation (7 patients) and esophageal endoprosthesis placing (3 patients). Seven patients presented within 24 h (Group A), and 3 patients presented after 24 h (Group B). In Group A, 4 patients underwent primary repair, 2 patients required esophagectomy and 1 patient was treated conservatively. In Group B, 2 patients were treated conservatively and 1 patient required an esophagectomy.

RESULTS

Hospital morbidity was 20% and mortality was 30%. In Group A no patients died. In Group B hospital mortality was 100%. The most common cause of death was multiorgan failure resulting from sepsis.

CONCLUSIONS

The prognosis for esophageal perforations is influenced by the time elapsed between diagnosis and treatment. Esophagectomy is indicated for patients with extensive perforation and necrosis of the esophagus when primary repair cannot be carried out. It is indicated also as treatment for the concomitant disease.

Extracorporeal Circulation With Low Systemic Heparinization During Lung Transplantation

BACKGROUND

Some lung transplantation (LT) recipients suffer from pulmonary hypertension and right ventricular dysfunction or failure requiring extracorporeal circulation (ECC) to avoid catastrophic complications during surgery. The extracorporeal support usually requires systemic heparinization which is potentially associated with important side effects. We performed eight LT using preheparinized ECC circuits and an oxygenator associated with a lower level of systemic heparinization without evidence of perioperative complications.

PATIENTS AND METHODS

From May 2002 to May 2005, 8 patients (5 men and 3 women) of mean age 22.5 +/- 9.5 years underwent bilateral sequential lung transplantation (BSLT) for cystic fibrosis (n = 6) or idiopathic pulmonary fibrosis (n = 2). All procedures were performed with ECC through a femoro-femoral veno-arterial bypass with preheparinized circuits and an oxygenator.

RESULTS

No intraoperative mortality occurred. The mean ECC time was 147.8 +/- 31.3 minutes and the mean heparin administered was 3525 +/- 969.16 UI. No coagulopathy or thrombotic events were observed perioperatively.

CONCLUSIONS

Our study confirmed the efficacy and safety of prehepanized circuits and oxygenator for femoro-femoral veno-arterial bypass during LT for patients with severe pulmonary hypertension requiring ECC.

[Mechanical cervical esophagogastric anastomosis after esophagectomy for cancer]

AIM

Fibrous stenosis of the esophagogastric cervical anastomosis remains a significant complication occurring in up to one third of cases. Trying to reduce the incidence of this complication, we describe our technique of cervical esophago-gastric anastomosis using endoscopic linear stapler which seems to reduce the incidence of fibrous stricture formation after resection of esophageal cancer.

METHODS

Between March 2000 and December 2004, 34 patients (20 males and 14 females) underwent esophagectomy using tubulized stomach for reconstruction. Mean age was 57 years. Eight patients with advanced stage (5 T3 and 3 T4) underwent induction chemotherapy. The most of patients was affected by squamous cell carcinoma. In all cases we performed cervical esophagogastric anastomosis using linear endoscopic stapler. The occurrence of postoperative anastomotic leak and development of anastomotic stricture were recorded and analyzed.

RESULTS

All patients survived esophagectomy and 30 of them (88%) were available for postoperative follow-up at 6 months. Anastomotic leak developed in 1 case. No patient developed fibrous stenosis that required dilatation therapy.

CONCLUSIONS

Complete mechanical esophago-gastric anastomosis, using endoscopic linear stapler is effective and safe, even when a narrow gastric tube is used as esophageal substitute. These technique seems superior to other techniques to reduce the incidence of postoperative anastomotic complications.

Evolving Techniques and Perspectives in Lung Transplantation

Lung transplantation is currently a suitable option for patients with end-stage lung disease. Since the early 1980s the surgical technique and immunosuppressive protocols have been progressively modified to improve results and favor long-term survival. The original heart-lung transplantation under cardiopulmonary bypass is now rarely performed and single or bilateral lung transplantation is the procedure of choice. Bilateral transplantation is performed with two single lung transplants performed in sequence. Extracorporeal support is rarely employed and in most cases it is instituted through the femoral approach. Also, the surgical approach has been modified and the original clam shell incision has been replaced by two small anterior thoracotomies. The use of marginal donors has been increasingly proposed to enlarge the number of organs potentially available for transplantation. Immunosuppressive protocols have evolved to patient-specific regimens that can be quickly modified if required by the clinical status. Induction is now more aggressive and also rescue protocols for obliterative bronchiolitis can contribute to improved outcomes. Overall, lung transplantation is now performed with encouraging long-term results.

Lung transplantation for cystic fibrosis

BACKGROUND

Lung transplantation is a robust therapeutic option to treat patients with cystic fibrosis.

PATIENTS AND METHODS

Since 1996, 109 patients with cystic fibrosis were accepted onto our waiting list with 58 bilateral sequential lung transplants performed in 56 patients and two patients retransplanted for obliterative bronchiolitis syndrome.

RESULTS

Preoperative mean FEV(1) was 0.64 L/s, mean PaO(2) with supplemental oxygen was 56 mm Hg, and the mean 6-minute walking test was 320 m. Transplantation was performed through a "clam shell incision" in the first 29 patients and via bilateral anterolateral thoracotomies without sternal division in the remaining patients. Cardiopulmonary bypass was required in 14 patients. In 21 patients the donor lungs had to be trimmed by wedge resections with mechanical staplers and bovine pericardium buttressing to fit the recipient chest size. Eleven patients were extubated in the operating room immediately after the procedure. Hospital mortality of 13.8% was related to infection (n = 5), primary graft failure (n = 2), and myocardial infarction (n = 1). Acute rejection episodes occurred 1.6 times per patient/year; lower respiratory tract infections occurred 1.4 times per patient in the first year after transplantation. The mean FEV(1) increased to 82% at 1 year after operation. The 5-year survival rate was 61%. A cyclosporine-based immunosuppressive regimen was initially employed in all patients; 24 were subsequently switched to tacrolimus because of central nervous system toxicity, cyclosporine-related myopathy, or renal failure, obliterative bronchiolitis syndrome, gingival hyperplasia, or hypertrichosis. Ten patients were subsequently switched to sirolimus. Freedom from bronchiolitis obliterans at 5 years was 60%.

CONCLUSIONS

Our results confirm that bilateral sequential lung transplantation is a robust therapeutic option for patients with cystic fibrosis.

[Mini-invasive treatment of pectus excavatum in adolescence. Initial experience]

BACKGROUND

Personal preliminary experience with Minimally Invasive Repair of Pectus Excavatum (MIRPE), "Nuss" procedure, using VATS is reported.

METHODS

From January 2001 to February 2002, MIRPE has been performed on 5 patients (age range 13-18 y; mean 14.8 y). Under general anesthesia, a curved steel bar is inserted into the retrosternal tunnel between 2 bilateral midaxillary line incisions. The tunnel passes initially under the pectoral muscles and enters the pleural space at level of the mammilary line. Under thoracoscopic vision, the bar is passed through the tunnel with the concavity facing the front and then is turned over thereby correcting deformity. An epidural catheter relieved perioperative pain successfully.

RESULTS

In all patients the repair has been good. Mean hospital length of stay has been 6.8 d. Pneumothorax occurred in 1 patient requiring tube thoracostomy. After 45 d 1 patient had a bar displacement requiring a reoperation. All patients have a normal life.

CONCLUSIONS

The Minimally Invasive Repair of Pectus Excavatum is an effective procedure even in adolescence. Thoracoscopic vision makes safer the creation of the retrosternal tunnel and the passage of the bar. Short-term results have been good. Further follow-up is necessary to determine long-term results.

[Thoracoscopic esophagectomy for esophageal cancer. Personal experience]

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.

Pneumoperitoneum for the management of pleural air space problems associated with major pulmonary resections

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.

Endoscopic treatment of lung cancer invading the airway before induction chemotherapy and surgical resection

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.

Thymectomy in the treatment of ocular myasthenia gravis

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.

A comparative study of Euro-Collins, low potassium University of Wisconsin and cold modified blood solutions in lung preservation in acute autotransplantations in the pig

OBJECTIVE

The aim of the study was to assess the quality of lung preservation offered by Euro-Collins solution (EC), Cold Modified Blood solution (CMB) and low potassium University of Wisconsin solution (UWLP).

METHOD

Fifteen right lung auto-transplantations (five for each solution) in the pig (Large White) were performed after 2 h of cold ischaemic storage in physiological solution at 4 degrees C. Right lung biopsies were performed before ischaemia and 30 min after reperfusion, for histoenzymatic, histopathological and electron microscope studies.

RESULTS

After reperfusion, significant alterations were observed in the haemodynamics with only the right lung perfused; pulmonary arteriolar resistance increased by a factor of 5 in the EC group, by a factor of 4 in the CMB group and by a factor of 1.2 in the UWLP group; the right ventricular ejection fraction fell by 60% in the EC group, by 50% in the CMB group and by 31% in the UWLP group. Haemodynamic impairment was lower in the UWLP group (P<0.05; P<0.001) as was ischaemic-reperfusion injury (P<0.05). Oedema was observed in the EC group and extensive alveolar wall damage in the CMB group. Hypoxaemia was observed in all groups but the differences in the degree of hypoxaemia were not significant.

CONCLUSIONS

The authors concluded that UWLP solution was the most effective of the three in this transplant model.

Therapeutic video-assisted thoracoscopic surgical resection of colorectal pulmonary metastases

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.

Diagnostic and therapeutic approaches for masses in the posterior mediastinum

Between January 1980 and December 1997 twenty-one patients with a mass in the posterior mediastinum came under our observation. All of the patients underwent chest radiography, bronchoscopy, respiratory function tests, perfusional and ventilatory radionuclide scans, a computed tomography (CT) of the chest and blood gas analysis. In cases involving neurogenic tumours magnetic resonance imaging (MRI) was used. Ten patients underwent CT guided transthoracic needle biopsy. The excision was performed by means of a thoracotomy in 12 cases (57.1%) and by video assisted thoracoscopy surgery (VATS) in the other 9 (42.9%); no deaths were recorded. Eleven neurilemmomas, two bronchogenic cysts, two paragangliomas, two neuroepitheliomas, one neurogenic sarcoma and three esophageal duplications were found. The authors believe an accurate pre-operative assessment of the lesion can be obtained using CT and MRI. The video assisted thoracoscopy (VAT) is a useful method of diagnosis and treatment as it can be converted into VATS if the lesion is benign or cystic. Thoracotomy is necessary when the mass is malignant or when there is adhesion to or invasion of surrounding tissues.

Pulmonary hemodynamics contribute to indicate priority for lung transplantation in patients with cystic fibrosis

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.

Lung conservation techniques: bronchial sleeve resection and reconstruction of the pulmonary artery

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.

Esophageal perforation after sequential double-lung transplantation

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.

Prognostic factors after surgical treatment of lung cancer invading the diaphragm

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.

Diagnostic and therapeutic video-assisted thoracic surgery resection of pulmonary metastases

BACKGROUND

Appropriateness of video-assisted thoracic surgery (VATS) pulmonary metastasectomy for curative intent has been a controversial topic. We reviewed our experience with VATS wedge resection for peripheral lung metastases to determine the efficacy and potential adverse consequences of this approach for pulmonary metastasectomy.

METHODS

One hundred seventy-seven patients underwent VATS resection of pulmonary metastases. Diagnostic resection (VATS-dx) was performed for 78 patients when percutaneous biopsy was unsuccessful or not feasible. Potentially curative resections (VATS-rx) were performed for 99 patients. The histologic findings in this group included colorectal (68), renal (7), sarcoma (6), breast (4), melanoma (3), head/neck (3), lymphoma (2), uterine (1), and "other" (5). The average number of lesions resected was 1.4 (range, 1-7).

RESULTS

VATS resection was successfully performed for all VATS-dx and VATS-rx patients. There were no perioperative deaths. Longitudinal follow-up demonstrated a mean survival of 18 months in the VATS-dx group and 28 months in the VATS-rx group. In the VATS-rx group, 37 (37%) of 99 were free of disease, at a mean follow-up interval of 37 months. Of the 57 recurrences, 5% were local, 26% were regional, and 69% were distant.

CONCLUSIONS

Results with VATS resection of peripheral pulmonary metastases for diagnostic and potentially curative intentions appear comparable with historical results by "open" thoracotomy. Careful patient selection based on high-resolution helical CT scanning is important to avoid compromise of therapeutic intent. Conversion to thoracotomy is indicated when lesions identified preoperatively are not found or when technical problems encountered may compromise surgical margins when resecting lung metastases for potential cure.

Diagnostic and therapeutic video-assisted thoracic surgery resection of pulmonary metastases

BACKGROUND

Appropriateness of video-assisted thoracic surgery (VATS) pulmonary metastasectomy for curative intent has been a controversial topic. We reviewed our experience with VATS wedge resection for peripheral lung metastases to determine the efficacy and potential adverse consequences of this approach for pulmonary metastasectomy.

METHODS

One hundred seventy-seven patients underwent VATS resection of pulmonary metastases. Diagnostic resection (VATS-dx) was performed for 78 patients when percutaneous biopsy was unsuccessful or not feasible. Potentially curative resections (VATS-rx) were performed for 99 patients. The histologic findings in this group included colorectal (68), renal (7), sarcoma (6), breast (4), melanoma (3), head/neck (3), lymphoma (2), uterine (1), and "other" (5). The average number of lesions resected was 1.4 (range, 1-7).

RESULTS

VATS resection was successfully performed for all VATS-dx and VATS-rx patients. There were no perioperative deaths. Longitudinal follow-up demonstrated a mean survival of 18 months in the VATS-dx group and 28 months in the VATS-rx group. In the VATS-rx group, 37 (37%) of 99 were free of disease, at a mean follow-up interval of 37 months. Of the 57 recurrences, 5% were local, 26% were regional, and 69% were distant.

CONCLUSIONS

Results with VATS resection of peripheral pulmonary metastases for diagnostic and potentially curative intentions appear comparable with historical results by "open" thoracotomy. Careful patient selection based on high-resolution helical CT scanning is important to avoid compromise of therapeutic intent. Conversion to thoracotomy is indicated when lesions identified preoperatively are not found or when technical problems encountered may compromise surgical margins when resecting lung metastases for potential cure.

Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer

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.

Preimplantation retrograde pneumoplegia in clinical lung transplantation

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.

Complications in the native lung after single lung transplantation

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.

Video-assisted thoracoscopic treatment of giant bullae associated with emphysema

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.

Thoracoscopic resection of solitary lung metastases from colorectal cancer is a viable therapeutic option

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.

Thymectomy for myasthenia gravis: a 27-year experience

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.

Mucinous cystadenoma of the lung

A 56-year-old male patient came under our observation when a peripheral round mass in his right lung which he had since 1991 and which was believed to be a bronchogenic cyst, showed a volumetric enlargement of 2 cm. After performing a lobectomy of the middle lobe, the histopathological examination revealed the presence of a mucinous cystadenoma of borderline malignancy.

Induction chemotherapy for T4 centrally located non-small cell lung cancer

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.

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.

Inhaled nitric oxide in patients with cystic fibrosis during preoperative evaluation and during anaesthesia for lung transplantation

INTRODUCTION

Inhaled nitric oxide (iNO) has been recently used as pulmonary vasodilator without any systemic effects because of a rapid inactivation by haemoglobin. We studied haemodynamic and oxygenation effects during iNO administration in cystic fibrotic patients during preoperative evaluation and during anaesthesia for lung transplantation.

METHODS

From March 1996 to November 1997, 35 patients received iNO (40 ppm) during preoperative evaluation in spontaneously breathing. 13 patients, who underwent double lung transplantation, received iNO (40 ppm) during the surgical procedures, after pulmonary artery clamping.

RESULTS

In the preoperative evaluation a significant decrease of mean pulmonary artery pressure, pulmonary vascular resistance index and intrapulmonary shunt, with an increase of PaO2/FiO2, were observed during iNO administration, compared to baseline in 100% O2. During lung transplantation a significant decrease in intrapulmonary shunt was noted. All the transplants were successfully performed without cardio-pulmonary bypass. In all procedures, after iNO administration, we observed no modification of systemic haemodynamics. In conclusion, our study confirms the pulmonary effects of iNO without any systemic effects in patients affected by cystic fibrosis during preoperative evaluation and during anaesthesia for lung transplantation.

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.

[Therapeutic approach in non-postoperative pleural empyema]

The Authors carried out an retrospective analysis on 81 patients, 67 men and 14 women, suffering from non post-surgical thoracic empyema, to evaluate the different therapeutic procedures and respective indications. The unsuccessful response to the preserving approach (intercostal drainage and pleural lavage twice a day with specific antibiotics or antiseptics) in 56 cases, induced the Authors to carry out a video-thoracoscopy (VAT), that allowed them to define the infection stage and subsequent treatment (the carrying on of a pleural drainage-lavage in 32 cases, the transcurrent pleural irrigation in 10 cases, the open window thoracostomy followed by myoplasty in 6 cases with bronchopleural fistula, the decortication with associated pleural exeresis in 6 cases with bronchopleural fistula, the decortication with associated pleural exeresis in 6 cases, the streptokinase in pleural cavity in 2 cases). There were registered totally 3 deaths (3.7%). The Authors in conclusion assert that the VAT, carried out after the unsuccessful preserving treatment, allows the evaluation of the infection stage and consequently suggests therapy.

[Chondro-costal abnormalities of anterior wall of the chest: operative indications and surgical technique]

The aim of this study is to evaluate the utility of surgical treatment in patients with pectus excavatum (PE) or pectus carinatum (PC). Fifteen patients underwent surgical treatment because of their psycological and anatomical condition, more serious in 6 patients (5 with PE and 1 with PC). The degree of these chest wall deformities was evaluated as resulting from CT scan of the thorax, by the ratio between the transversal and the front/back diameters, according to Haller. The Authors recommend surgical operation in the post-puberal age up to 21 years because of good results obtained using Ravitch approach (only 1 case of partial relapse of PE), even though modified in PE cases with the application of flat steel prosthesis and in PC cases for uncutting the perichondral beds. The choice of surgical procedure derives, in our opinion, from the correction of these anatomic deformities and from the greater sense of improved cosmesis that might result.

[Combined surgical treatment of pulmonary neoplasms with single brain metastasis]

The combined surgical treatment of primitive lung cancer with single brain metastasis is a frequently debated but still controversial problem. Up to day several therapeutic approaches are generally integrated (surgery, radiotherapy, chemotherapy) according to the clinical patterns and the technical possibilities. In general, the combined surgical operation (thoracotomy + craniotomy) when it is possible to be done, followed or proceeded by chemo-radiotherapy, has allowed to achieve a prolonged survival in these patients, maintaining an acceptable quality of life. The authors analyze 10 cases treated by thoracotomy and craniotomy at the Chair of Thoracic Surgery of University of L'Aquila. Although consisting of a small number of cases, this experience allows to detect the particular problems concerning these patients. The indications to the combined surgical treatment are considered, evaluating the surgical operation which is to be performed as first on the basis of lung cancer staging and of the location and size of the brain metastases. Finally the patients survival and their quality of life are considered.

MR study of N2 disease in lung cancer: contrast-enhanced method using gadolinium-DTPA

OBJECTIVE

In several previous studies, including one of our own, CT and MRI provided similar information on N2 detection in the staging of lung cancer. Both imaging techniques can be considered effective in detecting enlarged mediastinal lymph nodes but the results are often inaccurate when confronted with pathological findings. The purpose of this study was to assess the diagnostic accuracy of gadolinium-DTPA enhanced MRI in the detection of mediastinal lymph nodes in lung cancer.

METHODS

A prospective study to compare standard unenhanced MRI and Gd-DTPA enhanced MRI was carried out in patients with diagnosed lung cancer. The study focused on the status of mediastinal lymph nodes. Gd-DTPA was administered at a dosage of 0.2 mmol2/KG before T1 weighted sequences. Qualitative visual analyses of both standard and contrast enhanced MRI images were performed on each patient by 2 independent radiologists. The imaging results were then compared to pathological findings obtained after surgical operation.

RESULTS

In the identification of mediastinal lymph node metastases standard MRI was 62% sensitive, 100% specific and 74% accurate whereas Gd-DTPA enhanced MRI was 100% sensitive, 91% specific and 97% accurate.

CONCLUSIONS

Gd-DPTA enhanced MRI was more accurate than standard MRI in the detection of metastatic lymph nodes in patients with lung cancer. These initial results can be considered encouraging especially with regards to the reduction of false negative findings although further confirmation is, understandably, required.

[Use of magnetic resonance in the study of mediastinal diseases]

Clinical research on 75 cases of mediastinal masses has been carried out with the aim of evaluating the diagnostic value of Magnetic Resonance (MR). Results which have been achieved point to a remarkable potentiality of MR especially in the characterization and spatial definition of the masses and in the study of the spinal canal. These results, as well as the non-invasivity of the procedure, lead us to consider MR as an investigation of primary importance in the diagnostic assessment of mediastinal pathology.