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.

Long-term follow-up after bronchoscopic lung volume reduction in patients with emphysema

Bronchoscopic lung volume reduction (BLVR) is a novel emphysema therapy. We evaluated long-term outcome in patients with heterogeneous emphysema undergoing BLVR with one-way valves. 40 patients undergoing unilateral BLVR entered our study. Pre-operative mean forced expiratory volume in 1 s (FEV(1)) was 0.88 L · s(-1) (23%), total lung capacity was 7.45 L (121%), intrathoracic gas volume was 6 L (174%), residual volume (RV) was 5.2 L (232%), and the 6-min walk test (6MWT) was 286 m. All patients required supplemental oxygen; the Medical Research Council (MRC) dyspnoea score was 3.9. High-resolution computed tomography (HRCT) results were reviewed to assess the presence of interlobar fissures. 33 patients had a follow-up of >12 months (median 32 months). 37.5% of the patients had visible interlobar fissures. 40% of the patients died during follow-up. Three patients were transplanted and one underwent lung volume reduction surgery. Supplemental oxygen, FEV(1), RV, 6MWT and MRC score showed a statistically significant improvement (p ≤ 0.0001, p = 0.004, p = 0.03, p = 0.003 and p<0.0001, respectively). Patients with visible fissures had a functional advantage. BLVR is feasible and safe. Long-term sustained improvements can be achieved. HRCT-visible interlobar fissures are a favourable prognostic factor.

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.

Operative complications and early mortality after induction therapy for lung cancer

OBJECTIVE

Induction therapy for advanced lung cancer allows improvement of completeness of resection and survival. However, predictive risk factors for postoperative complications and early mortality remain controversial. We report our 14-year experience with this combined approach.

METHODS

One hundred and thirty-nine patients (100 males and 39 females) underwent induction therapy and surgery for stage IIIA and B lung cancer. The mean age was 58.4+/-7.7 years. We retrospectively collected demographic data, preoperative functional parameters, type of operation, associated disorders, staging, induction regimen (chemotherapy alone or associated with radiotherapy). Univariate and multivariate analyses were performed to identify predictors of postoperative complications and early mortality.

RESULTS

One hundred and nine patients received chemotherapy (mainly based on cisplatin and gemcitabine) and 30 received chemoradiotherapy (median dose 50Gy). Complications developed in 49 patients (35%). The most frequent was persistent air leakage (23-30% of the lobectomies), followed by cardiac complications, respiratory failure, and infections. Five patients (3.5%) died in the postoperative period and four of them had received pneumonectomy (mortality for pneumonectomy: 12.5%). The statistical analysis demonstrated that only pneumonectomy was associated with an increased mortality risk with no differences between intra- and extrapericardial dissection or right and left pneumonectomy.

CONCLUSIONS

Induction therapy seems to be associated with an increased incidence of air leakage; the risk of other complications is acceptable. Pneumonectomy is associated with an increased risk of mortality and should be performed in selected patients.

Bronchoscopic lung volume reduction

Emphysema is a debilitating lung disease continuing to be a major source of morbidity and mortality in the developed countries. Medical treatment is the mainstay of therapy and consists of smoking cessation, pulmonary rehabilitation, administration of bronchodilators and, when indicated, steroids and supplemental oxygen. Various surgical procedures have been promoted in the past to relieve dyspnoea and improve quality of life in patients with advanced emphysema; whilst early results were often encouraging, a sustained objective functional improvement was rarely achieved and most of those procedures were progressively abandoned. Despite controversies, LVRS has been shown to be beneficial to selected patients with end-stage emphysema when medical therapy has failed. There is no doubt that LVRS allows a significative functional improvement in a selected group of patients; however, it still carries a substantial morbidity, even if mortality is low at the centers with the larger experience. Patients with a most advanced functional deterioration show a higher surgical mortality and less impressive functional results, suggesting that LVRS should be considered more carefully in these situations. Bronchoscopic alternatives to the surgical approach have been recently proposed and some of them may play an important role in the future; in particular, the airway bypass and bronchoscopic lung volume reduction with one-way valves are certainly one step beyond on their way to clinical application. We hereby report the initial experimental and clinical experience with these new treatment options.

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.

Bronchoscopic procedures for emphysema treatment

Emphysema is a debilitating lung disease continuing to be a major source of morbidity and mortality in the developed countries. Medical treatment is the mainstay of therapy and consists of smoking cessation, pulmonary rehabilitation, administration of bronchodilators and, when indicated, steroids and supplemental oxygen. Various surgical procedures have been promoted in the past to relieve dyspnoea and improve quality of life in patients with advanced emphysema; whilst early results were often encouraging, a sustained objective functional improvement was rarely achieved and most of those procedures were progressively abandoned. Despite controversies, LVRS has been shown to be beneficial to selected patients with end-stage emphysema when medical therapy has failed. There is no doubt that LVRS allows a significative functional improvement in a selected group of patients; however, it still carries a substantial morbidity, even if mortality is low at the centres with the larger experience. Patients with a most advanced functional deterioration show a higher surgical mortality and less impressive functional results, suggesting that LVRS should be considered more carefully in these situations. Bronchoscopic alternatives to the surgical approach have been recently proposed and some of them may play an important role in the future; in particular, the airway bypass and bronchoscopic lung volume reduction with one-way valves are certainly one step beyond on their way to clinical application. We hereby report the initial experimental and clinical experience with these new treatment options.

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.

Bronchoscopic lung-volume reduction with one-way valves in patients with heterogenous emphysema

BACKGROUND

We evaluated the feasibility and short-term functional outcome after bronchoscopic lung-volume reduction performed with one-way valves in patients with severe heterogeneous emphysema.

METHODS

Thirteen patients entered this pilot study. Endobronchial one-way valves were placed in the segmental bronchi supplying the most hyperinflated parts of the emphysematous lungs to allow lung deflation, reduce lung volume, and alleviate symptoms. The valves and delivery catheter were inserted under intravenous anesthesia and spontaneous assisted ventilation, with visual control through a flexible bronchoscope. We performed unilateral bronchoscopic lung-volume reduction in 11 patients and staged bilateral procedures in 2. Preoperative median forced expiratory volume in 1 second (FEV1) was 0.75 L/s (22%), residual volume was 5.3 L (233%), total lung capacity, 7.9 L (123%); intrathoracic gas volume, 6.5 L (176%); and 6-minute walk test, 223 meters. All patients required supplemental oxygen at rest (1.4 L/min). The median preoperative Medical Research Council (MRC) scale dyspnea score was 4.

RESULTS

Six complications occurred in 3 patients: two bilateral and one contralateral pneumothorax, one pneumonia, and two episodes of bronchospasm. Functional results at 1 and 3 months showed a significant improvement in FEV1, residual volume, and 6-minute walk test; 43% of the patients were able to completely stop supplemental oxygen. The posttreatment MRC median dyspnea score at 1 and 3 months was 2. Bronchoscopic follow up at 1 and 3 months showed that the valves were correctly in place with no granulation.

CONCLUSIONS

Bronchoscopic lung-volume reduction with one-way valves can be performed with acceptable short-term safety and worthwhile functional benefits.

Recovery of Chronic Renal Impairment With Sirolimus After Lung Transplantation

BACKGROUND

Standard immunosuppression after lung transplantation includes calcineurin inhibitors, azathioprine, and steroids. Calcineurin inhibitor administration is associated with an increased renal impairment. Sirolimus shows no renal toxicity and could be used in selected patients.

METHODS

We have prospectively administered sirolimus as an alternative to calcineurin inhibitors in 15 lung transplantation recipients with persistent drug nephrotoxicity. Eight patients had also bronchiolitis obliterans syndrome. The mean serum creatinine and azotemia were 2.7 +/- 1.1 mg/dL and 111 +/- 39 mg/dL. After starting sirolimus, azathioprine was reduced to 50%-25% of baseline, calcineurin inhibitors were gradually reduced and eventually stopped, and steroids were maintained stable. Patients started sirolimus with 2 to 5 mg/d orally; adjustments were made according to trough levels (4 to 12 ng/mL for combined sirolimus + calcineurin inhibitors; 12 to 20 ng/mL as monotherapy), toxicity, and perceived efficacy. Patients were monitored for renal and graft function and clinical status.

RESULTS

A significant creatinine decrease was observed after 6 months of treatment (p < 0.02); azotemia decreased after 1 month and remained stable (p < 0.01). Pulmonary function tests did not show any significant modification from before sirolimus baseline in patients without bronchiolitis obliterans syndrome. There were eight infectious complications and 10 episodes of toxicity (4 dermatitis, 2 epistaxis, 1 headache, 1 diarrhea, 1 nausea, 1 laryngeal cancer). Moderate leukocytopenia (n = 3) and hypertriglyceridemia (n = 6) responded to dose reduction. One patient was lost to follow-up. Three patients died of complications related to bronchiolitis obliterans. One patient underwent transplantation again.

CONCLUSIONS

Sirolimus administration allows amelioration of renal function with a relatively low morbidity and is useful for chronic renal impairment rescue after lung transplantation.

Complete mechanical cervical anastomosis using a narrow gastric tube after esophagectomy for cancer

OBJECTIVE

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 esophagogastric 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 June 2003, 26 patients (15 males and 11 females) underwent esophagectomy using tubulized stomach for reconstruction. Cervical esophagogastric anastomosis using linear endoscopic stapler was performed in all cases. The occurrence of post-operative anastomotic leak and development of anastomotic stricture were recorded and analyzed.

RESULTS

All patients survived esophagectomy and were available for post-operative follow-up. Anastomotic leak developed in one case. No patient developed fibrous stenosis that required dilatation therapy.

CONCLUSION

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

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.

Improved results with lung transplantation for cystic fibrosis: a 6-year experience*1

Since 1996, 102 patients with cystic fibrosis were accepted on our waiting list and 57 bilateral sequential lung transplants were performed in 56 patients. Before transplantation, the mean FEV1 was 0.64 l/s, the mean PaO2 with supplemental oxygen was 56 mmHg and the mean 6-min walking test was 320 m. Transplantation was performed through a 'clam shell incision' in the first 29 patients; in the rest of the patients we performed a bilateral anterolateral thoracotomy without sternal division. In 21 patients the donor lungs had to be trimmed by extra-anatomical wedge resections with mechanical staplers and bovine pericardium buttressing to fit the recipient chest size. Hospital mortality was 11.6%. Acute rejection occurred 1.6 times per patient/year; pulmonary infections occurred 1.4 times per patient in the first year after transplantation. The mean FEV1 increased to 82% 1 year after the operation. The 2-year survival rate was 79%. Fifteen patients had BOS: one died 26 months after the operation with fungal sepsis after reinduction of immunosuppression, one has been successfully retransplanted, five were stabilized after modifications of immunosuppression and four are continuing to deteriorate. Lung transplantation is a concrete 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.

Long-term outcome after multimodality treatment for stage III thymic tumors

BACKGROUND

Surgery remains the cornerstone of therapy for thymic tumors, but the optimal treatment for advanced, infiltrative lesions is still controversial. The introduction of multimodality protocols has substantially modified survival and recurrence rate. We reviewed our 13-year prospective experience with multimodality treatment of stage III thymoma and thymic carcinoma.

METHODS

Since 1989 we have prospectively used a multimodality approach in 45 stage III thymic tumors. Sixteen patients (35%) had myasthenia gravis. Twenty-three patients (51%) had pure or predominantly cortical thymoma (group 1), 11 (24.5%) had well-differentiated thymic carcinoma (group 2), and 11 (24.5%) had thymic carcinoma (group 3). Tumors that were not considered radically resectable at preoperative workup underwent biopsy and induction chemotherapy (15 patients, 33%) followed by surgical resection; all patients were referred for adjuvant chemoradiotherapy.

RESULTS

No operative mortality was recorded; 1 treatment-related death during adjuvant chemotherapy was observed in group 1. Complete resection was feasible in 91% of patients in groups 1 and 2 and 82% in group 3. The overall 10-year survival was 78%. Ten-year survival for groups 1 and 2 was 90% and 85%, respectively; 8-year survival for group 3 was 56%. During follow-up, tumor recurrence was noted in 3 patients (13%) from group 1, 3 (27%) from group 2, and 3 (27%) from group 3.

CONCLUSIONS

Multimodality treatment with induction chemotherapy (when required) and adjuvant chemoradiotherapy offers encouraging results for stage III thymic tumors; the outcome is more favorable for cortical thymoma and well-differentiated thymic carcinoma.

Bilateral sequential lung transplantation without sternal division

OBJECTIVES

The 'clamshell incision' is considered the standard approach for bilateral sequential lung transplantation (BSLT); however, a considerable morbidity may be related to this incision. The bilateral anterolateral thoracotomy without sternal division is an alternative approach that may contribute to avoid chest wall complications.

METHODS

We have employed this approach in a prospective series of 34 patients undergoing bilateral transplantation (Group I). The results were retrospectively compared with an historical control group of 37 patients (Group II) undergoing transplantation through the clamshell incision.

RESULTS

The operative time in Groups I and II were 228+/-32 and 293+/-37 min, respectively; the difference between the ischemic time of the first and second lungs were 68+/-20 and 73+/-15 min. Intensive care unit stay was 5+/-6 vs. 13+/-10 days and length of hospitalization was 25+/-16 vs. 32+/-10 days. Vital capacity measured 3 weeks after the transplant was significantly higher in Group I (65+/-13 vs. 45+/-8% predicted) as well as FEV(1) (71+/-8 vs. 58+/-7% predicted). No wound related complication was observed in Group I; in Group II, there were 17 chest wall complications: sternal osteomyelitis in three patients (surgical debridement and closure with a muscle flap), migration of the Kirshner wire in three (removal of the wire), sternal override in three (surgical correction) and prolonged pain in eight.

CONCLUSIONS

The bilateral anterolateral thoracotomy without sternal splitting is a safe and effective approach for BSLT; it allows to avoid sternal complications and contributes to improve respiratory function in the early postoperative period.

Nd:YAG laser resection of lung cancer invading the airway as a bridge to surgery and palliative treatment

BACKGROUND

Thirty percent of patients with lung cancer have airway obstruction requiring palliation. In addition, endoscopic resection may be considered before surgery or induction therapy to improve quality of life and functional status, and to allow better staging. It may also help to prevent infectious complications during induction chemotherapy.

METHODS

Since 1993, 351 Nd:YAG laser resections were performed in 273 patients with lung cancer. The tumor involved the trachea in 36 patients, the carina in 28, the main bronchi in 154, the bronchus intermedius in 29, and the distal airway in 26. One hundred eight stents were placed. After the endoscopic treatment 36 patients were operated on (23 after induction chemotherapy) with 8 pneumonectomies (1 tracheal sleeve) and 28 lobectomies (15 bronchial sleeves). Spirometry, arterial blood gas analysis, and quality of life and performance status were recorded before and after laser treatment and after induction chemotherapy. Complications during chemotherapy, surgical morbidity and mortality, and survival were also recorded.

RESULTS

Major complications during laser resection were bleeding (7 patients) and hypoxia (5 patients). Three patients died within 24 hours after the procedure. No complications were observed in the group of patients who subsequently underwent induction chemotherapy or surgery. One patient developed pneumonia during induction chemotherapy. The airway caliber improved in 89% of patients undergoing palliation only. In the group of patients undergoing induction chemotherapy and/or surgery, the performance status, quality of life, and functional measurements significantly improved after endoscopic treatment (FEV1 from 1.4 +/- 0.5 L/s to 2.2 +/- 0.6 L/s). Three-year survival after induction chemotherapy and surgery, was 52%. Median survival after palliation alone was 12.1 months.

CONCLUSIONS

Nd:YAG laser resection is a safe and effective means of relieving airway obstruction. Before induction chemotherapy or surgery preliminary endoscopic palliation helps to improve evaluation and staging and contributes to reducing morbidity during chemotherapy without increasing surgical complications.

Thoracoscopic sympathectomy for symptomatic arterial obstruction of the upper extremities

BACKGROUND

Severely symptomatic arterial insufficiency of the hand and upper extremities requires adequate treatment. Medical therapy and local care are usually unsuccessful, and thoracic sympathectomy can represent an effective procedure to control pain, to help ulcer healing, and to prevent or delay amputation.

METHODS

We performed 20 thoracoscopic sympathectomies in 15 patients (13 men and 2 women) with upper extremity ischemia. Mean age was 47 years (range 21 to 72 years). All patients were thought to have organic blockage of digital arteries. The condition was unilateral in 10 patients and bilateral in 5. Primary diagnosis was digital arteriosclerosis in 8 patients, Buerger's disease in 4 patients and the remaining 3 were drug abusers with severe ischemia due to accidental intraarterial injection of drugs. Eleven patients (73%) presented with terminal digital necrosis, gangrene, or ulceration of the fingers associated with severe pain. Four patients complained of coldness, pain, and some degree of soft tissue infection without permanent loss of tissue.

RESULTS

We performed 10 unilateral and five bilateral staged (mean interval was 3 months) thoracoscopic sympathectomies. We had two minor complications and no mortality. Mean duration of postoperative chest drainage was 2.5 +/- 0.4 days and mean postoperative hospital stay was 5.3 +/- 0.5 days. Follow-up ranged from 3 to 71 months, with a mean of 33 months. All patients demonstrated clinical benefit after operation.

CONCLUSIONS

Thoracoscopic sympathectomy in patients with severe ischemia of upper limb extremities permits optimal symptomatic control and maximum tissue salvage. Because the procedure is minimally invasive, safe, and associated with a low rate of complications, it should be considered earlier the natural course of this disease.

[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.