Alessio Vincenzo Mariolo

Robotic Hybrid Approach for an Anterior Pancoast Tumor in a Severely Obese Patient

Several different surgical approaches to anterior Pancoast tumors have been proposed. The osteomuscular-sparing transmanubrial approach allows optimal exposure and control of apical chest wall structures, but it requires an additional thoracotomy to perform the lobectomy with radical lymph node resection. The presented technique combines the osteomuscular-sparing transmanubrial approach with robotic-assisted upper lobectomy in a severely obese patient, thereby reducing the invasiveness of the surgical approach and the postoperative complications.

Pericardial-peritoneal window for malignant pericardial effusion

Background: Malignant pericardial effusion is a pathological accumulation of fluid in the pericardial cavity occurring in patients with different types of cancer. The condition can be life-threatening not only in patients with terminal malignancies but also in those with a more favorable prognosis. The creation of a pericardial-peritoneal window is a surgical procedure connecting the pericardium with the peritoneal cavity and the definitive treatment of pericardial effusion. n Methods: Twenty consecutive patients with malignant pleural effusion undergoing pericardial-peritoneal window from 2006 to 2017 were enrolled in the present study. Data were collected on sex, age, preoperative ultrasound and computed tomography findings, histology and pathological stage of the neoplasm, intraoperative findings and additional surgical procedures needed. Further information included total postoperative complications, 30-day mortality rate, pulmonary and cardiac complications, ICU admission and hospital stay, median overall survival (OS). n Results: Eleven patients were male and nine were females; median age was 63 years; 14 patients had lung cancer, 3 breast carcinomas, 1 ovarian adenocarcinoma, 1 renal cell carcinoma and 1 malignant mesothelioma. Intraoperative mean volume of the drained pericardial effusion was 500 mL; mean duration of the procedure was 73 minutes; postoperative mean length of stay was four days; five patients had postoperative complications; one patient died within 30 days. OS after 34 months of follow-up was 80.8%. n Conclusions: Pericardial-peritoneal window is a safe and effective procedure to resolve malignant pericardial effusion in patients with a favorable short-term prognosis, whereas pericardial drainage should be considered the most appropriate treatment in patients with a less favorable prognosis.

Carinal resection: technical tips

Carinal resection (CR) is defined as the resection of the trachea-bronchial bifurcation with or without lung resection. It is an uncommon challenging surgery performed in case of NSCLC, primitive airway tumors or benign lesions invading the carina. A well-organized team is essential to manage patients undergoing CR and it must involve several specialists experienced in diagnosis, operative treatment and postoperative care. Before and during surgery a strict cooperation between surgeon and anesthesiologist is essential; cross-field ventilation is generally used to maintain the adequate gas exchange during surgical airway reconstruction, but also high frequency jet ventilation (HFJV) or extracorporeal membrane oxygenation (ECMO) could be valid alternative options when cross-field ventilation is not feasible. Right-sided lesions requiring a CR with pulmonary resection are better approached through an ipsilateral thoracotomy (IV intercostal space), whereas tumor involving the carina as well as the left main bronchus and requiring a left carinal pneumonectomy could be treated using a left thoracotomy with subaortic dissection (only for very limited tracheal resection due to a bad exposure of the trachea after moving the aortic arch). Instead, CR without pulmonary resection and left carinal pneumonectomy are better approached through a median sternotomy. Reconstruction of the airway could be performed in different ways according to the extension of the resection and to the surgeon experience with the sole purpose to obtain a tension-free anastomosis to reduce as much as possible the possible post-operative complications due to impairment healing of the suture. Based on tumor histology and the pathological staging the patient should be referred to the oncologist and/or radiotherapist for the further medical treatments. Improved patient selection, anesthetic management, surgical technique and better postoperative management are essential in such a challenging surgery to have the lowest possible rate of postoperative morbidity and mortality.

Bronchial carcinoid in anomalous right upper bronchus: a “patient-tailored” bronchoplasty resection technique

Bronchial carcinoids (BC) are indolent neuroendocrine tumors (NET) that are classified as malignant because they can locally infiltrate and metastasize. Resection is the primary treatment for most localized carcinoid tumors, with lung parenchymal-sparing surgery the favoured objective for patients with central airway tumors. Sleeve bronchoplasty techniques are complex surgical procedures defined as parenchyma-saving because they allow a radical resection with tumor-free margins while preserving the maximum amount of parenchyma. They are mainly indicated for tumors arising at the origin of a lobar bronchus, precluding simple lobectomy but not infiltrating so far as to require pneumonectomy. We describe a case of typical bronchial carcinoid of an anomalous right upper bronchus requiring a patient-tailored bronchoplasty technique. The surgical aspects and preoperative work-up are discussed.

Pleural catheters after thoracoscopic treatment of malignant pleural effusion: a randomized comparative study on quality of life

BackgroundnMalignant pleural effusion (MPE) complicates many neoplasms and its incidence is expected to rise in parallel with the aging population and longer survival of cancer patients. Although a clear consensus exists on indwelling catheters in patients with poor performance status, no study has hitherto compared different devices in patients requiring temporary or definitive drainage following talc poudrage.nnnMethodsnThis is a prospective, two-arm, pilot study on patients with MPE undergoing talc poudrage, comparing two different catheters (PleurX® versus Pleurocath®) positioned because of the inefficacy of the procedure or the high risk of short-term failure. End points of the study were quality of life (QoL), median dyspnea and chest pain assessment by EORTC questionnaires and a 100 mm visual analog scale, total in-hospital length of stay and frequency of serious adverse events.nnnResultsnNo difference was observed between the two groups in in mean dyspnea and mean chest pain in any questions of the EORTC QLQ-C30 and QLQ-LC13 questionnaires. Duration of the procedure was significantly longer in the PleurX® group versus the Pleurocath® group (72±33 versus 44±13 minutes; P=0.03). No difference was observed between the two groups in total length of hospital stay (P=1.00) or complication rate (P=1.00).nnnConclusionsnFor the cohort of patients still needing indwelling pleural catheters (PC) after thoracoscopic talc poudrage, PleurX® is suggested when drain removal is unlikely due to short life expectancy or the high chance of pleurodesis failure. Conversely, Pleurocath® should be recommended in all other patients as it is faster to place and easier to remove.nnnKeywordsnMalignant pleural effusion (MPE); talc poudrage; indwelling pleural catheter (indwelling PC).