Antonio Bobbio

Management of postintubation membranous tracheal rupture

BACKGROUNDnPostintubation tracheobronchial laceration is a rare complication of general anesthesia. A renewed interest in this disorder induced us to review our experience on its treatment, focusing on the evolution of the surgical approach, and describing a technical variation of the transcervical approach.nnnMETHODSnFrom January 1994 to December 2002 we treated 13 patients with diagnosis of postintubation tracheobronchial laceration. The treatment was nonsurgical in 3 patients (1-cm-long tear) and surgical in the other cases. Two lesions extending to the main bronchi were repaired through a right thoracotomy as well as four lesions limited to the trachea observed before January 2001. After this date we used the transcervical approach for entirely intratracheal lesions: in three cases we performed an anterior transverse tracheotomy and in one case a transverse and midline vertical incision (T tracheotomy).nnnRESULTSnBoth conservative and surgical therapy were successful in all the cases. Two patients in the thoracotomy group had a transient right vocal cord palsy. No morbidity was observed with the cervical approach. Normal healing of the sutures was evidenced by an endoscopic follow-up 30 days later.nnnCONCLUSIONSnIn our experience nonsurgical treatment is advisable in small (length < 2 cm) uncomplicated tears. Concerning surgery, thoracotomy is indicated in tracheal lacerations extending to the main bronchi, whereas the transcervical approach is preferred for intratracheal tears because of its efficacy in reaching and suturing the lesions extending to the carina and for its limited invasiveness.

Lung metastasis resection of adenoid cystic carcinoma of salivary glands

BACKGROUNDnAdenoid cystic carcinoma is a rare tumour originating from the exocrine mucous glands, known for its high propensity for distant metastases. The value of lung metastasis resection from adenoid cystic carcinoma of salivary glands origin is evaluated.nnnMETHODSnA retrospective study was conducted on patients undergoing surgery for primary adenoid cystic carcinoma of the salivary glands between 1982 and 2006. Patients were excluded who had primary tumour macroscopic incomplete resection or were lost at follow-up. From a database of 50 eligible patients, 27 were identified as having presented a tumour recurrence during follow-up; in 20 it was first diagnosed in the form of distant metastases, and in 7 in the form of loco-regional recurrence. Nine patients who presented isolated lung recurrence underwent complete lung metastasectomy. Demographic data, pathologic characteristics and operative and postoperative record were reviewed, as well as updated survival.nnnRESULTSnTwenty-six men and 24 women with a median age of 57 years (range 33-79) underwent radical surgery for adenoid cystic carcinoma during the study period. In 20 patients, at a median free interval time of 3 years (range 1-12), a distant metastasis relapse was observed. Nine patients with a median free interval time of 5 years (range 1-12) underwent lung metastasectomy: five had single metastasis resection, one multiple mono-pulmonary and three multiple and bilateral. In six of these patients a new disease recurrence was noted: four patients underwent further lung metastasectomy, but in all of them progression of the disease was observed. Mean survival of the population as a whole resulted as being 16 years (SE=1.4) with an actuarial survival of 77% at 5 years, 66% at 10 years and 56% at 15 years. Mean survival of patients having presented with distant metastases resulted as being 11 years (SE=2.2). Mean survival after appearance of distant metastases resulted as being 72 months (SE=15.8) in the 9 patients treated by metastasectomy, and 62 months (SE=15.1) in the 11 who did not have metastasis resection.nnnCONCLUSIONSnPatients with adenoid cystic carcinoma could be frequently encountered with disease recurrence confined to the lung. The impact of complete lung metastasis resection on the course of the disease, however, is yet to be determined.

Exercise capacity assessment in patients undergoing lung resection

BACKGROUNDnThe value is examined of preoperative functional assessment, including exercise capacity measurement by a cycloergometric maximal exercise test, in the prediction of postoperative cardio-pulmonary complication after lobar resection.nnnMETHODSnIn a prospective study over a 3-year period, all patients who were candidates for lung resection underwent preoperative functional evaluation by means of resting pulmonary function tests, measurement of the lung diffusing capacity for carbon monoxide and cardio-pulmonary exercise test. Patients who had had pneumonectomy or less than anatomical segmentectomy were excluded. The study population consisted of 73 patients. The postoperative morbidity and mortality record was collected.nnnRESULTSnSixty-four patients underwent lobectomy, five bilobectomy and four segmentectomy. Indication for surgery was NSCLC in 71 cases. Two postoperative deaths were recorded (2.7%). A pulmonary (n=19) and/or cardiac (n=17) complication was scored in 30 patients (41%). Mean preoperative FEV(1) and VO(2)max of patients who developed pulmonary complications were significantly lower (p=0.013 and p=0.043 respectively) than those of patients without pulmonary complications. Logistic regression analysis found FEV(1) to be an independent factor in pulmonary complication (p=0.002). With regard to pulmonary complication occurrence, the receiver operating characteristic curve showed an area of 0.69 with VO(2)max expressed in ml/kg min and of 0.62 when VO(2)max was expressed as a percentage of the predicted value. The widest point of the curve was found at a VO(2)max value of 18.7 ml/kg min. Six out of the 14 patients (43%) with a preoperative VO(2)max equal to or lower than 15 ml/kg min had a pulmonary complication. No functional preoperative identifiers were found for the 16 patients who presented with postoperative new onset atrial fibrillation. The mean preoperative value of carbon monoxide lung diffusing capacity was significantly lower (p=0.037) in the 30 patients who had postoperative cardio-pulmonary complications than in the complication-free population.nnnCONCLUSIONSnPreoperative exercise capacity assessment helps in stratifying patients at risk for postoperative pulmonary complication. However, it does not appear to be an independent prognostic factor for postoperative outcome.

Diaphragmatic laceration, partial liver herniation and catamenial pneumothorax.

Catamenial pneumothorax is a recurrent pneumothorax temporally associated with menstruation. Pathogenesis remains debated however pleural endometriosis or diaphragmatic abnormalities are almost always present. We report the case of a 35-year-old woman with recurrent right catamenial pneumothorax. At thoracoscopy a large laceration of the diaphragm with partial intrathoracic liver herniation was seen. Treatment involved repair of the diaphragmatic lacerations, and pleurodesis. This report shows that large diaphragmatic defects may be observed in patients with catamenial pneumothorax.

Changes in lung function and respiratory muscle strength after sternotomy vs. laparotomy in patients without ventilatory limitation.

A relevant ventilatory defect occurs after sternotomy, a very common thoracic surgical opening. The mechanism of the ventilatory impairment is unclear. Moreover, until now, the effect of sternotomy on pulmonary gas exchange has scarcely been investigated. We evaluated the time-course up to recovery and changes in spirometry, maximum static inspiratory (PImax) and expiratory (PEmax) mouth pressures and pulmonary gas exchange in 6 patients after sternotomy and in 8 patients after laparotomy. All patients were free of cardiopulmonary diseases and had normal preoperative lung function. Sternotomy and laparotomy decreased forced vital capacity (FVC) by 67 and 49%, respectively. Moreover, the percent decreases in PImax, PEmax and PaO2 after sternotomy vs. laparotomy were respectively 54 vs. 57%, 54 vs. 60%, and 22.6 vs. 7.5% (p < 0.05). Following sternotomy, the percent decreases in FVC correlated with the percent decreases in PImax (p < 0.05) and PEmax (p < 0.01). The return to baseline values occurred after approximately 2 weeks. The present study shows that sternotomy can induce greater respiratory effects than laparotomy and suggests a relevant involvement of respiratory muscle weakness after surgical opening of the thorax. The study also supports the view that the evaluation of patient’s lung function before sternotomy can be clinically relevant.

Histological and Immunohistochemical Study of the Bronchial Stump with Flap Coverage in an Animal Model

Objective: The purpose of our study was to evaluate the healing process of the bronchial stump after pneumonectomy reinforced with different pedicled flaps in an animal model. The specimens were analyzed by means of histology and immunohistochemistry. Materials and Methods: We have considered 45 New Zealand White male rabbits that underwent a left pneumonectomy under general anesthesia. Nine animals had no bronchial coverage and represented the controls. The other 36 rabbits were divided into three groups of 12 and had bronchial coverage with either diaphragmatic, intercostal or pericardial flaps. The histological examinations were performed on the animals sacrificed 7, 14 and 30 days after surgery. Immunohistochemical analyses were done on the specimens on postoperative day 7 and 14. On postoperative day 7, the specimens were examined for expression of proliferating cell nuclear antibody (PCNA) expression. On postoperative day 14, neoangiogenesis was measured by CD31 expression. The measurements of antibody expression were done with a computer-assisted morphometric count and analyzed with the t test. Results: On postoperative day 14, standard histology showed more evident neoangiogenesis in the bronchial stump specimens covered with intercostal and diaphragmatic flaps compared to pericardial flaps and controls. The immunohistochemical evaluation of PCNA by morphometric computer-assisted analysis did not show any statistically significant differences among the groups. The CD31 morphometric count revealed a higher and statistically significant antibody expression in muscular flaps compared to pericardial flaps and controls. Conclusions: Our study showed that bronchial coverage with a pedicled muscular flaps promotes the production of new vessels and gives the possibilities to optimize the healing process of a bronchial stump after pneumonectomy.