Benedetto Cristino

Awake Thoracoscopic Biopsy of Interstitial Lung Disease

BACKGROUND Surgical biopsy of interstitial lung disease (ILD) performed through general anesthesia and video-assisted thoracic surgery (VATS) is still associated with not negligible mortality and morbidity rates. We hypothesized feasibility and minimized side-effects of VATS lung biopsy performed by regional anesthesia methods in awake patients. METHODS Thirty patients with clinical and radiologic diagnosis of undetermined ILD underwent awake VATS lung biopsy under thoracic epidural anesthesia (20 patients) or intercostal blocks (10 patients). Primary outcome was technical feasibility scored from 0 (not performed) to 4 (excellent). Cardiorespiratory variables, including the ratio of arterial oxygen to fraction of inspired oxygen (PaO(2)/FiO(2)) and arterial carbon dioxide (PaCO(2)) were also assessed at fixed time points. RESULTS Mean age was 62 ± 10 years. No patient needed conversion to general anesthesia. The feasibility score was 3.4 ± 0.7. Feasibility score correlated with percent predicted diffusing capacity of lung for carbon monoxide (R = 0.67, p = 0.0001). Operative time and global in-operating room time (anesthesia time + operative time) was 22 ± 5 minutes and 47 ± 11 minutes, respectively. The average number of biopsies was 1.8 ± 0.4 per patient. There was no operative mortality and 1 minor complication (3.3%). Mean hospital stay was 1.4 ± 0.7 days and procedure-related cost was 2700 ± 472 euros. Both anesthesia methods resulted in optimal feasibility although by intercostal blocks procedure-related cost was lower (2,410 ± 337 vs 2,800 ± 486 euros, p < 0.002) than by epidural anesthesia. Precise histopathologic diagnosis was achieved in 29 (97%) patients. CONCLUSIONS Our study has shown that in patients with ILD, awake VATS lung biopsy was easily feasible by regional anesthesia and resulted in low morbidity, excellent diagnostic yield, short hospital stay, and low cost.

Changing indications for thoracotomy in blunt chest trauma after the advent of videothoracoscopy.

BACKGROUND The advent of videothoracoscopy may restrict the indications for thoracotomy in blunt chest trauma. METHODS We retrospectively compared two groups of patients with blunt chest trauma observed in consecutive periods, before and after the advent of videothoracoscopy, 989 patients from 1989 to 1993 and 908 patients from 1994 to 1998. RESULTS During the first period, 38 thoracotomies were performed; but in 8 instances (21%), no major injuries were found. In the second period, 36 videothoracoscopies were performed to repair the lung (n = 5) or diaphragm (n = 5), to evacuate clots (n = 4), pericardial effusion (n = 3), and empyema (n = 2). Six procedures were converted and 11 findings were negative for lesions. Only nine intentional thoracotomies were performed, and significant lesions were found in each case. CONCLUSION Videothoracoscopy has reduced the number of thoracotomies performed. Thoracotomy can be limited to massive bleeding with hemodynamic instability, major air leak, radiologic evidence of mediastinal enlargement or diaphragmatic rupture, or major anterolateral flail chest.

Recurrent Massive Hyperplasia of the Thymus

Differentiation of massive thymic hyperplasia from malignant lesions requires early resection. We report a case in which thoracoscopic thymectomy was performed for massive hyperplasia recurring 16 years after steroid therapy. This case provides additional information on the natural history, surgical management and histology of the disease.

Minimalist video-assisted thoracic surgery biopsy of mediastinal tumors

BACKGROUND Mediastinal tumors often require surgical biopsy to achieve a precise and rapid diagnosis. However, subjects with mediastinal tumors may be unfit for general anesthesia, particularly when compression of major vessels or airways does occur. We tested the applicability in this setting of a minimalist (M) uniportal, video-assisted thoracic surgery (VATS) strategy carried out under locoregional anesthesia in awake patients (MVATS). METHODS We analyzed in a comparative fashion including propensity score matching, data from a prospectively collected database of patients who were offered surgical biopsy for mediastinal tumors through either MVATS or standard VATS. Tested outcome measures included feasibility, diagnostic yield, and morbidity. RESULTS A total of 24 procedures were performed through MVATS. Diagnostic yield was 100%. Median hospital stay and time interval to oncologic treatment were 2 days (IQR, 2-3 days) and 7 days (IQR, 5.5-11.5 days), respectively. At overall comparison (MVATS, N=24 vs. VATS, N=23), there was a significant difference in both frequency and severity of postoperative complication as measured by Clavien-Dindo classification (P<0.006). In a propensity score matched comparison (8 patients per group), grade 3 or 4 complications requiring aggressive management were found only in the general anesthesia group. Global time spent in the operating room was shorter in the MVATS group (P=0.05). Time interval to oncological treatment was the same between groups. Other differences were also found in SIRS score (P=0.05) and PaO2/FiO2 (P=0.04) thus suggesting better adaption to perioperative stress. CONCLUSIONS MVATS biopsy appears to be a reliable tool to optimize diagnostic assessment in patients with mediastinal tumors. It can offer high diagnostic accuracy due to large tissue samples, while reducing morbidity rate compared to the same operation under general anesthesia. More robust evaluation is needed to define the appropriateness of MVATS in this specific clinical setting.

The complex care of severe emphysema: role of awake lung volume reduction surgery

The resectional lung volume reduction surgery (LVRS) procedure entailing nonanatomic resection of destroyed lung regions through general anesthesia with single-lung ventilation has shown to offer significant and long-lasting improvements in respiratory function, exercise capacity, quality of life and survival, particularly in patients with upper-lobe predominant emphysema and low exercise capacity. However mortality and morbidity rates as high as 5% and 59%, respectively, have led to a progressive underuse and have stimulated investigation towards less invasive surgical and bronchoscopic nonresectional methods that could assure equivalent clinical results with less morbidity. We have developed an original nonresectional LVRS method, which entails plication of the most severely emphysematous target areas performed in awake patients through thoracic epidural anesthesia (TEA). Clinical results of this ultra-minimally invasive procedure have been highly encouraging and in a uni-center randomized study, intermediate-term outcomes paralleled those of resectional LVRS with shorter hospital stay and fewer side-effects. In this review article we analyze indications, technical details and results of awake LVRS taking into consideration the available data from the literature.

Staged unilateral lung volume reduction surgery: from mini-invasive to minimalist treatment strategies

Lung volume reduction surgery (LVRS) entailing unilateral or bilateral non-anatomical resection of severely damaged emphysematous tissue carried out by thoracoscopic or open surgical approaches, under general anesthesia with single-lung ventilation, has resulted in significant and long-lasting clinical and functional benefit. Unfortunately, the morbidity rates reported by simultaneous bilateral resectional LVRS has led to raise criticism regarding its cost-effectiveness and has stimulated in recent years the development of less invasive bronchoscopic and surgical non-resectional methods of treatment that are preferentially performed in a staged unilateral fashion. We had previously proposed an innovative LVRS modality, which did not entail any resection of lung tissue and was electively carried out according to a staged unilateral strategy by a multiport thoracoscopic access, through thoracic epidural anesthesia in conscious, spontaneously ventilating patients (awake LVRS). The awake LVRS resulted in significant clinical benefit paralleling that achieved by the resectional method with lower morbidity rates and shorter hospital stay. Moreover, the awake LVRS proved also suitable to be employed in stringently selected patients to perform redo procedures following previous successful bilateral LVRS. More recently, in order to minimize the global surgery- and anesthesia-related traumas, we have modified our original non-resectional method by adopting a single thoracoscopic access as well as an anesthesia protocol entailing use of a simple intercostal block with target control sedation, to realize an ultra-minimally invasive or minimalist LVRS. Hence, a deeper investigation of the pros and cons of staged unilateral LVRS strategies as well as of the novel surgical non-resectional and redo LVRS is warranted in order to verify, the optimal strategies of treatment, which will prove to reduce the typical LVRS-related morbidity while assuring the most durable benefit in patients with advanced emphysema.

A new method of infrared-fluorescence-enhanced thoracoscopic segmentectomy

Optimal identification of the intersegmental plane can be challenging during thoracoscopic anatomical segmentectomy for lung cancer. We describe a simple new method of infrared-fluorescence-enhanced thoracoscopy with selected injection of indocyanine green into the bronchi not targeted for resection, which allows us to clearly identify the intersegmental plane in thoracoscopic segmentectomy.

Urgent awake thoracoscopic treatment of retained haemothorax associated with respiratory failure

A number of video-assisted thoracoscopic surgery (VATS) procedures are being increasingly performed by awake anesthesia in an attempt of minimizing the surgical- and anesthesia-related traumas. However, so far the usefulness of awake VATS for urgent management of retained haemothorax has been scarcely investigated. Herein we present two patients with retained haemothorax following previous thoracentesis and blunt chest trauma, respectively, who developed acute respiratory failure and underwent successful urgent awake VATS management under local anesthesia through a single trocar access.

Awake resection of solitary pulmonary nodules

The term Solitary Pulmonary Nodule (SPN) refers to a newly developed lung nodular lesion of unknown origin and up to 3 cm in diameter, which is completely surrounded by normal parenchyma without atelectasis or adenopathy. Video-Assisted Thoracic Surgery (VATS) has been increasingly advocated as an ideal approach for management of peripheral SPN due the satisfactory results and negligible morbidity rates reported with this minimal invasive surgical option. General anesthesia with one-lung ventilation has been considered mandatory to accomplish a safe operation by VATS. However, this type of anesthesia should not be considered strictly necessary to accomplish simple pulmonary resection and can be associated with several adverse effects that can increase the procedure-related morbidity with a potential negative impact on hospital stay and overall costs. We have employed VATS performed through sole thoracic epidural anesthesia in awake patients to resect undetermined lung nodules, solitary metastases and non-small-cell lung cancer in high-risk patients. Early results have been encouraging although the pros and cons of awake VATS pulmonary resections still need to be fully elucidated.

Awake videothoracoscopic treatment of pleural effusion

Pleural Effusion (PE) is a common clinical condition, which can greatly affect patients, quality of life. Etiology of PEs can be variable, although in over 70% of cases they prove to be malignant in nature. Video-Assisted Thoracoscopic Surgery (VATS) is now routinely employed for management of recurrent PE and allows a thorough exploration of the pleural cavity, accomplishment of gross multiple biopsies and, whenever required, pleurodesis to prevent recurrences. VATS is usually performed under general anesthesia although this type of anesthesia can be associated with several adverse effects, particularly in the presence of comorbidities such as advanced malignancy, cardiopathy and severe systemic diseases. For this reason, use of local anesthesia in spontaneously ventilating patients has been advocated and we also started a clinical program of VATS carried out through local or Thoracic Epidural Anesthesia (TEA) in fully awake, spontaneously ventilating patients. Awake VATS management of PE requires a single trocar access; it is easily performed and results in optimal patients tolerability, minimal hospitalization and satisfactory outcome.