C. Ricci

Technique to reduce air leaks after pulmonary lobectomy

OBJECTIVEnPatients undergoing pulmonary resections often present postoperative air leaks of varying magnitude and duration; this complication is more frequent with incomplete or absent interlobar fissures. Small leaks close spontaneously within 5-7 days; larger leaks may persist longer and could be associated with increased morbidity and prolonged hospitalization. We evaluated the role of different techniques to complete interlobar fissures before pulmonary lobectomy to prevent postoperative air leaks and reduce hospital stay and costs.nnnMETHODSnA total of 30 patients undergoing pulmonary lobectomy for lung cancer and presenting incomplete interlobar fissures that needed to be opened both anteriorly and posteriorly were randomized into three groups. In Group I, fissures were created with a GIA stapler and buttressed with bovine pericardial sleeves. In Group II, we used TA 55 staplers alone; in Group III we used the old fashion cautery, clamps and silk ties. The three groups were homogeneous for age, type of pulmonary resection and stage of the tumor. The duration of postoperative air leaks and hospital stay were compared with the one-way variance analysis.nnnRESULTSnPostoperative air leaks for Groups I, II and III persisted for 2 +/- 0.94, 5.3 +/- 2 and 5.3 +/- 1.7 days, respectively. Mean hospital stay was 4.4 +/- 0.96, 7.8 +/- 2.14 and 7.2 +/- 1.5, respectively. The difference between groups in terms of duration of postoperative air leaks and hospital stay was statistically significant (P = 0.0001).nnnCONCLUSIONSnThe use of GIA staplers and pericardial sleeves to complete interlobar fissures for pulmonary lobectomy significantly reduces the duration of postoperative air leaks and hospital stay; no complications were associated with this technique.

Video-assisted thoracoscopic treatment of giant bullae associated with emphysema

OBJECTIVEnSurgical 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.nnnMETHODSnTwenty-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.nnnRESULTSnNo 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 Students 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.nnnCONCLUSIONSnOur 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.

Intrathoracic lobe of the liver: case report and review of the literature

A case of a heterotopic intrathoracic lobe of the liver connected through a normal diaphragm to the main organ by a vascular and biliary pedicle is described. Eight similar cases reported in the literature are reviewed and a comparative evaluation is undertaken to elucidate the correct clinical diagnosis and the indications for operative exploration. Because the occurrence of ectopic supradiaphragmatic hepatic tissue should be considered, it is believed that the preoperative evaluation of a solid, smooth lump in the diaphragmatic region should include gallium liver scans prior to invasive procedures.

382 Is primary surgery for N2 non small cell lung cancer (NSCLC) still justified

37.0%, 47.1% in resected cases. Especially, improvement in resected cases was marked. Analysis of resected cases resulted in increase of cases detected by mass survey, cases of early stage, cases of adenocarcinoma of peripheral type, and cases of female. The proportions of stage I lung cancer in cases detected by mass survey were increasing as 36.7%, 47.3%, 49.0%, 52.0% in group A to D, so mass survey seemed to contribute to early detection of lung cancer. It was also important that accurate diagnosis of staging became possible by the progress of diagnostic technology such as CT and MRI. In conclusion, the result of treatment for lung cancer in the Natronal Chest Hospitals in Japan have been improving because of increase of early cases detected by mass survey. However, the proportion of cases found by mass survey is less than 30% even lately, and it is a problem left in the future that more than half of lung cancer patients are still discovered through their subjective symptoms. We conclude that N2 NSCLC can be effectively treated by primary surgery if radical resection can be performed. We believe that CT-negative patients can procede to resection without further invasive staging. Mediastinoscopy may screen out unsuspected N2 disease and shift the patient to neoadjuvant treatment. The latter can however hardly offer the 40% 5 year survival rate which we have obtained by primary surgery. CT-positive patients should not be denied primary surgery if the primary tumor and the N2 lymphnodes are resectable. Invasive staging (mediastinoscopy, thoracoscopy) and careful screening of clinical N2 may markedly reduce non radical procedures. Nevertheless, when the resection is deemed radical, primary surgery can offer good long term survival.

Report of a case of video-assisted thoracoscopic resection of bronchogenic cyst developed in the aorto-pulmonary window.

We report the case of a 28-years-old male with a bronchogenic cyst developed in the aorto-pulmonary window. Left video-assisted thoracoscopy was performed and the cyst was removed intact and completely. Operative time was 48 minutes. The postoperative course was uneventful and the patient was discharged on the third postoperative day. We believe that an uncomplicated mediastinal bronchogenic cyst can be successfully approached by video-assisted thoracoscopy. In the case of an intraparenchymal or complicated cyst, thoracoscopic resection can be technically difficult and hazardous, and open approach is preferable.