Camilla Vanni

Two-stage unilateral versus one-stage bilateral single-port sympathectomy for palmar and axillary hyperhidrosis

OBJECTIVES Video-assisted thoracoscopic sympathectomy is currently the best treatment for palmar and axillary hyperhidrosis. It can be performed through either one or two stages of surgery. This study aimed to evaluate the operative and postoperative results of two-stage unilateral vs one-stage bilateral thoracoscopic sympathectomy. METHODS From November 1995 to February 2011, 270 patients with severe palmar and/or axillary hyperhidrosis were recruited for this study. One hundred and thirty patients received one-stage bilateral, single-port video-assisted thoracoscopic sympathectomy (one-stage group) and 140, two-stage unilateral, single-port video-assisted thoracoscopic sympathectomy, with a mean time interval of 4 months between the procedures (two-stage group). RESULTS The mean postoperative follow-up period was 12.5 (range: 1-24 months). After surgery, hands and axillae of all patients were dry and warm. Sixteen (12%) patients of the one-stage group and 15 (11%) of the two-stage group suffered from mild/moderate pain (P = 0.8482). The mean operative time was 38 ± 5 min in the one-stage group and 39 ± 8 min in the two-stage group (P = 0.199). Pneumothorax occurred in 8 (6%) patients of the one-stage group and in 11 (8%) of the two-stage group. Compensatory sweating occurred in 25 (19%) patients of the one-stage group and in 6 (4%) of the two-stage group (P = 0.0001). No patients developed Horners syndrome. CONCLUSIONS Both two-stage unilateral and one-stage bilateral single-port video-assisted thoracoscopic sympathectomies are effective, safe and minimally invasive procedures. Two-stage unilateral sympathectomy can be performed with a lower occurrence of compensatory sweating, improving permanently the quality of life in patients with palmar and axillary hyperhidrosis.

A Novel Technique for Laryngotracheal Reconstruction for Idiopathic Subglottic Stenosis

Idiopathic subglottic stenosis is the most challenging condition in the field of upper airway reconstruction. We describe a successful novel technique for enlarging the airway space at the site of the laryngotracheal anastomosis in very high-level reconstructions.

Does a Multimodal No-Compression Suture Technique of the Intercostal Space Reduce Chronic Postthoracotomy Pain? A Prospective Randomized Study

Introduction: Chronic postthoracotomy pain is a significant adverse outcome of thoracic surgery. We evaluated with a prospective randomized trial the effect of a multimodal no‐compression suture technique of the intercostal space on postoperative pain occurrence in patients undergoing minithoracotomy. Methods: Patients undergoing a muscle‐sparing lateral minithoracotomy for different thoracic diseases were randomly divided into two groups: 146 patients received intercostal muscle flap harvesting and pericostal no‐compression “edge” suture (the IMF group), and 151 patients received a standard suture technique associated with an intrapleural intercostal nerve block (the IINB group). Pain scores and interference of pain with daily activities were assessed by using the Italian version of the Brief Pain Inventory on day 1, and at 1 to 6 months postoperatively. The results of pulmonary function tests (spirometry and the 6‐minute walking test) were evaluated preoperatively and at 1 and 6 months postoperatively. Results: Postthoracotomy pain scores throughout the first postoperative day were significantly lower in the IMF group. After 1 and 6 months, patients in the IMF group had a significantly lower average pain score (p = 0.001). There were no significant differences in pain interference scores at each evaluation time point in either group. However, differences were shown in lung function test results at 1 and 6 months postoperatively (the forced expiratory volume in 1 second in the IINB group averaged 68.8 ± 17.4% of predicted value and 72.8 ± 10.5%, respectively, and in the IMF group it averaged 83.1 ± 7.4% and 86.4 ± 12.8%, respectively [p = 0.023 and 0.013, respectively]; the 6‐minute walking test results in the IINB group averaged 311.1 ± 51.0 and 329.9 ± 54.8 m, respectively, and those in the IMF group averaged 371.2 ± 54.8 and 395.7 ± 56.4 m, respectively [p = 0.0001]). Conclusions: The multimodal no‐compression suture technique is a rapid and feasible procedure that reduces the intensity of early and chronic postthoracotomy pain.

Critical tracheal stenosis caused by mediastinal lipomatosis: Long-term efficacy of airway stenting

Mediastinal lipomatosis is a rare benign disease caused by accumulation of mature adipose tissue within the mediastinum, generally in the anterior compartment. The occurrence of this disease is generally related to endogenous or exogenous steroid excess or to obesity. This condition is asymptomatic in most cases; however, symptoms related tomass effect may be present and aremore frequently due to lung compression. Symptoms usually include dyspnea, cough, and chest pain. Hemidiaphragm elevation, caused by paralysis of the phrenic nerve, has also been described in some cases. Critical situations such as significant tracheal compression and ventricular outflow obstruction have been reported as anecdotal findings in the literature. We report here the exceptional case of a patient with severe tracheal stenosis caused by huge mediastinal lipomatosis who was effectively treated with airway stenting.

Superior Vena Cava Replacement for Thymic Malignancies

BACKGROUND Advanced-stage thymic tumors infiltrating the superior vena cava (SVC), when radically resectable, can be surgically treated by SVC prosthetic replacement within a multimodality therapeutic approach. We hereby present our series of patients undergoing SVC resection and prosthetic reconstruction for stage III or IV thymic malignancies. METHODS Between 1989 and 2015, 27 patients with thymic tumors (21 thymoma, 6 thymic carcinoma) infiltrating the SVC underwent radical resection with a SVC prosthetic replacement by a bovine pericardial conduit in 12 cases, a polytetrafluoroethylene conduit in 13, a porcine pericardial conduit in 1, and a saphenous vein conduit in 1. All the patients underwent vascular conduit reconstruction by the cross-clamping technique. RESULTS Six patients were myasthenic. All resections were complete (R0). Twelve patients received induction treatment. Pulmonary resection was associated in 16 patients (11 wedge, 5 pneumonectomy). Twenty-two patients were Masaoka stage III and 5 were stage IVa. Mortality rate was 7.4%; no mortality was related to the vascular reconstruction. Major complication rate was 11.1%. At a median follow-up of 58 (range, 4 to 134) months, recurrence occurred in 9 (36%) patients. Three- and 5-year overall survival rates were 80% and 58.1%, respectively. Three-and 5-year cancer-specific survival were 90.5% and 75.4%. Cancer-specific survival rates of thymoma patients at 5 years were 93.8%. Five-year cancer-specific survival of all stage III patients was 77.1%. Thymic carcinoma histology was a negative prognostic factor. Long-term patency of the pericardial conduits was 100%. CONCLUSIONS En bloc resection and conduit reconstruction of the SVC is a good option to allow radical resection of locally advanced thymic tumors. A heterologous pericardial conduit represents the favorite option in our experience.

Laryngotracheal resection for benign stenosis

Surgical treatment of benign subglottic stenosis encases a current therapeutic trouble. The need to achieve a complete resection with respect to recurrent nerves and proximity of the anastomosis to the vocal cords are the main technical issues. Interventional endoscopic treatments play a limited role in this setting due to the high rate of recurrences requiring repeated procedures. Surgical resection and reconstruction with primary anastomosis represent the curative treatment of choice for most subglottic strictures, allowing definitive and stable high success rate on long-term. Technical aspects and surgical results are discussed in the present review.

Surgical wound-site inflammation: video-assisted thoracic surgery versus thoracotomy

OBJECTIVES Mechanical trauma occurring during pulmonary resection through both video-assisted thoracic surgery (VATS) or thoracotomy causes profound alterations in cytokines and the cellular network. The aim of this study was to analyse biological changes occurring in both the microenvironment (wound site) and macroenvironment (systemic circulation) following pulmonary lobectomy via the VATS or thoracotomic approach. METHODS From October 2016 to July 2017, 30 patients with clinical Stage I lung cancer were recruited. In 12 cases (the VATS group), surgery was performed through a video-assisted thoracoscopic approach and in 15 cases (the thoracotomy group) through a muscle-sparing minithoracotomy. Following the skin incision, the wound was irrigated with a saline solution (20 ml) and then collected. After the pulmonary resection, the surgical incision was re-irrigated. The number of polymorphonuclears, granulocytes and lymphocytes in the fluids was determined by the fluorescence activated cell sorting (FACS) analysis. Cytokine profiles of interleukin (IL)-6, tumour necrosis factor (TNF)-α, IL-1 and IL-8 from sera and fluids were detected by the enzyme linked immunosorbent assay (ELISA) assay. Functional results were evaluated through spirometry, and pain was assessed using the visual analogue scale. RESULTS In the postoperative fluids of the VATS group, fewer polymorphonuclears were seen compared to the thoracotomy group (P = 0.001), as well as a decreased percentage of granulocytes (P = 0.01) and a parallel increased lymphocytes fraction (P = 0.001). Only the systemic IL-1β levels were significantly lower in postoperative sera of the VATS group (P = 0.038). No differences were observed regarding other cytokines. CONCLUSIONS The local microenvironment during VATS differs from that of thoracotomy by not producing the same inflammatory phenotype. The clinical efficacy of a less invasive surgical approach is confirmed by a reduced inflammation of the systemic and local districts.

Reimplantation of the upper lobe bronchus after lower sleeve lobectomy or bilobectomy: long-term results

OBJECTIVES The advantages of a bronchial sleeve resection are well established. A clear majority of reported cases are of upper lobe sleeve resection. Reimplantation of the upper lobe bronchus after a lower sleeve lobectomy or bilobectomy (the so-called Y-sleeve resection) is infrequent. Related technical peculiarities are the main issues. We present our experience and results in this setting. METHODS Between 1989 and 2015, we performed 28 Y-sleeve resections of the left lower lobe (n = 18) or right middle and lower lobes (n = 10). The lung-sparing reconstructive operation was performed for non-small-cell lung cancer in 23 cases, for bronchial carcinoid tumour in 4 cases and for a cystic adenoid carcinoma in 1 case. Anastomotic reconstruction was performed by interrupted 4-0 absorbable sutures (monofilament material). RESULTS All the resections were complete (R0). Postoperative mortality was 3.6%. The rate of major complications was 10.7% (1 myocardial infarction, 1 anastomotic stenosis requiring dilatation and 1 anastomotic fistula). Among the 23 patients with non-small-cell lung cancer (18 men and 5 women; mean age 58 ± 12 years), 8 were Stage I, 9 were Stage II and 6 were Stage IIIa. At a mean follow-up of 46 months, the recurrence rate was 32%. There were 2 loco-regional recurrences. No endobronchial or perianastomotic recurrence occurred. The 3- and 5-year overall and disease-free survival rates of patients with non-small-cell lung cancer were 76.3% and 55.1% and 68.7% and 62.9%, respectively. CONCLUSIONS A Y-sleeve resection with reimplantation of the upper load bronchus is a technically feasible and oncologically adequate operation.

Long-segment pulmonary artery resection to avoid pneumonectomy: long-term results after prosthetic replacement

OBJECTIVES Resection of a long pulmonary artery (PA) segment infiltrated by tumour and reconstruction by conduit interposition or wide patch is a challenging but feasible option to avoid pneumonectomy. Our goal was to report the long-term results of our experience with this type of operation using various techniques and materials. METHODS Between 1991 and 2015, 24 patients underwent sleeve resection of a long PA segment or extended resection (>2.5 cm) of 1 aspect of the circumference of the PA associated with lobectomy for centrally located lung cancer. Materials used for conduit reconstruction (20 patients) included pulmonary vein in 12 patients, autologous pericardium in 4, porcine pericardium in 3 and bovine pericardium in 1. Patches used in 4 patients consisted of porcine pericardium (2 patients) and pulmonary vein (2 patients). RESULTS Twenty-three patients underwent left upper lobectomy without associated bronchoplasty. One patient underwent bronchovascular left upper sleeve lobectomy. The postoperative morbidity rate was 29.1%. No complications related to the reconstructive procedure occurred. There were no postoperative deaths. Complete patency of the reconstructed PA was shown in all patients by postoperative contrast computed tomography performed every 6 months. Pathological tumour stage ranged from I to IIIA. Five-year overall survival and disease-free survival rates were 69.9% and 52.7%, respectively, at a median follow-up of 41 months. CONCLUSIONS Resection of the long PA segment followed by conduit or wide patch reconstruction is a feasible, safe and effective option to avoid pneumonectomy. Different biological materials can be used to provide adequate tissue characteristics; the choice is made on a case-by-case basis. Long-term results confirm the oncological reliability of this operation.

Transition from multiple-port to single-port video-assisted thoracic surgery pulmonary lobectomy: a technical evolution?

Minor and major anatomic pulmonary resections performed by a video-assisted thoracoscopic approach have been proved to be safe and feasible as demonstrated from the first multi portal video-assisted thoracic surgery (VATS) experiences published in early 1990s.