Cecilia Menna

Postoperative pain control: videothoracoscopic versus conservative mini-thoracotomic approach

OBJECTIVES The management of postoperative pain in thoracic surgery is an open issue. The aim of this study was to compare postoperative pain after a videothoracoscopic lobectomy versus a mini-thoracotomy approach. METHODS Between April 2011 and January 2013 we enrolled in a prospective, non-randomized study 145 patients undergoing pulmonary lobectomy with lymphadenectomy for Stage I lung cancer. In 75 cases (Group A), surgery was performed through a videothoracoscopic approach. In 70 cases (Group B), surgery was undertaken through a conservative mini-thoracotomy. Pain was assessed by visual analogue scale and lung function by spirometry and six-minute walking test (6MWT) before surgery, at 48 h and 1 month after surgery. RESULTS Patients were stratified by age, sex, lung function, type and duration of surgery. Length of hospital stay (median, days) was 4 for Group A and 6 for Group B (P = 0.088). The differences between mean postoperative pain values were significant at 1, 12, 24 and 48 h (6.24 vs 8.74, 5.16 vs 7.66, 4.19 vs 6.89 and 2.23 vs 5.33; P = 0.000). In Group A, mean preoperative forced expiratory volume in 1 second values were 2.65 ± 0.61, and 1.83 ± 0.65 and 2.09 ± 0.65, respectively, at 48 h and 1 month (P = 0.028); in Group B, they were 2.71 ± 0.71 preoperatively and 1.33 ± 0.52 and 1.82 ± 0.63, respectively, at 48 h and 1 month. In Group A, mean preoperative 6MWT values (m) were 426.85 ± 51.18, and 371.23 ± 55.36 and 392.07 ± 56.12, respectively, at 48 h and 1 month; in Group B, they were 421.76 ± 56.65 preoperatively and 312.03 ± 48.54 and 331.83 ± 47.99, respectively, at 48 h and 1 month (P = 0.000). CONCLUSIONS The videothoracoscopic approach in the treatment of Stage I lung cancer reduces postoperative pain, which seems to allow a rapid functional recovery of patients.

Axitinib Affects Cell Viability and Migration of a Primary Foetal Lung Adenocarcinoma Culture

Fetal lung adenocarcinoma (FLAC) is a rare variant of lung adenocarcinoma. Studies regarding FLAC have been based only on histopathological observations, thus representative in vitro models of FLAC cultures are unavailable. We have established and characterized a human primary FLAC cell culture, exploring its biology, chemosensitivity, and migration. FLAC cells and specimen showed significant upregulation of VEGF165 and HIF-1α mRNA levels. This observation was confirmed by in vitro chemosensitivity and migration assay, showing that only Axitinib was comparable to Cisplatin treatment. We provide a suitable in vitro model to further investigate the nature of this rare type of cancer.

Margin Distance Does Not Influence Recurrence and Survival After Wedge Resection for Lung Cancer.

BACKGROUND The relationship between the free margin distance and the recurrence rate and overall survival after R0 wedge resection for non-small cell lung cancer (NSCLC) is still not clear. We retrospectively evaluated the long-term oncologic outcome of patients who had undergone wedge resection for NSCLC to assess the prognostic effect of margin distance in this setting. METHODS Between 2003 and 2013, 243 consecutive patients with a functional contraindication to major lung resection underwent wedge resection with systematic lymph node dissection for clinical stage I NSCLC. The study enrolled 182 patients with pathologic stage I and R0 resection and divided them into three subgroups according to margin distance of less than 1 cm (n = 30), 1 to 2 cm (n = 80), and more than 2 cm (n = 72). RESULTS The histologic assessment was adenocarcinoma in 112 patients, squamous cell in 30, and other in 40. Postoperative morbidity was 18.7%, and postoperative mortality was 1.1%. The median follow-up was 31 months (range, 2 to 133 months). The locoregional (lung parenchyma, hilum, mediastinum) recurrence rate was 26.4% (n = 48). The distant recurrence rate was 11% (n = 20). Overall 5-year survival was 70.4%. Disease-free 5-year survival was 51.7%. There was no statistical difference in locoregional (p = 0.9) and distant (p = 0.3) recurrence rate and no difference in overall survival (p = 0.07) when the three groups were compared. CONCLUSIONS Wedge resection is a viable option for the surgical treatment of stage I NSCLC when lobectomy is contraindicated. The distance between the tumor and the parenchymal suture margin does not influence recurrence or the survival rate when an R0 resection is achieved.

Extensive Resections: Pancoast Tumors, Chest Wall Resections, En Bloc Vascular Resections

Infiltration by lung tumor of adjacent anatomic structures including major vessels, main bronchi, and chest wall not only influences the oncologic severity of the disease but also increases the technical complexity of surgery, requiring extended resections and demanding reconstructive procedures. Completeness of resection represents in every case one of the main factors influencing the long-term outcome of patients. Technical and oncologic aspects of extended operations, including resection of Pancoast tumors and chest wall, bronchovascular sleeve resections, and en bloc resections of major thoracic vessels, are reported in this article.

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.

The Effect of Silver Nitrate Pleurodesis after a Failed Thoracoscopic Talc Poudrage

Background. Chemical pleurodesis is the procedure of choice in the management of recurrent malignant pleural effusions (MPE). Talc is probably the most effective sclerosant, with a success rate of 80%. The aim of this study is to demonstrate the effectiveness of silver nitrate solution (SNS) pleurodesis after an unsuccessful thoracoscopic talc poudrage. Methods. Between 2011 and 2013 one hundred and nine patients with unilateral MPE underwent thoracoscopic talc poudrage. Seventeen patients who did not obtain a successful pleurodesis via thoracoscopic procedure were considered for an SNS slurry. The pleural injectate consisted of 100 mL 1% SNS with 10 mL of lidocaine (100 mg/5 mL). The SNS procedure was undertaken once and repeated with the same dose in 5 patients. Results. The duration of follow-up period was 30 days. Subjective pain was low and the same before and after SNS procedure (P value = NS). The mean daily fluid drainage was statistically different (P = 0.001) comparing values before (597.0 ± 122.8 mL) and after SNS procedure (109.1 ± 22.3 mL). After 30 days from SNS procedure recurrence of pleural effusion was observed in 2 patients (11%). Conclusions. The present study demonstrates that SNS is an effective agent for producing pleurodesis after a failed thoracoscopic talc poudrage.

Impact of Transcollation technology in thoracic surgery: a retrospective study.

OBJECTIVES This is a retrospective study to evaluate the effectiveness of Transcollation technology (TT) in reducing blood loss and improving the postoperative outcome in patients with severe pleural-parenchymal adhesions who underwent major lung resection. METHODS Between November 2010 and February 2012, TT was used to perform lysis of adhesions and dissection in 110 patients (TT Group) who underwent major lung resections via thoracotomy. Conventional electrocoagulation was used in 129 patients (EC Group). Operative time, daily drainage amount at 24, 48 and 72 h, pre- and postoperative haemoglobin levels, need for blood transfusion, intra- and postoperative air leaks and duration of chest tube placement and hospital stay were analysed. RESULTS No adverse events related to the TT system occurred, including reoperation for bleeding. The mean operating time was 95.2 ± 35.4 min in the TT Group versus 117.1 ± 73.4 min in the EC Group (P = 0.017). The mean postoperative haemoglobin level was 12.3 ± 3.9 g/dl versus the preoperative level of 13.8 ± 2.2 g/dl in the TT Group (P = 0.154) and 9.6 ± 2.8 vs 13.2 ± 2.1 g/dl in the EC Group (P = 0.001). Only 2 patients (1.8%) received postoperative blood transfusion in the TT Group vs 19 patients (14.7%) in the EC Group (P = 0.001). Intraoperative and postoperative (24 h) air leak rates were 4.7% (n = 5) and 2.8% (n = 3) in the TT Group vs 13.9% (n = 18) and 12.4% (n = 16) in the EC Group (P = 0.001), respectively. The mean duration of chest tube placement was shorter in the TT Group (4.7 ± 0.8 vs 6.8 ± 1.1 days, P = 0.013), as well as the mean hospital stay (5.3 ± 1.9 vs 7.5 ± 0.3 days, P = 0.007). CONCLUSIONS The use of TT seems to reduce haemorrhage occurrence and postoperative hospital stay after major lung resection in patients with severe pleural-parenchymal adhesions.

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.

Intraoperative bronchial stump air leak control by Progel® application after pulmonary lobectomy

Diffuse tracheobronchial calcification is a physiological condition associated with advanced age, especially in women. A calcified bronchus can be fractured during major lung resections (lobectomy, bilobectomy, and pneumonectomy), exposing patients to intraoperative air leakage and broncho-pleural fistula (BPF) occurrence. We retrospectively evaluated the use of Progel® application on the suture line of bronchial stump after pulmonary lobectomy analysing the intraoperative air leak and BPF occurrence. Between January 2014 and December 2014, Progel® was applied in 11 patients who presented intraoperative bronchial fractures after suture resection by mechanical staplers and air leak from bronchial stump, in order to treat air leakage. Patients were 7 men and 4 women, aged between 56 and 81 years (mean age 71.2 ± 12.1 years). Surgical procedures included 6 upper lobectomies (4 right, 2 left), 1 bilobectomy and 4 lower lobectomies (3 right, 1 left). Mean hospital stay was 4.5 ± 2.6 days (2-8 days). None of the patients had postoperative air leakage. No Progel® application-related complications occurred. No other major complications occurred. No mortality occurred. Progel® proved to be useful in treating intraoperative air leakage during major lung resections, particularly those occurring as a result of fracture of the bronchus from a mechanical stapler.

Short-term one-lung ventilation does not influence local inflammatory cytokine response after lung resection

Background One-lung ventilation (OLV) is a ventilation procedure used for pulmonary resection which may results in lung injury. The aim of this study was to evaluate the local inflammatory cytokine response from the dependent lung after OLV and its correlation to VT. The secondary aim was to evaluate the clinical outcome of each patient. Methods Twenty-eight consecutive patients were enrolled. Ventilation was delivered in volume-controlled mode with a VT based on predicted body weight (PBW). 5 cmH2O positive end-expiratory pressure (PEEP) and FiO2 0.5 were applied. Bronchoalveolar lavage (BAL) was performed in the dependent lung before and after OLV. The levels of pro-inflammatory interleukins (IL-1α, IL-1β, IL-6, IL-8), tumor necrosis factor alpha (TNFα), vascular endothelial growth factor (VEGF), endothelial growth factor (EGF), monocyte chemoattractant protein-1 (MCP-1) and anti-inflammatory cytokines, such as interleukins (IL-2, IL-4, IL-10) and interferon (IFN-γ), were evaluated. Subgroup analysis: to analyze the VT setting during OLV, all patients were ventilated within a range of 5-10 mL/kg. Thirteen patients, classified as a conventional ventilation (CV) subgroup, received 8-10 mL/kg, while 15 patients, classified as a protective ventilation (PV) subgroup, received 5-7 mL/kg. Results Cytokine BAL levels after surgery showed no significant increase after OLV, and no significant differences were recorded between the two subgroups. The mean duration of OLV was 64.44±21.68 minutes. No postoperative respiratory complications were recorded. The mean length of stay was for 4.00±1.41 days in the PV subgroup and 4.45±2.07 days in the CV group; no statistically significant differences were recorded between the two subgroups (P=0.511). Conclusions Localized inflammatory cytokine response after OLV was not influenced by the use of different VT. Potentially, the application of PEEP in both ventilation strategies and the short duration of OLV could prevent postoperative complications.