Emanuele Russo

Extracorporeal membrane oxygenation as bridge to lung transplantation

Lung transplantation (OLT) is a viable option for end-stage pulmonary diseases in selected patients with satisfactory long-term results. However, the paucity of available donors engenders a prolonged stay on the waiting list with progressive decline of lung function. In cases of sudden respiratory failure, admission to an intensive care unit with institution of extracorporeal membrane oxygenation (ECMO) may be an option while a waiting an emergency OLT. In 12 OLT candidates we started ECMO because of acute decline of lung function. Eleven patients had cystic fibrosis and the other subject, histiocytosis X. In 7 patients bilateral OLT was performed after a mean waiting time of 6 days from ECMO institution; 5 patients died on ECMO at a mean time of 11.6 days. After OLT 2 patients required reoperation for hemothorax; renal failure and acute leg ischemia occurred in 2 patients. The mean weaning time from ECMO after OLT was 2.14 days. No patient died in the perioperative period and 1-year survival was 85.7%. ECMO represents a valid option as a bridge to urgent OLT for selected candidates.

Extracorporeal Circulatory Support for Lung Transplantation: Institutional Experience

Lung transplantation (LT) represents the only available therapy for selected patients affected by end-stage pulmonary disease. Cardiopulmonary bypass (CPBP) is used, when required, during single and sequential double lung transplantation; however, it increases the risk of bleeding, early graft dysfunction, failure, and other potential side effects. We report our experience with 145 patients who underwent lung transplantations, among whom 34 required intraoperative CPBP. The indications for LT among these 34 patients were cystic fibrosis (n = 22), chronic obstructive pulmonary disease (n = 3), bronchiectasis (n = 2), primary pulmonary hypertension (n = 1), fibrosis (n = 2), pulmonary microlithiasis (n = 1), and retransplantation for obliterative bronchilitis (n = 3). CPBP was planned in 12 cases (group I) and unplanned in 22 (group II). The main reason for planning CPBP was primary and secondary pulmonary hypertension (mean pulmonary artery pressure >or=25 mm Hg). Acute right ventricular failure, hemodynamic instability, arterial desaturation, and increased pulmonary artery pressure were mandatory for unplanned CPBP. Among the 34 CPBP patients, the 30-day mortality rate was 35% (12/34) including 9 (70%) in group II (unplanned CPBP). The leading cause of death was multiorgan failure. The 1-year survival rates were 67% and 36%, and the 3-year survival rates were 47% and 18% for groups I and II, respectively. In conclusion, even if it represents a useful tool in the management of critical events, the use of unscheduled CPBP during LT procedures is associated with an increased postoperative morbidity and mortality.

MicroRNA expression profiling of thymic epithelial tumors

BACKGROUND Thymic epithelial tumors (TET) are the most frequent human primary mediastinal tumors in adults. A deep biological characterization of the processes at the basis of the transformed phenotype could strongly improve our understanding of the morphological and clinical heterogeneity of these diseases. MicroRNAs (miRNAs) are non-coding RNAs involved in post-transcriptional regulation and their altered expression accounts for the pathogenesis of several tumors. OBJECTIVES The aim of this study was to identify the miRNAs that are differentially expressed in tumor vs normal thymic tissues or among the different tumor histotypes and that could impact on the biology of TET. MATERIALS AND METHODS microRNAs expression profiling was performed by microarray analysis of formalin-fixed paraffin embedded (FFPE) tissue from 54 thymic tumor samples and 12 normal counterparts, derived from two patient cohorts. RESULTS AND CONCLUSION We identified groups of miRNAs differentially expressed between: (i) TET and normal thymic tissues, (ii) thymomas and thymic carcinomas, (iii) histotype groups. Moreover, we identified putative molecular pathways targeted by these differentially expressed miRNAs that could be involved in thymic carcinogenesis and in the maintenance and spreading of this tumor.

Lung Transplantation for Cystic Fibrosis After Thoracic Surgical Procedures

During their life, cystic fibrosis (CF) patients may require thoracic surgical procedures for a number of reasons before undergoing lung transplantation. In the past, this has been considered to be a contraindication to lung transplantation. However, a meticulous surgical technique and careful intraoperative management allows one to perform the transplantation safely. Herein we have reported our experience with CF patients undergoing lung transplantation after previous surgical treatment for pneumothorax or bronchiectasis.

Circulating miR-21-5p and miR-148a-3p as emerging non-invasive biomarkers in thymic epithelial tumors

ABSTRACT Thymic epithelial cells give rise to both thymoma and thymic carcinoma. A crucial advance in thymic epithelial tumors (TET) management may derive from the identification of novel molecular biomarkers able to improve diagnosis, prognosis and treatment planning.In a previous study, we identified microRNAs that were differentially expressed in tumor vs normal thymic tissues. Among the microRNAs resulted up-regulated in TET tissues, we evaluated miR-21-5p, miR-148a-3p, miR-141-3p, miR-34b-5p, miR-34c-5p, miR-455-5p as blood plasma circulating non-invasive biomarkers for TET management.We firstly report that the expression levels of specific onco-miRNAs, that we found upregulated in the blood plasma collected from TET patients at surgery, resulted significantly reduced in follow-up samples.This pilot study suggests that circulating miR-21-5p and miR-148a-3p could represent novel non-invasive biomarkers to evaluate the efficacy of therapy and the prognosis of TET.

Lung transplantation for cystic fibrosis: Outcome of 101 single-center consecutive patients

Bilateral sequential lung transplantation (BSLT) is nowadays considered a valid therapeutic option for patients with end stage cystic fibrosis. We report our experience with 104 BSLTs in 101 patients. The overall survivals at 1, 3, 5, 10 years were 79%, 65%, 58%, and 42%, respectively. Perioperative mortality was 14.8% (n = 15). The leading causes of perioperative mortality were primary graft dysfunction and sepsis. Three patients were retransplanted owing to obliterative bronchiolitis. In 70 cases (69%), patients displayed ≥ 1 additional risk factors: previous lung resections, colonization by Burkholderia cepacia, diabetes, pneumothorax, or noninvasive ventilatory support. The mean preoperative 1-second forced expiratory volume of 0.69 ± 0.2 L (22%) increased to 85% at 1 year after the operation. The mean time on the waiting list was 12 ± 5 months. The 5 patients treated with extracorporeal membrane oxygenation before urgent transplantation were operated after 3, 5, 6, 30, and 3 days respectively. During the procedure, cardiopulmonary bypass was required in 33 patients (32%). Lung transplantation represents a unique opportunity to ameliorate the quality and improve the survival of patients affected by cystic fibrosis. Timing of referral and patient selection remain crucial for success.

Post-intubation membranous trachitis after endotracheal intubation

We read with interest the paper entitled ‘Spontaneous expectoration of an obstructive fibrinous tracheal pseudomembrane after tracheal intubation’ from Fiorelli et al .[ 1]. Membraneous trachitis is a rare complication after tracheal intubation; however, it may pose several diagnostic and therapeutic problems if misdiagnosed. In particular, both benign tracheal strictures and simple granulation may be erroneously suspected. Direct endoscopic observation may be difficult due either to the presence of the endotracheal tube in place, or, in the case of spontaneously breathing patients, to respiratory distress. Radiological evaluation with computed tomography (CT) may also be difficult for the same reasons. We have observed this complication in four patients during the last years. In all cases, the intubation time was less than a week long and the suspect of tracheal obstruction was raised on the base of difficulties to extubate the patient notwithstanding optimal functional parameters. In all patients, inexperienced endoscopists made the diagnosis of fibrous tracheal strictures; in one case, the erroneous diagnosis was confirmed at CT performed with the patient still intubated. All patients were still intubated when they were referred with the diagnosis of ‘benign postintubation tracheal stricture’ to our unit for a more careful endoscopic evaluation through the rigid bronchoscope, potential initial treatment with mechanical debridement and/or laser, and subsequent tracheal or laryngo-tracheal resection [2]. In all cases, the thick fibrous membranes required careful mechanical debridement to be removed with the tip of the rigid bronchoscope, with the patient under deep sedation and spontaneously breathing; after the removal of the pseudomembranes, a bleeding airway wall was observed. All the lesions were at the level of the tracheal tube cuff. All patients were immediately extubated. Cultures showed the presence of Candida in two cases. After 1 month, fiberoptic bronchoscopy showed complete mucosal healing. This complication should always be suspected when extubation is not possible after short periods of mechanical ventilation notwithstanding adequate functional parameters. Bronchoscopy should be performed by an experienced thoracic surgeon familiar with tracheal disorders; the rigid bronchoscope should always be available for immediate treatment. Spontaneous expectoration is extremely rare due to adhesions with the tracheal wall, as reported by Fiorelli A et al. CT evaluation is not useful.

Primary inflammatory myofibroblastic tumor of the trachea

Inflammatory myofibroblastic tumors (IMTs) are rare neoplasms that can involve the airway. Recent studies have shown their malignant behavior with local recurrence and potential metastatic spread; half of the cases are associated with anaplastic lymphoma kinase gene rearrangement. Complete surgical resection is recommended, when feasible. We present a case of a 26‐year‐old woman admitted to our institution with severe respiratory failure; she was affected with primary IMT of the trachea and underwent complete surgical resection.

Safety of lymphadenectomy during video-assisted thoracic surgery lobectomy: analysis from a national database

OBJECTIVES The Italian VATS Group database was accessed to evaluate whether preoperative and intraoperative factors may affect the safety of lymphadenectomy (LA) during video-assisted thoracic surgery lobectomy. METHODS All video-assisted thoracic surgery lobectomy procedures performed between 1 January 2014 and 30 March 2017 for non-small-cell lung cancer with cN0 or cN1 disease were identified in the database. LA safety was evaluated based on intraoperative (operative time, bleeding and conversion rate) and postoperative (30-day morbidity and mortality, chest drain duration and length of stay) outcomes and was correlated with the number of resected lymph nodes and the rates of nodal upstaging. Continuous variables were presented as mean ± standard deviation and compared using the unpaired t-test; the χ2 test was used for categorical variables. Univariable analysis was performed on selected variables. Significant variables (P < 0.30) were entered into a Cox multivariable logistic regression model, using the overall and specific occurrence of complications as dependent variables. The Spearmans rank correlation coefficient was applied as needed. RESULTS A total of 3181 cases (2077 men, 65.3%; mean age of 69 years) met the enrolment criteria. Final pathology was consistent with adenocarcinoma (n = 2262, 67.5%), squamous cell (n = 520, 15.5%), typical (n = 184, 5.5%) and atypical carcinoid (n = 48, 1.4%) and other (n = 335, 10%). The mean number of resected lymph nodes was 13.42 ± 8.24; nodal upstaging occurred in 308 of 3181 (9.68%) cases. Six hundred and fifty-five complications were recorded in 404 (12.7%) patients; in this series, no mortality was observed. Univariable and multivariable analyses did not show any association between the extension of LA and intraoperative or postoperative outcomes. The number of resected lymph nodes and nodal upstagings showed a minimal correlation with intraoperative outcomes and a moderate correlation with postoperative air leak (ρ = 0.35 and ρ = 0.48, respectively), arrhythmia (ρ = 0.29 and ρ = 0.35, respectively), chest drain duration (ρ = 0.35 and ρ = 0.51, respectively) and length of stay (ρ = 0.35). CONCLUSIONS Based on the VATS Group data, video-assisted thoracic surgery LA proved to be safe and displayed good outcomes even when performed with an extended approach.

Erratum to nodal management and upstaging of disease: initial results from the Italian VATS Lobectomy Registry

[This corrects the article DOI: 10.21037/jtd.2017.06.12.].