Eugenio Pompeo

Reduction pneumoplasty versus respiratory rehabilitation in severe emphysema: a randomized study

BACKGROUND The purpose of the study was to determine in a prospective randomized trial the independent short-term physiologic impact of reduction pneumoplasty (RP) on respiratory rehabilitation (RR). METHODS Sixty patients eligible for RP were randomly selected by computer to receive either RP (n = 30) or comprehensive RR (n = 30). Pulmonary function tests, analysis of blood gas levels, measurement of respiratory muscle strength (maximal inspiratory and expiratory pressures), 6-minute walk test (6MWT), and incremental treadmill test (ITT), were performed at baseline and at 3 and 6 months. RESULTS Two treatment-related deaths occurred after RP and one after RR. At 6 months dyspnea index, maximal inspiratory pressure, 6MWT, ITT, and PaO2 were significantly improved in both groups whereas forced expiratory volume in 1 second and residual volume were significantly improved only in the surgical arm. In addition at 6 months, dyspnea index, 6MWT, maximal ITT, and PaO2 improved significantly more after RP than after RR. CONCLUSIONS In our study short-term improvements in dyspnea index, oxygenation, inspiratory muscle strength, and exercise capacity occurred after either RP and RR. However dyspnea index, PaO2, and exercise capacity improved more after RP than after RR whereas pulmonary function improved only after RP.

Thoracoscopic thymectomy in autoimmune myasthenia : Results of left-sided approach

BACKGROUND We undertook to analyze the results of video-assisted thoracoscopic thymectomy through a left-sided approach in patients with autoimmune myasthenia. METHODS Between 1993 and 1997, 31 patients underwent thoracoscopic thymectomy by a uniform left-sided approach. There were 8 men and 23 women with a mean age of 34 +/- 12 years. RESULTS Preoperative duration of disease was 14.8 +/- 11 months. There were no operative deaths or major complications. The mean hospital stay was 5.2 +/- 2.8 days. Mean follow-up was 39.6 +/- 15 months and was 100% complete. At 48 months, remission and improvement rates were 36% and 96%, respectively. Shorter duration of symptoms (< 12 months) correlated with improved outcome (13 of 13 patients versus 10 of 14 patients; p = 0.036). Age, sex, Osserman class, corticosteroid therapy, presence of ectopic thymic tissue, and temporary postoperative symptom increase (deterioration) did not affect outcome. CONCLUSIONS Thoracoscopic thymectomy facilitated the goal of early thymectomy. Through a left-sided approach, improvement or remission was achieved in more than 95% of the patients. Thoracoscopic thymectomy should be considered a valid less invasive alternative to the most radical open approaches.

The impact of cardiovascular comorbidity on the outcome of surgery for stage I and II non-small-cell lung cancer

OBJECTIVE The association between lung malignancy and cardiovascular disease has been frequently reported though its therapeutic and prognostic implications not thoroughly analyzed. This study aims at assessing the possible impact of coexisting cardiovascular disease on the outcome of surgical treatment of non small cell lung cancer (NSCLC). METHODS Among 247 consecutive patients undergone surgery for stage I and II NSCLC between 1990 and 1997, 34 (13.7%) had a cardiovascular comorbidity going to be treated by surgery, namely coronary artery disease (n=14), carotid stenosis (n=21), abdominal aortic aneurysm (n=9) and lower limbs arteriopathy (n=7). Among 22 patients (64.7%) who underwent cardiac/vascular surgery first, operation was performed after a median interval of 4.5 weeks. In five of this subset lung cancer was incidentally detected. In the other patients the cardiovascular disease was diagnosed and treated after the lung cancer had been detected and operated with a median interval of 3.5 months from thoracic procedure. Surgical procedures for lung cancer were three pneumonectomies, 12 lobectomies, 19 wedge resections. Uni and multivariate analysis for risk factors was carried out. RESULTS In the group with cardiovascular comorbidity overall postoperative mortality was 9%, while morbidity rate was 58.8%, both of them primarily caused by cardiovascular disease and significantly higher for major resections. The 3- and 5-year survival rates were 54.8% and 35.5% compared to 69.2% and 56.4% among patients without cardiovascular comorbidity (P=0.01) while the timing of vascular surgery (before or after thoracic procedure) did not significantly affect survival. Multifocal vascular disease resulted the only positive factor at multivariate analysis (P=0.005, Odd Ratio=3.51, 95% Confidence Interval=1.4-8.4). CONCLUSIONS Cardiovascular disease seems to have significant impact on survival and morbidity in patients undergone surgery for lung cancer, especially in presence of multifocal vascular disease and following major resections. The timing of vascular surgery and the extension of resection should rely on the severity of vascular disease, anaesthesiologists and surgeons final evaluation.

Awake Nonresectional Lung Volume Reduction Surgery

Objective:To assess the feasibility, safety, and early results of awake lung volume reduction surgery (LVRS) performed under thoracic epidural anesthesia by a new nonresectional technique. Summary Background Data:So far, resectional LVRS under general anesthesia and one-lung ventilation is the more frequently used technique, but procedure-related morbidity has been considerable. Methods:The study cohort included 12 patients undergoing unilateral awake LVRS. Evaluated parameters included technical feasibility and anesthesia satisfaction scored into 4 grades (from 1 = poor to 4 = excellent), global operating room time, and arterial carbon dioxide tension (PaCO2). In addition, 6-month changes in outcome measures, including forced expiratory volume in 1 second (FEV1), residual volume (RV), 6-minute walking test (SMWT), and dyspnea index were recorded. Perioperative and 6-month results were comparable with those of a control group undergoing unilateral resectional LVRS. Results:Technical feasibility was excellent to satisfactory in 11 patients. One patient required conversion to one-lung ventilation. Differences between the awake and control group included global operating room time (90 ± 17 minutes versus 145 ± 19 minutes, P < 0.00001); PaCO2 24 hours after surgery (45 ± 6 mm Hg versus 49 ± 6 mm Hg, P = 0.02); and hospital stay (7.8 ± 5 days versus 11.7 ± 4 days, P = 0.02). Significant (P < 0.002) improvements occurred at 6 months in FEV1 (0.31 ± 0.17 L), RV (−1.41 ± 0.7 L), SMWT (73 ± 25 m), and dyspnea index (−1.3 ± 0.5) and were comparable with those of the control group. Conclusions:In this study, awake nonresectional LVRS proved feasible and safe. This new modality was associated with a faster recovery and satisfactory 6-month outcome, which did not differ from that of resectional LVRS.

Awake video-assisted pleural decortication for empyema thoracis

OBJECTIVE To evaluate feasibility, technical features and results of video-assisted pleural decortication for empyema thoracis performed in awake patients. METHODS This retrospective analysis involved a cohort of 19 patients (median age: 58 years) undergoing awake video-assisted thoracoscopic pleural decortication under epidural anaesthesia (N=15) or paravertebral blocks (N=4) between March 2004 and September 2008. Baseline and perioperative data including degree of postoperative lung re-expansion at 48 h, hospital stay, morbidity rate and daily fluid loss were recorded. In addition, intra- and perioperative changes in main pathophysiological variables PaO(2)/FiO(2) ratio, PaCO(2), mean arterial pressure and heart rate were analysed. RESULTS Origin of the empyema was parapneumonic (N=14), post-traumatic (N=3) and cancer related (N=2). All patients underwent previous conservative management. The duration of the symptoms averaged 35 days (quartile range (QR): 28-40). Co-morbidities included chronic obstructive pulmonary disease (COPD) (N=4), HIV infection (N=1), diabetes mellitus (N=2) and cirrhosis (N=1). Operation was performed videothoracospically in 15 patients whereas four patients with major pleural thickening underwent awake lateral thoracotomy. Operative time averaged 50 min (QR: 40-70). Perioperative data analysis showed no intra-operative deterioration in arterial oxygenation (median-Delta: 0 mm Hg, QR: -5/+9, P=0.6). Transient permissive hypercapnia (<55 mm Hg) developed in three patients with no need of conversion to general anaesthesia. Median pain level assessed by a visual analogue score (VAS) 1h postoperatively was 4 (QR: 2-5), and it was significantly reduced on postoperative day 1 (median 3, QR: 2-4, P=0.03). There was neither mortality nor major morbidity. Hospitalisation averaged 6 days (QR: 5-7). At postoperative chest X-ray, lung re-expansion was rated as complete in 16 patients, satisfactory in (>80%) two patients and unsatisfactory in a 86-year-old patient with pleural mesothelioma who has the chest drain still in place 5 months after surgery. No patient had recurrence of the empyema at subsequent follow-ups. CONCLUSIONS In our study, awake video-assisted pleural decortication proved feasible and resulted in satisfactory lung re-expansion in 95% of the patients. We hypothesise that spontaneous ventilation facilitated both identification of the correct plane and dissection, thus resulting in lesser surgical injury on the underlying lung.

Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis.

To facilitate initial visualization and subsequent mobilization of the thymus, adjuvant pneumomediastinum was preoperatively induced in 4 patients who underwent video-assisted thoracoscopic thymectomy. Neither mortality nor technique-related morbidity was observed. This experience shows video-assisted thoracoscopic thymectomy to be a safe and reliable procedure. In addition, we believe that adjuvant pneumomediastinum seems to facilitate the dissection maneuvers and could shorten operative time.

Transxiphoid video-assisted pulmonary metastasectomy: Relevance of helical computed tomography occult lesions

BACKGROUND The new transxiphoid video-assisted approach allows manual palpation of both lungs, thus permitting better evaluation of helical computed tomography (CT) in detection of pulmonary metastases. METHODS From December 1995 to May 1999, 22 patients underwent a transxiphoid video-assisted pulmonary metastasectomy. Manual palpation of both lungs was possible in 18 patients, whereas only 13 had radiologic evidence of unilateral disease. Primaries were colon-rectum (n = 8), kidney (n = 3), uterus (n = 2), larynx (n = 2), limb osteosarcoma (n = 2), and one each of breast, skin melanoma, prostate, fibrosarcoma, and ovary. RESULTS No perioperative death occurred. Fifty-eight lesions, 49 metastatic, were resected, whereas only 46 had been predicted by helical CT scan. Twelve occult lesions were discovered, eight of which were malignant. Overall sensitivity for proved metastases was 83.7% (41 of 49) and 75.8% (22 of 29) for those less than or equal to 5 mm. Mean follow-up was 15.27 months. Only 2 patients had pulmonary relapse at 6 and 12 months. CONCLUSIONS Despite helical CT, occult metastases may still be identified in almost one-third of the patients. The transxiphoid approach allows routine bilateral palpation and safe resection, and overcomes this critical limitation of video-assisted metastasectomy.

Randomized comparison of awake nonresectional versus nonawake resectional lung volume reduction surgery

OBJECTIVE The study objective was to assess in a randomized controlled study (NCT00566839) the comparative results of awake nonresectional or nonawake resectional lung volume reduction surgery. METHOD Sixty-three patients were randomly assigned by computer to receive unilateral video-assisted thoracic surgery lung volume reduction surgery by a nonresectional technique performed through epidural anesthesia in 32 awake patients (awake group) or the standard resectional technique performed through general anesthesia in 31 patients (control group). Primary outcomes were hospital stay and changes in forced expiratory volume in 1 second. During follow-up, the need of contralateral treatment because of loss of postoperative benefit was considered a failure event as death. RESULTS Intergroup comparisons (awake vs control) showed no difference in gender, age, and body mass index. Hospital stay was shorter in the awake group (6 vs 7.5 days, P = .04) with 21 versus 10 patients discharged within 6 days (P = .01). At 6 months, forced expiratory volume in 1 second improved significantly in both study groups (0.28 vs 0.29 L) with no intergroup difference (P = .79). In both groups, forced expiratory volume in 1 second improvements lasted more than 24 months. At 36 months, freedom from contralateral treatment was 55% versus 50% (P = .5) and survival was 81% versus 87% (P = .5). CONCLUSIONS In this randomized study, awake nonresectional lung volume reduction surgery resulted in significantly shorter hospital stay than the nonawake procedure. There were no differences between study groups in physiologic improvements, freedom from contralateral treatment, and survival. We speculate that compared with the nonawake procedure, awake lung volume reduction surgery can offer similar clinical benefit but a faster postoperative recovery.

Impact of Awake Videothoracoscopic Surgery on Postoperative Lymphocyte Responses

BACKGROUND Surgical stress and general anesthesia can have detrimental effects on postoperative immune function. We sought to comparatively evaluate postoperative lymphocytes response in patients undergoing video-assisted thoracoscopic surgery (VATS) under thoracic epidural or general anesthesia. METHODS Between October 2008 and June 2009, 50 patients with nonmalignant pulmonary conditions were randomized to undergo VATS through either sole epidural anesthesia and spontaneous ventilation (awake group, n = 25) or general anesthesia with one-lung ventilation (control group, n = 25). In both groups, assessment of total lymphocytes count and changes in proportion of lymphocyte subsets including CD19+, CD3+, CD4+, CD8+, CD4+:CD8+ ratio, and CD16+CD56+ (natural-killer cell) were evaluated by two-way analysis of variance test for repeated measures at baseline and postoperative days 1, 2, and 3. The Mann-Whitney test was performed at each time point only for significant parameters at between-group analysis of variance. RESULTS Comparisons of baseline data showed relatively homogeneous groups. Between-group analysis of variance was significant for proportion of natural-killer cells (p = 0.01). In particular, the control group disclosed a significantly lower median proportion of natural-killer cells as compared with the awake group on postoperative day 1 (5% interquartile range [IQR]: 3% to 8%] vs 12% [IQR: 8% to 14%], p = 0.003) and 2 (7% [IQR: 4% to 10%] vs 11% [IQR: 8% to 21%], p = 0.02). Total lymphocyte count was significantly decreased in the control group only (p < 0.00001). No difference was found between groups in the remaining lymphocyte subsets. CONCLUSIONS In this randomized study, awake VATS resulted in a lesser impact on postoperative lymphocyte responses than procedures performed under general anesthesia, as shown by the significant difference in postoperative proportion of natural-killer cells.

Surgical stress hormones response is reduced after awake videothoracoscopy

This study was undertaken to assess stress hormones response after awake videoassisted thoracoscopic surgery (VATS). Plasma levels of adrenal-corticotropic hormone (ACTH), cortisol, epinephrine, norepinephrine, and glucose were assessed at baseline, 3 h postoperatively (T1), and on postoperative mornings 2 (T2) and 3 (T3) in 21 patients undergoing awake VATS with epidural anesthesia for non-malignant conditions (n=11) or equivalent procedures performed with general anesthesia. Epinephrine level peaked in both groups at T1, although significant change from baseline values occurred in the control group only [median-Delta: 6 ng/l (IQR: 4-6), P=0.005]. Cortisol level was lower in the study group at T1 (15.5 microg/dl vs. 23.0 microg/dl, P=0.001) and T2 (15.2 microg/dl vs. 19.2 microg/dl, P=0.002). In the control group, peak cortisol level proved not to be related to changes in ACTH (R=0.23, P=0.46). At T2, glucose (137 mg/dl vs. 98 mg/dl, P=0.01) and C-reactive protein (P=0.04) were higher in the control group. No other clinically relevant between-groups differences were found in aspecific acute-response factors. Overall, these preliminary findings suggest attenuated stress response after awake VATS in comparison with equivalent procedure performed under general anesthesia and one-lung ventilation.