Federico Varoli

Major pulmonary resections: pneumonectomies and lobectomies.

We report on our experience in 20 patients who underwent major thoracoscopic pulmonary resections between October 1991 and November 1992. These consist of 2 left pneumonectomies, 17 lobectomies, and 1 segmentectomy. The indications were strictly limited to benign pulmonary diseases and stage I (TNM) primary lung cancer. A hilar lymphadenectomy was performed in all cases of malignancy. Our surgical technique is described. Our findings demonstrate the feasibility of performing major video-assisted thoracoscopic pulmonary resections, even though the definite role of this procedure in the management of lung cancer must still be defined.

Videothoracoscopic staging and treatment of lung cancer.

Videothoracoscopy, routinely performed as the initial step of an operation, opens interesting opportunities for both the operative staging and treatment of lung cancer. Videosurgical maneuvers ensure thorough exploration of the cavity, thus avoiding unnecessary exploratory thoracotomies, confirming resectability of the lesion by open or, in selected cases, by a direct video-assisted approach. We report our experience of 155 patients submitted to videothoracoscopic operative staging between October 1991 and January 1994. Videothoracoscopic operative staging showed unresectability in 13 patients (8.3%) due to preoperatively unexpected (10 patients) or suspected conditions (3 patients). The remaining 142 patients were divided by staging of the lesion and general conditions into three groups. Group A consisted of 13 elderly patients with small peripheral tumor who could not tolerate lobectomy and who underwent thoracoscopic wedge resection. Group B consisted of 63 patients with peripheral clinical T1 N0 or T2 N0 tumor. Fifty-two lobectomies and 4 pneumonectomies were carried out thoracoscopically. Seven conversions to thoracotomy were necessary due to technical problems. The postoperative course was uneventful in 51, 5 had prolonged air leakage, and a bronchial fistula developed in 1 because of positive-pressure postoperative ventilation. Group C consisted of 66 patients with stage II or IIIa neoplasm. Thoracotomy after thoracoscopy proved unresectability in 4, whereas 62 were submitted to a radical pulmonary resection. In the literature the incidence of exploratory thoracotomies for conditions missed by preoperative staging still remains high. After adoption of videothoracoscopic operative staging we reported a 2.6% exploratory thoracotomy rate.(ABSTRACT TRUNCATED AT 250 WORDS)

State of the art in thoracoscopic surgery: A personal experience of 2000 videothoracoscopic procedures and an overview of the literature

BackgroundHerein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable.MethodsBetween June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n=910), wedge resections (n=261), lobectomies (n=221), pneumonectomies (n= 6) the diagnosis and treatment of pleural diseases (n=200), the treatment of pneumothorax (n=170), giant bullae (n=57), lung volume reduction surgery (LVRS) for emphysema (n=41), the diagnosis and treatment of mediastinal diseases (n=133), the treatment of esophageal diseases (n=39), and 30 other miscellaneous procedures.ResultsA review of the literature indicates that video-thoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications.ConclusionsAlthough we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.

Endoscopic Treatment of Bronchopleural Fistulas

BACKGROUND Bronchial fistula is one of the most serious complications of pulmonary resection. METHODS We present an endoscopic treatment that consists of multiple submucosal injections of polidocanol-hydroxypoliethoxidodecane (Aethoxysklerol Kreussler) on the margins of the fistula using an endoscopic needle inserted through a flexible bronchoscope. RESULTS From 1984 to 1995, 35 consecutive nonselected patients with a postresectional bronchopleural fistula were treated. All 23 partial postpneumonectomy or postlobectomy bronchopleural fistulas, ranging from 2 to 10 mm in diameter, healed completely. This did not occur in the 12 total bronchial dehiscences. No complications occurred due to the injection of the drug. CONCLUSIONS In our opinion this treatment can be considered a valid therapeutic approach, as it is simple, safe, scarcely traumatic, and inexpensive, particularly considering that, in patients in stable condition, it can be performed as an outpatient treatment.

Major vascular injuries in laparoscopic surgery

Background: Major vascular injuries (MVI) still occur in laparoscopic surgery. Methods: We report our institutions experience of two MVI (aortic lesions) in a series of 3545 laparoscopies (July 1991–December 2000). We compared this experience with other series reporting MVI from Medline, Embase, Current Contents, and Best Evidence. Results: There were no deaths, but we had 23 postoperative and eight intraoperative bleedings, including two hepatic vessel lesions during dissection and six vascular lesions (four minor vessels and two aortic) related to trocar insertion. Prevention and treatment options are also discussed. Conclusions: The incidence of MVI reported in the literature is 0.05%, but the true incidence is difficult to estimate because results are not always comparable and there is a possibility of underreporting. The mortality rates (8–17%) are high. No technique or instrumentation is completely safe; therefore, a high level of alertness must be maintained at all times and precautions must be adopted to avoid major complications.

Primary pulmonary tumours of neurogenic origin.

Primary intrapulmonary neurogenic tumours are extremely rare. In a series of 1664 patients with pulmonary neoplasms observed during 1967-80 only four such tumours were identified (0.2%). All four patients underwent surgical excision. The histological diagnosis was benign neurilemmoma in three cases and malignant schwannoma in the fourth. The patients with neurilemmoma are alive and well four to 12 years after surgery, but the patient with malignant schwannoma died from metastatic spread of the tumour four months after surgery. No association with von Recklinghausens disease was observed. Macroscopic and microscopic features generally lead to a correct diagnosis in benign types, but the histological diagnosis of malignant schwannoma may present some difficulties and requires the establishment of a definite origin in a nervous structure, identification of benign neurofibroma in different areas of the same tumour, and a high density of cells with appreciable pleomorphism, with mitosis and atypia. Benign tumours carry a good prognosis with little tendency to recur, but malignant schwannoma has a high invasive tendency and is associated with a low survival rate.

Videothoracoscopic treatment of oesophageal leiomyoma

BACKGROUND Oesophageal leiomyomas are usually so easily removed that thoracotomy seems out of proportion and thoracoscopic removal is therefore highly desirable. METHODS Out of a total of 1003 thoracoscopic operations undertaken between July 1991 and December 1996, seven patients underwent thoracoscopic removal of oesophageal leiomyoma. All of them had been preoperatively studied by oesophagogastroscopy and computed tomographic scanning of the chest which had confirmed the presence of a lesion with benign features. The surgical technique required intubation with a double lumen tube. Operative access was gained through the right chest via three ports and a small utility thoracotomy in the inframammary sulcus. The mean operating time was 120 minutes. RESULTS Conversion to open thoracotomy was necessary in one case with a very large horseshoe-shaped leiomyoma which was firmly adherent. The mean postoperative hospital stay was seven days. No intraoperative deaths or postoperative complications occurred. CONCLUSIONS The simplicity and safety of the thoracoscopic approach, combined with reduced surgical trauma and postoperative pain and functional and cosmetic advantages, make this technique the approach of choice for the removal of oesophageal leiomyomas.

Management of solitary pulmonary nodule

OBJECTIVES The pulmonary nodule is an important diagnostic and therapeutic problem. Diagnostic certainty is only obtained by histological examination. Mini-invasive surgery allows removal of the nodule with minimal sequelae for the patient. METHODS From October 1991 to December 2006, 370 resections for a pulmonary nodule were performed at our Department of General Surgery of the University of Milan: 276 wedge resections and 94 lobectomies. RESULTS Frozen section was performed in all the wedge resections, and in the presence of cancer (77 cases), whenever possible (61 cases), the intervention was converted to lobectomy in the same session. In the other 94 cases, the nodule was removed by lobectomy due to the impossibility of performing a wedge resection. CONCLUSIONS Despite the refinement of diagnostic techniques, only exeresis of a pulmonary nodule ensures a definitive diagnosis, thus resolving the problem of benign pathologies and initiating the correct therapy for malignant lesions in the same session.

Clinical application of a new compression anastomotic device for colorectal surgery

Fifty-six patients underwent large bowel anastomosis by the compression anastomotic device developed by the authors from May 1986 through December 1988. Operations performed were 40 left hemicolectomies or anterior resections of the sigmoid and rectum, 7 left colon resections, 7 right hemicolectomies, and 2 total colectomies. Twenty-one anastomoses were done on the extraperitoneal rectum, in 7 cases less than 4 cm from the anal verge and in 9 cases between 4.5 and 8 cm. Five intraoperative diverting colostomies were done (9%). The rings of the device were evacuated postoperatively after a mean of 11 days with little or no discomfort. Operative mortality was 1.8% (one patient died of myocardial infarction). Anastomotic complications were one (1.8%) clinical and one (1.8%) subclinical leak. Mean postoperative hospital stay was 14 days. This initial clinical experience shows that the anastomotic device is reliable.

Videolaparoscopic appendectomy: the current outlook

BackgroundMini-invasive techniques have revolutionized surgery, but the superiority of laparoscopic access for appendectomy is widely debated. The authors analyze their monocentric experience with 1,347 laparoscopic appendectomies.MethodsBetween October 1991 and December 2002, all the patients with an indication for appendectomy underwent surgery (301 emergency and 1,046 interval appendectomies) using the laparoscopic approach.ResultsFor 1,248 patients, appendectomy was performed laparoscopically, whereas for 99 patients (7.3%), it was converted to an open procedure because of technical reasons (90 patients, 6.7%) or intraoperative complications (9 patients, 0.6%). For 59 patients (4.4%), the appendectomy was associated with another procedure. Histology showed “acute” alterations in 261 of the 301 emergency surgeries and in 148 of the 1,046 elective operations. Postoperative complications arose in 37 patients (2.7%), with 5 patients (0.3%) requiring invasive treatment. The mean postoperative stay was 30 h.ConclusionsLaparoscopic appendectomy offers unquestionable advantages, but it is not yet considered the “gold standard” for appendiceal pathology. Many centers reserve it for selected patients (e.g., obese patients and women suspected of having other pathologies). No randomized trials or metaanalyses have definitively proved its superiority.