Francesco Cassiano

The adipose tissue of origin influences the biological potential of human adipose stromal cells isolated from mediastinal and subcutaneous fat depots

Indirect evidence suggests that adipose tissue-derived stromal cells (ASCs) possess different physiological and biological variations related to the anatomical localization of the adipose depots. Accordingly, to investigate the influence of the tissue origin on the intrinsic properties of ASCs and to assess their response to specific stimuli, we compared the biological, functional and ultrastructural properties of two ASC pools derived from mediastinal and subcutaneous depots (thoracic compartment) by means of supplements such as platelet lysate (PL) and FBS. Subcutaneous ASCs exhibited higher proliferative and clonogenic abilities than mediastinal counterpart, as well as increased secreted levels of IL-6 combined with lower amount of VEGF-C. In contrast, mediastinal ASCs displayed enhanced pro-angiogenic and adipogenic differentiation properties, increased cell diameter and early autophagic processes, highlighted by electron microscopy. Our results further support the hypothesis that the origin of adipose tissue significantly defines the biological properties of ASCs, and that a homogeneric function for all ASCs cannot be assumed.

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.

Resolution of a life-threatening complication after lung radiofrequency ablation

Lung radiofrequency ablation (RFA) is an option for the treatment of unresectable lung cancer. Clinical investigators have previously warned against severe complications associated with this procedure. We report a case of life-threatening complication after lung RFA for non-operable non-small-cell lung cancer consisting of pulmonary abscess evolving into a bronchopleural fistula, severe pneumothorax and septic pleuritis, which was successfully treated with a multimodal conservative approach.

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.

Coated expandable metal stents are effective irrespective of airway pathology

Background Tracheobronchial stents are a treatment option for inoperable benign or malignant tracheobronchial stenosis (TBS) or postoperative bronchopleural fistulas (POBPF). The present study evaluated the outcomes of patients with TBS and POBPF who were treated by placement of recent generation, fully covered, self-expanding metallic stents (SEMS) and determined stent efficacy relative to airway pathology. Methods From January 2009 to January 2016, 68 patients with TBS or POBPF underwent rigid bronchoscopy, laser/mechanical debridement and placement of fully covered SEMS. Eighteen patients had benign stenosis, 38 had malignant stenosis, and 12 patients had POBPF. Results Seventy-four SEMS were successfully placed in 68 patients. There were no perioperative deaths. Stent-related complications occurred in 20 (29.4%) patients: granulation tissue formation [TBS group, 10.7% (n=6); POBPF group, 8.3% (n=1)]; stent fracture [TBS group, 5.4% (n=3); POBF group, 8.3% (n=1)], stent migration [TBS group, 7.1% (n=4); POBF group, 0% (n=0)], severe secretions not removable by flexible bronchoscopy [TBS group, 7.1% (n=4); POBF group, 8.3% (n=1)]. No stent migration was observed in the POBPF group. Four patients (7.1%) in the TBS group had stent migration requiring stent replacement. After stenting, all TBS patients had a Hugh-Jones classification score improvement ≥1 grade and 42 patients (75%) had an improvement ≥2 grades. Logistic regression analysis showed that the disease (stenosis vs. fistula) did not influence the occurrence of stent complications [OR 0.96, 95% confidence interval (CI): 0.71-1.13, P=0.13]. Conclusions Fully covered SEMS are effective and provide a versatile treatment option for patients with inoperable TBS and POBPF.

Major thoracic surgery in patients under antiplatelet therapy

Advances in anticoagulant and antiplatelet regimes are associated with a significant risk reduction in the occurrence of thrombotic events. However, this thrombotic protection may carry an increased risk of bleeding during and after surgery. Aspirin is the main antiplatelet medication used in patients with coronary artery disease, nevertheless there is a growing evidence demonstrating that the use of the most potent antiplatelet medication, clopidogrel, on its own or in combination with aspirin, is more effective in both chronic and acute settings (1). The most recent recommendation for patients who have undergone to drug—eluting coronary artery stent placement advises toreceive the dual antiplatelet therapy for at least 12 months. Dual antiplatelet therapy has become the mainstay treatment strategy for the prevention of stent thrombosis. Premature discontinuation of antiplatelet therapy markedly increases the risk of stent thrombosis, a catastrophic event that frequently leads to myocardial infarction and/or death (2).

Seven months: the perfect time to complete the pectus excavatum correction

Figure 2: (A) ‘Half-moon’ shaped skin incision (4 cm) used for the correction, performed in correspondence with the deepest depressed point of the chondro-sternal deformity, allowing an optimal exposure of the sternum. (B and C) Chest CT scan with 3D reconstruction at 7 months from correction showing complete regeneration from the 3rd to 10th costal cartilages. The metallic bar was removed after 7 months.