G. F. Coloni

Reconstruction of the pulmonary artery for lung cancer: Long-term results

OBJECTIVEnReconstruction of the pulmonary artery in association with lung resection is technically feasible with low morbidity and mortality. To assess long-term outcome, we report our 20-year experience.nnnMETHODSnBetween 1989 and 2008, we performed pulmonary artery reconstruction in 105 patients with non-small cell lung cancer (tangential resections not included). Twenty-seven patients received induction therapy. We performed 47 pulmonary artery sleeve resections, 55 reconstructions by pericardial patch (with 3 left pneumonectomies under cardiopulmonary bypass), and 3 by pericardial conduit. In 65 patients, a bronchial sleeve resection was associated; in 6 cases superior vena caval reconstruction was also required. Fifteen patients had stage IB disease, 37 stage II, 31 IIIA, and 22 IIIB. Sixty-one patients had epidermoid carcinoma, and 38 adenocarcinoma. Mean follow-up was 46 +/- 40 months.nnnRESULTSnThe procedure-related complications were 1 pulmonary artery thrombosis requiring completion pneumonectomy and 1 massive hemoptysis leading to death (operative mortality, 0.95%); 28 patients had other complications, with the most frequent prolonged air leakage. Overall 5-year survival was 44%. Five- and 10-year survivals for stages I and II versus stage III were, respectively, 60% versus 28% and 25% versus 12%. Five-year survivals were 52.6% for N0 and N1 nodal involvement versus 20% for N2; 10-year survivals were 28% versus 3%. Multivariate analysis yielded induction therapy, N2 status, adenocarcinoma, and isolated pulmonary artery reconstruction as negative prognostic factors.nnnCONCLUSIONSnPulmonary artery reconstruction is safe, with excellent long-term survival. Our results support this technique as an effective option for patients with lung cancer.

Video-assisted thoracoscopic treatment of giant bullae associated with emphysema

OBJECTIVEnSurgical treatment of bullous emphysema has received renewed attention because of recent advances in minimally invasive techniques. We describe our experience in the thoracoscopic management of patients with bullous emphysema over the last 5 years.nnnMETHODSnTwenty-five patients (24 male, one female) with a mean age of 57 years with giant bullae associated with various degree of underlying emphysema, were operated on thoracoscopically at our Institution. The severity of the emphysema was classified according to the criteria of the American Thoracic Society: five patients were in stage I (FEV 1 > 50%), eight patients were in stage II (FEV1 35 to 49%) and 12 patients were in stage III (FEV1 < 35%). Nine patients underwent operation to treat complications related to bullae, 12 presented dyspnoea and four were asymptomatic. We performed 23 unilateral and two bilateral staged thoracoscopic procedures.nnnRESULTSnNo intraoperative complications developed. Mean operative time was 107+/-25 min. No patient dead. Mean post-operative chest tube duration was 8+/-4.13 days and mean post-operative hospital stay was 11+/-5.76 days. The most frequent post-operative complication was air-leakage that in 12 patients lasted more than 7 days. Pulmonary function tests were obtained 3-6 months after the operation and statistical comparison between pre-operative and post-operative data was performed using Students paired t-test. We observed best results in I and II stage patients, but also stage III patients experienced clinical improvement and better quality of life.nnnCONCLUSIONSnOur experience supports the safety and effectiveness of video-assisted thoracoscopy for the treatment of giant bullae. Minimally invasive approach is fully justified especially in the group of patients with severe impairment of lung function.

Multimodality Treatment of Thymic Tumors

Combined modality therapy is gaining acceptance for treating stage 3 and 4A thymic tumors. Also, specific subsets of stage 2 tumors deserve particular attention. Single-center experiences demonstrate that there are some advantages in selected groups of patients. The overall relatively low complete response rate, however, imposes the search for better systemic therapy to optimize results. In fact, although thymic tumors are responsive to different cytotoxic regimens, none has been demonstrated to be the ideal one. New therapies and strategies should be designed and tested in large-scale multicenter prospective trials. Among the others, epidermal growth factor receptor inhibitors have shown some clinical response, because EGFR is overexpressed in thymoma. c-KIT is overexpressed in thymic carcinoma. Although in a recent study a clinical response to imatinib has been reported, results of a prospective study in patients who have thymic carcinoma are pending. Clinical responses have been reported also to other tyrosine kinase inhibitors, such as dasatinib. Other reports have stressed the presence of an up-regulation of COX-2 with a potential separate therapeutic pathway. Other markers, such as the expression of thymidine synthase and dihydropyrimidine dehydrogenase, which predict sensitivity to 5-fluoruracil-based chemotherapy, were not correlated with the clinicopathological characteristics in a series of thymomas. These new therapies should be incorporated in a standardized approach that goes from a careful assessment of histology, staging, and lymph node status, and a constructive and nonempiric cooperation between the oncologist, radiotherapist, pathologist, and thoracic surgeon.

Anterior approach to the thoracic spine

An anterior approach affords the spine surgeon excellent visualization and access to the anterior thoracic spine, the vertebral bodies, intervertebral disks, spinal canal, and nerve roots. This approach is currently used in the surgical treatment of thoracic disk disease, vertebral osteomyelitis or discitis, fractures and tumors of the vertebral bodies, allowing for proper decompression of neural elements and spine stabilization. Over a 10-year period in a single institution, a total of 142 patients with a mean age of 49.6 years underwent anterior thoracic exposure of the spine. The indication for surgery was trauma fracture in 20 patients, malignancy in 35, degenerative disease in 29 and correction of scoliosis in 58. Surgical approaches were determined based on the location and length of spinal involvement, including cervico-thoracic approach (15) thoracotomic approach (85) video-assisted thoracoscopy (10) and thoracolumbar exposure (32). Mean operative time was 334 min (range from 256 to 410 min). There was no perioperative mortality. Thirty-one patients (21.8%) developed postoperative complications. The anterior approach to the thoracic spine is safe and effective and even the presence of complications can be appropriately managed. An adequate preoperative evaluation stratifying the risk and instituting measures to reduce it, accurate surgical planning and careful surgical technique are key to yielding a good outcome and to reduce the risk of complications.

Endobronchial Treatment of Emphysema with One-Way Valves

Numerous endoscopic procedures have recently been studied and progressively introduced in clinical practice to improve mechanics and function in patients who have emphysema. Bronchoscopic lung volume reduction with one-way endobronchial valves facilitates deflation of the most overinflated emphysematous parts of the lung. These valves have been designed to control and redirect airflow by preventing air from entering the target parenchymal area but allowing air and mucus to exit. The preliminary results have shown that this procedure is safe and effective at medium term in a selected group of patients.

Prevention of middle lobe torsion after right upper lobectomy with a polymeric sealant

Lobar torsion is a rare and potentially serious complication after pulmonary resection. A number of procedures have been described to prevent it. We report an easy and quick technique to avoid this complication after right upper lobectomy. Torsion of the lung represents a rotation of the hilar structures (bronchus, artery, and vein), with consequent vascular compromise and airway obstruction. Reported occurrence rates are between 0.1% and 0.3%. The degree of rotation is generally 180 , but 90 and 360 torsions have also been described. This complication occurs more frequently in the middle lobe after right upper lobectomy; however, torsion of even the entire lung has been reported after the resection of other lobes, chest surgery not involving pulmonary resection, or lung transplant. Mortalities from 12% to 16% has been reported for complicated torsions. Several methods of fixation of the remaining lobes have been described to prevent this dreadful complication.