Gino Zaccagna

Cost-effectiveness analysis of sealant impact in management of moderate intraoperative alveolar air leaks during video-assisted thoracoscopic surgery lobectomy: a multicentre randomised controlled trial

Background Intraoperative alveolar air leak (IOAAL) is one of most common complications after video-assisted thoracoscopic surgery (VATS) lobectomy. The study aimed to evaluate if, in moderate IOAAL, intraoperative polymeric biodegradable sealant (ProgelTM) reduced postoperative air leak (PAL) and consequently was cost-effective. Methods Patients with moderate IOAAL were randomised in a multicentre trial to intraoperative use of a sealant (Sealant group) or standard management of air leaks (Control group). Primary endpoint was the postoperative duration of air leakage. Secondary outcomes included: time to drainage removal, length of hospital stay, postoperative complications within 2 months, and cost analysis. Results Between January 2015 and January 2017, 255 VATS lobectomies were performed in four centres. Fifty-five met inclusion criteria and were randomly assigned to Sealant group [28] and Control group [27]. The mean air leakage duration was statistically different between groups (Sealant group =1.60 days, Control group =5.04 days; P<0.001). The average length of drainage was significantly (P=0.008) shorter in Sealant group (4.1 days) than in Controls (6.74 days). The mean time of hospital stay was statistically shorter in sealant group (Sealant =5.75 days, Control =7.85 days; P=0.026). Sealant group observed a statistically significant reduction of costs. Conclusions In moderate IOAAL after VATS lobectomy, polymeric biodegradable sealants are safe and efficient. Compared with standard treatments, sealant significantly reduces PAL, time to drain removal and length of hospital stay resulting in significant costs benefits.

National adoption of video-assisted thoracoscopic surgery (VATS) lobectomy: the Italian VATS register evaluation

Background The expertise curve of video-assisted thoracoscopic surgery (VATS) lobectomies still stirs debate and controversy both because of the number of procedures to carry out and of the evaluation of the learning threshold. The purpose of our study was the examination of the variables related to the learning curve of the video-assisted approach, to establish what may be an expression of the technical maturity of the surgeon. Methods The National Register for VATS lobectomy built in 2013 was used to collect data from 65 Thoracic Surgery Units. Out of more than 3,700 patients enrolled, only information from Units with ≥100 VATS lobectomies were retrospectively analysed. Unpaired Students t-tests, Fishers exact tests, Pearsons χ2 were applied as needed. Cumulative summative analysis and one-way ANOVA were used to identify the expertise curve of VATS lobectomy. Results Ten institutions contributed a total of 1,679 patients, who were divided into three uniform groups according to the chronological sequence of surgery. The length of utility incision, the number of dissected lymph nodes and the operative time were not statistically significant (P=0.999, P=0.972 and P=0.307, respectively) among groups. Conversion to thoracotomy and postoperative air leaks occurred in 125 (7.44%) and 109 (6.49%) patients, gradually declined in Group 3 with statistical significance (P=0.048 and P=0.00086). Conclusions The conversion rate and the percentage of air leaks seem to define the expertise of VATS lobectomy, being linked to the ability to manage more complicated surgical cases or intraoperative adverse events.

Diagnostic performance of fluorine-18 fluorodeoxyglucose positron emission tomography in the management of solitary pulmonary nodule: a meta-analysis

Background In the setting of solitary pulmonary nodules (SPNs), fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) is considered a useful non-invasive diagnostic tool though false positive (FP) and false negative (FN) results affects accuracy due to different conditions, such as inflammatory diseases or low-uptake neoplasms. Aim of this study is to evaluate overall diagnostic performance of 18F-FDG-PET/CT for malignant pulmonary nodules. Methods A computerized research, including published articles from 2012 and 2017, was carried out. 18F-FDG-PET/CT overall sensitivity (Se), specificity (Spe), positive likelihood ratio (PLR), negative likelihood ratio (NLR), positive predictive value (PPV), negative predictive value (NPV), diagnostic index and odds ratio were pooled. No selection-bias were found according to asymmetry test. Results A total of twelve studies were included in the meta-analysis. The pooled Se, Spe, PLR, NLR, PPV, NPV and accuracy index (AI) with relative 95% confidence intervals (CI) were 0.819 (95% CI: 0.794-0.843), 0.624 (95% CI: 0.582-0.665), 2.190 (95% CI: 1.950-2.440), 0.290 (95% CI: 0.250-0.330), 0.802 (95% CI: 0.783-0.819), 0.652 (95% CI: 0.618-0.684) and 0.649 (95% CI: 0.625-0.673), respectively. The diagnostic odds ratio (DOR) was 7.049 with a relative 95% CI between 5.550 and 8.944. Conclusions The results suggest 18F-FDG-PET/CT has good diagnostic accuracy in SPNs evaluation; but, it should not be considered as a discriminatory test rather than a method to be included in a clinical and diagnostic pathway.

VATS anatomic resections for lung cancer: insights from the Italian VATS Group

Background: The VATS Group and the National Register for VATS Lobectomy were set up in 2013. Both quality and quantity of collected data within the database are two fundamental tools for scientific and statistical purposes, similar to other important databases, such as the European Society of Thoracic Surgeons (ESTS) Database, the Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) and the Danish Lung Cancer Registry (DLCR). Methods: Four thousand seven hundred and four VATS lobectomy patients have recruited to date. Several parameters were recorded, such as preoperative clinical condition, surgical treatment as far as technical details, postoperative course and follow-up. Results: The Eastern Cooperative Oncology Group (ECOG) performance status was 0.27. Uni-portal approach was used in 332 patients, three-portal approach in 3,825 and bi-portal approach in 547. Lymphadenectomy was performed in 4,704 patients: a sampling nodal dissection in 1,180 patients and a radical nodal dissection in 3,524 cases. Conversion rate was in 9.99% of cases. Adenocarcinoma is the most common histologic type (53.34%), followed by squamous carcinoma (15.53%). Conclusions: The structure of the Italian Registry of VATS Lobectomy makes it a valid source to draw on for statistical studies for scientific purposes.

Management of Bronchopleural Fistula Complicated by Skin Wound Necrosis after Thoracomyoplasty

Summary: Skin necrosis is a rare complication after thoracomyoplasty and usually needs conservative treatment. We described positive findings with surgical approach. A 54-year-old man showed bronchopleural fistula after undergoing right pneumonectomy for lung cancer, treated with thoracomyoplasty. On the 20th postoperative day, a skin wound lesion was noted, whose deterioration required a skin flap transposition. Patient was discharged from hospital on the 7th postoperative day and did not show relapse at the 7th year follow-up. Surgery can be the most viable alternative to medical treatments in the management of a chest wall cutaneous complication even in high-risk patients.

Basic statistics with Microsoft Excel: a review

The scientific world is enriched daily with new knowledge, due to new technologies and continuous discoveries. The mathematical functions explain the statistical concepts particularly those of mean, median and mode along with those of frequency and frequency distribution associated to histograms and graphical representations, determining elaborative processes on the basis of the spreadsheet operations. The aim of the study is to highlight the mathematical basis of statistical models that regulate the operation of spreadsheets in Microsoft Excel.

Fluorine-18 fluorodeoxyglucose positron emission tomography in the management of solitary pulmonary nodule: a review

Abstract Solitary pulmonary nodules are common radiologic findings and their detection has increased due to the introduction and improvement of diagnostics. Since a nodule can be an expression of early lung cancers, a proper classification and management are required because its treatment might lead to decreased morbidity and mortality. In this regard, prominent guidelines are available although they are characterized sometimes by discordant and misleading evidences. Furthermore, the same results of studies in the literature appear conflicting. Aim of this work is to evaluate the role of imaging through an extensive literature review but focusing on 18-fluorine fluorodeoxyglucose positron emission tomography combined with computed tomography (18F-FDG-PET/CT) in order to assess the limits and future perspectives of solitary pulmonary nodule characterization in early detection of lung cancer. Key messages Detection of solitary pulmonary nodules has increased. Management of solitary pulmonary nodules is still debated. Future perspectives of early solitary pulmonary nodule characterization.