Giulio Maurizi

Sleeve Lobectomy Compared with Pneumonectomy after Induction Therapy for Non–Small-Cell Lung Cancer

Background: We compared morbidity, mortality, and oncological results of bronchial and/or vascular sleeve lobectomy (SL) with those of pneumonectomy (PN) after induction therapy for lung cancer. Methods: Between 1998 and 2011, 82 patients receiving induction therapy (chemo or chemo-radiotherapy) for non–small-cell-lung-cancer underwent sleeve lobectomy (n = 39) or pneumonectomy (n= 43). Only patients undergoing preoperative chemotherapy (39 in the SL group and 39 in the PN group) were included in the study. SL was bronchial in 21, vascular in 12, and broncho-vascular in six cases, respectively. Clinical stage before induction therapy was IIb in seven patients (1 in PN group; 6 in SL group), IIIa in 66 (36 in PN group; 30 in SL group), and IIIb in five patients (2 in PN group; 3 in SL group), respectively. N3 patients were not included in this series. Results: The rate of downstaged patients (pathological complete response and stage I–II) was 79.5% in the SL group and 53.8% in the PN group (p = 0.01).Postpneumonectomy mortality rate was 2.6 %. There was no postoperative mortality after SL. Complications occurred in 12 patients (30.8%) after PN and in 11 patients (28.2%) after SL (p = 0.6). Three-year and 5-year survival rates were 68 ± 3% and 64 ± 8% in the SL group; and 59.5 ± 5% and 34.5 ± 8% in the PN group (p = 0.02). The difference in terms of recurrence rate (locoregional and distant) between the two groups was not significant (p = 0.2). Conclusions: SL represents a valid therapeutic option even after induction chemotherapy, providing better long-term survival than PN, with no increase of postoperative complications or recurrence rate. Pathological downstaging is a favorable prognostic factor.

Long-term results after resection of bronchial carcinoid tumour: evaluation of survival and prognostic factors

OBJECTIVES We retrospectively analysed morbidity, mortality and oncological results of patients who had undergone surgery for bronchial carcinoid tumours. METHODS Between 2002 and 2012, 65 patients with bronchial carcinoids underwent lobectomy (n = 34), sublobar resection (segmentectomy/wedge) (n = 18), sleeve lobectomy (n = 5) (reconstruction of the pulmonary artery was associated in 1 case), sleeve resection of the main bronchus (n = 4) or pneumonectomy (n = 4) (reconstruction of the carina was associated in 1 case). RESULTS Resection was radical with histologically negative margins in all patients (R0). Histology showed typical carcinoid (TC) in 55 (84.6%) patients and atypical carcinoid (AC) in 10 (15.4%) patients. Final pathological stages were Stage I in 42 (64.6%) patients, Stage II in 18 (27.7%) and Stage III in 5 (7.7%). No postoperative mortality was observed. The postoperative morbidity rate was 15.4% (no bronchial and/or vascular reconstructive-related complications occurred). The median follow-up was 58 (range 2-121) months. The overall recurrence rate was 12.3% (n = 8). The survival rate at 5 years was 100% for TC and 87% for AC. Disease-free survival rates at 3 and 5 years were 95 and 93% for TC and 78 and 44% for AC, respectively (P = 0.004). Pathological nodal involvement (pN1-N2) did not affect overall survival or recurrence. CONCLUSIONS The surgical treatment of bronchial carcinoids provides high long-term survival rates. Low postoperative morbidity and mortality can be expected even after bronchial reconstruction. The AC appears to be the main factor that determines the risk of recurrence. Bronchial reconstructive lung sparing operations are not related to an increased recurrence rate.

Margin Distance Does Not Influence Recurrence and Survival After Wedge Resection for Lung Cancer.

BACKGROUND The relationship between the free margin distance and the recurrence rate and overall survival after R0 wedge resection for non-small cell lung cancer (NSCLC) is still not clear. We retrospectively evaluated the long-term oncologic outcome of patients who had undergone wedge resection for NSCLC to assess the prognostic effect of margin distance in this setting. METHODS Between 2003 and 2013, 243 consecutive patients with a functional contraindication to major lung resection underwent wedge resection with systematic lymph node dissection for clinical stage I NSCLC. The study enrolled 182 patients with pathologic stage I and R0 resection and divided them into three subgroups according to margin distance of less than 1 cm (n = 30), 1 to 2 cm (n = 80), and more than 2 cm (n = 72). RESULTS The histologic assessment was adenocarcinoma in 112 patients, squamous cell in 30, and other in 40. Postoperative morbidity was 18.7%, and postoperative mortality was 1.1%. The median follow-up was 31 months (range, 2 to 133 months). The locoregional (lung parenchyma, hilum, mediastinum) recurrence rate was 26.4% (n = 48). The distant recurrence rate was 11% (n = 20). Overall 5-year survival was 70.4%. Disease-free 5-year survival was 51.7%. There was no statistical difference in locoregional (p = 0.9) and distant (p = 0.3) recurrence rate and no difference in overall survival (p = 0.07) when the three groups were compared. CONCLUSIONS Wedge resection is a viable option for the surgical treatment of stage I NSCLC when lobectomy is contraindicated. The distance between the tumor and the parenchymal suture margin does not influence recurrence or the survival rate when an R0 resection is achieved.

Safe Resection of the Aortic Wall Infiltrated by Lung Cancer After Placement of an Endoluminal Prosthesis

BACKGROUND Few investigators have reported the results of combined resection of lung cancer infiltrating the thoracic aorta; only anecdotal accounts of off-label use of thoracic aortic endografts to facilitate resection of such tumors have been published. In this paper, we describe our experience using this innovative approach in terms of technical details and outcomes. METHODS We retrospectively reviewed data on 9 patients (6 men and 3 women, median age 61 years) with preoperatively suspected thoracic aorta neoplastic invasion, who were operated on after positioning of an endograft and underwent en bloc tumor resection including the aortic wall. RESULTS All but one cancer were non-small cell lung carcinomas; 4 patients received neoadjuvant chemotherapy, and 7 received adjuvant therapy. Aortic endografting was performed 2 to 17 days before resection of the tumor in 7 patients and as part of a one-stage procedure in 2 patients. The proximal end of the stent graft was deployed in the aortic arch (n = 1) or the descending aorta (n = 8). Lung resections were left pneumonectomies in 4 patients and left lower lobectomies in 5. Five patients underwent additional buttressing of the aortic defect using a synthetic patch (n = 2) or the omentum (n = 3). No cardiopulmonary bypass was required. At the last follow-up, 3 patients had evidence of tumor recurrence (one local and two distant). No endograft-related complications were detected. CONCLUSIONS Thoracic aortic endografting allowed safe en bloc resection of tumors invading the aortic wall, avoiding the need for extracorporeal circulatory support. Such an extended indication for thoracic aortic endografts seems promising and should be considered for selected oncologic cases.

Two-stage unilateral versus one-stage bilateral single-port sympathectomy for palmar and axillary hyperhidrosis

OBJECTIVES Video-assisted thoracoscopic sympathectomy is currently the best treatment for palmar and axillary hyperhidrosis. It can be performed through either one or two stages of surgery. This study aimed to evaluate the operative and postoperative results of two-stage unilateral vs one-stage bilateral thoracoscopic sympathectomy. METHODS From November 1995 to February 2011, 270 patients with severe palmar and/or axillary hyperhidrosis were recruited for this study. One hundred and thirty patients received one-stage bilateral, single-port video-assisted thoracoscopic sympathectomy (one-stage group) and 140, two-stage unilateral, single-port video-assisted thoracoscopic sympathectomy, with a mean time interval of 4 months between the procedures (two-stage group). RESULTS The mean postoperative follow-up period was 12.5 (range: 1-24 months). After surgery, hands and axillae of all patients were dry and warm. Sixteen (12%) patients of the one-stage group and 15 (11%) of the two-stage group suffered from mild/moderate pain (P = 0.8482). The mean operative time was 38 ± 5 min in the one-stage group and 39 ± 8 min in the two-stage group (P = 0.199). Pneumothorax occurred in 8 (6%) patients of the one-stage group and in 11 (8%) of the two-stage group. Compensatory sweating occurred in 25 (19%) patients of the one-stage group and in 6 (4%) of the two-stage group (P = 0.0001). No patients developed Horners syndrome. CONCLUSIONS Both two-stage unilateral and one-stage bilateral single-port video-assisted thoracoscopic sympathectomies are effective, safe and minimally invasive procedures. Two-stage unilateral sympathectomy can be performed with a lower occurrence of compensatory sweating, improving permanently the quality of life in patients with palmar and axillary hyperhidrosis.

Submucosal injection of the silver–human albumin complex for the treatment of bronchopleural fistula

OBJECTIVE Postoperative bronchopleural fistula (BPF) is a serious complication and a therapeutic challenge in thoracic surgery. The purpose of this study is to assess the efficacy of the use of the silver-human albumin (SHA) complex injected in the bronchial submucosa for the treatment of BPF. METHODS From January 2005 to March 2008, we treated 11 patients with BPF (seven post-pneumonectomy and four post-lobectomy) by endoscopic injection of the SHA complex into the bronchial submucosa. In all patients a chest drain was positioned and employed for antibiotic pleural irrigation. Simultaneously, the endoscopic treatment including repeated injection of the SHA complex was started. In 10 patients the diameter of the fistulas was equal to or smaller than 5mm (range: 3-5mm) and in one it was larger than 5mm (8mm). RESULTS There was no morbidity or mortality related to the procedure. Permanent closure of the fistula was achieved in all 10 patients with a BPF of 3-5mm. In four of these patients (post-lobectomy fistula), the good general condition allowed early discharge with the Heimlich valve before the completion of treatment. Two other patients with a fistula smaller than 5mm presented persisting empyema and compromised general conditions after closure of the post-pneumonectomy BPF. These patients underwent fast-track treatment of the empyema achieving definitive cure. In the patient with a BPF larger than 5mm, the conservative treatment was not sufficient and an omental flap transposition was necessary. CONCLUSIONS The SHA complex submucosal injection is easy, safe and inexpensive. It can be considered a valid therapeutic option in selected patients presenting an early fistula with a size equal to or smaller than 5mm. Early diagnosis, simultaneous insertion of a chest drain and achievement of a sterile pleural cavity are fundamental conditions for the final success of the procedure.

Long-term results of laryngotracheal resection for benign stenosis from a series of 109 consecutive patients

OBJECTIVES Long-term results of patients undergoing laryngotracheal resection for benign stenosis are reported. This is the largest series ever published. METHODS Between 1991 and March 2015, 109 consecutive patients (64 males, 45 females; mean age 39 ± 10.9 years) underwent laryngotracheal resection for subglottic postintubation (93) or idiopathic (16) stenosis. Preoperative procedures included tracheostomy in 35 patients, laser in 17 and laser plus stenting in 18. The upper limit of the stenosis ranged between actual involvement of the vocal cords and 1.5 cm from the glottis. Airway resection length ranged between 1.5 and 6 cm (mean 3.4 ± 0.8 cm) and it was over 4.5 cm in 14 patients. Laryngotracheal release was performed in 9 patients (suprahyoid in 7, pericardial in 1 and suprahyoid + pericardial in 1). RESULTS There was no perioperative mortality. Ninety-nine patients (90.8%) had excellent or good early results. Ten patients (9.2%) experienced complications including restenosis in 8, dehiscence in 1 and glottic oedema requiring tracheostomy in 1. Restenosis was treated in all 8 patients with endoscopic procedures (5 laser, 2 laser + stent, 1 mechanical dilatation). The patient with anastomotic dehiscence required temporary tracheostomy closed after 1 year with no sequelae. One patient presenting postoperative glottic oedema underwent permanent tracheostomy. Minor complications occurred in 4 patients (3 wound infections, 1 atrial fibrillation). Definitive excellent or good results were achieved in 94.5% of patients. Twenty-eight post-coma patients with neuropsychiatric disorders showed no increased complication and failure rate. CONCLUSIONS Laryngotracheal resection is the definitive curative treatment for subglottic stenosis allowing very high success rate at long term. Early complications can be managed by endoscopic procedures achieving excellent and stable results over time.

Reconstruction of the bronchus and pulmonary artery

Sleeve lobectomy (SL) (lobectomy associated with resection and reconstruction of the bronchus, the pulmonary artery, or both) has proved to be a suitable choice for the treatment of centrally sited non-small cell lung cancer. SL for lung cancer is indicated when a tumor or an N1 lymph node infiltrates the origin of a lobar bronchus, the origin of the lobar branches of the pulmonary artery, or both but not to the extent that a pneumonectomy is required. SL can be performed safely and effectively, even after induction therapy, without an increased complication rate.

Evaluation of the efficacy of a haemostatic matrix for control of intraoperative and postoperative bleeding in major lung surgery: A prospective randomized study

OBJECTIVES This prospective randomized study was designed to assess the safety and efficacy of a haemostatic matrix in intraoperative bleeding control and prevention of postoperative bleeding after major lung surgery. METHODS One hundred and twenty patients undergoing major lung resection and presenting with intraoperative persistent active bleeding have been prospectively enrolled and randomly assigned to receive [Floseal® group (FG)] or not (control group) the application of Floseal® to the bleeding site and to the site of the hilar dissection. To evaluate the efficacy of the product, several intraoperative and postoperative data were compared between the two groups. RESULTS No adverse event related to the haemostatic matrix application occurred. The intraoperative haemostasis rate at 3 (primary end-point), 6 and 10 min was significantly higher and the mean time to haemostasis was significantly shorter in the FG. The quantity of chest drain fluids did not show significant differences at 24, 48 and 72 h between the two groups. Postoperative haemoglobin-level variation was significantly lower in patients of the FG (-0.7 ± 0.66 vs -2.3 ± 5.87 g/dl; P = 0.04). Similarly, haematocrit variation was lower in the haemostatic group (-2.6 ± 2.19 vs -4.2 ± 3.71; P = 0.006). The chest drain duration resulted significantly shorter in the FG (10.3 ± 5.05 vs 13.3 ± 6.28 days; P = 0.005). In-hospital stay was shorter in the FG (6.4 ± 2.9 vs 8.1 ± 5.42 days; P = 0.044). CONCLUSIONS In conclusion, the application of Floseal® in major lung resections proved safe and effective in increasing the intraoperative successful haemostasis rate and in reducing postoperative variation in haemoglobin and haematocrit levels. The sealant use was also related with a significantly shorter chest drain duration and hospitalization.

Bronchial and Arterial Sleeve Resection After Induction Therapy for Lung Cancer

Lobectomy with reconstruction of the bronchus and pulmonary artery is a viable therapeutic option for patients with centrally located non-small cell lung cancer. Preoperative chemotherapy or chemoradiotherapy may represent an additional risk factor for postoperative complications because of increased difficulty in surgical dissection and potential impairment of bronchial healing. Although limited data are available in the literature in this setting, a few published studies have reported the possibility of performing even complex bronchovascular reconstructions after neoadjuvant treatment with no increased morbidity and mortality. This article discusses the main technical details and data from the literature.