Giulio Melloni

Diagnosis and treatment of traumatic pulmonary pseudocysts.

BACKGROUND Traumatic pulmonary pseudocysts (TPPs) are rare sequelae of blunt chest trauma. We present a retrospective review of TPPs observed in our hospital and discuss the diagnosis, treatment, and complications of these unusual lesions. METHODS Between 1991 and 1999, 11 TPPs were diagnosed in 10 patients. None of the lesions was detectable on the chest radiograph obtained on the day of injury. In contrast, computed tomographic scan of the chest always demonstrated the TPPs. RESULTS In nine cases, spontaneous healing of the lesions was observed. One patient with a large lesion of the left lower lobe developed significant endobronchial bleeding and underwent successful emergency lobectomy. CONCLUSION TPPs are often missed by chest radiography, particularly when it is obtained in the supine position, whereas computed tomographic scan allows the identification of these lesions in all cases. TPPs are self-limiting, benign lesions that usually require no specific therapy. Surgical treatment is indicated in rare instances and only when complications occur.

Surgical treatment of catamenial pneumothorax: a single centre experience

We retrospectively reviewed our experience with catamenial pneumothorax (CP) in terms of treatment and follow-up. From 1993 to 2008, ten women presented at our department with CP. CP was right-sided in all patients: seven presented diaphragmatic defects including one endometriosis, five had apical bulla or blebs that in three patients were the only pathological findings. Surgical approach was thoracoscopic with a muscle-sparing thoracotomy when diaphragmatic defects where present. All patients underwent apical resection and apical pleurectomy associated in seven cases with diaphragmatic plication and chemical pleurodesis. After surgery nine patients underwent hormonal treatment: three were put on estrogen-progesterone complex treatment and six received gonadotropin-releasing hormone agonist (GnRH agonist). Recurrence rate was 40% and it was significantly correlated with estrogen-progesterone treatment (P<0.005). The mean follow-up was 52+/-32 months (range 14-168). At the present time, no recurrence has occurred in all women. Occurrence of CP is often underestimated. At the time of surgery the diaphragm should be carefully inspected for defects and/or endometriosis. Standard pleurodesis may not suffice and we suggest apical resection and apical pleurectomy associated with a diaphragmatic procedure when indicated. Hormonal treatment with GnRH agonist seems to improve the outcome.

Decortication for chronic parapneumonic empyema: Results of a prospective study

ABSTRACTDespite advances in diagnostic methods, surgical techniques, and supportive therapy, chronic parapneumonic empyema is still associated with considerable morbidity and mortality. A prospective study was performed on a consecutive series of patients with chronic parapneumonic empyema to analyze the results of surgical treatment and identify clinical predictors of poor outcome. From 1993 to 2000 a total of 40 patients underwent decortication for chronic parapneumonic empyema. There was no mortality. All 40 patients had definitive resolution of the empyema. Altogether, 34 patients (87.5%) had an uneventful postoperative course, and 5 (12.5%) experienced complications (2 prolonged febrile syndromes, 3 cases of sepsis requiring mechanical respiratory assistance). All complications resolved well with adequate treatment without further consequences. Definitive results of the surgical procedures assessed at the 6-month follow-up examination were good in 21 patients and satisfactory in 19. No unsatisfactory results were observed in any of the patients. Univariate analysis showed that three variables predicted morbidity: co-morbidities (p = 0.039), symptom duration ≥ 60 days (p = 0.009), and duration of preoperative conservative treatment ≥ 30 days (p = 0.006). Multivariate analysis showed that only symptom duration ≥ 60 days (p = 0.041) and duration of conservative treatment ≥ 30 days (p = 0.025) were associated with morbidity. Decortication is a highly effective treatment for chronic parapneumonic empyema and may be performed with low morbidity and mortality. Because prolonged duration of symptoms and conservative treatment increase morbidity, early surgical intervention seems to be the optimal modality for the treatment of chronic parapneumonic empyema.

Montgomery T-tube placement in the treatment of benign tracheal lesions

INTRODUCTION Although surgery remains the gold standard for the treatment of benign tracheal stenosis, airway stenting may be indicated in the event of complex lesions or associated diseases. We retrospectively investigated Montgomery T-tube placement as an alternative or complementary treatment to surgery. METHODS From January 1984 to March 2008, 158 patients were treated for benign tracheal lesions. Eighty-three patients underwent airway resection and reconstruction as the only treatment. Seventy-five other patients with complex lesions or major associated diseases were treated with a T-tube and were retrospectively analysed. Seven of them had undergone unsuccessful treatment with Dumon stents. T-tube placement was the only procedure adopted in 51 patients with a contraindication to surgery (group I), a temporary measure in 15 patients prior to surgery (group II), and in 9 patients (group III) for complications of airway reconstruction, 5 of whom were referred from other institutions. RESULTS Complications after T-tube placement were: stent dislocation in 3 (4%) patients, endoluminal granulomas in 14 (19%), subglottic edema in 3 (4%), and sputum retention in 7 (9%). Treatment of complications (tracheostomy cannula, steroid infiltration, Argon/LASER coagulation, and bronchoscopy) was required in 20 (27%) patients. In group I, the tube was removed in 12 (24%) patients after 35.3 +/- 8.2 months following resolution of the stenosis. In group II, the tubes were maintained in place before surgery for 17.1 +/- 4.8 months. In group III, three stents were removed following tracheal healing after 115.3 +/- 3.7 months. After 5 years the stents were in place in 82%, 7% and 100% of the patients, respectively in groups I, II and III. CONCLUSIONS Montgomery T-tube placement represents a useful option in patients with complex benign tracheal stenosis or associated diseases as an alternative or complementary treatment to surgery, and is effective even when other types of stents are unsuccessful.

Identification of Novel Subdominant Epitopes on the Carcinoembryonic Antigen Recognized by CD4+ T Cells of Lung Cancer Patients

The carcinoembryonic Ag (CEA) is an attractive target for immunotherapy because of its expression profile and role in tumor progression. To verify the existence of spontaneous anti-CEA CD4+ T cells in lung cancer patients, we first identified CEA sequences forming naturally processed epitopes, and then used the identified epitopes to test their recognition by CD4+ T cells from the patients. We had previously identified CEA177–189/355–367 as an immunodominant epitope recognized by CD4+ T cells in association with several HLA-DR alleles. In this study, we identified four additional subdominant CEA sequences (CEA99–111, CEA425–437, CEA568–582, and CEA666–678), recognized in association with one or more HLA-DR alleles. Peptide-specific CD4+ T cells produced proinflammatory cytokines when challenged with the native protein and CEA-expressing tumor cells, thus demonstrating that the identified CEA sequences contain naturally processed epitopes. However, CEA is expressed in the thymus and belongs to the CD66 family that comprises highly homologous molecules expressed on hemopoietic cells, raising concerns about tolerance interfering with the in vivo development of anti-CEA immunity. We thus tested the spontaneous reactivity to the identified epitopes of peripheral blood CD4+ T lymphocytes from eight early-stage lung cancer patients bearing CEA-positive tumors. We found GM-CSF- and IFN-γ- producing CD4+ T cells in two patients. Our data indicate that CD4+ immune responses against CEA develop in neoplastic patients, suggesting that tolerance toward CEA or cross-reactive CD66 homologous molecules might be either not absolute or be overcome in the neoplastic disease.

Preoperative assessment in patients with postintubation tracheal stenosis : Rigid and flexible bronchoscopy versus spiral CT scan with multiplanar reconstructions

BackgroundPostintubation stenosis remains the most frequent indication for tracheal surgery. Rigid bronchoscopy has traditionally been considered the technique of choice for the preoperative diagnostic assessment. However, this technique is not routinely available, and new techniques such as flexible videobronchoscopy and spiral computed tomography (CT) scan with multiplanar reconstructions have been proposed as alternatives to rigid bronchoscopy. The aim of this study was to compare these techniques in the diagnostic assessment of patients with tracheal stenosis submitted to surgical treatment.MethodsTwelve patients who underwent airway resection and reconstruction for postintubation tracheal and laryngotracheal stenosis were preoperatively evaluated with rigid and flexible bronchoscopy and with spiral CT scan with multiplanar reconstructions. The following parameters were examined: involvement of subglottic larynx, length of the stenosis, and associated lesions. The results were compared with the intraoperative findings.ResultsThe accuracy of rigid bronchoscopy, flexible bronchoscopy, and CT scan in the evaluation of the involvement of subglottic larynx was, respectively, 92%, 83%, and 83%. The evaluation of the length of the stenosis was correct in 83%, 92%, and 25% of the patients, respectively, with rigid bronchoscopy, flexible bronchoscopy, and CT scan. A significant correlation was observed between the length of the stenosis measured intraoperatively and preoperatively with rigid (p < 0.001) and flexible bronchoscopy (p < 0.05) but not with CT scan (p = 0.08). The three techniques correctly showed the presence of an associated tracheoesophageal fistula in two patients, but CT scan did not correctly show the exact location of the fistula in relation to the airway. Flexible bronchoscopy was the only effective technique in the assessment of laryngeal function.ConclusionsRigid bronchoscopy remains the procedure of choice in the evaluation of candidates for tracheal resection and reconstruction for postintubation stenosis, and it should be available in centers that perform surgery of the airway. Flexible bronchoscopy and CT scan have to be considered complementary techniques in the evaluation of laryngeal function and during follow-up.

Pulmonary resection for non-small-cell lung cancer in patients on hemodialysis: Clinical outcome and long-term results

Patients on hemodialysis (HD) who undergo surgery represent a high risk group requiring careful perioperative management to avoid electrolyte imbalance and hemodynamic instability. The aim of the study was to analyze the postoperative outcome in terms of complications and survival of a group of patients on HD who had undergone pulmonary resection for non-small cell lung cancer (NSCLC). Six patients on HD underwent seven pulmonary resections at our institution from 1998 to 2003. The underlying kidney disease was nephrosclerosis in two patients and glomerulonephritis in four. The mean levels of blood urea nitrogen and serum creatinine were 107 ± 11.5 mg/dl and 7.9 ± 0.64 mg/dl, respectively. The mean preoperative PO2 and FEV1 were 77.6 ± 2.4 mmHg and 2.4 ± 0.16 liters, respectively. The histologic diagnosis was squamous cell carcinoma in four cases and adenocarcinoma in three. One patient underwent two lung resections in 4 years for two primary lung cancers. Five patients underwent lobectomy, one underwent a wedge resection, and in one case pneumonectomy was performed after neoadjuvant chemotherapy. There was no operative mortality. Postoperatively, atrial fibrillation occurred in two patients associated with sputum retention in both, and two other patients had hyperkalemia (complication rate 57%). One patient died of cardiac complications 27 months after surgery. The remaining five patients are currently alive with no evidence of disease. Patients on HD who undergo lung resection have a high rate of postoperative complications. Although the underlying disease influences long-term survival, radical lung resection in NSCLC patients is recommended in selected cases. Careful metabolic, hematologic, and pharmaceutical management is mandatory during the perioperative period.

Conservative and Surgical Treatment of Acute Posttraumatic Tracheobronchial Injuries

BackgroundAcute posttraumatic tracheobronchial lesions are rare events associated with significant morbidity and mortality. They are caused by blunt and penetrating trauma, or they are iatrogenic, appearing after intubation or tracheotomy. Although surgery has traditionally been considered the treatment of choice for these injuries, recent reports show that conservative treatment can be effective in selected patients. The aim of this study was to evaluate the role of surgical and conservative management of these lesions, differentiated on the basis of clinical and endoscopic criteria.MethodsFrom January 1993 to October 2010, a total of 50 patients with acute posttraumatic tracheobronchial lesions were referred for treatment to our department. In all, 36 patients had iatrogenic injuries of the airway, and 14 had lesions resulting from blunt or penetrating trauma.ResultsOf the 30 patients who underwent surgery, the lesion was repaired with interrupted absorbable sutures in 29; the remaining patient, with an associated tracheoesophageal fistula, underwent single-stage tracheal resection and reconstruction and closure of the fistula. In all, 20 patients were treated conservatively: clinical observation in 5 patients, airway decompression with a mini-tracheotomy cannula in 4 spontaneously breathing patients, and tracheotomy with the cuff positioned distal to the lesion in 11 mechanically ventilated patients. One surgical and one conservatively-managed patient died after treatment (4% overall mortality). Complete recovery and healing were achieved in all the remaining patients.ConclusionsSurgery remains the treatment of choice for posttraumatic lesions of the airway. However, conservative treatment based on strict clinical and endoscopic criteria—stable vital signs; effective ventilation; no esophageal injuries, signs of sepsis, or evidence of major communication with the mediastinal space—enables favorable results to be achieved in selected patients.

Surgical Treatment of Multiple Primary Adenocarcinomas of the Lung

INTRODUCTION The incidence of lung adenocarcinomas has steadily increased over the last decades. The aim of this study was to assess the results of surgical treatment of multiple primary adenocarcinomas of the lung (MPAL) analyzing the radiological and histological features. METHODS From 1988 to 2005, 26 patients underwent surgical treatment for MPAL at our department, for a total of 52 tumors. Three patients had synchronous and 23 had metachronous tumors. RESULTS Thirty-seven tumors were classified as solid, two as ground-glass opacities (GGO) and 13 as mixed solid/GGO tumors on the basis of CT scan evaluation. Histology revealed 26 adenocarcinomas, five adenocarcinomas with a bronchioloalveolar (BAC) pattern and 21 BAC. There was no postoperative mortality. Five-year survival of patients with synchronous tumors was 66 %. Survival of patients with metachronous tumors was 95 % and 70 % from the first and second operation. Patients with stage II and III a tumors had significantly reduced survival rates ( P < 0.05). Survival was 60 % after lobectomy and 78 % after wedge resection. CONCLUSIONS Surgical treatment of MPAL is associated with favorable results. Sublobar resections, when technically feasible, provide adequate oncological management.

Early surgical repair of isolated traumatic sternal fractures using a cervical plate system.

BACKGROUND We reviewed our experience of the surgical management and follow-up of patients admitted with an isolated traumatic sternal fracture (TSF) to a Thoracic Surgical Unit through the Emergency Department. METHODS During a 5-year period, six patients were surgically treated for an isolated TSF. Presence of physical deformity or acute and persistent pain were considered indications for surgical repair. Surgical repair was performed within 1 week from the trauma by means of a titanium cervical plate system currently in use in spine surgery. RESULTS There were no postoperative complications. Mean hospital stay was 3 days. All patients showed regular sternal healing at 6 to 8 weeks. In one patient the plate was removed after 3 years because of persistent chest discomfort. CONCLUSIONS Early surgical repair of isolated TSF is advocated in cases of physical deformity or acute and persistent pain. The titanium cervical plate system provides effective repair of the fracture with satisfactory long-term results.