Luigi Busiello

Pre-emptive local analgesia in video-assisted thoracic surgery sympathectomy.

OBJECTIVE Our goal is to determine whether infiltration with a short-acting local anaesthetic such as lidocaine before the surgical incision has a pre-emptive effect on postoperative pain intensity and on incidence of paraesthesia in patients undergoing standard thoracoscopic sympathectomy for palmar hyperhidrosis. MATERIAL AND METHODS This prospective study includes a consecutive series of 18 patients undergoing bilateral standard thoracoscopic sympathectomy for palmar hyperhidrosis during January 2005-December 2007. Each patient enrolled in the study was randomised to receive pre-incisional lidocaine with epinephrine infiltration of the wounds on the one side, and normal saline solution on the other. The identical surgery was performed on each side to allow patients to act as their own controls. Then, the side which received local analgesia was compared with the control side with regard to pain control and paraesthesia after 4, 24 and 168 h postoperatively. The patients and investigators were both blinded concerning the side randomised to receive pre-emptive local analgesia (PLA). RESULTS We found that patients reported significantly less pain on the side treated with pre-emptive local anaesthesia in contrast to the control side 4 and 24h after surgery (p=0.001 and p=0.004, respectively). However, that difference decreased with time and was no longer significant 168 h following surgery (p=0.156). Regarding the paraesthesia, the incidence was higher in the control side than the PLA side at 4, 24 and 168 h postoperatively, but the difference was not statistically significant. A total of 17 of 18 (94%) patients noted a change in palmar hyperhidrosis status after surgery. CONCLUSION Our study shows that the pre-injection of local anaesthetic before standard thoracoscopic sympathectomy suppresses the local pain mediators, hence resulting in significantly less pain in the first postoperative 24 h but not thereafter. The clinical impact of the procedure is the possibility of early discharge to home and early return to work with potential economical benefits. However, because of the small number of patients, further studies are needed to corroborate our results.

The role of technetium-99m hexakis-2-methoxyisobutyl isonitrile in the detection of neoplastic lung lesions

OBJECTIVE Our goal was to determine the role of technetium-99m hexakis-2-methoxyisobutyl isonitrile ((99m)Tc-MIBI) in the detection of neoplastic lung lesions. MATERIALS AND METHODS We prospectively studied 79 consecutive patients with indeterminate lung lesion between January 2006 and September 2007. All patients were submitted to (99m)Tc-MIBI single-photon emission chest tomography (SPECT) before invasive diagnostic procedure. Qualitative analysis was performed to evaluate SPECT images in order to localize abnormal activity in the radiologically demonstrated lesion. In addition, semiquantitative analysis was made by calculating tumor/contralateral normal lung ratio (T/N). Finally, the scintigraphic findings were correlated to the histopathological diagnosis obtained by invasive procedure or confirmation of instrumental exams. RESULTS Sixty patients had a malignant lesion: 44 squamous cell carcinoma, 7 adenocarcinomas, 4 large cell carcinoma, 1 small cell lung cancer, and 4 metastases. The mean size+/-standard deviation of malignant nodules was 3.9+/-1.61 cm (range 1.5-5.5 cm). Nineteen patients had a benign disease. The mean size+/-standard deviation of benign nodules was 3.3+/-1.71 cm (range 2-6 cm). (99m)Tc-MIBI SPECT delineated focal lesions with an increase in tracer accumulation in 55/60 malignant lesions; in 5/60 malignant lesions was negative. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 91%, 73%, 91%, and 73%, respectively. In patients with neoplastic lesion, the mean T/N ratio value+/-standard deviation was 1.72+/-0.35 whereas in patients with benign lesions was 1.14+/-0.25. Semiquantitative analysis showed that for a T/N value >1.23, the value of sensitivity, specificity, PPV, and PNV were 91%, 84%, 94%, and 76%, respectively (ROC curve). Metastatic mediastinal lymph nodes were found in 3/57 patients. (99m)Tc-MIBI SPECT showed a specificity and PPV of 100% in the detection of mediastinal lymph nodes with sensitivity, and PNV of 66% and 97%, respectively. Age, sex, histological type, and size of lesion did not affect the SPECT results. CONCLUSION Our experiences seem to confirm that (99m)Tc-MIBI SPECT is a reliable diagnostic tool in the finding of lung cancer particularly cases in which radiological evaluation is indeterminate.

Electrothermal bipolar tissue sealing systems in lung surgery.

Various techniques have been proposed to reduce intraoperative blood loss in surgery. We report our experience with the use of LigaSure, a new electrothermal bipolar tissue sealing system, in lung surgery. This system has been already applied with good results in other surgical fields. However, the experience reported in the literature with the use of this technique in lung surgery is limited. Our clinical series with LigaSure (160 procedures in a 4-year period) is the largest reported to date. Technical aspects, clinical results and an overview of the literature are presented. We believe that LigaSure is an easy and safe technique, suitable for lung surgery. It could be a valid alternative or complement to staplers for several procedures, also in the thoracoscopic setting. Furthermore, it seems to allow functional lung tissue preservation and reduction of surgical supplies costs.

A Surgical Case of Pyothorax-Associated Lymphoma of T-Cell Origin Arising From the Chest Wall in Chronic Empyema

We report a surgical a case of pyothorax-associated lymphoma of T-cell origin arising from the chest wall and developing on pleural sequelae of therapeutic pneumothorax for pulmonary tuberculosis. The tumor was removed with resection of the fifth to eighth ribs. The chest wall defect repaired with a Marlex (Phillips Sumika Polypropylene Co, Houston, TX) prothesis. The histologic, immunohistochemical, and genotypic features were conclusive for a diagnosis of T-cell non-Hodgkin lymphoma. The patient received postoperative chemotherapy and is doing well after 15 months.

Pulmonary hernia secondary to limited access for mitral valve surgery and repaired by video thoracoscopic surgery

Iatrogenic pulmonary hernia is a rare condition. Repair is performed due to persistent symptoms and it is usually carried out by open surgery. We report a case of a 59-year-old woman who developed a lung hernia after small anterior thoracotomy that was performed for mitral valve surgery. The herniated lung is reduced with success by video thoracoscopic surgery and the chest wall defect is repaired by a polypropylene mesh fitted to the thoracic wall. At six-month follow-up, she was asymptomatic and without recurrence of hernia. Our experience suggests that video thoracoscopic surgery is a feasible surgical technique even for lung hernia secondary to mini-thoracotomy. However, before performing video thoracoscopic surgery, several factors preclusive to using this strategy must be considered, including the extensiveness of pleural adhesions due to the time interval between the previous operation and lung hernia, the site and the size of the hernia, and the insufficient experience in video thoracoscopic surgery.

F-18-2-fluoro-2-deoxyglucose positron emission tomography compared to technetium-99m hexakis-2-methoxyisobutyl isonitrile single photon emission chest tomography in the diagnosis of indeterminate lung lesions.

Background:¹⁸FDG-PET plays a significant role in diagnosing malignancy of lung lesions but remains an expensive test available at a limited number of sites in Italy. Objective: We prospectively compare the diagnostic accuracy of ^99mTc-MIBI- SPECT and ¹⁸FDG-PET in patients with indeterminate lung lesions to demonstrate that ^99mTc-MIBI-SPECT may be considered as a valid alternative when ¹⁸FDG-PET is not available. Methods: 52 patients with indeterminate lung lesion were examined by ¹⁸FDG-PET and ^99mTc-MIBI-SPECT before surgery. The scintigraphic findings were analyzed visually and semiquantitatively and then correlated to the definitive diagnosis. Results: 38 were malignant lesions while 14 were benign. At visual analysis, the sensitivities of ¹⁸FDG-PET and ^99mTc-MIBI-SPECT were 92 and 84%, respectively (McNemar test p = 0.4), whereas the specificities were 78.6 and of 93% (p = 1.0), respectively. At semiquantitative analysis, ¹⁸FDG-PET showed a sensitivity and specificity of 92 and 71.4%, respectively, while ^99mTc-MIBI-SPECT produced a sensitivity and specificity of 86 and 100%, respectively (p = 0.194). For lymph node staging, ¹⁸FDG-PET and ^99mTc-MIBI-SPECT have a sensitivity and specificity of 88 and 92 of 77 and 100%, respectively. Conclusion:^99mTc-MIBI-SPECT is similar to ¹⁸FDG-PET in the detection of lung malignancies and represents an alternative when PET is not available. Yet, the combination of both techniques may improve patient selection for surgery.