Marcello Migliore

Efficacy and safety of single-trocar technique for minimally invasive surgery of the chest in the treatment of noncomplex pleural disease

OBJECTIVE To assess the efficacy and the safety of a single-trocar technique for minimally invasive surgery of the chest in the management of multiple noncomplex thoracic diseases, a prospective study was performed and the results are presented. METHODS Between October 1998 and December 2001, 100 patients underwent video-assisted thoracic surgery through a single trocar. The patients were divided into 4 groups as follows: (1) benign, (2) malignant, (3) pleural effusion, and (4) empyema. The following data were analyzed: age, sex, forced vital capacity, forced expiratory volume in 1 second, percentage of the predicted forced expiratory volume in 1 second, type of anesthesia, anesthesia time, surgery time, intraoperative complications, morbidity, chest tube removal, hospital stay, and follow-up. RESULTS The patient population consisted of 64 men and 36 women with a mean age of 62 years (range 31-92 years). General anesthesia was used in 53 patients (25 double-lumen and 28 single-lumen tube) and local anesthesia and sedation in 47 patients. Talc pleurodesis was performed in 55 patients. Mean operative time was 65 +/- 37 minutes, 48 +/- 18 minutes for simple and 67 +/- 37 minutes (P =.004) for complex pleural effusion. Mean anesthesia time was 102 +/- 85 minutes. Chest tubes were removed after 5 +/- 2 days. Mean overall hospital stay was 6 +/- 3 days, 5 +/- 2 days for benign diseases, 7 +/- 3 days for malignant diseases, and 8 +/- 3 for empyema. Morbidity was present in 19 patients. Two patients had intraoperative bleeding; 1 required a mini-thoracotomy to control it. There was no hospital mortality. Three patients had wound infection, and no patient with malignant diseases had port site metastasis. CONCLUSION Video-assisted thoracic surgery through a single trocar is simple, effective, and beneficial for all patients in the diagnosis and treatment of noncomplex diseases of the chest. Furthermore, with this newest type of technologically advanced instrumentation it is possible to carry out simple intrathoracic procedures without using additional ports.

Pulmonary vein gas analysis for assessing donor lung function.

BACKGROUND Radial artery oxygenation (PaO2) is the standard method for assessing potential lung donors. This study was proposed to assess the use of pulmonary vein gases (PvO2) in selection of donor lung for transplantation. METHODS We studied 170 lungs from 85 consecutive donors. Lungs were classified into group A, PaO2 and PvO2 > 300 mm Hg; group B, PaO2 < 300 mm Hg, and PvO2 > 300 mm Hg; and group C, PvO2 < 300 mm Hg. RESULTS Lungs retrieved from group A and group B were used for transplantation. Allograft function, assessed by the arterial and alveolar oxygen tension ratio, was similar at 12 hours and at 24 hours after operation (0.69, 0.73, vs 0.70, 0.71, for groups A and B, respectively (p = 0.8, 0.7, respectively). Similar radiologic appearance was seen in both groups (p = 0.2). Median duration of intubation was also similar (p = 0.6). The 30-day mortality rate was 12% versus 11.3% (p = 0.8), and 1-year survival rate was 80% versus 82% (p = 0.8) for recipient received lungs from group A and B donors, respectively. CONCLUSIONS Selective pulmonary veins analysis gives an accurate assessment of individual gas exchange in comparison with arterial PaO2, identifying more potential donor lungs for transplantation.

FBLN-3 as a biomarker of pleural plaques in workers occupationally exposed to carcinogenic fibers: a pilot study

FBLN-3 has recently been proposed as a biomarker for malignant mesothelioma. A significantly increased standardized mortality rate from malignant mesothelioma has been reported in Biancavilla, Italy. Its cause has been identified in environmental exposure to fluoro-edenite. The aim of this study was to seek a correlation between plasma FBLN-3 concentration and pleural plaques in subjects exposed to fluoro-edenite and in a nonexposed control group. Pleural plaques was never detected in the control group, whereas it was found in 52% of exposed subjects. Median FBLN-3 concentrations were 12.96 and 5.29 ng/ml in the exposed and the control group, respectively (p < 0.001). FBLN-3 plasma levels exhibited a high predictive value for the presence of pleural plaques.

A single-trocar technique for minimally invasive surgery of the chest

BackgroundIn thoracic surgery, the classic thoracoscope is used to perform simple maneuvers in the chest. We have devised a minimally invasive technique that requires only a single trocar. This technique is used in our department to diagnose and treat a wide range of thoracic pathologies.MethodsBetween October 1998 and August 1999, 37 patients underwent surgery prospectively for a thoracic disease through a single trocar. There were 19 men and 18 women with a mean age of 60 years (range, 40–85). The trocar was flexible or soft and had a diameter of 15–20 mm. A 2-cm skin incision was made in the planned intercostal space. The chest drain was always inserted under video control.ResultsThe mean operative time was 53 ± 5 min. One patient developed intraoperative bleeding that required intubation and a 5-cm mini-thoracotomy. In one patient with stage II empyema, it was necessary to insert another trocar. Chest tubes were removed after 77.7 ± 7 h. Hospital stay was 4 ± 1 days (range, 2–14). Histologic examination revealed malignant disease in 26 cases and benign disease in 11. Two patients (5.4%) developed wound infections. None of the patients had port site metastasis. There were no hospital deaths.ConclusionBecause of its simplicity, we recommend the use of this mini-invasive technique in place of the classic thoracoscope or video-mediastinoscope.

Cervico-mediastinal goiter: is telescopic exploration of the mediastinum (video mediastinoscopy) useful?

Surgeons are aware that most mediastinal goiters can be excised through a Kocher transverse collar incision, but in rare circumstances a partial-complete median sternotomy or a thoracotomy are mandatory. During an operation to remove a large cervico-mediastinal goiter (CMG) a profound, not massive, bleeding in the anterior mediastinum developed. Bleeding was unsuccessfully treated with packing. Instead, to perform an urgent sternotomy we used telescopic imaging to identify the source of hemorrhage, and a metallic clip was used to stop the bleeding. Since then we have prospectively used the telescope in the case of large CMG causing compression of an adjacent structure. This report is a preliminary communication demonstrating the technique. Telescopic exploration of the mediastinum was performed in seven patients. The goiters were located in the middle mediastinum in five patients and in the anterior and middle mediastinum in one, respectively. The use of a telescope can help the surgeon during the removal of a large mediastinal goiter. It facilitates a) the visualization of the intrathoracic tributaries reducing the risk of hemorrhage, b) the research of ectopic thyroid gland, and finally c) minimizes the risk of complications of a median sternotomy.

The place of Belsey Mark IV fundoplication in the era of laparoscopic surgery

OBJECTIVES Laparoscopic fundoplication to correct or avoid gastroesophageal reflux decreased Belsey Mark IV fundoplication (BMIV) dramatically worldwide. The purpose of this paper was to determine the role of BMIV and its current indications. METHODS We reviewed all patients who underwent fundoplication between April 1997 and December 2001. All patients underwent a complete work-up included barium meal, endoscopy, 24-h pH-metry and manometry preoperatively. RESULTS Sixty-two consecutive fundoplications were performed. There were 23 males and 39 females. Forty-six patients were treated by laparoscopic approach (37 patients with total and nine patients with partial fundoplication). BMIV was preferred in 16 patients with the following indications: reoperations for failed oesophageal surgery (5), hiatal hernia fixed in the chest (4), epiphrenic oesophageal diverticula (3), diffuse oesophageal spam (2), hiatal hernia associated with bullous emphysema (1), leiomyoma of the oesophago-gastric junction (1). Excellent to good results were reported in 14 patients and poor in two. Follow-up was completed in all patients. CONCLUSIONS BMIV remains a valid fundoplication although the current indications are now limited. The technique is to be considered an additional, but necessary, weapon for thoracic surgeons with interest in oesophageal disease.

Cytoreductive surgery and hyperthermic intrapleural chemotherapy for malignant pleural diseases: preliminary experience

Cytoreductive surgery and hyperthermic-intraoperative-intrapleural-chemotherapy (HITHOC) is a known approach for malignant pleural diseases (MPD). This study was started to clarify the role of cytoreductive surgery and HITHOC in MPD. Criteria of inclusion were early-stage disease in malignant pleural mesothelioma (MPM), young age, good condition and selected stage-M1a lung cancer. Six patients with MPM and two patients with lung cancer were enrolled. After surgical debulking, intrapleural cisplatin was administered for 60 min at 42.5°C. Wedge, rib resection and repaired diaphragm were added in three, one and one patient, respectively. Morbidity, toxicity and mortality was nil. Hospital stay was 8 days. Mean survival is 13.6 months. This experience confirms that cytoreductive surgery and HITHOC is a good option in the treatment of MPD. A randomized controlled trial is necessary.

Finding the evidence for pulmonary metastasectomy in colorectal cancer: the PulMicc trial

The PulMiCC trial is a randomized controlled trial testing the effect on survival of pulmonary metastasectomy in patients with colorectal cancer. In stage 1 of the trial patients with treated primary colorectal cancer metastatic to the lungs are invited to consent for protocol-based evaluation of their suitability for metastasectomy. The evaluation is as in current practice and includes PET/CT. A decision for or against metastasectomy may be based on the opinion of the clinicians and the preference of the patient. If there is uncertainty the patient is invited to consent to have the treatment arm assigned by randomization in stage 2 of PulMiCC. More than 300 patients have entered stage 1 and more than 70 are in stage 2.

Episodic Abdominal and Chest Pain in a Young Adult

-dominal pain for a year. He stopped playing water polo because of re-current severe abdominal pain in his right and left upper quadrant. Hewas evaluated for suspected pancreatitis, but all diagnostic results were unre-markable. A few weeks later he was admitted for acute chest pain, and again alldiagnostic results were unremarkable. In 1 year the patient had 7 hospital ad-missions for abdominal or chest pain with no episodes of fever, chills, sweats,or cough. There is no history of trauma. The patient is currently treated withketoprofen, oral morphine, and anxiolytic drugs. He spends almost all day inbed but is unable to sleep in a prone position and has pain in his throat. He hastaken a leave of absence from college and reduced his social activities. The pa-tienthasreceivedinjectionsofcortisoneandketoprofeninthexiphoidareaad-ministered 10 days apart; however, pain persists. Physical examination is re-markableforconsiderablepainoverthexiphoidonpalpation.Slightpainiselicitedonexaminationoftherightsecondandthirdsternocostalcartilages.Chestcom-puted tomography (CT) has been performed several times with interpretationsranging from osteochondritis to xiphoid fracture (

Persistent hyperparathyroidism owing to a giant parathyroid adenoma in posterior mediastinum.

A 65-YEAR-OLD WOMAN presented to our observation with persistent hypercalcemic syndrome 4 months after a total thyroidectomy for a goiter associated with hypercalcemic syndrome. At that time, operative bilateral cervical exploration revealed 4 normal parathyroid glands. Postoperatively, the hypercalcemic syndrome did not disappear, and calcium and parathyroid hormone levels remained elevated. Chest tomography showed the presence of a ‘‘missed’’ 7-cm mass in the posterior mediastinum, which was confirmed on sestamibi scintigraphy. Remedial right videoassisted minithoracotomy was performed, and the mass removed. It descended to the level of azygous vein and was adherent to the esophagus and the trachea (Figure). Histology confirmed the presence of a large parathyroid adenoma weighing 95g. The calcium and parathyroid hormone levels returned to normal after surgery. The patient is symptom free 5 years postoperatively.