Paolo Lucciarini

Natural history of bronchopleural fistula after pneumonectomy: A review of 96 cases

BACKGROUND Various therapeutic approaches to bronchopleural fistula have been reported. Its natural history, which may be key to the best therapeutic management, early detection, and possibly, prevention of fistula formation, has received little attention. METHODS The cases of 96 patients with bronchopleural fistula after pneumonectomy seen over a 13-year period (1982 to 1995) were retrospectively analyzed. Cancer, TNM stage and histology, age, sex, side and size of the fistula at primary bronchoscopic diagnosis, time of occurrence after operation (days), cause of death, and survival after fistula formation (days) were analyzed. Management consisted of bronchoscopic closure with fibrin sealant or decalcified spongy calf bone or both, repeat thoracotomy with resection of the bronchial stump, thoracoplasty, or open window thoracostomy. RESULTS Except for one instance, all total stump dehiscences occurred within 90 days after operation. Sixty-four patients (67%) died during the observation period; in 25, the cause of death was aspiration pneumonia. Only 2 patients who died of aspiration pneumonia had development of a fistula after 90 postoperative days. The aspiration rate dropped with increasing interval between operation and fistula occurrence (p = 0.000). Patient survival after fistula formation was positively correlated to this interval (p = 0.002). Successful fistula closure was achieved by surgical intervention in 21 patients and endoscopically in 11 patients. The overall postoperative mortality rate irrespective of treatment method was 31%. CONCLUSIONS The incidence of aspiration pneumonia declines sharply if bronchopleural fistula occurs more than 3 months after operation. Formation of fibrothorax apparently represents a natural protection against fistula formation and subsequent fatal aspiration pneumonia. Close follow-up during the first 3 postoperative months should detect bronchopleural fistula before aspiration occurs.

Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases

BACKGROUND The value of bronchoscopic sealing of bronchopleural fistulas was studied retrospectively. METHODS The cases of 45 patients seen between 1983 and 1996 with bronchopleural fistula after pneumonectomy (40 patients) or lobectomy (5 patients) were reviewed. Age, underlying disease, side, fistula size (millimeters) at initial bronchoscopy, survival (days) after endoscopic treatment, mode and number of endoscopic interventions, interval (days) between operation and fistula occurrence, and pathologic TNM stage in the case of malignancy were recorded. On the basis of the therapeutic outcome (cure, death, chronic empyema with closed fistula, or chronic empyema with open fistula) and the modality (successful sealing or bronchoscopic failure with subsequent surgical intervention), various groups were assessed and compared. RESULTS Of 29 patients (64%) treated only endoscopically, 9 were cured. Seven patients had fistula closure, but persistent chronic empyema necessitated permanent drainage. In another 7 patients, the fistula remained open and also was controlled by permanent drainage. Six patients in this group died. The overall rate of fistula closure was 35.6% (16 patients), and recurrence occurred in 2 patients. Sixteen patients (35.6%) required surgical intervention because of increasing fistula size (8 patients), sepsis with refractory empyema (7), and fecal empyema (1 patient). Two patients in the surgical group died. Small fistulas (<3 mm) responded particularly well to primary endoscopic treatment. CONCLUSIONS Bronchoscopic treatment of bronchopleural fistula appears an efficient alternative, especially when surgical intervention cannot be done because of the physical condition of the patient.

Intraoperative complications during VATS lobectomies from conversion to minimally-invasive “trouble-shooting”

The aim of this study was to explore intraoperative complications during video-assisted thoracoscopic surgery (VATS) lobectomy. Vascular and bronchial injuries, after a robust learning curve, can be sometimes successfully managed by VATS. During a VATS lobectomy, it is necessary: to be prepared in potentially dangerous situations; to think about strategies to handle intraoperative complications and to share these strategies with your own staff. Herein we present some videos showing cases where vascular injuries led to conversion and others where a minimally-invasive trouble shooting of intraoperative complications was achieved.

Video-assisted thoracoscopic pneumonectomy: a minimally invasive approach for a rare inidication

Minimally invasive video-assisted thoracoscopic surgery (VATS) is considered as an alternative to thoracotomy for early stage lung cancer. Since 2009, we use a VATS approach for all early stage lung tumors as well as benign indications for lung lobectomy. As experience with the technique is growing, indications are expanded. Here, we report our first minimally invasive pneumonectomies of two patients with non-small cell lung cancer (NSCLC). Case 1: A 60-year-old man was diagnosed with a centrally located tumor of the right lung invading all three lobes without any obvious lymph node metastasis in the preoperative work-up. The patient was scheduled for a right-sided VATS pneumonectomy. Case 2: A 62-year-old woman was diagnosed with a centrally located tumor of the left lung with an ipsilateral positron emission tomography (PET) positive lymph node (aortopulmonary window). After neoadjuvant treatment, the patient was scheduled for a left-sided pneumonectomy. Written informed consent was given in both cases. The procedures were completed using three incisions. A complete mediastinal lymph node dissection was performed. The postoperative courses were uneventful. VATS pneumonectomy is feasible in highly selected cases. It offers all advantages known from minimally invasive lung lobectomy with less pain and faster rehabilitation, which might facilitate the delivery of adjuvant treatment.

A critical comparison of robotic versus conventional laparoscopic splenectomies. Commentary

The benefit of robotic systems for general surgery is a matter of debate. We compare our initial series of robotic splenectomies with our first series of conventional laparoscopic ones. A retrospective analysis of the first six robotic versus the first six conventional laparoscopic splenectomies is presented. Patients were matched with regard to age, body-mass index, ASA score, and preoperative platelet levels. All procedures were performed by a single surgeon. Size and weight of the resected specimens were comparable in both groups. Median overall operating time was 154 (range, 115-292) min for the robotic and 127 (range, 95-174) min for the laparoscopic group. No complications occurred. There were no open conversions. The median postoperative hospital stay was 7 (robotic group) and 6 (laparoscopic group) days. Median average costs were

Robotic-assisted thoracoscopic surgery (RATS) for benign and malignant esophageal tumors

6927 for the robotic procedure versus

Video-Assisted Thoracoscopic Surgery versus Robotic-Assisted Thoracoscopic Surgery Thymectomy

4084 for the conventional laparoscopic procedure (p < 0.05). Minimally invasive splenectomies are feasible using either conventional laparoscopic techniques or the da Vinci robotic system. In this analysis, procedures performed with the da Vinci robotic system resulted in prolonged overall operative time and significantly higher procedural costs. The use of a robotic system for laparoscopic splenectomy offers, at this stage, no relevant benefit and thus is not justified.