Roberto Crisci

Is video-assisted thoracic surgery justified at first spontaneous pneumothorax

OBJECTIVE The fundamental role of video-assisted thoracic surgery (VATS) in the treatment of spontaneous pneumothorax is generally acknowledged today. This study intends to evaluate whether VATS is justified at the onset of a first spontaneous pneumothorax through analysis of parameters tested on two group of patients treated respectively with pleural drainage and VATS. PATIENTS/METHODS The study includes 70 patients affected by first spontaneous pneumothorax divided into two groups of 35 patients for the purpose of therapeutic treatment. The first group underwent pleural drainage while the second underwent VATS. Parameters analyzed were as follows: (1) prolonged air leaks (more than 6 days); (2) time required for pleural drainage; (3) time of hospital stay; (4) management costs; (5) recurrences (follow-up at 12 months). RESULTS Prolonged air leaks occurred in four patients (11.4%) in the first group and two patients (5.7%) in the second; recurrences occurred in eight patients in the first group (22.8%), and only one in the second group (2.8%). Mean time for drainage and hospitalization was, respectively, 9 and 12 days in patients with pleural drainage against 3.9 and 6 days of those using VATS. Average management costs per patients including hospitalization was calculated at

Preoperative pulmonary rehabilitation in patients with lung cancer and chronic obstructive pulmonary disease

2,750.00 per patient for the first group compared with

18-fluorine fluorodeoxyglucose positron emission tomography with computerized tomography versus computerized tomography alone for the management of solitary lung nodules with diameters inferior to 1.5 cm.

1,925.00 for the second group. CONCLUSIONS The use of VATS at first spontaneous pneumothorax is justified in the interest of both patients and health administrations as demonstrated by the number of recurrences in patients in the first group and economy savings resulting from use of VATS.

MR study of N2 disease in lung cancer: contrast-enhanced method using gadolinium-DTPA

OBJECTIVES Impaired cardiopulmonary reserve is the main cause of inoperability in non-small-cell lung cancer (NSCLC). This study aims to evaluate the role of a preoperative pulmonary rehabilitation (PPR) programme in the improvement of functional parameters, which can enable an increase in the number of patients eligible for surgery. METHODS From January 2008 to June 2011, we observed a uniform group of 27 patients with NSCLC and chronic obstructive pulmonary disease (COPD). It showed: (i) a body mass index of 21.5 ± 2 kg/m2;; (ii) forced expiratory volume in 1 s (FEV(1)) of 1.14 ± 0.7 l; (iii) maximal peak of oxygen consumption (VO(2)max) of 12.9 ± 1.8 ml/kg/min; (iv) carbon monoxide diffusing capacity (DLCO) of 72 ± 3% predicted; (v) stage IB of lung cancer. All patients underwent a 4-week PPR programme, 6 days a week and were re-evaluated before inclusion for surgery. RESULTS The rehabilitation programme was completed by all patients and extended by 2 weeks in nine patients, in order to obtain a further functional improvement. A statistically significant increase has been in the values of PaO(2) (60 ± 10 vs 82 ± 12 mmHg), of VO(2)max (12.9 ± 1.8 vs 19.2 ± 2.1 ml/kg/min, P = 0.00001) and of FEV(1) (1.14 ± 0.7 vs 1.65 ± 0.8 l, P = 0.02). All patients underwent a lobectomy, with a postoperative morbidity of 15%. CONCLUSIONS A 4 to 6-week PPR programme prepares the NSCLC and COPD patients properly for the surgical approach, reducing the functional limitations of inoperability.

Giant bullous emphysema resection by VATS. Analysis of laser and stapler techniques

OBJECTIVE Aim of the study was to establish a noninvasive method for the preoperative characterisation of a pulmonary nodule when biopsy of the small mass is impossible. METHODS From 1 January 2006 to 31 December 2008, we observed 124 asymptomatic patients with a noncalcified single lung nodule highlighted by computerised tomography (CT) of the thorax. Patients were divided into 2 groups: Group A consisted of 57 patients with lesion diameters between 0.5 cm and 0.99 cm; Group B consisted of 67 patients with lesion diameters between 1.0 cm and 1.5 cm. Fibreoptic bronchoscopy was negative for endobronchial neoformation in all patients. The topographic distribution of the lesions advised against CT-guided transthoracic needle biopsy or video-assisted thoracoscopy. All patients had preoperative 18-fluorine fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) associated with CT of the thorax, which was compared with CT for evaluation of the mass. RESULTS Postoperative histological diagnosis revealed 54 primary lung cancers, 47 lung metastases and 23 benign lesions. In Group A the sensitivity of 18F-FDG PET/CT and CT was 95 % and 73 % and the specificity was 72 % and 64 %, respectively ( P = 0.000001 for 18F-FDG PET/CT; P = 0.000177 for CT). In Group B the sensitivity of 18F-FDG PET/CT and CT was 95 % and 97 %, and the specificity was 80 % and 87 %, respectively ( P = 0.000001). CONCLUSIONS Our study shows that 18F-FDG PET/CT improves the identification and characterisation of potentially malignant pulmonary nodules with a diameter < 1 cm. This technique could be a valid alternative to a surgical approach, currently the main method to investigate indeterminate lung nodules.

Fantoni translaryngeal tracheostomy versus ciaglia blue rhino percutaneous tracheostomy: A retrospective comparison

OBJECTIVE In several previous studies, including one of our own, CT and MRI provided similar information on N2 detection in the staging of lung cancer. Both imaging techniques can be considered effective in detecting enlarged mediastinal lymph nodes but the results are often inaccurate when confronted with pathological findings. The purpose of this study was to assess the diagnostic accuracy of gadolinium-DTPA enhanced MRI in the detection of mediastinal lymph nodes in lung cancer. METHODS A prospective study to compare standard unenhanced MRI and Gd-DTPA enhanced MRI was carried out in patients with diagnosed lung cancer. The study focused on the status of mediastinal lymph nodes. Gd-DTPA was administered at a dosage of 0.2 mmol2/KG before T1 weighted sequences. Qualitative visual analyses of both standard and contrast enhanced MRI images were performed on each patient by 2 independent radiologists. The imaging results were then compared to pathological findings obtained after surgical operation. RESULTS In the identification of mediastinal lymph node metastases standard MRI was 62% sensitive, 100% specific and 74% accurate whereas Gd-DTPA enhanced MRI was 100% sensitive, 91% specific and 97% accurate. CONCLUSIONS Gd-DPTA enhanced MRI was more accurate than standard MRI in the detection of metastatic lymph nodes in patients with lung cancer. These initial results can be considered encouraging especially with regards to the reduction of false negative findings although further confirmation is, understandably, required.

Right Diaphragm Spontaneous Rupture: A Surgical Approach

OBJECTIVE Advances in video-assisted thoracic surgical (VATS) technique led the authors to reconsider the treatment and thoracoscopic management of patients with giant bullous emphysema (GBE). METHODS From January 1993 to December 2001 we treated 40 patients with unilateral GBE: 24 males and 16 females, mean age 51+/-1 years. Thirty patients presented respiratory insufficiency, seven patients a spontaneous pneumothorax and three patients a bullae infection. Excision was performed by using Nd:YAG laser in five patients (12.5%) and stapling device in 35 patients (87.5%). Among the last 35, in 20 patients a partial pleurectomy stripping up to the 5th intercostal space was associated. In 15 patients this technique was modified through the systematic application of polytetrafluoroethylene (PTFE) to reinforce stitches. RESULTS We experienced one conversion to open thoracotomy owing to haemorrhaging, in one patient who underwent a partial pleurectomy stripping. In the stapler resection patients, with PTFE application, the mean duration of air leaks, for type 1 bullae of Wakabayashi was 2.2+/-1.8 days and, for type 4, 5.9+/-1.4 days; the mean length of hospital stay was 6.1+/-0.5 days. CONCLUSIONS The resection in VATS of giant bullous emphysema by stapling device associated to reinforcement in PTFE reduces duration of air leaks and hospitalisation and improves pulmonary function.

Use of demineralized bone matrix and plate for sternal stabilization after traumatic dislocation.

PurposeTo compare the operative technique and complications of the Fantoni tracheostomy (TLT) with those of the Ciaglia Blue Rhino tracheostomy (CBR). We also compared the costs of mini-invasive tracheostomy with those of surgical tracheostomy (ST).MethodsBetween January 1998 and January 2006, 530 patients needed emergency intubation and protracted assisted ventilation in our department. We performed 470 mini-invasive tracheostomies: as TLT in 350 and as CBR in 120. The time between intubation and tracheostomy was 4 ± 1 days. Interventions were carried out in our intensive care unit (ICU).ResultsOne hundred and nine patients died within 20 ± 5 days of intervention, but 361 are still alive after 100 ± 3 months. TLT and CBR complications were independent of the operative technique (P = 0.74, r = 0.285 vs P = 0.61, r = 0.271) or procedure time (P = 0.95, r = 0.297 vs P = 0.92, r = 0.295). Ciaglia Blue Rhino tracheostomy was noted to have a cost-benefit advantage over TLT and ST (P = 0.0002, P = 0.009, P = 0.22, respectively). The average time until decannulation was 20 ± 1 days.ConclusionsMini-invasive tracheostomies are easy, safe, and fast. Ciaglia Blue Rhino tracheostomy took less time to perform and had fewer complications than TLT, because the technique was simpler.

Cost-effectiveness analysis of sealant impact in management of moderate intraoperative alveolar air leaks during video-assisted thoracoscopic surgery lobectomy: a multicentre randomised controlled trial

We present a case of spontaneous rupture of the diaphragm, characterized by nonspecific symptoms. The rapid diagnosis and appropriate surgical approach led to a positive resolution of the pathology.

Necrotizing mediastinitis linked to Boerhaave's syndrome: a surgical approach.

Traumatic sternal segments dislocation is a rare pathology that is on the increase because of road accidents. Ideal treatment is controversial as it is a benign non-life-threatening lesion. The few cases reported in the literature do not shed light on any preferred procedure. In the present study, three patients were treated by surgical steel monofilament and eight by titanium screws and plates and demineralized bone matrix. The reduced hospitalization, rapid functional recovery, and excellent aesthetic results of the titanium patients make use of the surgical approach inevitable.