Roberto Giobbe

Neurophysiologic assessment of nerve impairment in posterolateral and muscle-sparing thoracotomy

OBJECTIVE This study was aimed at analyzing the degree of intercostal nerve impairment in posterolateral and muscle-sparing thoracotomy and at correlating the nerve damage to the severity of long-lasting postthoracotomy pain. METHODS Neurophysiologic recordings were performed 1 month after either posterolateral or muscle-sparing thoracotomy to assess the presence of the superficial abdominal reflexes (mediated in part by the intercostal nerves), the somatosensory-evoked responses after electrical stimulation of the surgical scar, and the electrical thresholds for tactile and pain sensations of the surgical incision. RESULTS The patients who underwent a posterolateral thoracotomy showed a higher degree of intercostal nerve impairment than the muscle-sparing thoracotomy patients as revealed by the disappearance of the abdominal reflexes, a larger reduction in amplitude of the somatosensory-evoked potentials, and a larger increase of the sensory thresholds to electrical stimulation for both tactile perception and pain. In addition, these neurophysiologic parameters were highly correlated to the postthoracotomy pain experienced by the patients 1 month after surgery, indicating a causal role for nerve impairment in the long-lasting postoperative pain. CONCLUSIONS This study shows for the first time the pathophysiologic differences between posterolateral and muscle-sparing thoracotomy and suggests that the minor long-lasting postthoracotomy pain in muscle-sparing thoracotomy patients is partly due to a minor nerve damage. In addition, because nerve impairment is responsible for the long-lasting neuropathic component of postoperative pain, it is necessary to match specific treatments to the neuropathic pain-generating mechanisms.

Control of postoperative pain by transcutaneous electrical nerve stimulation after thoracic operations

BACKGROUND Transcutaneous electrical nerve stimulation (TENS) has been used extensively to control postoperative pain, but its effects are controversial. This is probably due to the different types of operations performed and, therefore, to the varying intensity of postoperative pain. Here we present an extensive study with TENS in 324 patients who underwent different types of thoracic surgical procedures: posterolateral thoracotomy, muscle-sparing thoracotomy, costotomy, sternotomy, and video-assisted thoracoscopy. METHODS Each patient cohort was randomly subdivided into three treatment groups: TENS, placebo TENS and control. The effectiveness of TENS was assessed by two factors: the time from the beginning of treatment to the request for further analgesia and the total medication intake during the first 12 hours after operation. RESULTS Whereas posterolateral thoracotomy produced severe pain, muscle-sparing thoracotomy, costotomy, and sternotomy caused moderate pain, and video-assisted thoracoscopy caused only mild pain. The TENS treatment was not effective in the posterolateral thoracotomy group, but it was useful as an adjunct to other medications in the muscle-sparing thoracotomy, costotomy, and sternotomy groups. In contrast, representing the only pain control treatment with no adjunct drugs, it was very effective in patients having video-assisted thoracoscopy. CONCLUSIONS These findings show that TENS is useful after thoracic surgical procedures only when postoperative pain is mild to moderate; it is uneffective for severe pain.

Descending necrotizing mediastinitis: surgical management

OBJECTIVE Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. METHODS Between April 1994 and April 2000, 13 patients, mean age 39.23+/-18.47 (median 38, range 16-67) years, with DNM were submitted to surgical treatment. Primary odontogenic abscess occurred in six, peritonsillar abscess in five and post-traumatic cervical abscess in two patients. Diagnosis was confirmed by computed tomography (CT) of the neck and chest. All patients underwent surgical drainage of the cervico-mediastinal regions by a bilateral collar incision associated with right thoracotomy in ten cases. RESULTS Six patients out of 13 required reoperation. Two patients previously submitted only to cervical drainage required thoracotomy; four patients, which have been submitted to cervico-thoracic drainage, underwent contralateral thoracotomy in two cases and ipsilateral reoperation in two cases. Ten patients evolved well and were discharged without major sequelae; three patients died of multiorgan failure related to septic shock. Mortality rate was 23%. CONCLUSION Early diagnosis by CT of the neck and chest suggest a rapid indication of surgical approach to DNM. Ample cervicotomy associated with mediastinal drainage via large thoracotomic incision is essential in managing these critically ill patients and can significantly reduce the mortality rate for this condition, often affecting young people, to acceptable values.

Combined radiosurgical treatment of pancoast tumor

Operative technique and long-term results of 60 consecutive patients with Pancoast tumor treated with combined radiosurgical treatment were evaluated. External radiation therapy was administered preoperatively in a dose of 30 Gy in 50 patients. Operation was considered radical (R0) in 36 patients (60%). A microscopic invasion of the margin of resection (R1) was observed in 5 patients (8.3%). In 19 patients (31.6%) the operation was considered presumably not radical (R2). Three patients died in the postoperative period (5%). Fourteen major postoperative complications occurred in 13 patients (21%). Seven patients had recurrence of pain postoperatively. Overall 3- and 5-year actuarial survival rates were 34% and 17.4%, respectively. The corresponding figures for the R0 and combined R1-R2 groups were 45.8% and 23.5% (R0), and 11.4% (R1-R2; no 5-year survivors were observed in this group) (p < 0.025). Median survivals in the R0 and combined R1-R2 patients were 19 and 7 months, respectively. Different median survivals for the patients with residual tumor were as follows: intervertebral foramina, 5 months; subclavian artery (isolated), 9 months; subclavian artery (in association), 7 months; brachial plexus, 4 months; and vertebral body, 7 months. We conclude that combined radiosurgical treatment represents a valuable therapeutic option in the treatment of Pancoast tumor. In case of residual tumor a poor outcome may usually be anticipated, but in the majority of these patients the operation permits good control of the pain.

Videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease

OBJECTIVE Interstitial lung diseases (ILD) require lung biopsy for the diagnosis in more than 30% of patients. Open lung biopsy (OLB) was generally considered the most reliable method of biopsy and tissue diagnosis. This study tests the diagnostic accuracy and safety of the videothoracoscopic lung biopsy (VTLB) in the diagnosis of ILD. METHODS During the last 5 years, 58 patients were submitted to VTLB under general anesthesia. The mean age was 49.6 +/- 12.0 years (range 21-69). All the biopsies were performed by an endostapler EndoPath 30 or 45. Conversion to minithoracotomy was necessary in only one patient because of extensive pleural sinfisis. All the specimens were sent to the microbiology and pathology department for microbiological and histopathological diagnosis. One chest-tube (28F) was positioned and connected to a drainage-system and placed on suction. RESULTS The histopathological diagnosis was obtained for all patients and therefore the diagnostic accuracy of the procedure was 100%. No postoperative haemothorax occurred and only two patients experienced a prolonged air-leakage (3.4%). The median duration of the chest-drain was 3 days (range 1-7) and the median hospital stay was 4 days (range 2-7). CONCLUSION VTLB provides adequate specimen volume for histopathologic diagnosis and achieves a very high diagnostic accuracy (100% in our series). The postoperative morbidity and mortality rates are lower than those related to OLB. We conclude that VTLB is an effective and safe procedure in the diagnosis of ILD.

The management of malignant pleural mesothelioma

there was a local recurrence of the tumor 2 years after the last operation on the thorax (right upper lobe of the lung, right pulmonary hilum, and behind the sternum). Surgical resection was not indicated because a right pneumonectomy under permanent left phrenic paralysis would have been necessary for a complete resection. Concurrent chemoradiotherapy using cisplatin (10 mg) 1 5-FU (50 mg) twice a week for 1 month (irradiation 66 Gy totally) was effective and the patient is doing well 1.5 years after treatment and 16 years after the primary operation. I would like to emphasize the importance of long-term follow up of the patient with this tumor. In our case, the first local recurrence was seen 5 years after the primary operation followed by prophylactic adjuvant chemotherapy. In recent reports, Tsuchida et al. [2] described one long-term survivor of this tumor who had a recurrence 6 years after the primary operation and another who had a recurrence 8 years after the primary operation. It would be suggested that this tumor is malignant but slow-moving. Body CT scanning is required for long-term postoperative follow-up to find small tumor recurrences and it would be concluded in the early surgical intervention. In conclusion, because this is a rare tumor, it is very difficult to collect evidence for appropriate treatment in a prospective study. As thoracic oncologists, it is our responsibility to report our experiences with these cases on a global scale.

Adenosquamous lung carcinomas: A histologic subtype with poor prognosis

INTRODUCTION The aim of this study is to evaluate the prognostic factors and outcome of patients operated for adenosquamous (ADS) carcinoma of the lung, in comparison with adenocarcinoma (AD) and squamous cell carcinoma (SCC). METHODS a retrospective review of our thoracic cancer surgical database for patients operated for ADS, SCC and AD between January, 1995 and December, 2009 was done. RESULTS Forty-eight patients (39 males, 81.3%) had ADS; complete tumor resection and lymphadenectomy was accomplished in all patients. A higher stage at presentation was observed in ADS, as compared to AD or SCC (p=0.0001). Three and 5-year survival rates were 25% and 15%. ADS overall survival was worse than AD or SCC (p=0.0005). Three and 5-year survival rates of ADS Stage I were similar to those of Stage IIIA AD or SCC. More than half ADS patients developed distant metastases (MTS) or local recurrences. Brain MTS were the most frequent. Median survival for those patients was 8±2.3 months. Postoperative platinum-based chemotherapy statistically improved patients survival (p=0.02). In the multivariate analysis, the presence of MTS (p=0.001), the tumor perineural invasion (p=0.01) and the tumor stage (p=0.0005) were factors associated with poor prognosis. Adjuvant chemotherapy was a significant positive prognostic factor (p=0.00001). CONCLUSIONS ADS are uncommon and extremely aggressive lung tumors. Adjuvant chemotherapy should be administered even in Stage I radically resected tumors. A whole brain postoperative prophylactic radiotherapy could be proposed to reduce risk of developing brain MTS.

The significance of intrapulmonary metastasis in non-small cell lung cancer: upstaging or downstaging? A re-appraisal for the next TNM staging system §

OBJECTIVE The management of patients with non-small cell lung cancer (NSCLC) with intrapulmonary metastases (PM) is controversial. In TNM classification, PM are designed as T4 when in the same lobe of the primary tumour (PM1) and M1 when in a different lobe(s) (PM2). Some authors have questioned the negative prognostic impact of PM. The present study assessed prevalence, correlation with clinico-pathologic variables and impact on survival of PM, along with a review of the literature. METHODS From January 1993 to December 2006, 2013 NSCLC patients underwent surgical resection at our institution. Of these, 74 presented with PM (39 PM1, 35 PM2). Patients with bronchioloalveolar carcinoma (BAC), carcinoid tumours, contralateral disease and preoperative chemo/radiotherapy were excluded from the analysis. A logistic regression analysis was undertaken to evaluate a relationship between the presence of PM and different clinico-pathologic variables. Survival analysis was undertaken to investigate the prognostic significance of PM. RESULTS PM represent 3.6% of our patient population of operated NSCLC. Metastases were multiple in 36 cases and single in 38. Thirty-six patients had node-negative disease. Among all the variables for the logistic regression analysis only vascular invasion (OR: 0. 45; 95% CI 0.24-0.85, p=0.01) and N status (OR: 0. 6; 95% CI 0.43-0.82, p=0.001) were significantly correlated with the presence of PM. Median survival rates of PM1, PM2, other T4 and other M1 patients were 25, 23, 15 and 14 months, respectively. A survival advantage was observed in patients with PM as compared to other T4/M1 patients, although the difference was not significant either overall (p=0.21) or in the N0 disease group (p=0.12). CONCLUSIONS The presence of PM in NSCLC patients is a rare occurrence. Risk factors for the development of PM are a microscopic vascular invasion and a high nodal status. A survival advantage over other T4/M1 patients is evident from our experience, although not significant. The results of the literature which have been accumulating in the most recent years including ours bend to the conclusion that there is sufficient validated information to consider a downstaging in the presence of intrapulmonary metastases from NSCLC for the seventh edition of the TNM classification.

Efficacy and safety of human fibrinogen-thrombin patch (TachoSil®) in the treatment of postoperative air leakage in patients submitted to redo surgery for lung malignancies: a randomized trial

OBJECTIVES Previous studies of the human fibrinogen-thrombin patch TachoSil® for air leak management in thoracic surgery have excluded patients undergoing redo surgery, a group at high risk of persistent air leaks. This is the first study to assess TachoSil® in patients undergoing redo surgery. METHODS Patients who had undergone pulmonary resection for primary lung cancer or lung metastasis and were scheduled for completion lobectomy plus lymphadenectomy due to tumour recurrence were eligible. After complete lobectomy, patients with intraoperative Macchiarini grade 3 air leaks (or >30% of the tidal volume at plethysmographic assessment) were randomized to receive either TachoSil® or further lung parenchymal stapling/suturing procedures according to standard surgical practice. RESULTS A total of 24 patients were randomized to TachoSil® (n = 13) or standard treatment (n = 11). Mean duration of surgery was significantly shorter in the TachoSil® group than in the standard group (3.6 vs 4.0 h; P = 0.023). The mean duration of air leaks was also significantly reduced in the TachoSil® group (4.7 vs 10.0 days; P < 0.001), and the removal of both the first and the second chest tubes occurred earlier (mean 3.8 vs 5.5 days; P = 0.005; and 6.1 vs 10.8 days; P < 0.001, respectively). TachoSil® was also effective in reducing persistent (≥ 9 days) air leaks (1 vs 7 patients; P = 0.008). There were no significant differences between groups in other postoperative complications. Mean length of hospital stay was significantly shorter in TachoSil®-treated patients (6.9 vs 9.5 days; P < 0.001). CONCLUSIONS TachoSil® was superior to standard stapling and suturing aerostatic techniques in reducing postoperative air leaks in patients undergoing redo thoracic surgery.

Primary spontaneous pneumothorax. Is video-assisted thoracoscopy stapler resection with pleural abrasion the gold-standard?

Spontaneous pneumothorax is a common disorder with an incidence of between four and nine cases per 100,000 per year. Tube thoracostomy is the usual initial treatment and has been successful in most patients. The greater liability of pneumothorax to recur constitutes a special problem since the chances of a further recurrence increase with the number of episodes. The effective way to resolve the pneumothorax and prevent recurrences is surgical excision of the pathological lesion related to its onset (blebs or bullae) associated with pleural surface fusion. We submitted 133 patients, 113 males and 20 females (median age 26, range 12–37 years) to video-assisted thoracoscopic surgery (VATS) procedures for primary spontaneous pneumothorax. Nineteen were operated on for persistent air-leak after first episode, 114 for recurrent pneumothorax; four patients were operated on for contralateral episode after the first intervention. In 107 operations out of 137 (78%), blebs or bullae were identified and submitted to stapler resection; every patient underwent pleural abrasion. Persistent air-leak for more than 7 days (median 9, range 7–12) in six (4.3%) and bleeding in three out of 137 (2.2%) operations were encountered. Two patients out of six were submitted to revision minithoracotomy because of a copious air-leak: not previously identified leaking lesion was