Rosanna Accardo

Awake Single-Access (Uniportal) Video-Assisted Thoracoscopic Surgery for Peripheral Pulmonary Nodules in a Complete Ambulatory Setting

PURPOSE Traditional 3-port video-assisted thoracoscopic surgery (VATS) in a patient who is awake has been proposed as a breakthrough in the direction of fast tracking patients through routine thoracic surgical procedures. We wanted to explore the possibility of further reducing surgical invasiveness by resecting a peripheral pulmonary nodule with single-access (uniportal) VATS in an awake, nonintubated, nonventilated patient, with selective occlusion of the tributary lobar bronchus. DESCRIPTION A 47-year-old woman with bilateral peripheral nodules underwent uniportal VATS wedge resection of an undetermined nodule in the right middle lobe. The patient was awake and under mild sedation for the entire procedure. Single-shot epidural regional anesthesia was administered. Under guidance provided by a reusable, portable flexible bronchoscope, a Fogarty balloon was positioned to occlude the right middle lobe bronchus to facilitate collapse of the targeted parenchyma. At the end of the procedure, the chest drain was connected to a portable vacuum system delivering autonomous suction. EVALUATION Awake uniportal VATS resection of peripheral nodules in selected patients is feasible and appears to be safe. Available technology may enable further reduction of costs related to length of hospitalization. CONCLUSIONS The concept of ambulatory thoracic surgery may further evolve by utilizing uniportal VATS in an awake patient to solve the often-challenging diagnostic dilemmas represented by undetermined lung lesions.

Ten-Year Experience on 644 Patients Undergoing Single-Port (Uniportal) Video-Assisted Thoracoscopic Surgery

BACKGROUND Uniportal video-assisted thoracic surgery (VATS) technique has been described both for diagnostic and therapeutic indications. Outcomes after uniportal VATS have never been reported in large series. METHODS Between January 2000 and December 2010, 644 uniportal VATS procedures (334 male and 310 female patients; median age, 55.5 years; range, 16 to 85) were performed by a single surgeon. This figure represents 27.7% of all the thoracic surgical procedures in the study period (2,369). Of the 644 uniportal VATS, 329 (51.1%) were diagnostic procedures for pleural conditions. Of the remaining 315 uniportal VATS procedures, 14 (2.2%) were performed for pre-thoracotomy exploration for lung cancer, and 115 (17.8%) for miscellaneous conditions including diagnosis of mediastinal masses. In addition, 186 nonanatomic wedge resections (28.9% of the total uniportal VATS procedures) were performed for pulmonary conditions; of these, 146 were done for pulmonary nodules. RESULTS Median operative time was 18 and 22 minutes for uniportal VATS for diagnostic non-pulmonary indications and for wedge resections, respectively. Out of 644 patients, conversion to either 2 or 3 port VATS or minithoracotomy was necessary in 3.7% of the patients, often due to incomplete lung collapse (92%). Inclusive of the day of insertion, the chest drain was removed after a median of 4.3 (range, 2 to 20) and 2.4 days (range, 0 to 6) after uniportal VATS for pleural effusions and uniportal VATS lung wedge resections, respectively. Mortality and major morbidity after uniportal VATS was 0.6% and 2.8%, respectively. All deaths reported after uniportal VATS were for pleural effusions. Inclusive of the operative day, median hospitalization after surgery for uniportal VATS for pleural effusions and for wedge resections were 5.3 and 3.4 days, respectively. CONCLUSIONS In our experience, uniportal VATS was performed in one third of our surgical candidates with limited operative time, a very low conversion rate to conventional VATS or minithoracotomy, a very low morbidity and mortality, and, short hospitalization. Uniportal VATS is an underappreciated procedure that can be reliably used in the diagnostic pathways of several intrathoracic conditions and to resect small pulmonary nodules with either diagnostic or therapeutic purposes. As such, uniportal VATS represents a consolidated addition to the surgical armamentarium.

Is flexible bronchoscopy necessary to confirm the position of double-lumen tubes before thoracic surgery? §

OBJECTIVES Flexible bronchoscopy is recommended to confirm correct placement of double-lumen tubes used for thoracic anesthesia. However, there is still controversy over routine bronchoscopic confirmation of their position. This study aimed to verify the usefulness of flexible bronchoscopy for confirming the position of double-lumen tubes after blind intubation. METHODS During a 9-month period, consecutive patients undergoing elective oncologic thoracic surgery were prospectively enrolled in the study. All patients were intubated with a left disposable polyvinyl chloride double-lumen tube. Immediately after intubation, clinical verification was made by the anesthesiologist. Then, the endoscopist performed flexible bronchoscopy with a 2.8-mm diameter Olympus(®) video bronchoscope, and verified the position of the double-lumen tube, before positioning the patient. The double-lumen tube was in optimal position, if the bronchial cuff was immediately below the tracheal carina, and there was a clear view of the left subcarina, with unobstructed left upper and lower bronchi. Misplacement of the double-lumen tube was diagnosed when the tube had to be moved (in or out) for more than 0.5 cm to correct its position. Critical malposition meant a double-lumen tube dislocated in the trachea or in the right bronchi, requiring immediate re-intubation under bronchoscopic guidance. RESULTS A total of 144 patients (44 women (42%) and 60 men (58%), with a mean age of 51 years (range 25-77 years)) were enrolled in the study. Surgical procedures included 37 right-sided and 31 left-sided thoracotomies, 22 video-assisted thoracoscopic surgeries (VATSs) (16 right-sided and six left-sided), one median sternotomy, six mediastinotomies, and seven miscellaneous procedures. In 66 (63%, 95% confidence interval 53.2-71.8%) cases, there was complete agreement between the anesthesiologist and the endoscopist. The latter diagnosed misplacement of the double-lumen tube in 33 (32%, 95% confidence interval 22.8-40.7%) patients and critical malposition in five (5%, 95% confidence interval 0.7-8.9%) cases. CONCLUSIONS After blind intubation, 37% of double-lumen tubes required repositioning by means of flexible bronchoscopy, despite positive evaluation made by the anesthesiologist. Our data suggests that initial bronchoscopic assessment should be made with the patient still in the supine position, and confirms that flexible bronchoscopy is useful in verifying the correct position of double-lumen tubes or adjusting possible misplacements, before starting thoracic surgery.

V-Y latissimus dorsi flap for coverage of anterior chest wall defects after resection of recurrent chest wall chondrosarcoma

The choice of prosthetic materials for tissue coverage to stabilize extensive defects in the chest wall is of paramount importance to a successful outcome of reconstructive surgery. The V-Y latissimus dorsi flap has been described in the reconstruction after resection for recurrent breast cancer. We report one example of such a reconstruction technique in the surgical management of a recurrent aggressive chondrosarcoma of the anterior chest wall. Nine months earlier, a 44-year-old patient had undergone in another institution an extensive chest wall resection for a right-sided chondrosarcoma of the chest wall arising from the third and fourth costochondral junctions. The patient was referred to our attention for the detection of recurrent chondrosarcoma at the same site and immediately below (Figure 1), mandating removal of the prosthesis and resecVideo clip is available online.

Erratum to: Multidisciplinary approach and anesthetic management of a surgical cancer patient with methylene tetrahydrofolate reductase deficiency: A case report and review of the literature (Journal of Medical Case Reports (2015) 9:175)

The original version of this article [1] unfortunately contained a mistake. The presentation of the author names is incorrectly marked up and therefore it is presented incorrectly in the HTML version of this article. The corrected author list is given below: Cascella M, Arcamone M, Morelli E, Viscardi D, Russo V, De Franciscis S, Belli A, Accardo R, Caliendo D, De Luca E, Di Caprio B, Di Sauro F, Giannoni G, Iermano C, Maciariello M, Marracino M, Cuomo A. The original article was corrected accordingly.

Multidisciplinary approach and anesthetic management of a surgical cancer patient with methylene tetrahydrofolate reductase deficiency: a case report and review of the literature

IntroductionHyperhomocysteinemia is a known risk factor for myocardial infarction, stroke, peripheral vascular disease, and thrombosis. Elevated plasma homocysteine levels have been demonstrated in patients with recurrent episodes or a single episode of thrombosis. Here we describe the development of cardiovascular disease as a complication of a surgical intervention in a patient with colorectal cancer and hyperhomocysteinemia.Case presentationA 65-year-old Caucasian man complained of pain and constipation, attributed to previously diagnosed adenocarcinoma (stage IIB) of the hepatic flexure. An anamnestic investigation showed that he had undergone two surgical interventions. During both, he suffered thrombotic postoperative complications, a deep vein thrombosis of the upper extremity after the first operation and retinal vein occlusion after the second. He was diagnosed with hyperhomocysteinemia associated with a homozygous C677T mutation of the gene encoding the enzyme methylenetetrahydrofolate reductase. Our patient was initially treated with folic acid and high-dose B vitamins. On day 7 he underwent a right hemicolectomy. Anesthesia was performed with sevoflurane in 40% O2 and without the use of nitrous oxide. Postoperatively, our patient remained on folic acid and B vitamins and was without immediate or subsequent complications.ConclusionsNeoplastic disease and related surgery followed by the administration of chemotherapeutic drugs alter the hemostatic balance in cancer patients. Those suspected of also having a thrombophilic disease require a thorough laboratory diagnostic workup, including a molecular analysis aimed at identifying the genetic mutation responsible for the hyperhomocysteinemia, as indicated. The case described in this report highlights the importance of a multidisciplinary approach that includes expertise in peri-operative anesthesia, surgery, oncology, and hematology.

The use of a bone substitute composite in the management of a post-pneumonectomy bronchopleural fistula

Post-pneumonectomy bronchopleural fistulas (BPFs) still represent a formidable therapeutic challenge. Several procedures have been proposed of which the least invasive are gaining distinct recognition and favour. We report the case of small-sized BPF treated by plastering the bronchial stump with a combination of bone substitute composite sprayed on a scaffold made of a Vycril mesh and placed on the mediastinal pleura overlying the right hilum.