Acquired tracheoesophageal fistula repair, due to prolonged mechanical ventilation, in patient with double incomplete aortic arch

We report a case of the repair of an acquired benign tracheoesophageal fistula (TEF) after prolonged mechanical invasive ventilation. Patient had an unknown double incomplete aortic arch determining a vascular ring above trachea and esophagus. External tracheobronchial compression, caused by the vascular ring, increasing the internal tracheoesophageal walls pressure determined by endotracheal and nasogastric tubes favored an early TEF development. The fistula was repaired through an unusual left thoracotomy and vascular ring dissection. TEFs are a heterogeneous group of diseases affecting critically ill patients. Operative closure is necessary to avoid further complications related to this condition. Pre-operative study is mandatory to plan an adequate surgical approach

Two-port intrapericardial left VATS pneumonectomy

: Pneumonectomy is a surgical treatment for locally advanced lung tumors that deeply infiltrate into the pulmonary hilum, and is a major thoracic procedure. An intrapericardial approach may be necessary in cases where it is  impossible to safely deal with the extrapericardial non-invaded sections of the pulmonary vessels. This article describes our technique for intrapericardial left video-assisted thoracoscopic pneumonectomy in a patient with hilar squamous cell carcinoma. The procedure was performed through a two-incision approach and, because of the involvement of the proximal portion of the pulmonary vessels, an intrapericardial isolation and closure of these structures was performed. Radical lymphadenectomy was performed and a pericardial flap was used for coverage of the bronchial stump. This is a complex and challenging procedure, however the patient had an uneventful postoperative course and was discharged on the 7th postoperative day

Video-assisted left lower lobectomy with intrapericardial pulmonary vein isolation

The thoracoscopic approach to lobectomy is now the gold standard in cases of pulmonary malignancies because it is associated with a significant reduction in both postoperative hospital stay and pain. Even in cases of complex resection, as in the case reported here, the procedure can be performed safely after careful pre-operative planning. This video tutorial describes our technique for the intrapericardial isolation of the left inferior pulmonary vein in a patient affected by a left lower lobe metastasis from a colonic carcinoma. The lesion was retracting the inferior vein to such an extent that an intrapericardial approach was required in order to obtain a radical resection. The operation was carried out using a 3-port technique to allow for safe and unhindered manipulation of the hilar structures and the parenchyma. The pericardial sac was easily opened and the feasibility of the procedure was readily confirmed. The patient made an uneventful recovery; specifically, we did not record any arrhythmia or hemodynamic instability. She was discharged home on the 4th postoperative day

Video-assisted thoracic surgery lobectomy simulation and training with a new human cadaver model

Video-assisted thoracic surgery (VATS) lobectomy is the gold standard for the treatment of early-stage lung cancer. The use of surgical models for training and simulation in minimally invasive surgery simulation is an integral part of surgical education and skills acquisition for residents, and also for more experienced surgeons.Live animals \ua0are still the most frequently used realistic surgical models.\ua0 In this video tutorial, we demonstrate the use of a new human cadaver model with the aim of replacing the live animal model without compromising the fidelity of the simulation.\ua0 To prepare the cadaver, selective cannulation of the heart was performed to fill the pulmonary vessels with a gel used to improve the visibility and tactile feed-back of the vessels, and to simulate any bleeding complications. The complete cadaver was then used for the simulation, with all the same instruments and devices required in normal clinical practice, to demonstrate and practice both surgical and non-surgical skills for VATS lobectomy. In our opinion this model provides most of the features necessary for a valid surgical simulator and allows realistic training for VATS lobectomy. We believe that the cadaver model can be an effective alternative to anesthetized animals for VATS lobectomy training and simulation

Adult Benign, Non-Iatrogenic Bronchoesophageal Fistulae: Systematic Review and Descriptive Analysis of Individual Patient Data

Adult, benign, non-iatrogenic bronchoesophageal fistula (BEF) is a rare condition, which is occasionally described in single case reports. Therefore, little is known about its possible causes, presentation and management

Extracorporeal membrane oxygenation in lung transplantation: Indications, techniques and results

The use of extracorporeal membrane oxygenation (ECMO) in the field of lung transplantation has rapidly expanded over the past 30 years. It has become an important tool in an increasing number of specialized centers as a bridge to transplantation and in the intra-operative and/or post-operative setting. ECMO is an extremely versatile tool in the field of lung transplantation as it can be used and adapted in different configurations with several potential cannulation sites according to the specific need of the recipient. For example, patients who need to be bridged to lung transplantation often have hypercapnic respiratory failure that may preferably benefit from veno-venous (VV) ECMO or peripheral veno-arterial (VA) ECMO in the case of hemodynamic instability. Moreover, in an intra-operative setting, VV ECMO can be maintained or switched to a VA ECMO. The routine use of intra-operative ECMO and its eventual prolongation in the post-operative period has been widely investigated in recent years by several important lung transplantation centers in order to assess the graft function and its potential protective role on primary graft dysfunction and on ischemia-reperfusion injury. This review will assess the current evidence on the role of ECMO in the different phases of lung transplantation, while analyzing different studies on pre, intra- and post-operative utilization of this extracorporeal support

The biological approach for sternal replacement: sternochondral allograft transplantation

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Total lung sparing surgery for tracheobronchial low-grade malignancies

BACKGROUND: Total-lung sparing tracheo-bronchial sleeve resections are a step forward in the treatment of low-grade bronchial tumors where minimal resection margins are required to achieve the complete control of the disease.METHODS: We retrospectively collected the data of patients who underwent total-lung sparing procedures for low-grade trachea-bronchial tumors at two thoracic surgery centres from January 1984 until October 2019.RESULTS: We selected 98-patients, 46-females(47%) and 52-males(53%) with a median age of 39years(range7-70). Thirty-four patients underwent an operative endoscopy before surgery(32-laser-treatment,2-endobronchial-stenting). The surgical resection were 9(9%)-tracheal carina, 18(18%)-second carina, 31(32%)-left main bronchi, 25(26%)-right main bronchi and 15(15%)-intermediate-bronchus. The median length of the resected bronchus was 2.2cm. Median post-operative in-hospital stay was 8-days, no perioperative mortality was observed. Postoperative complications were recorded in 26-patients(27%). The final histology was 37-typical carcinoids(38%), 10-atypical carcinoids(10%), 29-adenoid cystic carcinomas(30%), 15-mucoepidermoid carcinomas(15%), 6-inflammatory myofibroblastic tumors(6%) and 1-glomic tumor(1%). Twenty-two patients had positive resection margins and received adjuvant radiotherapy. Three patients with adenoid cystic carcinoma had recurrence(1-local,2-systemic). After a median follow-up time of 54.5months(range4-360), the overall actuarial 5-year survival was 97%.CONCLUSIONS: Total-lung sparing tracheo-bronchial sleeve resection for low-grade malignancy require high surgical skills but the hospital morbidity and mortality are very low. This Technique is adequate and safe for highly selected patients with low-grade endobronchial malignancies and it's use should be encouraged in experienced centres