L’EMPIEMA PLEURICO NEI PAZIENTI HIV-NEGATIVI CON DIPENDENZA DA SOSTANZE E/O ALCOOL: CARATTERISTICHE, TRATTAMENTO E RISULTATI IN UN SINGOLO CENTRO.

SCOPO DEL LAVORO L’empiema pleurico è una patologia temibile per gravità e frequenza che a volte è sottovalutata nei pazienti che abusano di sostanze stupefacenti e/o di alcool. Scopo del lavoro è studiare caratteristiche e trattamento di un gruppo di pazienti HIV-negativi con dipendenza patologica. MATERIALI E METODI Da Gennaio 2004 ad Aprile 2019 sono stati trattati chirurgicamente per empiema pleurico 121 pazienti (M/F: 81/40; età media 65 anni; range 21-83 anni) presso la nostra Unità Operativa. L’eziologia è stata principalmente parapneumonica con 103 casi (85%) e post-traumatica con 18 casi (15%). I pazienti sono stati retrospettivamente stratificati in due gruppi a seconda che avessero o no una dipendenza da sostanze e/o alcool fino a due anni prima (43 vs 78 pazienti – 36% vs 64%). Le caratteristiche dei pazienti con dipendenza sono state poi approfondite mediante analisi statistica univariata. Sono stati infine esclusi dallo studio i pazienti con empiema post-chirurgico e i casi dovuti a fistola bronco-pleurica. RISULTATI I casi di empiema pleurico parapneumonico sono stati 33 (77%; p=0,1) e post-traumatico 10 (23%; p=0,1) tra i pazienti con dipendenza patologica. L’età media era di 43 anni (range 21-56 anni) con un rapporto M/F di 28/15 (p=0,2). Ventiquattro pazienti (56%) sono stati sottoposti all’ingresso a posizionamento di drenaggio pleurico (p<0,05) e tutti i pazienti sono stati poi sottoposti, con buon esito, a intervento di empiemectomia e decorticazione (p<0,05) per persistenza di febbre e/o dispnea nonostante la terapia sistemica. La via di accesso finale è stata in tutti i casi la toracotomia (p<0,05), indipendentemente dallo stadio dell’empiema, a causa dell’estensione della flogosi. In 6 casi (14%, p=0,07) è stato necessario eseguire anche una lobectomia o wedge resection per la presenza di ascesso polmonare/micetoma (5 casi, 12%; p<0,05) o bronchiectasie (1 caso, 2%; p=1,00). All’analisi dei fattori di rischio la malnutrizione (BMI<19) è emersa come principale fattore con 15 pazienti (35%, p<0,05). Anche il diabete con 12 pazienti (28%, p<0,05) e la flebite con 4 pazienti (9%, p<0,05), associata o no ad ascesso nel sito d’iniezione della sostanza, rappresentano le comorbilità più frequenti in questo gruppo omogeneo di pazienti. È stato segnalato inoltre un caso di endocardite della valvola tricuspide (2%, p=0,4) e 4 pazienti erano HCV-positivi (9%, p=0,05) in assenza di cirrosi. CONCLUSIONI I pazienti con empiema pleurico e dipendenza presentano caratteristiche cliniche e comorbilità peculiari. L’intervento chirurgico di empiemectomia/decorticazione, più impegnativo in questi pazienti, è necessario per la persistenza di segni di sepsi anche dopo il posizionamento del drenaggio pleurico. La possibile spiegazione potrebbe essere, secondo noi, la presenza di malnutrizione e diabete oltre al già noto effetto immunosoppressore esercitato dagli oppiacei (eroina in primo luogo) e dall’alcool

Tips and tricks in video-assisted thoracoscopic surgery lobectomy

In 2012, open procedures represented 63% of the total number of lobectomies performed in our unit; in 2015, video-assisted thoracoscopic surgery (VATS) lobectomy numbers increased up to 66% of the total number of lobectomies performed. When carrying out the procedures, we followed the guidelines presented by the International VATS Lobectomy Consensus Group regarding indications, contraindications, preoperative investigations and conversions. In view of 280 VATS major lung resections from May 2012 to May 2016, we describe some tips and tricks that can be useful in this surgical technique, from general principles to single operative procedures

Cervico-manubrio-toracotomia secondo Grünenwald. Nostra esperienza in 3 casi di tumori dello stretto toracico superiore

Tumors of the cervical-thoracic area can be treated by the Grünenwald approach, which consists of an L-shaped cervical-manubrialthoracotomy without section of the clavicle. We used this access in three different tumors of the cervical-thoracic inlet: a tumor of T1 vertebral body, a tumor of the left superior sulcus, and a rare tumor originating from the root T1 of the brachial plexus. The first patient was a 39-years-old man with a somatic fracture of T1 and tumor invasion of the residual vertebral body by multiple myeloma. The 2nd patient was a 61-years-old man with a squamous cell carcinoma of S1 left upper lobe, infiltrating the parietal pleura and the chest wall, in the anterior-lateral part of the 2nd intercostal space. The 3rd patient was a 35-years-old woman with a glomic tumor originating from the T1 root of the right brachial plexus. The only post-operative complication was a modest diaphragm elevation in the 3rd patient, completely disappeared after 3-4 months. The 2nd patient is dead one year after the operation for cerebral metastases. The other two patients are presently in good conditions, without signs of relapse. Is our opinion the Grünenwald technique is technique for the treatment of tumors of the cervical-thoracic area allows a safe visibility of the anatomical structures without the necessity of a clavicle section

Pros-cons debate about the role and evolution of biportal video-assisted thoracoscopic surgery. Luigi Gaetano Andriolo, Camillo Lopez, Dario Gregori, Giovanna Imbriglio, Daniele Bottigliengo, Corrado Surrente, Valentina Larocca, Gaetano Di Rienzo.

Thoracoscopic surgical techniques have numerous advantages compared to open techniques such as decreasing hospital stay, analgesic requirements and postoperative pain. Since the first video-assisted thoracoscopic surgery (VATS) lobectomy performed 20 years ago this procedure, associated with mediastinal lymph node dissection, has been widely accepted as a standard surgical treatment for early stage non-small cell lung cancer. Traditionally the videoscopic approach is based on the three- or four-port approach but more than 50% of the patients developed post-operative chest wall paraesthesia due to nerve injury. In order to avoid this postoperative complication traditional VATS approach has been modified by using few and smaller working ports developing the so called two-portal VATS. The purpose of this study is to establish the advantages of biportal VATS reviewing a series of 400 consecutive cases of VATS lobectomy performed from May 2012 to December 2017, using progressively less ports (4-3-2 ports), at our Institution. There were 42 patients in four-port, 56 patients in three-port and 302 patients in two-port group. A propensity-score analysis showed that, as compared with two- and three-port group, patients in the four-port group had increased duration of chest tube (respectively difference and 95% CI are 1.493, 0.965; 2.053 and 1.246, 0.472; 2.002), increased postoperative length of stay (respectively difference and 95% CI are 2.564, 1.336; 3.952 and 2.205, 0.672; 3.740), increased postoperative pain only in comparison with two-ports (difference and 95% CI in VAS score 1.482, 0.909; 2.055). There were no significant differences in terms of demographic characteristics, histology, type of intervention, number of complications, operative time, number of lymph nodes retrieved and pStage between the three groups

The Overweight Paradox: Impact of Body Mass Index on Patients Undergoing VATS Lobectomy or Segmentectomy

The aim of this study was to assess the impact of BMI on perioperative outcomes in patients undergoing VATS lobectomy or segmentectomy. Data from 5088 patients undergoing VATS lobectomy or segmentectomy, included in the VATS Group Italian Registry, were collected. BMI (kg/m2) was categorized according to the WHO classes: underweight, normal, overweight, obese. The effects of BMI on outcomes (complications, 30-days mortality, DFS and OS) were evaluated with a linear regression model, and with a logistic regression model for binary endpoints. In overweight and obese patients, operative time increased with BMI value. Operating room time increased by 5.54 minutes (S.E. = 1.57) in overweight patients, and 33.12 minutes (S.E. = 10.26) in obese patients (P < 0.001). Compared to the other BMI classes, overweight patients were at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications. In the overweight range, a BMI increase from 25 to 29.9 did not significantly affect the length of stay, nor the risk of any complications, except for renal complications (OR: 1.55; 95% CI: 1.07-2.24; P = 0.03), and it reduced the risk of prolonged air leak (OR: 0.8; 95% CI: 0.71-0.90; P < 0.001). 30-days mortality is higher in the underweight group compared to the others. We did not find any significant difference in DFS and OS. According to our results, obesity increases operating room time for VATS major lung resection. Overweight patients are at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications following VATS resections. The risk of most postoperative complications progressively increases as the BMI deviates from the point at the lowest risk, towards both extremes of BMI values. Thirty days mortality is higher in the underweight group, with no differences in DFS and OS