The surgical point of view about persistent air leaks: prevention first

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Vena cava anomalies in thoracic surgery

Background: Vena cava anomalies are a rare group of anatomical variations due to an incorrect development of the superior or inferior vena cava during fetal life. They generally show no clinical relevance and the diagnosis is done due to the association with congenital heart diseases in most of cases. However, preoperative identification of these anomalies is mandatory for surgeons to proper surgical planning. If not recognized, lethal complications may occur, as already reported in literature. Case presentation: We report a case series of three different unidentified vena cava anomalies in patients undergoing lung resection. These unrecognized anomalies led to minor complications in two cases and required an accurate intraoperative evaluation in another. A careful retrospective evaluation of preoperative radiological images showed the anomalies. Conclusions: A careful evaluation of the vena cava anatomy at pre-operative imaging is mandatory for thoracic surgeons to properly plan the surgery and avoid complications

Operative complications and early mortality after induction therapy for lung cancer

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A challenging upper digestive tract continuity restoration after recurrent esophago-colonic anastomosis complications

Background: Acute and chronic complications in esophago-colonic anastomosis have a significant impact in the postoperative course of patients with colonic transposition. Evidence about their management is poor and surgical treatment is mostly based on tailored approaches, so each new experience could be useful to improve knowledge about this peculiar condition. We report a unique case of an esophago-colonic resection and re-anastomosis without sternal approximation after recurrent anastomosis failure and strictures. Case presentation: A 69-year-old woman was referred to our hospital for worsening dysphagia. The patient had undergone esophago-gastrectomy with right colon interposition 12 years prior due to caustic ingestion. The esophago-colonic anastomosis was initially complicated by an enterocutaneous fistula, which was treated with anastomosis resection and left colon transposition. This was then further complicated by dehiscence and sternal infection treated with resection of the distal portion of the sternum and a new colo-jejunal anastomosis. Finally, a chronic anastomotic stricture occurred, refractory to endoscopic dilatation and prothesis positioning. We planned a new colonic-esophageal resection and re-anastomosis. The main technical challenges were addressing the adhesions resulting from previous surgery and mobilizing an adequate length of the intestinal tract to allow conduit continuity restoration. Blood supply was assessed through Indocyanine Green Fluorescence. To avoid compression of the digestive conduit sternal margins were not re-approximated, and the transposed tube was covered and protected using both pectoralis major muscles flap. We decided to avoid the use of any prosthetic material to reduce the risk of infection. The patient was able to resume oral food intake on the 12th day postoperatively after a barium swallowing test showed an adequate conduit caliber. Conclusion: Esophago-colonic anastomosis complications represent a life-threatening condition. Therefore, reports and sharing of knowledge are important to improve expertise in management of these conditions

Unidirectional endobronchial valves for management of persistent air-leaks. Results of a multicenter study

Background: To evaluate the efficacy of Endo-Bronchial Valves in the management of persistent air-leaks (PALs) and the procedural cost. Methods: It was a retrospective multicenter study including consecutive patients with PALs for alveolar pleural fistula (APF) undergoing valve treatment. We assessed the efficacy and the cost of the procedure. Results: Seventy-four patients with persistent air leaks due to various etiologies were included in the analysis. In all cases the air leaks were severe and refractory to standard treatments. Sixty-seven (91%) patients underwent valve treatment obtaining a complete resolution of air-leaks in 59 (88%) patients; a reduction of air-leaks in 6 (9%); and no benefits in 2 (3%). The comparison of data before and after valve treatment showed a significant reduction of air-leak duration (16.2±8.8 versus 5.0±1.7 days; P<0.0001); chest tube removal (16.2±8.8 versus 7.3±2.7 days; P<0.0001); and length of hospital stay (LOS) (16.2±8.8 versus 9.7±2.8 days; P=0.004). Seven patients not undergoing valve treatment underwent pneumo-peritoneum with pleurodesis (n=6) or only pleurodesis (n=1). In only 1 (14%) patient, the chest drainage was removed 23 days later while the remaining 6 (86%) were discharged with a domiciliary chest drainage removed after 157±41 days. No significant difference was found in health cost before and after endobronchial valve (EBV) implant (P=0.3). Conclusions: Valve treatment for persistent air leaks is an effective procedure. The reduction of hospitalization costs related to early resolution of air-leaks could overcome the procedural cost