Intercostal muscle flap to reinforce the bronchial stump after VATS pneumonectomy

In open surgery, the buttressing of bronchial stump is a common procedure, in order to prevent the occurrence of bronchopleural fistula after pneumonectomy or after anatomic resections in high-risk patients (i.e. induction chemotherapy, inflammatory disease, diabetes mellitus, arteriopathy). Several techniques have been proposed for the prophylactic coverage of the bronchial stump, most of them using parietal pleura, pericardial fat pad, or intercostal muscle flap. In our Institution, we routinely cover the bronchial stump with an intercostal muscle flap after both left and right pneumonectomy, and in case of sleeve lobectomy; the flap is usually prepared before rib spreading, for maintaining an adequate blood flow. Intercostal muscle flap in VATS surgery is rarely utilized, even in high-risk patients; there are only few decriptions in Literature. We describe a VATS procedure of protecting the bronchial stump with an intercostal muscle flap, harvested with an harmonic scalpel from the utility incision. We evaluated two patients for VATS pneumonectomy in the last year, both after induction chemotherapy. The first patient was a 54-year-old women, with an adenocarcinoma of the right lung, previously treated with cisplatin and gemcitabin for 3 cycles for a huge hilar nodal involvement. The second patient was a 57-year-old male, with an adenocarcinoma of the left lung, treated with 3 cycles of cisplatin and gemcitabin for N2 disease, confirmed by endobronchial ultrasonography. Both patients had a three-ports technique approach. In the first case, after the bronchial closure, the stump was verified to have no air leak. The intercostal muscle flap was harvested with an harmonic scalpel from the under surface of the fifth rib, paying attention to not injure the vascular structures. The flap was transacted and sutured to the bronchial stump with an interrupted 4/0 readsorbable suture. In the second case, the flap was dissected at the beginning of the operation, after the utility incision, and positioned out from the soft tissue retractor. The technique of flap mobilization and the suture to the bronchial stump was the same of the previous case. The time required for harvesting the flap was very short, almost 5 minutes. Both patients had an uneventful postoperative course; this procedure helped to avoid negative consequences of pneumonectomy, without providing technical difficulties. The only caution is taking care to preserve vascular supply. In conclusion, we believe that intercostal muscle flap is a valid choice, increasing the vascularity of the bronchial stump; the procedure is easy to perform, even in VATS

Trapianto di polmone da graft con bronco tracheale: aspetti tecnici e revisione della letteratura

Il caso descritto dimostra la fattibilit\ue0 tecnica di resezione bronchiale e segmentectomia del graft su banco. Tale procedura \ue8 risultata essere un ottimo espediente per permettere l\u2019impianto del polmone in assenza di rischi intraoperatori e di complicanze post-operatorie. Introduzione: La presenza di anomalie anatomiche a livello della trachea e dei bronchi principali rappresenta una condizione rara e spesso riscontrata occasionalmente, con un\u2019incidenza dello 0,1-0,5%. In letteratura vengono riportati solo 4 casi di trapianto polmonare bilaterale sequenziale in cui nel donatore sia presente un bronco tracheale e soltanto in uno di questi casi viene descritta l\u2019esecuzione di una segmentectomia apicale, dopo impianto, per permettere l\u2019anastomosi bronchiale. L\u2019approccio da seguire in tali situazioni risulta ancora controverso. Metodologia: Viene riportato un caso di trapianto polmonare bilaterale in paziente affetta da fibrosi cistica, da donatore portatore di bronco tracheale superiore destro emergente a circa 2 anelli dalla carena tracheale. Dopo l\u2019impianto del polmone sinistro, veniva eseguita su banco una resezione anatomica del segmento apicodorsale destro con sacrificio del bronco accessorio, con successivo impianto del graft destro con tecnica standard. Risultati: L\u2019intervento \ue8 risultato esente da eventi avversi ed il tempo operatorio sovrapponibile a quello della nostra casistica. L\u2019immediato decorso post-operatorio si \ue8 svolto in modo regolare con rapido svezzamento respiratorio. Non si sono verificate stenosi o deiscenze anastomotiche, n\ue8 perdite aree prolungate. Ad otto mesi dal trapianto la paziente \ue8 in discrete condizioni generali, in assenza di rigetto. Conclusioni: Il caso descritto dimostra la fattibilit\ue0 tecnica di resezione bronchiale e segmentectomia del graft su banco. Tale procedura \ue8 risultata essere un ottimo espediente per permettere l\u2019impianto del polmone in assenza di rischi intraoperatori e di complicanze post-operatorie

Analisi quantitativa polmonare mediante tomografia computerizzata nel primo anno dopo trapianto di polmone

Questo lavoro preliminare ha dimostrato l'affidabilit\ue0 dell\u2019analisi dello specific gas volume come parametro quantitativo di grande interesse per la comprensione e l\u2019analisi della funzione polmonare dopo LT. Sono necessari ulteriori studi futuri per verificare la possibilit\ue0 di sfruttare questa metodica innovativa nella valutazione dei pazienti con lung allograft dysfunction. Introduzione: L'analisi funzionale del parenchima polmonare mediante rielaborazione della tomografia computerizzata (CT) del torace \ue8 uno strumento emergente e di grande interesse per l'interpretazione dell'evoluzione del graft dopo il trapianto polmonare (LT). L'obiettivo del nostro studio \ue8 determinare l\u2019andamento degli indici di funzionalit\ue0 rspiratoria e dei parametri quantitativi alla CT nel primo anno di follow-up dopo LT. Metodologia: Abbiamo ottenuto prospetticamente e ad intervalli di tempo standard (3-6-12 mesi) gli usuali test di funzionalit\ue0 respiratoria (FEV1 e FVC) e le scansioni CT in inspirio ed espirio, capacit\ue0 polmonare totale (TLC) e volume residuo (RV), rispettivamente. Il volume specifico del gas (SVg, ml/g) \ue8 stato misurato sulle immagini CT come descritto in precedenza. Gli indici quantitativi selezionati sono stati il volume polmonare !"#$!$!,! !5&6!(708 -'11 2 !*,0!3&4! !5&!%93&4:3&4;!?,--@ ( -')'!)7(7! stati inclusi i pazienti che hanno sperimentato un decorso clinico regolare nei primi 12 mesi dopo LT bilaterale. Risultati: Quindici pazienti hanno completato lo studio. Come previsto, i valori di FEV1 e FVC sono significativamente migliorati ad ogni intervallo fino al controllo a 12 mesi. Allo stesso modo, Vinsp e 93&4:3&4;<=!)7(7! A8,(2ati con una tendenza a stabilizzarsi verso valori di normalit\ue0. Conclusioni: Questo lavoro preliminare ha dimostrato l'affidabilit\ue0 dell\u2019analisi dello specific gas volume come parametro quantitativo di grande interesse per la comprensione e l\u2019analisi della funzione polmonare dopo LT. Sono necessari ulteriori studi futuri per verificare la possibilit\ue0 di sfruttare questa metodica innovativa nella valutazione dei pazienti con lung allograft dysfunction

Modeling of hybrid stepper motor finalized to the optimization of the holding torque

The hybrid stepper motor is an electronically commutated brushless synchronous rotating electrical machine that defines incremental motion. Thanks to its remarkable precision and versatility, in recent years it has been the subject of increasing industrial applications. To obtain stepper motors with better performance, software modelling, finite element simulations and iterative optimizations by means of genetic algorithms were performed. The software used to carry out these simulations were Altair Flux 2D, Flux 3D and Hyperstudy. The computational complexity of the model obtained and the hardware tools available have imposed a magneto-static and non-transient analysis. Despite this simplification, it was necessary to proceed with a probabilistic "design of experiments"approach and a specific mathematical model before developing the optimization that otherwise would have been enormously expensive in terms of time and memory space

Validity and reliability of the CatWalk system as a static and dynamic gait analysis tool for the assessment of functional nerve recovery in small animal models

Introduction: A range of behavioral testing paradigms have been developed for the research of central and peripheral nerve injuries with the help of small animal models. Following any nerve repair strategy, improved functional outcome may be the most important evidence of axon regeneration. A novel automated gait analysis system, the CatWalk™, can measure dynamic as well as static gait patterns of small animals. Of most interest in detecting functional recovery are in particular dynamic gait parameters, coordination measures, and the intensity of the animals paw prints. This article is designed to lead to a more efficient choice of CatWalk parameters in future studies concerning the functional evaluation of nerve regeneration and simultaneously add to better interstudy comparability. Methods: The aims of the present paper are threefold: (1) to describe the functional method of CatWalk gait analysis, (2) to characterize different parameters acquired by CatWalk gait analysis, and to find the most frequently used parameters as well as (3)&nbsp;to&nbsp;compare their reliability and validity throughout the different studies. Results: In the reviewed articles, the most frequently used parameters were Swing Duration (30), Print Size (27), Stride Length (26), and Max Contact Area (24). Swing Duration was not only frequently used but was also the most reliable and valid parameter. Therefore, we hypothesize that Swing Duration constitutes an important parameter to be chosen for future studies, as it has the highest level of reliability and validity. Conclusion: In conclusion, CatWalk can be used as a complementary approach to other behavioral testing paradigms to assess clinically relevant behavioral benefits, with the main advantage that this system demonstrates both static and dynamic gait parameters at the same time. Due to limited reliability and validity of certain parameters, we recommend that only the most frequently assessed parameters should be used in the future

Carinal resection : technical tips

Carinal resection (CR) is defined as the resection of the trachea-bronchial bifurcation with or without lung resection. It is an uncommon challenging surgery performed in case of NSCLC, primitive airway tumors or benign lesions invading the carina. A well-organized team is essential to manage patients undergoing CR and it must involve several specialists experienced in diagnosis, operative treatment and postoperative care. Before and during surgery a strict cooperation between surgeon and anesthesiologist is essential; cross-field ventilation is generally used to maintain the adequate gas exchange during surgical airway reconstruction, but also high frequency jet ventilation (HFJV) or extracorporeal membrane oxygenation (ECMO) could be valid alternative options when cross-field ventilation is not feasible. Right-sided lesions requiring a CR with pulmonary resection are better approached through an ipsilateral thoracotomy (IV intercostal space), whereas tumor involving the carina as well as the left main bronchus and requiring a left carinal pneumonectomy could be treated using a left thoracotomy with subaortic dissection (only for very limited tracheal resection due to a bad exposure of the trachea after moving the aortic arch). Instead, CR without pulmonary resection and left carinal pneumonectomy are better approached through a median sternotomy. Reconstruction of the airway could be performed in different ways according to the extension of the resection and to the surgeon experience with the sole purpose to obtain a tension-free anastomosis to reduce as much as possible the possible post-operative complications due to impairment healing of the suture. Based on tumor histology and the pathological staging the patient should be referred to the oncologist and/or radiotherapist for the further medical treatments. Improved patient selection, anesthetic management, surgical technique and better postoperative management are essential in such a challenging surgery to have the lowest possible rate of postoperative morbidity and mortality

Lo pneumotorace catameniale: nostra esperienza monocentrica e revisione della letteratura

Lo pneumotorace catameniale rappresenta una rara forma di pneumotorace spontaneo ricorrente che colpisce giovani donne in et\ue0 fertile. La sua eziologia \ue8 associata alla presenza di endometriosi toracica ma la variabilit\ue0 del decorso clinico, la difficolt\ue0 di riscontro istologico e la possibile assenza di lesioni diaframmatiche evidenti spesso impediscono una diagnosi di certezza. Quesito pu\uf2 rendere il successivo iter terapeutico soltanto empirico con alti tassi di recidive post-chirurgiche. Scopo di questo lavoro \ue8 descrivere l'indicazione chirurgica ed il successivo follow-up terapeutico eseguiti in caso di pneumotorace catameniale nella nostra esperienza monocentrica

Lung Transplant From Donor With Tracheal Bronchus : Case Report and Literature Review

Donor lung abnormalities are quite rare; one of them is the presence of bronchial anomalies, whose incidence range is from 0.1% to 0.5%. The upper right tracheal bronchus is one of the most frequent anatomic variations. We present a case of successful double lung transplant in a young female patient affected by cystic fibrosis from a donor with upper right tracheal bronchus, emerging 2 rings before the tracheal carina. During implantation of the left lung, we performed a double apical segmentectomy on back table; therefore, the right lung was implanted with the standard technique. Four cases of graft transplant characterized by the presence of tracheal bronchus are reported in the scientific literature; the authors report 4 different technical solutions to tackle the problem of anatomic anomaly. We report the first case of graft segmentectomy at back table suggesting a simple, safe, and time-sparing procedure. In conclusion, provided that the team has sufficient skill in reductive surgery at the back table and the anthropometric data are permissive, we stress the opportunity to downsize the graft in order to minimize anastomotic risks and save time

Lung transplantation from donors after previous cardiac surgery: ideal graft in marginal donor?

Lung transplantation has clearly become the definitive therapeutic option for patient with end-stage lung disease but the number of available donor currently limits this option. Despite the efforts to expand donor criteria on different fields, previous cardio-thoracic surgery is still considered a contraindication from large part of ransplant centres