Prediction of Ablation Volume in Percutaneous Lung Microwave Ablation: A Single Centre Retrospective Study

Background: Percutaneous Microwave Ablation (MWA) of lung malignancies is a procedure with many technical challenges, among them the risk of residual disease. Recently, dedicated software able to predict the volume of the ablated area was introduced. Cone-beam computed tomography (CBCT) is the imaging guidance of choice for pulmonary ablation in our institution. The volumetric prediction software (VPS) has been installed and used in combination with CBCT to check the correct position of the device. Our study aimed to compare the results of MWA of pulmonary tumours performed using CBCT with and without VPS. Methods: We retrospectively reviewed 1-month follow-up enhanced contrast-enhanced computed tomography (CECT) scans of 10 patients who underwent ablation with the assistance of VPS (group 1) and of 10 patients who were treated without the assistance of VPS (group 2). All patients were treated for curative purposes, the maximum axial diameter of lesions ranged between 5 and 22 mm in group 1 and between 5 and 25 mm in group 2. We compared the presence of residual disease between the two groups. Results: In group 1 residual disease was seen in only 1 patient (10%) in which VPS had ensured complete coverage of the tumour. In group 2 residual disease was found in 3 patients (30%). Conclusions: Using this software during MWA of lung malignancies could improve the efficacy of the treatment compared to the conventional only CBCT guidance

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

Multicenter randomized study on the comparison between electronic and traditional chest drainage systems

Background: In patients submitted to major pulmonary resection, the postoperative length of stay is mainly influenced by the duration of air leaks and chest tube removal. The measurement of air leaks largely relies on traditional chest drainage systems which are prone to subjective interpretation. Difficulty in differentiating between active air leaks and bubbles due to a pleural space effect may also lead to tentative drain clamping and prolonged time for chest drain removal. New digital systems allow continuous monitoring of air leaks, identifying subtle leakage that may be not visible during daily patient evaluation. Moreover, an objective assessment of air leaks may lead to a reduced interobserver variability and to an optimized timing for chest tube removal. Methods: This study is a prospective randomized, interventional, multicenter trial designed to compare an electronic chest drainage system (Drentech\u2122 Palm Evo) with a traditional system (Drentech\u2122 Compact) in a cohort of patients undergoing pulmonary lobectomy through a standard three-port video-assisted thoracic surgery approach for both benign and malignant disease. The study will enroll 382 patients in three Italian centers. The duration of chest drainage and the length of hospital stay will be evaluated in the two groups. Moreover, the study will evaluate whether the use of a digital chest system compared with a traditional system reduces the interobserver variability. Finally, it will evaluate whether the digital drain system may help in distinguishing an active air leak from a pleural space effect, by the digital assessment of intrapleural differential pressure, and in identifying potential predictors of prolonged air leaks. Discussion: To date, few studies have been performed to evaluate the clinical impact of digital drainage systems. The proposed prospective randomized trial will provide new knowledge to this research area by investigating and comparing the difference between digital and traditional chest drain systems. In particular, the objectives of this project are to evaluate the feasibility and usefulness of digital chest drainages and to provide new tools to identify patients at higher risk of developing prolonged air leaks. Trial registration: ClinicalTrials.gov, NCT03536130. Retrospectively registered on 24 May 2018

Stenosis of bronchus intermedius: an unusual complication after transplantation and its treatment

Complications related to ischemia are the most important cause of morbidity and mortality after lung transplantation. Ischemia suffered by large bronchi during topical cooling and transplantation of the graft is considered the possible pathogenic noxa for late stenosis as well as a possible cause of anastomotic leak or ulceration of the mucosa. It seems to emerge from the literature that the bronchus intermedius may be particularly prone to ischemia and may undergo stenosis late after transplantation

Muscle sparing versus posterolateral thoracotomy for pulmonary lobectomy: Randomised controlled trial

Muscle sparing thoracotomy (MST) has been proposed as an alternative to posterolateral thoracotomy (PLT) for pulmonary lobectomy. This issue has been addressed by few clinical reports. To explore that subject, a prospective, controlled randomised, double-blind trial comparing MST through the auscultatory triangle and PLT was planned. The study included patients scheduled for pulmonary lobectomy for stage I or II non-small-cell lung cancer and were followed for three years. The primary endpoints were pain, analgesic consumption and post-thoracotomy pain syndrome. The secondary endpoints included morbidity plus shoulder and pulmonary functions. The trial randomised 100 patients into two groups. Postoperative pain results were similar, although analgesic consumption was higher in the PLT group (Ps0.001). The MST group had a shorter hospital stay (Ps0.003). Three years post-thoracotomy syndrome was unaffected by the type of incision. The women suffered more than men during the early and late postoperative time. An inverse correlation between incision length and pain was found. Immediate shoulder strength was significantly better in the MST group (Ps0.004) but postoperative pulmonary function and complications were comparable. The two incisions results were very similar in the patient outcome, however, few aspects indicated the MST as the more suitable incision for pulmonary lobectomy

Autofluorescence bronchoscopy as innovative marker of airway complications after lung transplantation

Aim of this prospective study was to find a relationship between the degree of bronchial vascularization and the onset of airway stenosis with AFB and investigative its possible role as pre-clinical marker

La toracotomia con risparmio muscolare : quali vantaggi?

OBIETTIVI: Paragonare il dolore post-operatorio, la ripresa della forza muscolare e la funzione polmonare dopo toracotomia con risparmio muscolare e toracotomia postero-laterale tradizionale. MATERIALI E METODI: Nel periodo compreso tra marzo e dicembre 2005 i pazienti candidati a lobectomia per carcinoma polmonare I stadio sono stati randomizzati e sottoposti a toracotomia con risparmio muscolare o a toracotomia postero-laterale tradizionale. I criteri di esclusione sono stati: pregressa toracotomia, diabete mellito, malattie psichiatriche o assistenza post-operatoria > 24 ore. In tutti i pazienti \ue8 stato eseguito il blocco intraoperatorio dei nervi intercostali ed \ue8 stata somministrata analgesia post-operatoria con morfina per via endovenosa e ketoralac. I dati relativi al dolore, alla funzione post-operatoria e alla ripresa della forza muscolare del cingolo scapolare sono stati raccolti in maniera prospettica prima e 1, 7, 30 e 90 giorni dopo l\u2019intervento da un ricercatore non informato del tipo di toracotomia eseguita. \uc8 stata registrata la quantit\ue0 totale di analgesia richiesta. Lo studio \ue8 stato approvato dal comitato etico del nostro ospedale. RISULTATI: Quarantotto pazienti sono stati arruolati nello studio. Nei due gruppi vi \ue8 stato lo stesso numero di pazienti, senza differenze anagrafiche significative. La lunghezza dell\u2019incisione, l\u2019entit\ue0 dell\u2019apertura del divaricatore, il tempo operatorio, la durata della degenza post-operatoria sono state sovrapponibili nei due gruppi. Non abbiamo osservato la comparsa di sieromi. Il dolore, la funzione respiratoria post-operatoria e la ripresa della forza muscolare del cingolo scapolare non hanno dimostrato differenze statisticamente significative tra i due gruppi. L\u2019analisi multivariata dei dati ha dimostrato solamente correlazioni tra la lunghezza dell\u2019incisione e il body mass index, e tra il dolore post-operatorio e la durata dell\u2019intervento. CONCLUSIONI: Entrambe le toracotomie permettono un ottimo accesso alla cavit\ue0 toracica, e hanno sequele paragonabili in termini di dolore e di diminuita funzione muscolare. La scelta tra le due toracotomie \ue8 quindi basata sulla preferenza personale del chirurgo

Sternal reconstruction for unusual chondrosarcoma : innovative technique

The authors report a clinical case of a primary sternal chondrosarcoma, presented as a mass in the anterior mediastinum. The patient was treated with subtotal sternectomy and sternal transplantation followed by radiotherapy. Twelve months after surgery, the patient is in good clinical condition, without any sign of tumor relapse and with normal respiratory mechanics. Primary malignant tumors of the sternum are uncommon and a presentation mimicking thymoma is rare and unreported. The stermal replacement with a cryopreserved allograft sternum is an innovative technique that overcomes the problems related to the prosthetic biocompatibility or to the bone autograft

Early detection of obliterative bronchiolitis with an air trapping index based on specific gas volume analysis of chest computed tomography

INTRODUCTION- Bronchiolitis obliterans (BO) is a major long-term complication and a leading cause of death after lung transplantation. Transbronchial biopsy has limited value in detecting and quantify BO due to the irregular distribution of the disease. - Air trapping is the most frequent thin-section CT abnormality observed in patients with BOS and has been proposed in several series as the most reliable indicator of BO (Sens. 50%-91%; spec. 67%-94%). - To overcome interobserver disagreements and the gravity factor, the variation of specific gas volume (SVg) on CT was proposed as a valuable tool for identifying and quantifying the extent and severity of trapped gas. - We analyse SVg variation obtainig an Air Trapping (AT) index as indicator for obliterative bronchiolitis in recently transplanted patients. MATERIALS AND METHODS - Eight patients recently transplanted were included in the study: 3 women and 5 men; mean age 42.8 yrs (range 26-67). Six patients underwent a double lung transplant for FC and two patients underwent a single lung transplant for IPF. - The patients were clinically stable and were scheduled for sourveillace bronchoscopy with transbronchial biopsy (TBB). - Before the biopsy a chest CT scan at residual volume (RV) in addition to standard scan at total lung capacity (TLC) was performed: mean time after transplant 8.7 months . - Total lung capacity and residual volume correspondent images were selected. The residual volume images were deformed onto the total lung capacity images by an automatic algorithm based on an optical flow method. Two-dimensional maps of pixel-by-pixel differences in density and SVg were obtained at level of the aortic arch, the carina and top diagphram. - Air Trapping index was defined as \u394SVg/SVg,RV. - Bronchoscopies were performed with patients under conscious sedation and local anestesia. Transbronchial biopsies and bronchoalveolar lavage were obtained from lung target areas indentified by the two-dimensional maps. - All the procedures were free of complications. RESULTS - All transbronchial biopsies were classified as A1, B0, C0 (ISHLT 2007). - Three patients had increased neutrophilia at bronchoalveolar lavage and a mean 1.3% FEV1/month improvement versus 3.5% in the other five patients without neutrophilia. - Some grade of Air Trapping is present in the whole study population with a mean AT index 0.71 \ub1 0.57. - Patients with neutrophilia had mean AT index 0.50 versus 0.90 in patients with normal bronchoalveolar lavage. - Patient with neutrophilia had lower AT index variance: 0.03 versus 0.15. CONCLUSIONS - This preliminar study suggests that the Air Trapping index is congruent with increased neutrophilia in bronchoalveolar lavage and poor FEV1 improvement in recently lung transplanted patients. - Air Trapping index could be useful in early detection of bronchiolits obliterans. - Further studies are needed to confirm a strong relationship between Air Trapping index and bronchiolitis obliterans

Pulmonary Resection for Metastasis of Hepatocellular Carcinoma Recurring After Liver Transplant : An Italian Multicenter Experience

Background and aim: Liver transplantation (LT) is a validated treatment for hepatocellular carcinoma (HCC). HCC recurrence occurred between 8 and 20% of patients and lung is the most frequent site. Pulmonary metastases resection (PMR) prolongs survival, however in LT-setting the impact on survival is unclear. To give new lights on this issue, we report the experience of three Italian LT Centers. Methods: All consecutive HCC transplanted patients in three Italian LT Centers, who developed pulmonary metastasis from HCC (PM-HCC), as first metastasis, from 2008 to 2018, were included whenever treated with PMR. Results: Twenty-five patients were enrolled (median age 58 yrs, 84% male, 3% cirrhotics). HCC recurred after 34 months (9\u2013306) since LT and PMR was performed after 2.4 months (0\u201343.1). A total of 28 PMR (19 single resections; 9 multiple resections; 16 right; 2 left) have been performed on 24 patients while in one case percutaneous microwave ablation (MWA) was preferred. Four patients have been re-operated due to pulmonary HCC-recurrence after surgery. The majority of surgical resection type was wedge resection (26, 89%). Surgical access was: video-assisted thoracic surgery (VATS) in 17 cases (59%); thoracotomy in 11 (38%); MWA in 1 (3%). The 48% of nodule was in right lower lobe. Perioperative in-hospital mortality and 30 days mortality were nil; median surgical time 90 min (50\u2013365); median post-operative overall stay 5 days (2\u201311). Post-operative ICU treatment was necessary in 1 case (3%) for 3 days; blood transfusions in 2 cases (7%). Overall, 5 complications (2 bleeding; 1 AKI; 1 major cardiac; 1 wound dehiscence) occurred, with an overall complications rate of 23%. Eight (32%) patients died during a follow-up after HCC recurrence of 32 months (7\u2013213): 7 for HCC progression, 1 for severe liver failure due to chronic rejection. The 1 and 5 year cumulative probability of OS from recurrence were 100 and 43% (95%CI 12\u201374), respectively, with a median OS of 51 months (95%CI 24\u201378). Conclusion: Selected patients with isolated pulmonary HCC-recurrence after LT and with preserved hepatic function showed that a pulmonary metastasectomy could be efficacious in managing a PM-HCC and could give an opportunity for long-term survival