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

Surgical treatment of lung cancer with adjacent lobe invasion in relation to fissure integrity

Background Tumor with adjacent lobe invasion (T‐ALI) is an uncommon condition. Controversy still exists regarding the optimal resection of adjacent lobe invasion, and the prognostic value in relation to fissure integrity at the tumor invasion point. The aims of this paper were to evaluate the prognosis of T‐ALI with regard to fissure integrity, and type of resection. Methods This was a retrospective multicenter study which included all consecutive patients with T‐ALI undergoing surgical treatment. Based on radiological, intraoperative and histological findings, T‐ALI patients were differentiated into two groups based on whether the fissure was complete (T‐ALI‐A group) or incomplete (T‐ALI‐D Group) at the level of tumor invasion point. Clinico‐pathological features and survival of two study groups were analyzed and compared. Results Study population included 135 patients, of these 98 (72%) were included into T‐ALI‐A group, and 37 (38%) into T‐ALI‐D Group. T‐ALI‐D patients had better overall survival than T‐ALI‐A patients (63.9 ± 7.0 vs. 48.9 ± 3.9; respectively, P = 0.01) who presented with a higher incidence of lymph node involvement (35% vs. 4%; P = 0.004), and recurrence rate (43% vs. 16%; P = 0.01). At multivariable analysis, T‐ALI‐D (P = 0.01), pN0 stage (P = 0.0002), and pT≤5 cm (P = 0.0001) were favorable survival prognostic factors. Conclusions T‐ALI‐D presented a better prognosis than T‐ALI‐A while extent of resection had no effect on survival. Thus, in patients with small T‐ALI‐D and without lymph node involvement, sublobar resection of adjacent lobe rather than lobectomy could be indicated. Key points The extent of resection of adjacent lobe had no effect on survival while T‐ALI‐D, pN0 stage, and pT≤5 cm were significant prognostic factors. In patients with small T‐ALI‐D and without lymph node involvement, sublobar resection of adjacent lobe could be indicated as an alternative to lobectomy

Simultaneous MALT lymphoma of the thymus and parotid gland: independent lymphomas or metastatic spread?

Background: Mucosa associated lymphoid tissue (MALT) lymphoma of the thymus is rare and generally associated with autoimmune disorders. It is generally suspected in middle-aged asian women with Sjogren’s syndrome or other autoimmune diseases presenting a multicystic mediastinal mass. Contrary to other MALT lymphomas, the etiology of these tumors is still uncertain especially those affecting patients with no autoimmune diseases. Thymic MALT lymphoma with simultaneous salivary gland involvement is extremely rare, with only few cases described in literature. Case presentation: We present a case of a 33 years-old male, with a recent history of MALT lymphoma of right parotid gland, affected by thymic mass. The patient underwent a right video-assisted thoracoscopy with radical thymectomy. The histological examination revealed a MALT lymphoma of the thymus. The molecular analysis on both thymic and parotid MALT lymphoma for clonal rearrangement of the immunoglobulin heavy chain gene suggests the origin from the same lymphomatous clone. Conclusions: It is still unclear if multiple localizations of MALT lymphomas are attributable to the development of different primary lymphomas or can be caused by lymphatic metastatic spread. Our analysis reveal that the hypothesis of metastatic spread cannot be excluded in patients with simultaneous MALT lymphoma of the thymus and parotid gland, especially in non-autoimmune related MALT lymphomas

Pulmonary artery resections for lung cancer. When and how?

Resection and reconstruction of the pulmonary artery (PA), whether associated or not to a sleeve resection of the bronchus, allows complete resection of centrally located lung cancer, thus avoiding pneumonectomy. Despite initial concern related to technical difficulties, perioperative management and long term survival, recent studies showed continuous enhancement of the surgical technique and reconstruction materials, reduction of the complication rate and improvement in the survival. This allowed this procedure to gain widespread acceptance in the treatment of lung cancer

Coaxial Drainage versus Standard Chest Tube after Pulmonary Lobectomy: A Randomized Controlled Study

Chest tubes are routinely inserted after thoracic surgery procedures in different sizes and numbers. The aim of this study is to assess the efficacy of Smart Drain Coaxial drainage compared with two standard chest tubes in patients undergoing thoracotomy for pulmonary lobectomy. Ninety-eight patients (57 males and 41 females, mean age 68.3 ± 7.4 years) with lung cancer undergoing open pulmonary lobectomy were randomized in two groups: 50 received one upper 28-Fr and one lower 32-Fr standard chest tube (ST group) and 48 received one 28-Fr Smart Drain Coaxial tube (SDC group). Hospitalization, quantity of fluid output, air leaks, radiograph findings, pain control and costs were assessed. SDC group showed shorter hospitalization (7.3 vs. 6.1 days, p = 0.02), lower pain in postoperative day-1 (p = 0.02) and a lower use of analgesic drugs (p = 0.04). Pleural effusion drainage was lower in SDC group in the first postoperative day (median 400.0 ± 200.0 mL vs. 450.0 ± 193.8 mL, p = 0.04) and as a mean of first three PODs (median 325.0 ± 137.5 mL vs. 362.5 ± 96.7 mL, p = 0.01). No difference in terms of fluid retention, residual pleural space, subcutaneous emphysema and complications after chest tubes removal was found. In conclusion, Smart Drain Coaxial chest tube seems a feasible option after thoracotomy for pulmonary lobectomy. The SDC group showed a shorter hospitalization and decreased analgesic drugs use and, thus, a reduction of costs

Video-assisted thoracoscopic treatment of pneumothorax

in the last three decades, minimally invasive techniques have progressively gained acceptance, as shown by the numerous studies published in the literature. Before the 1990s, video-assisted thoracoscopic surgery (VATS) was considered feasible almost exclusively for the diagnosis of pleural diseases. The availability of better instruments and endoscopic stapling devices allowed thoracoscopy to evolve into a new “therapeutic era”. Nowadays, VATS is considered the approach of choice for the treatment of pneumothorax and other lung, mediastinal and esophageal diseases, replacing traditional approaches as thoracotomy and sternotomy. The use of ports through small incisions (one to three-four) for the camera and surgical instruments allows the surgeon to explore the pleural cavity and work easily on the lung parenchyma. This approach translates into less discomfort for the patient, reduced morbidity, shorten hospital stay and faster functional recovery. The optimal treatment of pneumothorax certainly refers thoracoscopy as the approach of choice maintaining the same indications as for open surgery

Surgical treatment of lung cancer with adjacent lobe invasion in relation to fissure integrity

Background Tumor with adjacent lobe invasion (T‐ALI) is an uncommon condition. Controversy still exists regarding the optimal resection of adjacent lobe invasion, and the prognostic value in relation to fissure integrity at the tumor invasion point. The aims of this paper were to evaluate the prognosis of T‐ALI with regard to fissure integrity, and type of resection. Methods This was a retrospective multicenter study which included all consecutive patients with T‐ALI undergoing surgical treatment. Based on radiological, intraoperative and histological findings, T‐ALI patients were differentiated into two groups based on whether the fissure was complete (T‐ALI‐A group) or incomplete (T‐ALI‐D Group) at the level of tumor invasion point. Clinico‐pathological features and survival of two study groups were analyzed and compared. Results Study population included 135 patients, of these 98 (72%) were included into T‐ALI‐A group, and 37 (38%) into T‐ALI‐D Group. T‐ALI‐D patients had better overall survival than T‐ALI‐A patients (63.9 ± 7.0 vs. 48.9 ± 3.9; respectively, P = 0.01) who presented with a higher incidence of lymph node involvement (35% vs. 4%; P = 0.004), and recurrence rate (43% vs. 16%; P = 0.01). At multivariable analysis, T‐ALI‐D (P = 0.01), pN0 stage (P = 0.0002), and pT≤5 cm (P = 0.0001) were favorable survival prognostic factors. Conclusions T‐ALI‐D presented a better prognosis than T‐ALI‐A while extent of resection had no effect on survival. Thus, in patients with small T‐ALI‐D and without lymph node involvement, sublobar resection of adjacent lobe rather than lobectomy could be indicated. Key points The extent of resection of adjacent lobe had no effect on survival while T‐ALI‐D, pN0 stage, and pT≤5 cm were significant prognostic factors. In patients with small T‐ALI‐D and without lymph node involvement, sublobar resection of adjacent lobe could be indicated as an alternative to lobectomy

Uniportal thoracoscopy for pneumothorax

Introduction: Videothoracoscopy (VATS) is the gold standard for pneumothorax (PNX). However, in the last years, the surgical technique has been progressively modified towards less invasiveness to reduce postoperative pain and hospitalization. We present our experience with uniportal VATS to treat PNX. Methods: Seventy-six patients (mean age 19 ±14 years) with PNX underwent surgery with an uniportal approach. In fifty-eight patients (76.3%) the indication was a recurrence of previous spontaneous PNX, in 14 (18.4%) prolonged air leakage after chest tube placement for the first episode of PNX and in 4 (5.3%) redo surgery after no resolution of air leakage. One patient with bilateral PNX was simultaneously treated on both sides. All patients had a chest drainage before the surgery and VATS has been performed through a single port of 2.5 cm corresponding to the chest tube insertion. All patients have received blebs or bullae resection and partial parietal pleurectomy. Results: One postoperative bleeding required reoperation through the same approach. One recurrence on the operated side occurred after 2 years and it was successfully treated with uniportal VATS through the previous incision. Comparing this series with an historical population of patients treated with three-port VATS, we observed a significant decrease of postoperative pain measured with Visual Analog Scale (VAS) at 1st postoperative day, at discharge and at one month (2.92 vs 4.03 p=0.04; 1.2 vs 2.6 p=0.04; 0.58 vs 1.34 p=0.03). Furthermore, Uniportal group has been discharged earlier (3.67 vs 6.3 days; p=0.003). Conclusions: Uniportal VATS is a safe and effective approach to treat PNX also in difficult situations