How to identify intersegmental planes in performing sublobar anatomical resections

Pulmonary segmentectomy is a common surgical procedure in thoracic surgery nowadays. Though this technique helps preventing postoperative pulmonary function loss, potential challenges are the management of air leaks and the difficulty of palpating ground-glass components during surgery, as well as how to deal with the intersegmental planes. Several techniques have been proposed for the identification and treatment of the intersegmental planes during sublobar anatomical resections: this review focuses on preoperative planning and workup and intraoperative strategies. Three-dimensional computed tomography bronchography and angiography (3D-CTBA), virtual-assisted mapping (VAL-MAP) using bronchoscopy multi-spot dye marking and three-dimensional computed tomography (3D-CT) are preoperative tools that may facilitate the planning of operation. Inflation-deflation techniques, infrared-fluorescence-enhanced method combined with bronchial and intravenous injection of indocyanine green (ICG) and near-infrared fluorescence (NIF) mapping with ICG have been described as intraoperative strategies to identify the intersegmental plane. The treatment and section of the intersegmental planes is mainly accomplished by stapler and electrocautery or energy devices. The use of staplers reduces postoperative air leaks, bleeding risks and operative time but seems to reduce preserved lung volume, compromising adjacent lung expansion; in addition, higher costs and sometimes non-adequate oncological margins, being a non-anatomical technique have been described. The electrocautery and energy devices allow for a more anatomical and precise dissection maintaining safe oncological margins, with a better lung expansion and so an increased postoperative lung function. Time consuming procedure and frequent requirement of aero-haemostatic tools to treat air and blood leaks are the main drawbacks. In conclusion, there are several methods to identify and treat the intersegmental planes but there are no significant differences between the different tools, therefore the use of one technique rather than another depends overall on surgeon’s preference and the location of the segment

Catamenial pneumothorax: Not only VATS diagnosis

BackgroundCatamenial pneumothorax (CP) is a rare type of spontaneous, recurring pneumothorax occurring in women, from the day before menstruation until 72 hours after its beginning. Conservative treatment is generally associated with recurrence of CP. Video-assisted thoracic surgery (VATS) approach allows not only to obtain diagnosis but also to guide definitive treatment of causing lesions, such as ectopic endometrial implants or diaphragmatic defects and fenestrations. We report our experience in VATS management of CP to focus on its role in CP.Materials and methodsIn this retrospective observational study, we collected data from women referred to our center for CP, from January 2019 to April 2022. All patients underwent VATS approach, with muscle-sparing thoracotomy when diaphragmatic fenestrations were detected, to perform selective diaphragmatic plication and/or partial diaphragmatic resection. Results were analyzed in terms of pneumothorax recurrence after surgical treatment. All patients were referred to gynecologists for medical therapy.ResultsEight women (median age 36 years, range: 21–45), all with right side CP, were included; three already had pelvic endometriosis and two had already undergone lung apicectomy at other institutions. VATS allowed us to detect diaphragmatic fenestrations in seven patients (87.5%) and apical bullae in five (62.5%). Apicectomy was performed in five cases (62.5%), selective diaphragmatic plication in two (25%), and partial diaphragmatic resection in five (62.5%). Chemical pleurodesis with talc was performed in all to minimize the risk of recurrence. Pathological diagnosis of endometriosis on the resected diaphragm was achieved in five patients (62.5%). No recurrence occurred, except for one woman who stopped medical treatment for endometriosis.ConclusionsIn the management of patients with CP, VATS should be recommended not only to obtain an explorative diagnosis of ectopic endometrial implants or diaphragmatic fenestrations but also to allow the most appropriate surgical treatment and obtain pathological specimens for confirmation and definitive diagnosis of thoracic endometriosis. Medical therapy to achieve ovarian rest is mandatory in the postoperative period and should not be discontinued

Pulmonary and mediastinal paragangliomas: Rare endothoracic malignancies with challenging diagnosis and treatment

Background: Pulmonary and mediastinal paragangliomas are rare tumors that may have neuroendocrine activity or be non-functional, incidental, in asymptomatic patients, or causing mass effect symptoms. Although being low-grade tumors, they can display an aggressive behaviour, developing local infiltration and distant metastases. We report our experience with three endothoracic paragangliomas and a Literature review, to point out diagnostic difficulties and problems related to surgical treatment. Methods: From 2009 to 2017, we treated 3 patients with histological diagnosis of paraganglioma: 2 pulmonary, 1 mediastinal. No one presented catecholamine-secreting syndromes; pulmonary cases were asymptomatic, while the mediastinal one had aspecific cough and dyspnea. Imaging diagnosis was based on chest computerized tomography (CT) and magnetic resonance imaging (MRI) scan. No patient had preoperative histological diagnosis. Intraoperative pathological examination was suggestive for malignancy: in pulmonary cases, wedge resection and lobectomy were performed; the middle mediastinal mass was completely removed after challenging dissection, isolation and section of numerous vascular pedicles. Results: Postoperative course was uneventful in all cases. No patient received adjuvant treatments. At a median follow-up of 47 months (range, 6-102 months), two patients are alive, without local or distant recurrence; one patient died 6 months after surgery, due to disease progression. Conclusions: Endothoracic paragangliomas, rare and often asymptomatic tumors, are of difficult diagnosis and should be considered malignant tumors, due to the potential aggressive behaviour of cases with high mitotic index and the frequent possibility of recurrence and metastases. Surgical resection is the treatment of choice and careful intraoperative manipulation is recommended, due to the high vascularity of these tumors, to prevent complications. After complete excision, long-term prognosis is generally good. However, even after surgical removal, a close, periodical and life-long follow-up is mandatory

Case report: Successful multimodal assessment and management of chemothorax

Dislocation or wrong placement of central venous catheters into the pleural cavity is rare, but if undiagnosed, may cause major, sometimes life-threatening, complications (pneumothorax, hemothorax, infection, and migration) and accidental pleural effusion due to intravenous injection of fluids containing drugs (i.e. chemotherapy, antibiotics, parenteral nutrition, other). We report a rare case of pleural effusion consisting of chemotherapy (chemothorax) directly injected into the pleural cavity due to the wrong placement of a central venous catheter (Porth-A-Cath) in a woman with breast cancer. A multidisciplinary management consisting of antidote administration, followed by removal of the venous device and washing of the pleural cavity through video-assisted thoracic surgery (VATS), avoided any major complication related to the adverse event

Current Practices in the Management of Pulmonary Ground-Glass Opacities: A Survey of SICT Members

Several gray areas and controversies exist concerning the management of pulmonary ground-glass opacities (GGOs) and there is a lack of consensus among clinicians on this topic. One of the main aims of the Italian Society of Thoracic Surgery (SICT) is to promote education and research, so we decided to perform a survey on this topic to estimate current trends in practice in a large sample of thoracic surgeons

Endoscopic removal of tracheobronchial foreign bodies: results on a series of 51 pediatric patients

Purpose: Rigid bronchoscopy (RB) is still considered the gold standard approach for the removal of airway foreign bodies (FBs) in children; however, flexible bronchoscopy (FOB) has recently been proposed both as diagnostic and therapeutic means. Our purpose was to evaluate the outcomes of FOB, associated with the Dormia basket, for the removal of FBs. Methods: Retrospective data about 124 children who underwent bronchoscopy for the suspicion of a FB aspiration between January 2008 and January 2019 in our department were collected. Results: In a total of 51 cases, FBs were removed through FOB or RB associated with forceps or Dormia basket. Male to female ratio was 1.8:1, mean age 30 ± 26.1 months. Thirty-four (67%) FBs were directly removed through FOB, in most of the cases using Dormia basket and twelve (23%) patients underwent RB. The overall left-versus-right distribution was 57% vs. 43%. The mean retrieval procedural time was 36.29 ± 24.99 min for FOB and 52.5 ± 29.74 min for RB; the success rate of the procedures was 97% vs. 67%. Conclusion: FOB can be used not only as a diagnostic procedure, but also as the first method for the removal of airway FBs. The Dormia basket is a useful tool, especially to remove peripherally located FBs

Multidisciplinary Approach in the Treatment of Descending Necrotizing Mediastinitis: Twenty-Year Single-Center Experience

Descending necrotizing mediastinitis (DNM) is an acute, rare, severe condition with high mortality, but the optimal management protocol is still controversial. We retrospectively analyzed the results of multidisciplinary management in patients treated for DNM at our center over the last twenty years. Fifteen male patients, mean age 49.07 ± 14.92 years, were treated: 9 with cervico-pharyngeal etiopathogenesis, 3 peri-tonsillar/tonsillar, 2 odontogenic, 1 post-surgical; 6 with DNM type I, 6 with type IIA, and 3 with type IIB (Endo’s classification). Mean time between diagnosis and treatment was 2.24 ± 1.61 days. In all cases, mediastinum drainage via thoracotomy was performed after neck drainage via cervicotomy, associated with tooth treatment in two; one required re-operation; tracheostomy was necessary in 9, temporary intensive care unit stay in 4; 6 developed complications, without post-operative mortality. Main isolated germs were Staphylococci and Candida; 7 had polymicrobial infection. The most used antibiotics were meropenem, metronidazole, teicoplanin, third-generation cephalosporins and clyndamicin; anti-fungal drugs were fluconazole, caspofungin and anidulafungin. On multivariate analysis, presence of cardiovascular disease was statistically significantly associated with longer chest tube duration and hospital stay. DNM requires early diagnosis and treatment to reduce mortality and morbidity. The most effective treatment should provide a multidisciplinary approach, combining cervicotomy and thoracotomy to drain all infectious collections with administration and monitoring of the proper antimicrobial therapy

Current practices in the management of pulmonary Groun-Glass Opacities: a survey of SICT members

Background: Several gray areas and controversies exist concerning the management of pulmonary ground-glass opacities (GGOs), and there is a lack of consensus among clinicians on this topic. One of the main aims of the Italian Society of Thoracic Surgery is to promote education and research, so we decided to perform a survey on this topic to estimate current trends in practice in a large sample of thoracic surgeons. Methods: A total of 160 thoracic surgeons responded, namely, completed our questionnaire (response rate, 53%; 160 of 302). The survey was composed of 36 questions divided into six subsections: (1) demographic characteristics of the respondents; (2) terminology and taxonomy; (3) radiologic and radiometabolic evaluation; (4) diagnostic approach and indications for surgery; (5) surgical management; and (6) radiologic surveillance. Results: We observed some divergence of opinion regarding the definition of mixed GGOs, the role of 18F fluorodeoxyglucose positron emission tomography and computed tomography scans, indications for nonsurgical biopsy, intraoperative techniques for localizing GGOs, indications for surgery, extension of lung resection and lymph node dissection according to the radiologic scenario, use of intraoperative frozen section analysis, and radiologic surveillance of pure GGOs. Conclusions: This topic warrants more investigation in the future. An upcoming consensus conference of Italian Society of Thoracic Surgery experts (also open to experts in other specialties) could provide updated indications for GGO management based on the literature, expert opinions, and the results of the present survey