Il supporto ECMO in Chirurgia Toracica ad eccezione del Trapianto Polmonare: la nostra esperienza nei casi chirurgici complessi.

Obiettivi: Extracorporeal membrane Oxygenation (ECMO) è generalmente usato nelle Unità di Terapia Intensiva, ma raramente è utilizzato come supporto ventilatorio durante gli interventi chirurgici toracici se si esclude il trapianto polmonare. Lo scopo del lavoro è quello di dimostrare l’utilità ed il vantaggio di questo sistema di supporto ventilatorio nei casi chirurgici particolarmente complessi. Materiali e metodi: In 3 anni abbiamo trattato, presso il nostro centro, 6 pazienti ( 4 uomini e 2 donne, di età compresa tra 19 ed 85 anni) con supporto ventilatorio ECMO. I tipi di interventi eseguiti (3 in regime di urgenza e 3 in elezione) sono stati: broncotomia e rimozione di protesi endobronchiale dislocata, precedentemente posizionata per complicanza chirurgica in pregressa pneumonectomia n=1; esofagectomia totale in recente resezione carenale e confezionamento di neocarena per fistola tracheo-esofagea n=1; lacerazioni e riparazioni tracheali post traumatiche (entrambe in regime di urgenza) n=2; lacerazione tracheale iatrogena post intubazione in urgenza n=1; resezione-anastomosi bronchiale per neoformazione endobronchiale in pregressa lobectomia controlaterale per ETP nel 2010 n=1. In tutti i casi clinici non era possibile eseguire una ventilazione monopolmonare. Risultati: In tutti i nostri casi è stato utilizzato solamente un supporto ECMO periferico: in 2 casi veno-arterioso (VA) e in 4 casi veno-venoso (VV). Dei casi VA uno è stato giugulo-femorale e l’altro femoro-femorale. I casi VV sono stati tutti femoro-femorale tranne uno in cui è stata utilizzata la vena giugulare ed una cannula bilume tipo Avalon (Elite®). Il supporto ventilatorio è stato esclusivamente intraoperatorio in 3 casi (pazienti 1,2 e 6: Gruppo A) con tempo di perfusione variabile tra 27 min e 3.95 h (2.06 h in media); Intra e postoperatorio in un caso (paziente 3: Gruppo B) con tempo di perfusione intraoperatorio di 6.41 h e di 17.16 h totali; Pre, intra e postoperatorio in 2 casi (pazienti 4 e 5: Gruppo C) con tempo di perfusione variabile tra 1.58 h e 5.75 h intraoperatorio (4.45 h in media) e di un tempo di perfusione totale che varia tra 120 h (4.25 giorni) e 250 h (10.4 giorni) ( 176 h in media = 7,3 giorni). La mortalità è stata del 16% (un solo paziente deceduto per sepsi) e non ci sono state complicanze legate alla procedura. Conclusioni: Sulla base della nostra esperienza l’utilizzo dell’ ECMO VV o VA è un ottimo e valido supporto ventilatorio nei casi chirurgici complessi delle vie aeree

Development of a video-assisted thoracoscopic lobectomy program in a single institution: Results before and after completion of the learning curve

BACKGROUND: The development of a video assisted thoracic surgery lobectomy (VATS-L) program provides a dedicated surgical team with a recognized learning curve (LC) of 50 procedures. We analyse the results of our program, comparing the LC with subsequent cases. METHODS: From June 2012 to March 2015, we performed n = 146 VATS major pulmonary resections: n = 50 (Group A: LC); n = 96 (Group B). Pre-operative mediastinal staging followed the National Comprehensive Cancer Network guidelines. All procedures were performed using a standard anterior approach to the hilum; lymphadenectomy followed the NCCN recommendations. During the LC, VATS-L indication was reserved to clinical stages I, therefore evaluated case by case. RESULTS: Mean operative time was 191 min (120-290) in Group A and 162 min (85-360) in Group B (p <0,01). Pathological T status was similar between two Groups. Lymphadenectomy included a mean of 5.8 stations in Group A and 6.6 in Group B resulting in: pN0 disease: Group A n = 44 (88 %), Group B n = 80 (83.4 %); pN1: Group A n = 3 (6 %), Group B n = 8 (8.3 %); pN2: Group A n = 3 (6 %), Group B n = 8 (8.3 %). Conversion rate was: 8 % in group A (n = 4 vascular injuries); 1.1 % in Group B (n = 1 hilar lymph node disease). We registered n = 6 (12 %) complications in Group A, n = 10 (10.6 %) in Group B. One case (1.1 %) of late post-operative mortality (90 days) was registered in Group B for liver failure. Mean hospital stay was 6.5 days in Group A and 5.9 days in Group B. CONCLUSIONS: We confirm the effectiveness of a VATS-L program with a learning curve of 50 cases performed by a dedicated surgical team. Besides the LC, conversion rate falls down, lymphadenectomy become more efficient, indications can be extended to upper stages

Search superiority in autism within, but not outside the crowding regime

AbstractVisual cognition of observers with autism spectrum disorder (ASD) seems to show an unbalance between the complementary functions of integration and segregation. This study uses visual search and crowding paradigms to probe the relative ability of children with autism, compared to normal developments children, to extract individual targets from cluttered backgrounds both within and outside the crowding regime. The data show that standard search follows the same pattern in the ASD and control groups with a strong effect of the set size that is substantially weakened by cueing the target location with a synchronous spatial cue. On the other hand, the crowding effect of eight flankers surrounding a small peripheral target is virtually absent in the clinical sample, indicating a superior ability to segregate cluttered visual items. This data, along with evidence of an impairment to the neural system for binding contours in ASD, bring additional support to the general idea of a shift of the trade-off between integration and segregation toward the latter. More specifically, they show that when discriminability is balanced across conditions, an advantage in odd-man out tasks is evident in ASD observers only within the crowding regime, when binding mechanism might get compulsorily triggered in normal observers

Search superiority in autism within, but not outside the crowding regime. Vision Research 49(16

a b s t r a c t Visual cognition of observers with autism spectrum disorder (ASD) seems to show an unbalance between the complementary functions of integration and segregation. This study uses visual search and crowding paradigms to probe the relative ability of children with autism, compared to normal developments children, to extract individual targets from cluttered backgrounds both within and outside the crowding regime. The data show that standard search follows the same pattern in the ASD and control groups with a strong effect of the set size that is substantially weakened by cueing the target location with a synchronous spatial cue. On the other hand, the crowding effect of eight flankers surrounding a small peripheral target is virtually absent in the clinical sample, indicating a superior ability to segregate cluttered visual items. This data, along with evidence of an impairment to the neural system for binding contours in ASD, bring additional support to the general idea of a shift of the trade-off between integration and segregation toward the latter. More specifically, they show that when discriminability is balanced across conditions, an advantage in odd-man out tasks is evident in ASD observers only within the crowding regime, when binding mechanism might get compulsorily triggered in normal observers

Animal Biomonitoring for the Surveillance of Environment Affected by the Presence of Slight Contamination by &beta;-HCH

The aim of this study was to evaluate the influence of hidden environmental pollution on some blood parameters of sheep to detect susceptible biomarkers able to reveal slight contamination. Four dairy sheep farms, two with semi-extensive and two with intensive type systems were involved in this study. Two farms in different systems were chosen as properly located in a southern area of Latium (Italy), close to the Sacco River, in which contamination with &beta;-hexachlorocyclohexane (&beta;-HCH) occurred in the past due to industrial waste. A recent study established the presence of low but detectable residual contamination in these areas. The other two farms were outside the contaminated area. Erythrocyte glutathione transferase (e-GST) and oxidative stress parameters were monitored as well as some immune response and metabolic profile parameters throughout the investigated period of four months. The present study showed a relevant and significant increase in e-GST (+63%) in the extensive farming system of the contaminated area, whereas some immune response biomarkers, i.e., white blood cells, neutrophils, lymphocytes, and lysozyme resulted within the physiological range. In all farms, oxidative stress and acute phase response parameters were also within the physiological range. Our results suggest that e-GST is a very effective alarm signal to reveal &ldquo;hidden&rdquo; persistent contamination by &beta;-HCH, and reasonably, by many other different dangerous pollutants

Short and long-term results of sternectomy for sternal tumours

BACKGROUND: We analyzed our experience in sternal resections (SRs) for primary or secondary neoplasm focusing on technical aspects of reconstruction, post-operative outcomes and long term survival. METHODS: From January 2005 to December 2015, 36 patients (24 males, 67%) underwent surgical excision of primary (chondrosarcoma n=18 patients, 50%; osteosarcoma n=2, 6%; Ewing sarcoma n=1, 3%; other n=2, 6%) or secondary (breast cancer n=7, 19%; kidney carcinoma n=2, 6%) sternal tumour. We performed n=30 partial sternectomy and n=6 total sternectomy with en-bloc resection of the sternocostal cartilages in all patient and extended resection in 7 patients. Stability was obtained with prosthetic material, rigid and non-rigid and a muscular flap: rigid material [Strasbourg Thoracic Osteosynthesis System (STRATOS), MedXpert GmbH] and muscle flap n=11 (30.6%); polytetrafluoroethylene patch and muscle flap n=6 (16.7%); muscle flap alone n=19 (52.8%). RESULTS: The 30-day mortality rate was 0, overall complication rate was 19%. The median ICU stay was 1.5 days and mean hospital stay was 10.6±5.9 days. We obtained a complete (R0) resection in all patients. Overall survival (OS) at 5 and 10 years were 59% and 40%; in the group of primary neoplasm OS rate at 5 and 10 years was 79% and 54%. Disease free survival (DFS) rate at 5 years was 61%. Higher grading was identified as negative prognostic factor. CONCLUSIONS: Wide radical resections of anterior chest wall are basilar in a multimodality treatment for primary or metastatic neoplasm of the sternum. Stabilization with titanium bars and clips provides rigidity of chest wall with good functional results