Videothoracoscopic approach to stage I non-small cell lung cancer

SCOPO: A oltre vent\u2019anni dalla loro introduzione, le lobectomie videotoracoscopiche non sono ancora estensivamente eseguite. Scopo del presente studio \ue8 valutare la validit\ue0 dello staging e del trattamento videotoracoscopico analizzando un\u2019esperienza ventennale di 286 lobectomie videotoracoscopiche per cancro polmonare non a piccole cellule al primo stadio clinico TNM. MATERIALI METODI: Dall\u2019Ottobre 1991 al dicembre 2013, 1549 pazienti con tumore polmonare non a piccole cellule, candidati alla resezione chirurgica sulla base dello staging convenzionale sono stati sottoposti a videotoracoscopia come primo tempo dell\u2019intervento pianificato per escludere cause occulte d\u2019 inoperabilit\ue0 e verificare la resecabilit\ue0 e la sua fattibilit\ue0 in tecnica videoendoscopica. La lobectomia videotoracoscopica \ue8 stata volutamente limitata a pazienti in stadio clinico I. Pazienti con tumori pi\uf9 avanzati sono stati sottoposti a resezione toracotomica anche qualora tecnicamente resecabili toracoscopicamente. I dati di sopravvivenza, inseriti in un data base dedicato, sono stati analizzati col metodo di Kaplan- Meier e log-rank test. RISULTATI: Nei 1549 pazienti la videotoracoscopia rivel\uf2 cause occulte d\u2019 inoperabilit\ue0 in 62 (4%), per la maggior parte dovute a carcinosi (33 pz. 2,1%) infiltrazione mediastinica (22 pz. 1,4%),o infiltrazione dell\u2019arteria in scissura in pazienti non tolleranti una pneumonectomia (7pz. 0,4%). 534 (34,5%) pazienti furono sottoposti a resezione videotoracoscopica (286 lobectomie, 7 pneumonectomie, 241 wedge resections), 919 (59,3%) ebbero una resezione toracotomica (649 lobectomie, 158 pneumonectomie, 35 trachealsleeve pneumonectomies, 77 wedge resections), 34 (2,2%) ebbero una toracotomia esplorativa (TE) nonostante la videotoracoscopia preliminare. Tra le 286 videolobectomie la mortalit\ue0 operatoria \ue8 stata nulla, ma 2 pazienti decedettero entro i 60 giorni postoperatori per una polmonite controlaterale in un caso e per rottura del cuore dopo IMA in un altro. Non sono state osservate recidive locali. Nel follow-up prolungato al 2013, 41 (14,3%) pazienti morirono di progressione di malattia neoplastica, 6 (2%) ebbero un cancro polmonare metacrono, 25 (8.7%) morirono per cause non correlate al tumore, 7 (2,4) morirono per altri tumori e 28 (9.8%) per cause non conosciute. Il tasso di sopravvivenza globale a lungo termine dopo lobectomia videotoracoscopica per i pazienti allo Stadio I \ue8 stato dell\u201983,8% a tre anni e del 64,3% a 5 anni. La sopravvivenza a 5 anni \ue8 stata significativamente migliore (p=0.004) per i pazienti T1N0 (70%) che T2N0 (55%) e per i pazienti di et\ue0 inferiore ai 55 anni (86,4% p=0.0001) o con lesioni < di 2cm (80,8% p=0.03). COMMENTI E CONCLUSIONI: La toracoscopia preliminare di routine ebbe un tasso di accuratezza del 72.4%, si dimostr\uf2 estremamente affidabile nell\u2019escludere cause di non resecabilit\ue0 (NPV 0.95) e consent\uec di diminuire il tasso di TE al 2,1%. Considerando le toracotomie esplorative evitate e le resezioni videoendoscopiche effettuate, la videotoracoscopia consent\uec globalmente di evitare 596 (38,5%) toracotomie non necessarie. Nella nostra esperienza, la lobectomia videotoracoscopica si \ue8 dimostrata una tecnica sicura con un basso tasso di complicanze intraoperatorie. Lo studio retrospettivo della nostra esperienza, esteso su un lungo lasso di tempo e condotto su una casistica monocentrica e standardizzata ha dimostrato tassi di sopravvivenza a lungo termine comparabili a quelli delle convenzionali lobectomie toracotomiche. Sulla base dei nostri dati e di quelli dell\u2019 esperienza internazionale la lobectomia videotoracoscopica rappresenta oggi una valida opzione per il trattamento del cancro polmonare al primo stadio.AIM: Aim of this study is to evaluate the validity of videothoracoscopic staging and treatment in a twenty-year-long series of 286 VATS lobectomies for Clinical Stage I NSCLC. MATERIAL OF STUDY: We retrospectively reviewed 1549 candidates to resection after conventional staging from November 1991 to December 2013, and routinely submitted to videothoracoscopy immediately before the procedure. Patients deemed operable at videoexploration were resected by thoracoscopy or thoracotomy. Out of 534 VATS resections 286 thoracoscopic lobectomies for clinical stage I cancers were performed with strict indications and standardized technique; more advanced tumours were converted even when thoracoscopically resectable. Impact of preliminary videothoracoscopy and and longterm Kaplan-Meier survival was analyzed. RESULTS AND DISCUSSION: Out of 1549 patients, videothoracoscopy disclosed inoperability in 62 (4 %), mostly for pleural carcinosis (33pts.-2.1%) or mediastinal infiltration (22pts-1.4%). 534 (34.5%) patients had videothoracoscopic resection (286 lobectomies, 7 pneumonectomies, 241 wedge resections), 919 (59.3%) had thoracotomy resection, 34 (2.2%) had an exploratory thoracotomy (ET). Thoracoscopy had an accuracy rate of 72.4%, was reliable in excluding unresectability (NPV 0.95), and decreased the rate of ETs to 2.1%, ,sparing 596 (38.5%) thoracotomies. There was no intraoperative mortality or recurrence. Stage I patients had 83.8% 3-yr survival and 64.3% 5-yr survival. Five-year survival was significantly better (p=0.004) for T1N0 patients (70%) than T2N0 (55%) and for patients younger than 55 (86.4%) or with lesion < 2 cm (80.8%). CONCLUSIONS: Preliminary videothoracoscopy reliably assesses tumor resectability and feasibility of thoracoscopic resection, limiting unnecessary thoracotomies. Videolobectomies are safe and survival is comparable to open lobectomy. KEY WORDS: Lobectomy, Lung cancer, Minimally invasive surgery, Thoracoscopy, VATS

Trans-obturator colonic suspension during Altemeier\u2019s operation for full-thickness rectal prolapse : preliminary results with a new technique

AIM: With the aim of reducing recurrence after perineal surgery for full-thickness rectal prolapse, a new operation consisting of a trans-obturator colonic suspension during Altemeier's operation has been developed. METHOD: Eighteen women with full-thickness rectal prolapse were examined clinically, with validated quality of life and continence scores, colonoscopy, anorectal manometry, anal EMG and sacral reflex latency. Ten had a newly diagnosed and eight a recurrent prolapse. The Altemeier operation was combined with a levatorplasty in all cases using two porcine collagen prostheses sutured to the descending colon and passed through the trans-obturator space bilaterally. The operation was completed by a manual or stapled colo-anal anastomosis. Clinical examination, with quality of life and continence scores, anorectal manometry, EMG and sacral reflex latency, was scheduled during follow up, with the recurrence of prolapse as the primary outcome measure. RESULTS: There were no recurrences at 30 months. There was no mortality and no complications. All patients experienced significant improvement in quality of life and faecal continence scores (P<0.01). Surgery did not affect anorectal pressures or sacral reflex latencies. CONCLUSION: The new technique appears to be relatively easy to perform and is complication free with no recurrence after a short period of follow up. A larger study with appropriate controls and longer follow up is now needed to assess its real effectiveness in reducing the risk of recurrenc

New method for the early design of BIPV with electric storage: a case study in northern Italy

This paper presents a new method for the planning of photovoltaic systems in the early architectural design. The method finds capacity and position of a photovoltaic system over the envelope of a building by means of optimization. The input consists in: geometry of the building, surrounding shadings, local weather, hourly electric demand, unitary costs of the system and benefits for the production of electricity (sold or self-consumed). In the input there are known values (e.g. PV installation costs [€/kWp] or present costs for the electricity [€/kWh]) and unknown ones (e.g. degradation rate [%/year], maintenance costs [€/kWp year] or discount rate [%/year]). The optimization is performed using the expected value out of a set of parametric scenarios generated by the unknown input values. The results show that, if capacity and position of the system are tailored on its aggregated electric demand, a large penetration of photovoltaic electricity is profitable at current prices without incentives or valorization from the grid. The optimization performed with an arbitrary set of electric storages shows how the presence of storage fosters a higher optimal capacity for the PV system. This method has the potential to hugely expand the installation of urban photovoltaic

Systemic long-term consequences of polycystic ovary syndrome

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Antibody Recognition Of Plasmodium Falciparum Infected Red Blood Cells By Symptomatic And Asymptomatic Individuals In The Brazilian Amazon

In the Amazon Region, there is a virtual absence of severe malaria and few fatal cases of naturally occurring Plasmodium falciparum infections; this presents an intriguing and underexplored area of research. In addition to the rapid access of infected persons to effective treatment, one cause of this phenomenon might be the recognition of cytoadherent variant proteins on the infected red blood cell (IRBC) surface, including the var gene encoded P. falciparum erythrocyte membrane protein 1. In order to establish a link between cytoadherence, IRBC surface antibody recognition and the presence or absence of malaria symptoms, we phenotype-selected four Amazonian P. falciparum isolates and the laboratory strain 3D7 for their cytoadherence to CD36 and ICAM1 expressed on CHO cells. We then mapped the dominantly expressed var transcripts and tested whether antibodies from symptomatic or asymptomatic infections showed a differential recognition of the IRBC surface. As controls, the 3D7 lineages expressing severe disease-associated phenotypes were used. We showed that there was no profound difference between the frequency and intensity of antibody recognition of the IRBC-exposed P. falciparum proteins in symptomatic vs. asymptomatic infections. 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