The Series on "How to Deal with Early Stage Lung Cancer: Sublobar Resections as A Possible Choice (Report of the 2019 Spring Meeting of Italian Society of Thoracic Surgery)?"

This series is the result of the work of different specialists from all around Italy and from Fudan University in Shanghai, who gathered in Milan on April 2019, to attend the Spring Meeting of Italian Society of Thoracic Surgery (SICT). The meeting discussed new evidences suggesting sublobar resection as the elective surgical treatment of early stage lung cancer

A valid academic path to promote respiratory physiotherapy

A one- year post- graduate Master in Physiotherapy and Pulmonary Rehabilitation has been offered within the University of Milan Medical School in collaboration with Associaz ione Italiana Riabilitatori dell\u2019Insufficienz a Respiratoria (ARIR). The aim is to cover a gap in Italian Physiotherapy academic curricula offering a course with theoretical and practical teaching that make students capable of using different techniques and procedures in respiratory physiotherapy. After the recognition by the International Education Recognition System (IERS), ARIR wanted to investigate if and how this course has affected students'attitude and their profession. METHODS A structured questionnaire made up of 15 multiple- choices items (8 on perceived quality of education and 7 on professional change) was sent by email to all physiotherapists who graduated in the previous four editions of the Master. One month was given for completion. Age, gender, year of degree and year of Master where considered as background variables. RESULTS We had a 78% response rate with 57 out of 73 physiotherapists sending the questionnaire back. Mean age was 37 years (23- 60) and women were the majority (78%). Forty- two students (74%) worked in the respiratory field at the time of application but only 15 (36%) dealt with respiratory patients only. Expectations were completely met at the end of Master for 71% of physiotherapists. 96% reported greater professional and clinical skills after the master with a 67% saying working team relationship has improved. 28% improved their job position thanks to the master degree and physiotherapy working in the respiratory field increased by 22%. CONCLUSIONS This course seems to meet students expectations and offer a solid knowledge to better work within the field of respiratory physiotherapy. It is also a way to promote the profession of respiratory physiotherapy in Italy

Lung transplantation from donation after controlled cardiocirculatory death: Systematic review and meta-analysis

Background: The interest in donation after cardiocirculatory death (DCD) donors for lung transplantation (LT) has been recently rekindled due to lung allograft shortage. Clinical outcomes following DCD have proved satisfactory. The aim of this systematic review is to provide a thorough analysis of published experience regarding outcomes of LT after controlled DCD compared with donation after brain death (DBD) donors. Methods: We performed a literature search in Cochrane Database of Systematic Reviews, PubMed and Web of Science using the items "lung transplantation" AND "donation after circulatory death" on November 1, 2018. The full text of relevant articles was evaluated by two authors independently. Quality assessment was performed using the NIH protocol for case-control and case series studies. A pooled Odds ratio (OR) and mean differences with inverse variance weighting using DerSimonian-Laird random effect models were computed to account for between-trial variance (tau 2). Results: Of the 508 articles identified with our search, 9 regarding controlled donation after cardiac death (cDCD) were included in the systematic review, including 2973 patients (403 who received graft from DCD and 2570 who had DBD). Both 1-year survival and 2 and 3-grade primary graft dysfunction (PGD) were balanced between the two cohorts (OR = 1.00 and 1.03 respectively); OR for airway complications was 2.07 against cDCD. We also report an OR = 0.57 for chronic lung allograft dysfunction (CLAD) and an OR = 0.57 for 5-year survival against cDCD. Conclusions: Our meta-analysis shows no significant difference between recipients after cDCD or DBD regarding 1-year survival, PGD and 1-year freedom from CLAD. Airway complications and long-term survival were both related with transplantation after cDCD, but these statistical associations need further research

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

Extracellular vesicles as graft biomarkers to address lung transplantation outcome

Lung transplantation is the last therapeutic option for end-stage pulmonary failure. Yet, clinical complications may rise after transplantation, such as primary grafts dysfunction (PGD) or chronic lung allograft dysfunction (CLAD). Current clinical parameters have failed to assess the quality of the graft and to predict transplantation outcome. Extracorporeal photopheresis (ECP) is a treatment for graft-versus-host disease. Peripheral blood white blood cells (WBC) are isolated, exposed to 8-methoxypsoralen photosensitizing agent, and subsequently treated with ultraviolet radiation before reinfusion into the patient, causing massive WBC apoptosis. Our working hypothesis is that extracellular vesicles (EV) produced by either the pre-transplantation organ (donor) or host (recipient) could be non-invasive biomarkers to evaluate tissue damage at the cellular level and to monitor organ engraftment

Autofluorescence bronchoscopy in lung transplantation

Despite little is known about airway perfusion in the early period after lung transplantation, central bronchial stenosis is attributed to pour vascularization. Autofluorescence bronchoscopy was developed to discover preinvasive lesions, based on the fact that dysplasia shows less fluorescence than normal tissue when excited by blue light. Despite some questions about the origin of autofluorescence are left, the presence of good vascularization seems to be crucial. The aim of the present study was to evaluate the bronchial mucosa modification after lung transplantation by autofluorescence bronchoscopy

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

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

Role of autofluorescence bronchoscopy in evaluation of bronchial mucosa after lung transplantation

Airway complications are a significant and persistent source of morbidity and mortality after lung transplantation; the incidence of these complications is around 15% with a mortality rate of 2- 3%. Airway complications arise, typically, the first two years post-transplant, and of these almost half are identified prior to discharge; their pathogenesis, as well as to opportunistic infections, appear to be related to the difficult revascularization of the bronchi resulting in chronic ischemia

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