Naples 2000 - Abstractsxoomer.virgilio.it/naples2000/13_0845.doc · Web view2002-03-05 · Marcello Migliore, Riccardo Giuliano, Francesco Basile*, ... surgical treatment for spontaneous

NAPLES 2000 FREE COMMUNICATIONS, POSTER DISCUSSION, SELECTED PAPERS

1. PLEURAL MESOTHELIOMA TREATED BY EXTRAPLEURAL PNEUMONECTOMY AND ADJUVANT RADIOTHERAPY

P.P. Brega Massone, C. Lequaglie, B. Conti, *B. Magnani, I. Cataldo

2. SURGICAL TREATMENT OF PULMONARY MUCORMYCOSIS IN THE DIABETIC: REPORT OF A CASE.

P. Sardelli*, F. Sollitto*, A. De Palma*, M. Loizzi*, G. Stefanelli°, L. D’Amato°, R. Giorgino°

3. A COMPARATIVE STUDY OF EC, UWLP, CMB SOLUTIONS IN LUNG PRESERVATION IN ACUTE AUTOTRANSPLANTATIONS IN THE PIG

D. Divisi, *P. Montagna, C. Battaglia, L. Scuteri, W. Di Francescantonio, G. Torresini, *O. Jegaden, R. Crisci.

4. LUNG METASTASES: ROLE OF SURGERY AND OUR RESULTS

S. Sanna, S. Folli, M. Mengozzi, D. Lelli, C. Barbieri, D. Dell'Amore

5. BRONCHIAL CARCINOIDS: OUR EXPERIENCE ON 47 CASES

S. Sanna, S. Folli, D. Lelli, m. Mengozzi, C. Barbieri, D. Dell'Amore

6. PREOPERATIVE EMBOLIZATION IN THE TREATMENT OF MEDIASTINAL HEMANGIOPERICYTOMA

A.Stefani, M.DeSantis, U.Morandi

7. SURGICAL TREATMENT OF SPONTANEOUS PNEUMOTHORAX WITHOUT PLEURODESIS: OUR EXPERIENCE

S Saita, E Potenza, F Mannino, A Maresca, T Nicolosi, C Riscica Lizzio

8. LUNG RESECTION FOR NON-SMALL CELL LUNG CANCER IN PATIENTS WITH CONCOMITANT NON-SURGICAL CARDIAC DISEASE

P. Ciriaco, B. Canneto, A. Puglisi, P. Zannini

9. SURGICAL TREATMENT OF ANEURYSMAL DISEASE OF THE DESCENDING THORACIC AORTA

K. Athanassiadi, A. Loutsidis, A. Hatzimichalis, I. Bellenis.

10. BENIGN STENOSES OF THE TRACHEA

K. Athanassiadi, A. Loutsidis, A. Hatzimichalis, I. Bellenis.

11. VATS LUNG RESECTION WITHOUT STAPLER. IS IT SAFE ENOUGH?

NAPLES 2000 http://members.xoom.it/naples2000/ 1

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V. Porhanov, I. Poliakov

12. VIDEOTHORACOSCOPY RESECTION FOR LUNG TUBERCULOMAS: EXPERIENCE WITH 92 CASES.

V. Porhanov, I. Poliakov

13. CLINICAL DIAGNOSTIC APPLICATION OF 111IN-DTPA-OCTREOTIDE SCINTIGRAPHY IN SMALL CELL LUNG CANCER

M.Vaccarili, F.Fabiani*, A.Staffilano*, F.G.Torresini, C.Battaglia, W Di Francescantonio, R.Crisci

14. INTEGRATED TREATMENT OF NON-SMALL CELL LUNG CANCER

M.Vaccarili, F.G.Torresini, C.Battaglia, W Di Francescantonio, R.Crisci

15. USEFULNESS OF THE VIDEOMEDIASTINOSCOPY

V.Jedlicka, I Capov, A.Pestal, T.Stasek

16. ENDOSCOPIC TREATMENT OF MALIGNANT AIRWAY LESIONS: A REVIEW OF OUR RECENT EXPERIENCE.

M. Loizzi, F. Sollitto, P. Sardelli, M. Genualdo, A. De Palma.

17. LONG TERM SURVIVAL AFTER BRONCHOPLASTIC LOBECTOMY FOR NON SMALL CELL LUNG CANCER

C. Ghiribelli, L. Voltolini, L. Luzzi, P.Paladini, G. Gotti

18. STAGING OF LUNG CANCER: VIDEO-ASSISTED THORACOSCOPY

M. Santini, G. Vicidomini, N. Martucci, G. D'Aniello, A. Sica, A. Fiorello

19. VIDEO-ASSISTED THORACOSCOPIC SURGERY FOR LUNG WEDGE RESECTIONS

M. Santini, G. Vicidomini, L. Scotti, A.G. De Filippo, M. Cioffi, A. Fiorello

20. ENDOBRONCHIAL TREATMENT OF AMYLOIDOSIS

M. Mastroberardino, A. Iannaccone, P. Papa

21. ADVANCES IN DIAGNOSIS OF RECURRENT PLEURAL EFFUSIONS

A. Fersini, M. Angiolillo, M. Capuano, M. Loizzi

22. CHARACTERISTICS OF TIGHT FUNDOPLICATION

Marcello Migliore, Riccardo Giuliano, Francesco Basile*, Giulio Deodato




23. VIDEO ASSISTED THORACIC SURGERY THROUGH A SINGLE PORT

Marcello Migliore, Riccardo Giuliano, Giulio Deodato

24. PHASE I-II STUDY WIT EPIDOXORUBICIN AND GEMCITABINE IN STAGE IV NSCLC. PRELIMINARY REPORT.

Illiano A., De Marino V., Tortoriello A., Turitto G., Battiloro C., Frattolillo A., Lombardi R., Ributti M., Perone V., Griffo S., Elia S., Gentile M., Iaffaioli R. V.,

25. SURGICAL STABILIZATION OF FLAIL CHEST

Di Nuzzo D., Buonsanto A., Iarussi T., Mucilli F., Sacco R.

26. MALIGNANT PLEURAL MESOTHELIOMA: OUR EXPERIENCE ON RADICAL MULTIMODALITY MANAGEMENT

Giua R, Quidaciolu F., Pastorino G., Guasone F., Denegri A., Novello L., Giua D.

27. PATHOLOGICAL, RADIOLOGICAL AND FUNCTIONAL CORRELATION IN EMPHYSEMATOUS PATIENTS SUBMITTED TO LOBECTOMY

A Carretta, A Ballarin, A Vagani, P Scifo*, P Brambilla*, A Del Maschio*, P Zannini




PLEURAL MESOTHELIOMA TREATED BY EXTRAPLEURAL PNEUMONECTOMY AND ADJUVANT RADIOTHERAPYP.P. Brega Massone, C. Lequaglie, B. Conti, *B. Magnani, I. CataldoOncologic Thoracic Surgery, Istituto Nazionale Tumori, Milan - Statistical Unit, IIAARR, Pavia, Italy

BACKGROUND. Malignant pleural mesothelioma is still considered a rare disease of the pleura. Presently any standard treatment of this kind of tumor is reported. The increasing incidence of young mean age of this disease patients associated with an early diagnosis induced surgeons, in absence of alternative therapy, to execute extrapleural pneumonectomy, considered, in the past, an high risk intervention not always balanced by a favourable impact on the prognosis. The aim of this work is to evaluate the efficacy of this surgical intervention and its impact on long-time survival .

METHODS. In the Department of Thoracic Surgery of National Cancer Institute of Milan, from 1994 to 1997, 17 patients were submitted to extrapleural pneumonectomy for malignant pleural mesothelioma. Nine were male and 8 female. The mean age was 51.82±10.23 years, with a median of 54 years (range 31-65 years). The selective parameters for admission to this treatment were good condition of patient, the clinical stage I, a predictive postpneumonectomy FEV 1 >1300 ml. and a decrease of perfusion of resectable lung >= to 50%. The surgical technique, utilized in our experience, was that described by Sugarbaker.

RESULTS. We performed 7 right extrapleural pneumonectomy and 10 left. Perioperative mortality was nil. Pericardium reconstruction was executed in 13 cases with a patch of goretex and in 4 with a patch of marlex. Diaphragm was reconstructed in 9 patients by a reverse flap of latissimus dorsi muscle, in 4 by teflon, in 2 by dura madre and in 2 by goretex. Histologic test showed 13 epithelioid mesotheliomas, 2 biphasic and 2 sarcomatous. Eight subjects were at stage III and 9 at stage I. All the patients received adjuvant radiotherapy. The average of disease-free interval was 16.54±12.31 months, median 12 months, (range: 5-50 months). Mean survival was 26.50±15.60 months, with a median of 22.5 months, on a range from 9 to 59 months.

CONCLUSIONS. Extrapleural pneumonectomy in association with adjuvant radiotherapy seems to be an appropriate treatment for selected patients with malignant pleural mesothelioma. By our data we can affirm that extrapleural pneumonectomy has also a low risk of morbidity with a good quality of life. Postoperative respiratory functionality was on average 70% of beginning value.




SURGICAL TREATMENT OF PULMONARY MUCORMYCOSIS IN THE DIABETIC: REPORT OF A CASE.P. Sardelli*, F. Sollitto*, A. De Palma*, M. Loizzi*, G. Stefanelli°, L. D’Amato°, R. Giorgino° *Chair of Thoracic Surgery, °Institute of Endocrinology, Polyclinic of Bari, Bari, Italy.

BACKGROUND. Pulmonary Mucormycosis is a rare but potentially lethal opportunistic fungal infection occurring in immunocompromised patients: diabetes mellitus, hematologic malignancies, chronic renal failure and organ transplantation represent the clinical conditions most commonly predisposing to this disease. Mortality is high as the fungus invades the lung vessels and causes a massive pulmonary hemorrhage.

METHODS. We report the successful surgical management of pulmonary mucormycosis complicated with massive hemoptysis in a 22-year-old diabetic woman. She had already undergone two surgical operations for a rhinocerebral form.

RESULTS. The patient was admitted to the Institute of Endocrinology of our Hospital because of fever, dyspnoea and diabetic ketoacidosis. Blood analyses showed increased WBC and decreased RBC, hemoglobin and hematocrit. Chest X-rays and CT-scans revealed a large pulmonary mass involving the right upper and medium lobes. Bronchoscopy showed some yellowish cheesy material in the main right bronchus. BAL led to the diagnosis of mucormycosis. After three days of treatment with amphotericin B, the patient showed massive hemoptysis. Transferred to our Division of Thoracic Surgery, an urgent thoracotomy with an upper bilobectomy was performed. On the eighth postoperative day a bronchopleural fistula developed. Pleural drainage led to spontaneous resolution after 6 months. Actually no signs of recurrence are evident.

CONCLUSIONS. When pulmonary mucormycosis is suspected, early diagnosis and prompt aggressive treatment are mandatory. Once diagnosed and after 2-3 days of unsuccessful treatment with amphotericin B, pulmonary resection should be performed as an emergency procedure, because of the risk of a lethal pulmonary hemorrhage due to the vascular involvement.




A COMPARATIVE STUDY OF EC, UWLP, CMB SOLUTIONS IN LUNG PRESERVATION IN ACUTE AUTOTRANSPLANTATIONS IN THE PIGD. Divisi, *P. Montagna, C. Battaglia, L. Scuteri, W. Di Francescantonio, G. Torresini, *O. Jegaden, R. Crisci.Department of Thoracic Surgery-University-L’Aquila (Italy)-*Lyon (France)

INTRODUCTION. Organ preservation is a limiting factor in lung transplants, regardless of the surgical procedure involved (monopulmonary, bipulmonary or heart-lung). Present systems in use permit 6 to 8 hours of cold ischaemia although a degree of functional insufficiency is observed in the period immediately following the transplant. This insufficiency is due to an increase in resistance and vascular permeability resulting in oedema, necrosis, parenchymal haemorrage and structural alterations (1). The Collins solution, which is of an intracellular nature, together with prostaglandins (EC solution) is used in a lot of clinical and experimental work. The high concentration of K+ and absence of macromolecules would appear, in theory, to: a) eliminate electrochemical Na/ K membrane gradients; b) reduce ionic fluxes; c) inhibit cell lesions. Experience has shown however, that high levels of potassium result in (2): a) the permanent depolarization of the smooth muscle cells that make up blood vessel walls; these cells are responsible for the opening of the slow Ca++ channels and vasoconstriction; b) an increase in intracellular K+ that causes direct cellular lesions. Vasoconstriction causes a reduction of the flux in the pulmonary microcirculation at reperfusion (no reflow phenomenon); this reduction is accentuated by the stacking of red blood cells caused by the loss of membrane elasticity and the formation of leucocyte-platelet aggreges (3).These side effects have lead to the development of extracellular ionic solutions. The aim of this work was to examine and compare the functional and anatomical-pathological aspects of Euro-Collins solution (EC), Cold Modified Blood solution (CMB) and low potassium University of Wisconsin solution (UWLP) in lung preservation.

Materials and methods. Fifteen pigs each weighing approximately 25kg were randomly divided into three groups of five. A right lung auto-transplant was performed, the transplanted organs being flushed with one of the solutions under examination.

Surgical procedure. The anaesthesia started with the administration of ketamine: 35 mg/kg i.m. and 2% xylazine: 3 mg/kg via a marginal vein in the ear and was continued with xylazine: 1.5 mg/kg and ketamine: 2.5 mg/kg, administered at 10ml/hour via a marginal vein in the ear and the animals intubated. A postero-lateral right thoracotomy was performed in the fifth intercostal space together with a transversal hemisternotomy and the fourth and fifth ribs were excised. 3mg/kg of heparin was administered at the beginning of the operation. A Swan-Ganz ejection fraction volumetric TD catheter (Baxter) in the pulmonary artery allowed us to evaluate the ejection fraction of the right ventricle. The right pulmonary artery and veins were clamped and venal structures successively incised after the administration of 10 mg/kg of PGE1 in the right pulmonary artery. Pneumoplegy was carried out by flushing a litre of solution enriched with 50 mg/l of PGE1 at 4°C through the right pulmonary artery; the animal was ventilated with 100% FIO2. The right lung was removed after bipolar exclusion of the main and tracheal bronchi and conserved in physiological solution at 4°C.

Right lung autotransplant. The following steps were followed for the re-insertion of the lung: a) anastomosis of the principal bronchus by means of a continuous suture along the membranous tunic and individual stitches through the cartilage with Prolene 5/0; b) anastomosis of the tracheal bronchus by means of a continuous suture with Prolene 7/0; c) anastomosis of the pulmonary artery by means of a continuous suture with Prolene 7/0; d) separate anastomosis of the pulmonary veins by means of two continuous hemisutures with Prolene 7/0.

Functionality of the transplanted lung. Before ischaemia and an hour after reperfusion arterial blood gas and haemodynamic measurements were taken with: both lungs perfused and individual lungs the other being excluded by clamping of the controlateral pulmonary artery. Right lung biopsies were performed before ischaemia and 30 minutes after reperfusion, for histoenzymatic, histopathological and electron microscope studies.

RESULTS. After reperfusion, significant alterations were observed in the haemodynamics (p<0.05) with only the right lung perfused; pulmonary arteriolar resistance increased by a factor of 5 in the EC




group, by a fac-tor of 4 in the CMB group and by a factor of 1,2 in the UWLP group; the right ventricular ejection fraction fell by 60% in the EC group, by 50% in the CMB group and by 31% in the UWLP group. Haemodynamic impair-ment was significantly lower in the UWLP group (p<0.05) as was ischaemic-reperfusion injury (p<0.05). Oedema was observed in the EC group and extensive alveolar wall damage in the CMB group. Hypoxaemia was observed in all groups but the differences in the degree of hypoxaemia were not statistically significant.

CONCLUSIONS. In this study the Euro-Collins and Cold Modified Blood solutions give similar results as far as the quality of lung preservation is concerned. A significant degree of oedema is observed with the Euro-Collins solution whilst the Cold Blood Solution determines severe alterations in the alveolar-capillary membrane; a significant leucocyte infiltration was observed in both groups. The low potassium Wisconsin solution appears to be the most efficient of the three; the histopathological lesions observed were less serious and the functionality of the transplanted lung was satisfactory. Improvements in the quality of lung preservation might be achieved by introducing other molecular groups such as scavengers and/or the anti-platelet activating factor.

REFERENCES.1) Paull DE, Keagy BA, Kron E, Wilcox BR. Reperfusion injury in the lung preserved for 24 hours.

Ann Thorac Surg 1989; 47: 187-92.2) Miyoshi S, Shimokawa S, Scheinemakers H, Date H, Weder W, Harper B, Cooper JD. Comparison

of the University of Wisconsin preservation solution and other crystalloid perfusates in a 30 hour rabbit lung preservation model. J Thorac Cardiovasc Surg 1992; 103: 27-32.

3) Massad M, LoCicero III J, Matano J, Greener, Khasho FH, De Tarnowsky J. Pulmonary flush preservation decreases polymorphonuclear cell sequestration in the isolated perfused working lung model. Transplant Proc 1990; 22: 553-4.




LUNG METASTASES: ROLE OF SURGERY AND OUR RESULTSS. Sanna, S. Folli, M. Mengozzi, D. Lelli, C. Barbieri, D. Dell'AmoreThoracic Surgery Department - Morgagni Hospital - Forlì

There is no doubt that the treatment of lung metastases in selected patients with a controlled resected or resectable primary tumour improve patient's survival. Some Authors proposed VATS approach for lung metastasectomy, but most of the Authors prefer thoracotomy for the possibility of bimanual palpation of lung parenchyma. From 1979 to 1999 111 patients, 66 males and 45 females, were surgically treated in our department for lung metastases. 5 patients presented lung metastases when the primary tumour was diagnosed, 103 patients had received radical surgery for the primary lesion at least 12 months prior to the development of metastases; only 3 patients presented a disease-free interval of less than one year. The primary tumour was a carcinoma in 101 cases (90.9%), melanoma in 6, sarcoma in 4 and malignant giant cell fibrohystiocitoma in one. The sites of primary tumours were: colon-rectum in 61 cases (54.9%), kidney in 17 cases (15.3%), breast in 7 cases (6.3%) and the remaining 23.5% in other sites. The disease free interval varied from 8 months to 5 years. 61 patients (54.9%) presented solitary monolateral lesions, 39 (35.1%) multiple monolateral lesions and 11 (10%) multiple bilateral lesions. We performed 82 wedge resections 24 lobectomies (of which 2 including the diaphragm) 6 regulated segmentectomies and one pneumonectomy. Thoracotomy was the standard approach, with the exception of 4 median sternotomies and 10 VATS. Limphadenectomy was carried out in 50 patients and in 7 of them (14%) we found nodes involvment. There were no cases of postoperative mortality. Long term survival calculated using the Kaplan-Meier test was 33% at 60 months. The Authors conclude that the significant criteria for a correct selection of patients with lung metastases are the control of primary tumour, no extrapulmonary spread, the presence of lung metastases resectable and a long disease free interval. For these selected patients lung metastasectomy seems to be a safe, feaseble and efficient method of treatment, with the possibility of repeated resections, indipendent on either the location or histological pattern of primary tumour and with a demonstrated improved survival.




BRONCHIAL CARCINOIDS: OUR EXPERIENCE ON 47 CASESS. Sanna, S. Folli, D. Lelli, m. Mengozzi, C. Barbieri, D. Dell'AmoreThoracic Surgery Department - Morgagni Hospital - Forlì

Bronchial carcinoids are neuroendocrine tumours, represent 0.6 to 2% of all lung tumours and approximately 5% of malignant lung cancers. There are two histological types: classical carcinoid with central bronchial growth and smaller dimensions; atypical carcinoid, peripheral, with aggressive behavior. A conservative radical surgical resection with locoregional limphadenectomy is the treatment of choice. The extent of this resection is largely determined by the location of tumour and the degree of distal parenchymal destruction. From 1975 to 1999 we treated 47 patients affected by bronchial carcinoid, 23 males and 24 females, mean age 56 years, 56% smokers. The lesion had hilar site in 32 patients (68%) and a peripheral one in 15 patients (32%). Symptoms presented were emoptysis in 10 patients, insistent cough in 12, recurrent infection in 13, febricula in 10 and thoracoalgia in 2. In 3 patients a carcinoid was diagnosed quite by chance during tests for another pathology. No patients presented a carcinoid syndrome, the right hemithorax was involved in 25 cases, the left one in 22. Postoperative diagnostic tests revealed the presence of lobar or segmental atelectasis in 23 patients. There was an histological preoperative diagnosis of carcinoid in 17 cases, the remaining 30 diagnosed intraoperatively. We carried 4 pneumonectomies, 4 bilobectomies 1 sleeve lobectomy, 32 lobectomies, 1 bisegmentectomy, 3 segmetectomies and 3 thoracoscopic wedge resections in two cases for the poor respiratory conditions of patients, and in one case for the presence of bilateral carcinoid treated with lobectomy on the right site. Loco-regional limphadenectomy was carried out in 44 of 47 patients. Postoperative mortality was 2.1% (1 patient) died for cardiocirculatory complications. The postoperative complications were: an hemothorax (which required surgery), a chylous fistula (which required VATS closure) and 3 prolonged parenchymal air leaks. Histological classification revealed 31 typical and 16 atypical carcinoids. Lymphonode metastases were present in 4 patients, 3 of whom had atypical carcinoids. 39 patients had stage I, 3 stage II and 5 stage III. Follow-up which is still incomplete, reveals a survival of more 88%. The Authors wish to underline the importance of treating bronchial carcinoids in the same way as malignant tumours, with standard bronchopulmonary exeresis and loco-regional lymphonode dissection.




PREOPERATIVE EMBOLIZATION IN THE TREATMENT OF MEDIASTINAL HEMANGIOPERICYTOMAA.Stefani, M.DeSantis, U.MorandiCattedra e Divisione di Chirurgia Toracica – Università di Modena

INTRODUCTION. Hemangiopericytoma is an uncommon tumor of the mediastinum. The tumor arises from pericytes and there are benign and malign forms. When there is no involvement of vital mediastinal structures and no metastases, surgical resection is the treatment of choice. Hemangiopericytoma is often highly vascularized and the risk of perioperative bleeding is high.

CASE REPORT. A 47-year old man presented with a bulky mass in the right posterosuperior mediastinum, which seemed to be resectable. At operation, massive bleeding from the tumor tissue prevented the dissection and resection of the mass; a biopsy showed a malignant hemangiopericytoma. Two months later a thoracic aortogram with embolization of three feeding arteries of the neoplasm was performed. Ten days later the patient underwent re-thoracotomy with complete removal of the tumor. The intraoperative and postoperative blood loss was minimal, the postoperative period was uneventful and the patient is alive and well 42 months after the operation.

CONCLUSIONS. In recent years embolization has become popular as a preoperative treatment for vascularized tumors.

Hemangiopericytoma is often a hypervascular neoplasm and cases of massive bleeding are described. In the reported case preoperative embolization made the complete resection feasible by contributing to the significant reduction of perioperative bleeding. When preoperative diagnosis of hemangiopericytoma is available, we recommend an angiographic study, with embolization if needed. The possibility to carry out an angiographic study on the radiologic evidence of hypervascular tumor should be considered, even without preoperative diagnosis, in order to perform preoperative embolization.




SURGICAL TREATMENT OF SPONTANEOUS PNEUMOTHORAX WITHOUT PLEURODESIS: OUR EXPERIENCES Saita, E Potenza, F Mannino, A Maresca, T Nicolosi, C Riscica Lizzio Div. di Chirurgia Toracica - Az. Osp. V. Emanuele, Ferrarotto e S. Bambino - CT

BACKGROUND. The gold standard of surgery for spontaneous pneumothorax (PNX) consist in the treatment of lung disease (blebs e/o bullae) associated with pleurodesis (abrasion, pleurectomy).

METHODS. From 1990 to 1996, in the Unit of Toracic Surgery - at Vittorio Emanuele Hospital - in Catania, surgical treatment for spontaneous PNX has been the resection of bullae and blebs via axillary mini-thoracothomy; when no obvious enphisematous disease was present an elective apical resection was performed. 65 patients have been treated: 50 of them did not receive any pleurodesis and only 1 recurrence (2%) was noticed.

From 1997, we treat 28 patients with spontaneous PNX with a V.A.T.S. procedure without pleurodesis. Within this group of patients 2 cases of recurrence were registrated. 1 patient had a PNX a month later and a V.A.T.S. re-exploration demonstrated the presence of an "azigos lobe" with evidence of multiple bullae, which had been missed during the previous operation. The second case lead to an early recurrence 24 hours after the removal of chest drains, following a V.A.T.S. elective apical resection. It was not possible to detect any air leak during the "redo" procedure and a mechanical and talc pleurodesis was performed.

RESULTS and CONCLUSIONS. According to our esperience, which shows a PNX recurrence rate of 2.5% (i.e. 2 cases out of a total of 78 patients, open + V.A.T.S.) we think that pleurodesis as a complement to parenchimal resection could be avoided in patients affected by spontaneous pneumothorax, especially when an obvious lung abnormality is evident.




LUNG RESECTION FOR NON-SMALL CELL LUNG CANCER IN PATIENTS WITH CONCOMITANT NON-SURGICAL CARDIAC DISEASEP. Ciriaco, B. Canneto, A. Puglisi, P. ZanniniDepartment of Thoracic Surgery, Scientific Institute H San RaffaeleMilan, Italy

BACKGROUND. Cardiac diseases increase operative risk in patients who undergo lung resection for non-small cell lung cancer (NSCLC). Previous studies have however demonstrated the possibility of extending indications for surgery in selected patients. The aim of this study was to identify the risk factors associated with occurrence of postoperative complications following lung resection in patients with concomitant cardiac diseases.

METHODS. Out of a total of 973 patients resected for NSCLC, 55 (5.6%) presented concomitant cardiac diseases consisting in myocardial infarction (MI) dating more than 6 months (27 pts), MI dating less than 6 months (7 pts), arrhythmias (12 pts), angina (4 pts), dilatative cardiomyopathy (3 pts) and mitral valve insufficiency (2 pts). Ten patients required preoperative evaluation other than ECG which consisted in coronary angiography (4 pts), echocardiography (4 pts) and exertion ECG (2 pts).

RESULTS. Forty-three patients required a lobectomy, 10 a wedge resection, 1 a pneumonectomy and 1 had an explorative thoracotomy. Postoperative complications occurred in 18 out of the 55 patients (32%); and were prevalent in patients who underwent lobectomy (13/43 pts; 30%). Arrhythymia occurred in 11 cases, 3 patients required a minitracheotomy for repeated aspirations of secretions and one had a surgical tracheotomy. One patient had a prolonged air leak and one developed an early broncopleural fistula. There was one in-hospital death related to stroke (1.8% mortality). Multivariate analysis revealed that extent of pulmonary resection was a significant risk factor for occurrence of postoperative complications (p<0.05).

CONCLUSIONS. Accurate pre-operative evaluation and limited resections can decrease the incidence of postoperative complications in patients with NSCLC and concomitant cardiac diseases.




SURGICAL TREATMENT OF ANEURYSMAL DISEASE OF THE DESCENDING THORACIC AORTAK. Athanassiadi, A. Loutsidis, A. Hatzimichalis, I. Bellenis.Dept of Thoracic & Vascular Surgery, “Evangelismos” General Hospital, Athens - Greece

OBJECTIVE. Surgical management of aneurysmal disease of the descending thoracic aorta has long been established as the preferred method of treatment. We present a videotape of our 10 year experience in treating aneurysms of the descending thoracic aorta by using a Gott-Shunt.

MATERIAL AND METHODS. Thirty-nine patients (32 men / 7 women) ranging in age from 17 to 78 years were admitted in our department between 1989 and 1998. The majority of our patients were hypertensive (n=31, 79%) and symptomatic (n=34, 87%). Most had been diagnosed with medial degeneration (n=21, 54%) or aortic dissection (n=14, 36%). Four patients (10%) were admitted with aortic rupture.

The surgical treatment consisted of different techniques such as resection of the aneurysm and graft replacement (n=26, 67%), anroofing of the aneurysm and primary repair of the aorta (n=9, 23%), enforcement of the aortic wall with a patch (n=2, 5%) and finally fenestration (n=2, 5%). In 3 cases a Gott-shunt was used and a partial femoro-femoral bypass in one case. The mean aortic clamping time was 34' (16-52'). Autotransfusion has been used in all cases.

RESULTS. The perioperative mortality reached 25.6% (10/39). Three patients with a ruptured aneurysm died intraoperatively and the rest 7 died in the postoperative period due to renal / multiple organ failure (n=3), cardiac and respiratory insufficiency (n=2) and central progression of the dissection. Two patients developed temporary paraplegia (although in one of them a Gott-shunt was used intraoperatively) and in one case we had a permanent one (7,7%). In a follow up of 13 to 76 months no re-operation was done and no death was attributed directly to the previous operation.

CONCLUSION. Beside the progress in surgical management of the aneurysmal disease of the descending thoracic aorta, mortality and paraplegia rates are still quite high consisting a challenging problem for the cardiothoracic surgeon.




BENIGN STENOSES OF THE TRACHEAK. Athanassiadi, A. Loutsidis, A. Hatzimichalis, I. Bellenis.Dept of Thoracic & Vascular Surgery, “Evangelismos” General Hospital, Athens - Greece

AIM. Surgical reconstruction of the trachea is a relatively complex procedure. We present our modest experience in treating 16 cases of benign tracheal stenosis.

MATERIAL. From January 1990 through December 1999 there were 11 men and 5 women with a mean age of 32 years (ranges 17-64) admitted in our departement with a benign tracheal stenosis. In 15 cases the etiology was prolonged ventilation and in one case we had an idiopathic tracheal stenosis. Six patients had preoperative Nd YAG laser sessions without success. The approach was either through a cervical collar incision with the option to extend exposure to the upper sternum (T incision) or through median sternotomy and the treatment of choice was resection of the stenotic segment and end to end anastomosis in the 15 cases. The excised segments ranged from 3 to 5cm in length. One patient denied operation and was treated with dilatations with the rigid bronchoscope.

RESULTS. No deaths occurred. In 2 cases we had a recurrence of the stenosis 4 and 6 months postoperatively, both needed a reoperation which took place without other major complications.

CONCLUSION. Tracheal stenosis is a serious complication that the thoracic surgeon is facing more often today. Early resection of the stenotic segment of the trachea and primary reconstruction is the method of choice.




VATS LUNG RESECTION WITHOUT STAPLER. IS IT SAFE ENOUGH? V. Porhanov, I. Poliakov350047, Russia, Krasnodar, Krasnyh partizan str. 6\2, Regional Thoracic center

OBJECTIVE. One of the obstacles to wide application of VATS resections is high prices of accessories and, particularly, stapler cartridges. Though excluding cartridge application we face a problem of lung tightness. We report our experience of 47 segmental lung resections for various pathologies without stapler application.

MATERIALS AND METHODS. Since December 1996 to January 2000 in Krasnodar Regional thoracic surgery center we performed 69 lung resections without stapler application: 27 males and 39 females. Mean age was 52 year. Of those, in 21 we resected tuberculomas, in 14 chondromas, resections for lung cancer was performed in 17 (Stage I), metastases resection in 6, removal of echinococcus cysts in 8 patients. We performed following operative interventions atypical segmental resection, benign tumor enucleation, excision of metastases, removal of echinococcus cysts. Three patients had multiple lesions. Size of spherical lesions was 1-4cm. Resections was performed by ultrasonic knife or scissors connected to coagulator. Bleeding was stopped by monopolar coagulation, vessels and small bronchi were clipped. Argon-beam coagulator or aerohemostatic sponge achieved final tightness of lung.

RESULTS. There were no cases of hospital mortality. Four patients (6%) had complications. One patient developed bleeding, two had prolonged air leak, one patient had empyema. Mean operative time was 45 minutes. Drainage time was 5 days. Patients were recharged on 7 postoperative day.

CONCLUSIONS. Endoscopic resection without stapler application is a method of choice. This method does not increase postoperative complications, and preserves lung tissue. Best results are achieved in cases with tumors up to 2cm.




VIDEOTHORACOSCOPY RESECTION FOR LUNG TUBERCULOMAS: EXPERIENCE WITH 92 CASES.V. Porhanov, I. Poliakov350047, Russia, Krasnodar, Krasnyh Partizan Str. 6\2, Regional Thoracic Center

OBJECTIVE. Currently it is estimated that about 30% of patients in surgical phthisiatrical departments have tuberculomas. Thoracotomy is a routine surgical approach. Complication level following thoracotomy reaches 7-8%. Applying videothoracoscopy for lung resections we expected to have good outcomes in those patients.

MATERIALS AND METHODS. Since January 1994 till January 2000 we have performed VATS resections in 92 patients for lung tuberculomas in Krasnodar Regional thoracic surgery center. Of those, 57 (62%) were males and 35(38%) - females. Mean age was 37 years. Size of tuberculomas was from 0,5 cm to 6 cm. 67 (72,8%) patients were found to have single tuberculomas, and 25 (27,2%) patients had multiple. Multiple lateral tuberculomas were in 6, bilateral in 19 patients. We have performed 92 atypical segmental resections and 17 lobectomies. Surgery for bilateral tuberculomas was undertaken sequentially under the same anesthesia. Control group included 115 patients undergone thoracotomy or sternotomy for lateral or bilateral tuberculomas .

RESULTS. Conversion to thoracotomy was required in 3 (3,2%) cases, and complications were in 3 more cases. There was no cases of mortality. Operative time for atypical resection was 25 minutes. It took 145 minutes to perform lobectomy. Облитерация плевральной полости увеличивала время операции на 30 мин. Среднее количество картриджей для атипичной резекции 4. Mean hospital stay was 4 days. Long-term outcomes were followed in all patients.

CONCLUSIONS. VATS resections for tuberculomas demonstrate good immediate and long term outcomes and should be recommended as a routine surgical procedure for patients with tuberculomas.




CLINICAL DIAGNOSTIC APPLICATION OF 111IN-DTPA-OCTREOTIDE SCINTIGRAPHY IN SMALL CELL LUNG CANCERM.Vaccarili, F.Fabiani*, A.Staffilano*, F.G.Torresini, C.Battaglia, W Di Francescantonio, R.CrisciDepartment of Thoracic Surgery, University of L'Aquila*Nuclear Medicine - Teramo

BACKGROUND. Some years ago it was proved that a good percentage of small cell lung cancer, classified among cancers of APUD system, produces receptors SS that can be detected in vivo by scintigraphy with 111In-DTPA-Octreotide. With this method in whole body it’s possible to identify both the principal neoformation and the probable metastases. The authors present a study on 32 patients afflicted with SCLC diagnosed histologically.

METHODS. Whit this study, done between January 1995 and December 1999, the radiological iconography of the TC is compared with the scintigraphical map obtained by a planar scintigraphy and in SPECT 1, 4 and 24 hours after i.v. injection of 110 MBq of 111In-DTPA-Octreotide. This comparison is made with reference to principal neoplasm and to probable metastases.

RESULTS. A scintigraphical study, a CT of re-staging and a follow-up, done after 3 and 6 months of chemotherapy, on 23 patients with cancer that produces receptors SS proved the neoplasm sometimes regresses and sometimes progresses. In this second case, it’s possible to identify cerebral, mediastinal and hepatic metastases with the administration of 200 gr of Octreotide 3 times a day for 7 days before the scintigraphy. In fact, this administration lowers the background activity.

CONCLUSIONS. The Authors conclude that the scintigraphy with 111In-DTPA-Octreotide plays an important part in the study of the patients afflicted with SCLC. The scintigraphy identifies the subgroups of patients that can be cured with somatostatin analogues together with chemotherapy. The scintigraphy presents a good sensibility in the re-staging and in the follow-up of patients that are treated, even if it’s difficult to identify subdiaphragmatic metastases where liver, spleen and kidney increase the 111In-DTPA-Octreotide.




INTEGRATED TREATMENT OF NON-SMALL CELL LUNG CANCERM.Vaccarili, F.G.Torresini, C.Battaglia, W Di Francescantonio, R.CrisciDepartment of Thoracic Surgery, University of l'Aquila

BACKGROUND. The disappointing results of only surgical therapy on patients with NSCLC at stage III have directed many Researchers to elaboration of integrated treatments with pre-operative (neo-adjuvant) or post-operative (adjuvant) radio-chemotherapy.

The Authors presents their experience about integrated treatment chemo-radio-surgical practised from 1996 to 1999 on 28 patients with NSCLC at stage IIIA - IIIB.

METHODS. The plan of treatment indicated 3 cycles of pre-operative NIC chemotherapy (Vinorelbine, Ifosfamide, Carboplatin); these cycles were repeated every 21 or 28 days in the ground of tolerability of patients and with frequent administration of G-CSF, GM-CSF and -EPO. After 3th cycle the patients were re-stadied and operated if detected in complete remission (CR), partial remission (PR) or standing (SD). The mediastinal or chest wall radiotherapy (RT) has been practised always after surgical treatment, followed by others 3 cycles of chemotherapy NIC (adjuvant).

RESULTS. 25 patients have completed the neo-adjuvant chemotherapy and have been observed 15 (60%) PR, 4 (16%) SD, 6 (24%) P. 20 (80%) patients have been operated practising lobectomy in 12 cases, bilobectomy in 1 case and pneumonectomy in 7 cases. The grade III-IV of toxicity (WHO) observed has been leukocytopenia in 8 (28.5%) patients, leuko-thrombocytopenia in 7 (25%) patients, leuko-erythrocytopenia in 3 (10.7%) patients, leuko-thrombo- erythrocytopenia in 4 (14.2%) patients; not in any case are observed neurotoxicity or renal toxicity therapy related.

CONCLUSIONS. The Authors conclude that neo-adjuvant chemotherapy NIC in their experience results considerably effective to induce neoplastic remission (PR = 60%) principally in squamous cell carcinomas, consenting radical operations also in tumors involving mediastinum or chest wall. The medullary toxicity therapy related observed is considerable and during the treatment must monitor hematic parameters, practising in all cases specific supporting therapy (adequate dosage of G/GM-CSF and -EPO).




USEFULNESS OF THE VIDEOMEDIASTINOSCOPYV.Jedlicka, I Capov, A.Pestal, T.Stasek1st Department of Surgery, St. Anna University Hospital, Brno, Czech Republic

BACKGROUND. Videomediastinoscopy is probably safer and more accurate than the "old-fashioned" method. The advantages of the videotechnology become evident especially during the introduction of the method. The "learning curve" is shorter and it is possible, with the respectful approach, exclude the major complications completely.

METHODS. Sixty patients were operated consecutively by videomediastinoscopy during the last two years for mediastinal lymphadenopathy or other mediastinal expansion. Staging for the bronchial carcinoma by videomediastinoscopy was not provided routinely.

RESULTS. Sensitivity and specificity of the videomediastinoscopic procedures were 86.0% and 96.1% respectively. No minor or major complication occurred.

CONCLUSIONS. Videomediastinoscopy is safe and accurate even without previous extensive experience with this method. We recommend its use especially where the last generation of CT and PET scanners is not avaible.




ENDOSCOPIC TREATMENT OF MALIGNANT AIRWAY LESIONS: A REVIEW OF OUR RECENT EXPERIENCE.M. Loizzi, F. Sollitto, P. Sardelli, M. Genualdo, A. De Palma.Cattedra di Chirurgia Toracica, Università degli Studi di Bari.

BACKGROUND. Balloon dilatation, coring, Nd:YAG laser and stenting are the most widely used endoscopic treatment modalities to relieve respiratory symptoms caused by malignant tracheobronchial lesions. We report here our last three years experience.

METHODS. We observed 25 patients. Primary lung cancer and primary tracheal tumor caused main airway obstruction in seventeen and three patients, respectively. Thyroid carcinoma in two patients and lung metastasis from renal carcinoma in one case caused an asphyxtic condition. In another case we observed multiple tracheal metastasis from intestinal adenocarcinoma. Laryngeal carcinoma produced a tracheo-esophageal fistula in one patient.

RESULTS. In 15 patients with airway obstruction due to primary lung cancer, various stents were inserted, in five cases after Nd:YAG laser therapy; in 2 patients laser resection only was performed. For primary tracheal tumor, one patient received a Dumon stent with subsequent laser treatment; in one patient a Polyflex stent was positioned, while in another one the tracheal tumor was removed using biopsy forceps. Three patients with extrinsic compression received self-expandible stents. The patient with tracheal metastasis from intestinal adenocarcinoma was treated with Nd:YAG laser. The patient with tracheo-esophageal fistula received a tracheal Freitag dynamic stent and an esophageal Ultraflex covered stent.

In 10 patients subsequent chemo-radiotherapy was performed. All patients received immediate relief of respiratory symptoms after laser and/or stent treatment.

CONCLUSIONS. Combined endoscopic treatment with laser resection and stent insertion and subsequent chemo-radiotherapy may improve survival and quality of life in patients with malignant airway lesions.




LONG TERM SURVIVAL AFTER BRONCHOPLASTIC LOBECTOMY FOR NON SMALL CELL LUNG CANCERC. Ghiribelli, L. Voltolini, L. Luzzi, P.Paladini, G. GottiUniversità di Siena, Ospedale “Le Scotte”, Viale Bracci, 53100 Siena

BACKGROUND. This study was designed to determine whether bronchoplastic resection could be a valid oncologic alternative to pneumonectomy, with the advantage of preservation of functional lung parenchyma, in patients with primary lung cancer involving a main bronchus.

METHODS. We retrospectively reviewed our experience with sleeve resection for non small cell lung cancer from January 1990 to December 1995. In 9 patients preoperative investigations contraindicated pneumonectomy, in 25 patients sleeve lobectomy was performed electively. The bronchoplasty was a full sleeve in 28 patients and a bronchial wedge resection in 6. The most common procedures were sleeve lobectomy of the right upper lobe (41%), and of the left upper lobe (24%). Five patients underwent associated resection of the pulmonary artery (all with N1 disease). One patient had microscopic invasion of the bronchial margin without the possibility of further resection.

Follow-up was updated until the end of 1999, so minimum follow-up was 5 years for surviving patients.

RESULTS. There were 2 postoperative deaths (5,9%) and 10 postoperative complications (29%). Stricture as a late complication occurred in 1 patient, treated with a bronchial stent. None patient developed a second primary lung cancer. Ten patients (29%) developed locoregional recurrence. Three of them died with local recurrence alone, 5 developed metastatic progression, two patients are still alive, one following completion pneumonectomy and one endoscopic laser excision.

Five-year survival rate was 38%, with a median survival time of 45 months. Five-year survival rates for patients with stage I,II and IIIA disease were 65%, 27% and 13% respectively.

CONCLUSIONS. Sleeve resection for N0 disease provides comparable local control and long-term survival to standard resections and may be considered as a valuable alternative to pneumonectomy. On the contrary, local recurrence rate in patients with N1 disease seems to be higher for sleeve lobectomy than for pneumonectomy; however a randomized study is mandatory to confirm that sleeve lobectomy can be performed without the risk of decreasing long-term survival.




STAGING OF LUNG CANCER: VIDEO-ASSISTED THORACOSCOPYM. Santini, G. Vicidomini, N. Martucci, G. D'Aniello, A. Sica, A. Fiorello Department of Thoracic Surgery - Second University of Naples - Italy

BACKGROUND. Video-assisted thoracoscopy (VAT) has an expanding role in the staging of lung cancer; it allows detection of pleural metastases and histologic evaluation of peripheral pulmonary nodules and mediastinal lymph-nodes. We report our experience with use of VAT for the staging of lung cancer.

METHODS. Between 1991 and 1999, we performed 48 VAT procedures to confirm diagnosis and/or to define TNM stage of lung cancer. The procedures included evaluation of pleural effusion with negative cytology (24), diagnosis of mediastinal involvement (3), histologic evaluation of mediastinal lymph-nodes (4), and evaluation of pulmonary nodules with negative FNAB cytology (17). Eight patients considered resectable underwent conversion to thoracotomy and lung resection.

RESULTS. In 18 cases (75%) of pleural effusion with negative cytology, VAT detected pleural metastases; in 6 (25%), pleural involvement was excluded by VAT, and thoracotomy was performed (pleural metastases were excluded in 5 and confirmed in 1). In 33.3% of cases, VAT excluded mediastinal involvement; in 75%, VAT biopsies confirmed lymph-node metastases. In the patients treated by thoracoscopic wedge resection, diagnosis of lung cancer was confirmed in 5 (29.4%); among these, 3 underwent thoracotomy with lung resection and 2 with bilateral cancer underwent contralateral thoracotomic lung resection. Among all patients undergone thoracoscopy, in 18 (37.5%) with pleural effusion we avoided unnecessary exploration thoracotomy, in 14 (29.2%) we avoided diagnostic thoracotomy. Two patients (4.2%) considered not resectable by imaging studies underwent surgery with curative purpose.

CONCLUSION. Video-assisted thoracoscopy is a useful diagnostic tool for the staging of lung cancer. It allows reduction of unnecessary thoracotomies, without precluding surgery to patients with potentially resectable lung cancer.




VIDEO-ASSISTED THORACOSCOPIC SURGERY FOR LUNG WEDGE RESECTIONSM. Santini, G. Vicidomini, L. Scotti, A.G. De Filippo, M. Cioffi, A. FiorelloDepartment of Thoracic Surgery - Second University of Naples - Italy

BACKGROUND. Video-assisted thoracoscopic surgery (VATS) has become the preferred surgical technique for lung wedge resections. We report our experience with VATS used for lung wedge resections.

METHODS. Between 1991 and 1999 we performed 31 thoracoscopic lung wedge resections. The indication to the procedure included solitary pulmonary nodule with negative FNAB cytology (17), interstitial lung disease (3), and spontaneous pneumothorax with bullous disease (11). In the group of patients with solitary pulmonary nodule, 14 had preoperative methylene blue injection during computed tomographic scan to facilitate nodule localization in VATS.

RESULTS. The pulmonary nodule was localized in all patients, even those without methylene blue injection. We did not perform any conversion to thoracotomy, except for 3 patients with diagnosis of lung cancer who underwent thoracotomic lobectomy. The mean VATS duration was 15+/-3.6 min for wedge resections performed in cases of interstitial lung disease, 38+/-12 min in cases of solitary pulmonary nodules injected with methylene blue, and 55+/-8.8. min in 3 nodules not injected. Postoperative histologic examination of the pulmonary nodules showed 8 benign lesions (tubercoloma in 3, hamartoma in 4, and pleural fibroma in 1) and 9 malignant lesion (metastasis in 6, and lung carcinoma in 3). In the cases of interstitial disease, histology showed sarcoidosis in 2 and multiple hemangiomatosis in 1). The postoperative period was uneventful, except for 2 prolonged air leaks in patients treated for spontaneous pneumothorax.

CONCLUSIONS. VATS appears to be a valid surgical procedure for lung wedge resections. It allows diagnosis of interstitial disease and has a diagnostic and therapeutic role in cases of solitary pulmonary nodules. However, VATS remains mainly a diagnostic procedure for lung cancer.




ENDOBRONCHIAL TREATMENT OF AMYLOIDOSISM. Mastroberardino, A. Iannaccone, P. PapaServizio Autonomo di Fisiopatologia Respiratoria. Struttura di Broncopneumologia Resp. -Dott. M. Mastroberardino

BACKGROUND. Rarely the tracheobronchial tree presents amyloidosis, which can be defined as a fibrous, homogenous, eosinophilic, hialine protein called amyloid, producing either plaques or tumor masses. If the involvement of the airways is diffuse the patient will become more symptomatic. In contrast, localized mass lesions are more likely to produce symptoms of localized bronchial obstruction (Fishman's 97).

METHODS. We have observed two patients with COPD and hemoptysis. Pulmonary function tests is of obstructive variety (moderate degree). We discovered that the first patient had pseudo-neoplastic masses in trachea, main, lobar bronchi, superior left bronchus, midle and lower right bronchus. The second patient had a pseudo-neoplastic mass producing stenoses in the right main and intermediate bronchus and in the lateral and posterobasal left segments. He also had worsening dyspnoea not respond to 2-Agonists. Bronchoscopic examination was done, which shows a characteristic macroscopical feature. We made multiple biopsies with precaution, without relevant hemorrhages. These cases have been treated by laser ablation without complications. Till now there is no recurrance of the amyloid tissue at the sites of the growth. The patient with moderate-severe obstruction, shows a regression of his symptoms.

RESULTS. We have had good results by laser ablation therapy in our two cases. We have never observed hemorrhages and the masses no recurrent till now.

CONCLUSIONS. Bronchoscopy is an invasive procedure, but it gives good results regarding diagnosis and therapy (by laser ablation) in bronchopulmonar amyloidosis, which improve the symptoms of the patients.




ADVANCES IN DIAGNOSIS OF RECURRENT PLEURAL EFFUSIONSA. Fersini, M. Angiolillo, M. Capuano, M. LoizziCattedra di Chirurgia Toracica Università di Foggia

BACKGROUND. Pleural effusions can be a sign of several thoracic, abdominal and systemic diseases. Frequently, however, ethiological diagnosis of the effusions remains unknown after repeated thoracentesis and pleural percutaneous biopsies. For this reason and thanks to the improvement of technology, the use of videothoracoscopy has been revalued. Recently, the possibility to perform minithoracotomy of 7-10 centimetres of length, has followed more rapid and complete inspection of the parietal pleura and of the hilus, as well as to perform surgical biopsies of the pleura, pulmonary parenchyma, hilar and mediastinal limphonodes. The study of the pleural cavity is completed using an optic introduced through the drainage incision.

METHODS. From November 1997 to January 2000 13 patients, suffering from pleural effusions were operated on. Preoperative cytological investigations on pleural liquid were repeatedly negative, suspicious or positive.

RESULTS. Six patients suffering from bronchogenous carcinoma in four cases, malignant pleural mesothelioma in one case and pleural amyloidosis in another case, have been submitted to VATS, with an average operation time of 45 minutes (range 37-55). Prolonged air leak was the only complication in this group of patients. Thoracic drainage have been removed after an average of 6,5 days (range 4-10), and average hospitalization has been of 7,5 days (range 6-11). Seven patients have been submitted to video-assisted minithoracotomy; three cases suffering from bronchogenous carcinoma; three cases from malignant pleural mesothelioma and one case from metastatic breast carcinoma; the average operation time was of 37 minutes (range 30-46). In this group of patients thoracic drainage have been removed after an average of 6,14 days (range 5-8) and average post-operative hospitalization has been of 7 days (range 6-8). No complications have been observed.

CONCLUSIONS. Video-assisted minithoracotomy allows to get the same results obtained with VATS (reduction of mortality and morbidity), with diagnostic and therapeutic results similar to those obtained with classical thoracotomy. From our little experience we can deduce that no remarkable differences are evident between these two methodologies.




CHARACTERISTICS OF TIGHT FUNDOPLICATIONMarcello Migliore, Riccardo Giuliano, Francesco Basile*, Giulio Deodato Section of General Thoracic Surgery, * Section of General and Oncological Surgery, Department of Surgery, University of Catania, ITALY – [email protected]

INTRODUCTION. Tight fundoplication (TF), an early and persistent complication of surgery for gastroesophageal reflux (GOR), is generally caused by wrong patient selection, absence of preoperative functional tests or an inappropriate surgical technique.

We have recently demonstrated how some patients operated for correction of GOR with a fundoplication develop postoperatively the pharyngo-esophageal dysphagia (POD) (1). The following article describes our experience and the review of the pertinent literature of this subject.

MATERIAL AND METHODS. Sixteen consecutive patients with persistent postoperative dysphagia following fundoplication for GOR have been evaluated. All patients answered a detailed clinical questionnaire (dysphagia, POD, chest pain, epigastric pain, heartburn, gas bloat, weight loss, regurgitation and salivation). The diagnostic tests used to identify the cause of complication were oendoscopy, barium meal or video-roentgenography, and manometry.

Manometric studies were performed after an overnight fast with the use of a standard motility catheter consisting of four water-filled polyvinyl tubes bonded together with lateral openings spaced 5 cm apart. The proximal ends of the polyvinyl tubes were connected to pressure transducer and in turn to a polygraph connected to a computer system. A constant infusion of distilled water was delivered by a pneumohydraulic system with an infusion rate of 0.6 ml/min. The stationary pull-through technique was used to study both oesophageal sphincters pressure and relaxations. In particular pharyngo-oesophageal manometry was performed as previously described (2).

Computerized research using “Medline” was performed to find appropriate articles.

RESULTS. Ten out 16 patients patients were included in group A: 3 males and 7 females with a mean age of 51 y (range 28-60). The other 6 patients were excluded because dysphagia was the consequence of oesophageal clearance failure. In the group B we included 21 patients, 7 males and 14 females with a mean age of 53 y (range 28-79). Pressures modifications are shown in table 1.

Table 1 GROUP A GROUP BUOS resting pressure 86.6 42.8

Pharyngeal contraction 147.8 76.7UOS contraction 251.4 103.4

Two out of 3 patients with POD presented a cricooesophageal incoordination; nevertheless one of them presented an incomplete relaxation of the sphincter; the third patient showed a higher pressure and long duration of the pharyngeal contraction resulting in incoordination between pharynx and UOS.

DISCUSSION. Tight fundoplication is probably the most unwanted complication of GOR surgery, because symptoms are generally severe, develop immediately following operation and persist for months and years. In recent years the laparoscopic technique increases dramatically the number of operations performed for correction of gastro-oesophageal reflux resulting in an increased number of reported failures and complications such as the creation of a tight wrap.

The pathophysiological mechanisms responsible for the development of postoperative dysphagia are still uncertain and the aetiology seems to be multifactorial (3,4,5). Manometry is a useful diagnostic test to study a TF because functional studies are of paramount importance to obtain informations on the oesophageal motility and can suggest the appropriate treatment.

We have noted that all patients with TF had a total fundoplication, that 80 % of the operations were performed laparoscopically and finally that 4 out of 10 patients had no manometric studies performed prior to surgery demonstrating the importance of a full preoperative diagnostic work-up. Few randomized




trial have been published comparing open and laparoscopic surgery for GOR, Bais et all. published on The Lancet a randomized trial confirming the high incidence of TF in the laparoscopic group (6).

Manometric changes of the oesophagus in patients with a TF have been previously described in part by Skinner (7) and Low et al. (8) who reported a motor disorder which may be secondary to an oesophageal obstruction following the antireflux repair.

Our group (1) and Lerut et al. (9) reported the presence of POD in patients with fundoplication. Lerut treated one of these patients with a crico-oesophageal myotomy to solve the problem; in our experience, because all 3 patients presented a TF we preferred to treat the tight wrap: two patients, following failure of oesophageal dilatations, required a surgical intervention for symptom relief and were operated through a left thoracotomy to enable full mobilization of the oesophagus and complete visualization of the cardia, upper stomach and fundoplication.

A tight fundoplication is, in our experience, always associated with a total fundoplication. Oesophageal dilatations and, if necessary, redo surgery, which consists of taking down the prior repair with the association of a partial fundoplication such as Belsey Mark IV, are necessary to solve the symptom.

ACKNOWLEDGEMENTS. This paper was supported in part by a research grant of the “Dottorato di Ricerca in Fisiopatologia pre e postoperatoria in chirurgia generale e d’urgenza” of the University of Catania.




REFERENCES

1. Migliore M and Deodato G: Clinical features and oesophageal motility in patients with tight fundoplication. Europ. J. Cardiothorac. Surg. 1999; 16:266-72.

2. Migliore M, Payne HR, Jeyasingham K: Pathophysiological basis for surgery of Zenker’s diverticulum. Ann Thorac Surg 1994;57:1616-21.

3. Stein HJ, Feussner H, Siewert JR: Failure of antireflux surgery: causes and management strategies. Am J Surg 1996; 171:36-40.

4. Ellis Jr FH, Gibbs SP, Heatley GJ: Reoperation after failed antireflux surgery: review of 101 cases. Europ. J. Cardiothorac. Surg. 1996;61:1106-111.

5. Peters JH, Heimbucher J, Kauer WKH, Incarbone R, Bremner CG, DeMeester TR: Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication. J am Coll Surg 1995;180(4): 385-93.

6. Bais JE, Bartelsman JFWM, Bonjer HJ, et all. Laparoscopic or conventional Nissen Fundoplication for gastro-esophageal reflux disease: randomized clinical trial. The Lancet 2000;355(9199):170-74.

7. Skinner DB: Surgical management after failed antireflux operations. World J Surg 1992;16:359-63.8. Low DE, Mercer CD, James EC, Hill LD: Post Nissen syndrome. Surg Gynecol Obst. 1988;167:1-5.9. Lerut T, Lassen P, Knod J, Coosemans W, De Leyn P, Deneffe G, VanRaemndonck D: Laparoscopic

antireflux surgery: a critical analysis. VII World Congress of ISDE. Can.J.Gastroenterol. 1998;12 (8):n° 197. Abstract.




VIDEO ASSISTED THORACIC SURGERY THROUGH A SINGLE PORTMarcello Migliore, Riccardo Giuliano, Giulio Deodato Section of General Thoracic Surgery, Department of Surgery, University of Catania, ITALY - [email protected]

INTRODUCTION. Video Assisted Thoracic Surgery (VATS) needs operative channels to insert the surgical instruments into the chest. The accepted trocars strategy is the baseball diamond concept for triangulation of the instruments as described by Laundrenau (1). When a single port is used generally the classic thoracoscope is insert into the pleural cavity to perform simple operations (2).

We postulated that through a modified single flexible port it is possible to perform operations more complex than those performed through a thoracoscope.

PATIENTS AND METHODS. From October 1998 until February 2000, we performed 58 VATS through a single port at the Section of Thoracic Surgery, Department of Surgery of the University of Catania. Preoperative evaluation included chest radiography, thoracentesis, respiratory functional tests and ECG. Flexible broncoscopy and chest computerized tomography were performed when appropriate. Our current indication for the procedure are summarized in table 1.

TABLE 1Pleural effusion (recurrent, undiagnosed, malignant)Clotted haemothoraxPleural thicheningEmpyema II stageHuge anterior mediastinal massAdhesionlysisStaging of lung cancer

We artigianally developed a trocar which is flexible but rigid enough to avoid the collapse when it is introduced through the intercostal muscle into the chest. The trocar is 20 mm and circular at the skin edge and oval at the opposite side (pleural). The characteristic of flexibility allows the introduction of the optic and simultaneously of one or two rotating thoracoscopic instruments. The instrumentation of a thoracotomy on emergency setting was always ready in the operative theatre.

RESULTS. There were 37 males and 21 females with a mean age of 60 yeras (range 32 - 93). There was one intraoperative bleeding which required a 5 cms mini-thoracotomy. Mean operative time was 50 + 25 min, range from 20 to 130 min. Chest tubes were removed after 5 + 2.7 (1 - 13) days, a regular diet was resumed. Hospital stay was 5 + 2 (2 - 8) days. Pleural effusion was present in 40 patients.There was no hospital mortality. Istologic examination was obtained in all the patient. Mean follow-up is 5 months (10 – 460). Eight patients with malignant pleural effusion died for metastatic disease within 3 months after the procedure.

DISCUSSION. In 1910 Jacobaeus used the cystoscope as a thoracoscope to perform adhesionlysis for tubercolosis. In 1987 Rush and Mountain (3) described the advantages of thoracoscopy using a mediastinoscope to diagnose and manage pleural disease (easy maneuverability, suctioning, control of bleeding and finally better quality biopsies). The mediastinoscope was also used by Gokhan et all. to create a pericardial window (4) and recently Yamamoto et all. described a VATS through a single skin incision to treat pneumothorax in 6 pts. (5).

In our experience we initiated using the different trocars available in commerce (6, 7), but we found the different characteristics not compatible with the proposed technique. Infact when the characteristic is the rigidity it is not possible to manouver the instruments easily. If the trocar is too flexible it generally collapses in the intercostal space between the two ribs therefore creating problem with the introduction




and manouverability of the instruments. We do not advocate the operation through the simple skin incision because the optic is easily dirty and the several movements of the instruments can create lesions of the intercostal bundle.

The advantages of our technique versus the classic thoracoscopy are summarized in table 2.

TABLE 2VisualizationInstrumentations are separated from the optic Manouverability of instrumentsTwo instruments can be used simultaneouslyStandard open instruments can be employed Better control of bleedingThe chest tube is positioned under video control

In summary this study shows the major advantages of our proposed technique compared to the standard thoracoscopy. On the basis of our experience we recommend the use of this technique instead of the classic thoracoscopy or video-thoracoscopy.

ACKNOWLEDGEMENTS. This paper was supported in part by a research grant (60%) of the Department of Surgery of the University of Catania.




REFERENCES

1. Landreneau RJ, Mack MJ, Hazelrigg SR, Dowling RD, Acuff TE et al.: Video-Assisted Thoracic Surgery: Basic Technical Concepts and Intercostal Approach Strategies. Ann Thorac Surg 1992; 54: 800-807.

2. Migliore M and Deodato G: Thoracoscopic surgery, videothoracoscopic surgery or VATS: a confusion in definition. Ann Thorac. Surg. 2000. In press.

3. Rush VW and Mountain C: Thoracoscopy under regional anaesthesia for the diagnosis and management of pleural disease. Am J Surg 1987; 274-78.

4. Ozuner G, Davidson PG, Isnberg JS and McGinn JT: Creation of a Pericardial Window Using Thoracoscopic Techniques. Surgery, Gynecology & Obstetrics 1992; 175: 69-71

5. Yamamoto H, Okada M, Takada M, Mastuoka H, Sakata K, Kawamura M: Video-Assisted Thoracic Surgery Through a Single Skin Incision. Arch Surg. 1998; 133: 145-147.

6. Migliore M, Arcerito M, Petino A, Chisari A, Terminella A, Spadaro C, Deodato G: A single trocar technique for VATS. Proceedings SAGES, P 253. Atlanta (Georgia-USA) March 29-April 1, 2000.

7. Migliore M, Petino A, Galatà A, Deodato G: Videothoracoscopic treatment of malignant pleural effusion under conscious sedation. J. Surg. Oncol. 1999; suppl 4, pag. 111.




PHASE I-II STUDY WIT EPIDOXORUBICIN AND GEMCITABINE IN STAGE IV NSCLC. PRELIMINARY REPORT.Illiano A., De Marino V., Tortoriello A., Turitto G., Battiloro C., Frattolillo A., Lombardi R., Ributti M., Perone V., Griffo S., Elia S., Gentile M., Iaffaioli R. V.,IV Pneumologia az. Osp. Monaldi—Napoli Servizio di medicina Oncologica Villalba –Napoli ASL NA 1 ASL CE 1 Chir. Toracica Federico II--Napoli Cattedra di Oncologia Clinica di Cagliari.

Aim. In order to test the toxicity spectrum, DLT and MTD dose of this combination we are performing a phase I / early phase II study.

Patients. 27 patients (pts), 17 and 10 female, median age 59 years (range 36-70 ), P.S. ECOG 0:5 pts 1: 18 pts ; 2: 4 pts with stage iv NSCLC recruited.

Methods. The Gemcitabine dose was fixed in 1000 mg/mq day 1 and 8 and Epidoxorubicine escalated from 80mg/mq to 110mg/mq wit 10 mg/mq increments in each level; every 21 days 3 pts at level II, 13 pts at level III, 5 pts level IV were registered.

Toxicity. Level I well tolerated a part alopecia; neutropenia grade II in 2/6 pts at level I and 5/13 pts at level III; neutropenia grade iv in 2 pts, grave hypertensions, pneumonitis and fever in 1 pts (MTD) were bregistrerendat level IV.

Conclusion. The mtd was established at level IV. First observed response date are very promising




SURGICAL STABILIZATION OF FLAIL CHESTDi Nuzzo D., Buonsanto A., Iarussi T., Mucilli F., Sacco R.Department of Thoracic Surgery - Università di Chieti - Italy

The incidence of flail chest is rapidly increasing due to the occurrence of traffic, working and war traumas. Paradoxic movements of the fractured segment are always responsable not only for pain but mainly for disventilation with - sometimes - severe respiratory distress. This condition may request prompt surgical stabilization: different techniques have been applied so far and recently very good results have been achieved with minimally invasive surgery.

In the past 25 years over 1400 thoracic traumas have been admitted to our Unit and - among these - 77 patients suffered from flail chest: 44 were managed by conservative methods while 33 had surgical stabilization. 30 patients (90%) with postero-lateral or anterior flail chest were successfully treated by using two or three Kirschner wires inserted behind the flail segment passing throught the intercostal spaces of the upper and lower intact ribs, during standard thoracotomy (21 patients), minimally surgical approach with only subcutaneous incision (3 patients) and videothoracoscopy only (6 patients), according to different clinical conditions, yung involvment and surgical experience.




MALIGNANT PLEURAL MESOTHELIOMA: OUR EXPERIENCE ON RADICAL MULTIMODALITY MANAGEMENTGiua R, Quidaciolu F., Pastorino G., Guasone F., Denegri A., Novello L., Giua D. Genova, Italy

Malignant pleural mesothelioma




PATHOLOGICAL, RADIOLOGICAL AND FUNCTIONAL CORRELATION IN EMPHYSEMATOUS PATIENTS SUBMITTED TO LOBECTOMY A Carretta, A Ballarin, A Vagani, P Scifo*, P Brambilla*, A Del Maschio*, P ZanniniDepartments of Thoracic Surgery, Radiology* and PathologyScientific Institute H San Raffaele; Università Vita-Salute San Raffaele; Via Olgettina, 60 - 20132 Milan, Italy

Background. Surgical treatment of lung cancer in emphysematous patients may be contraindicated by the impairment of respiratory function. Previous reports have nevertheless demonstrated the possibility of extending the indications for surgery in selected patients with emphysema. The aim of this study was to evaluate the correlation between emphysema, evaluated by quantitative CT, pathology and pulmonary function tests, and the variation in respiratory function after lobectomy.

Methods. Pre- and postoperative respiratory function tests were performed in 41 patients after a mean period of 4 (2-7) months after surgery. Quantitative CT assessment was performed in 26 patients, and a pathological scoring of emphysema was obtained in 24.

Results. Dynamic volumes were unchanged or improved after surgery in a group of 9 patients (FEV1 from 68.5 % " 13.1 to 73.1% " 13.5) compared to a change from 91.7% " 21 to 73.2% " 17.4 in the remaining 32 patients. Mean CT density of the lobe to be resected was - 877.8 " 57.6 HU for patients belonging to the former group and - 827.52 " 64.4 HU for patients in the latter group (n.s.). Mean pathological emphysema score in the two groups was 4.1 " 2.2 and 3.0 " 1.2 respectively. A significant correlation (p<0.05) was observed between FEV1 variation after surgery and preoperative FEV1, airway resistance (sRaw), quantitative CT and pathological grading of emphysema of the resected lobe.

Conclusion. Patients with a higher degree of emphysema, as assessed by pulmonary function tests, quantitative CT and pathology, had a lower reduction of pulmonary function after surgery, and in some cases improved their function. The definition of preoperative parameters that identify this subgroup of patients may allow the indications for surgical treatment to be extended.



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Naples 2000 - Abstractsxoomer.virgilio.it/naples2000/13_0845.doc · Web view2002-03-05 · Marcello Migliore, Riccardo Giuliano, Francesco Basile*, ... surgical treatment for spontaneous