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Author(s): Dario Amore [1]; Dino Casazza [1]; Umberto Caterino [2]; Danilo Rocco [3]; Carlo Bergaminelli [1] Sir, In the recent years, several studies have begun to evaluate the usefulness of [...]

Author(s): Dario Amore (corresponding author) [1]; Dino Casazza [1]; Umberto Caterino [2]; Carlo Bergaminelli [1] Sir, Acquired benign tracheoesophageal fistula (TEF) is a rare but serious condition and most often [...]

Persistent alveolar air leak (PAAL) after major lung resection remains a common complication in thoracic surgery. The aim of this study was to identify a subset of patients with high risk of developing PAAL after pulmonary lobectomy. Another objective was to evaluate the influence of PAAL on postoperative complications and length of hospital stay. A retrospective analysis on 895 patients undergoing pulmonary lobectomy from January 2014 to December 2019 was performed. PAAL was defined as air leak lasting more than 5 days after lung surgery. Univariate analyses and logistic regressions were performed to identify the predictors of PAAL. A backward selection algorithm was used to identify the optimal set of predictors. The incidence of PAAL was 8.2% (74/895). Male gender (p=0.017), BMI (p<0.001), transient ischemic attack (p=0.031), FEV1 (p=0.018), lobectomy combined with adjacent subsegmentectomy (p=0.018), partial and extended pleural adhesions (p=0.033 and p=0.038, respectively) were identified as independent risk factors for PAAL through logistic regression. A weak positive correlation was found between video-assisted thoracic surgery (VATS) and PAAL following pulmonary lobectomy (p=0.100). PAAL was found to be associated with higher risk of postoperative morbidity (p=0.002) and with longer hospital stay (p<0.001). Both preoperative and intraoperative risk factors may be responsible for PAAL after pulmonary lobectomy. VATS does not appear to prevent this postoperative complication. An alveolar air leak lasting beyond 5 days after pulmonary lobectomy is associated with worse postoperative outcomes. [ABSTRACT FROM AUTHOR]

Leiomyoma is the most common benign tumor of the esophagus. Open thoracotomy, the traditional approach adopted for the enucleation of the esophageal leiomyoma, over the years, has been gradually replaced by video-assisted thoracoscopic surgery. However, this minimally invasive approach has limitations, such as two-dimensional vision and reduced range of motion, which have recently been overcome by technical advantages of robot-assisted surgery. In the surgical management of circumferential esophageal leiomyoma, a combined use of robotic surgery and intraoperative endoscopy may be helpful to facilitate tumor enucleation and to prevent esophageal mucosal injury during the surgical procedure. [ABSTRACT FROM AUTHOR]

Alectinib is a highly selective tyrosine kinase inhibitor of anaplastic lymphoma kinase (ALK) that is approved as first-line treatment in adult patients with ALK-positive non-small cell lung cancer (NSCLC) and as second-line in patients previously treated with crizotinib, and has been shown in the literature to significantly prolong progression-free survival compared to chemotherapy in patients with advanced non-small cell lung cancer. The authors describe a clinical case of a 24-year-old woman with malignant massive pleural effusion caused by ALK rearranged pulmonary adenocarcinoma with pleural and pericardial metastasis, in which, despite a dramatic clinical debut, the correct and timely management of the diagnostic and therapeutic path allowed for extraordinary therapeutic success. [ABSTRACT FROM AUTHOR]

Key message: Conventional transbronchial needle aspiration (cTBNA) remains a basic technique that must be part of the bronchoscopists expertise. In cases where EBUS is not available, cTBNA must be kept in mind: 'the old bull knows best'. [ABSTRACT FROM AUTHOR]

We report an unusual mediastinal recurrence along descending thoracic aorta during oncologic follow-up in a 47-year-old female smoker issued by lung adenocarcinoma with a history of left lower lobectomy and lingulectomy en bloc followed by adjuvant chemotherapy for stage III A-N2. Regional recurrence occurring along the staple line was suspected and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) combined to PET/CT allowed to reach definitive tissue diagnosis. High focal hypermetabolic activity on PET/CT at the site of suspect recurrence was necessary to check the lesion sampling by EBUS-TBNA. [ABSTRACT FROM AUTHOR]

Malignant pleural effusion represents a prognostic negative factor on survival conferring stage IV disease. The median of survival is 5 months and a 5-year survival of about 3%. We describe the therapeutic success obtained from different strategies in anaplastic lymphoma kinase (ALK) inhibitors in 2 young women showing malignant pleural effusion secondary to advanced ALK-rearranged lung adenocarcinoma. This report shows that for patients with EGFR mutations in advanced lung adenocarcinoma-associated malignant pleural effusion, complete response to EGFR TKI inhibitor can be observed mostly if pleural effusion and primary lung adenocarcinoma show the same EGFR mutation status. [ABSTRACT FROM AUTHOR]

Anatomical variations of pulmonary venous drainage have been widely described in the literature in order to perform safe thoracic surgical procedures. We report a case of anomalous vein from the superior segment of the right lower lobe running in the posterior mediastinum and draining into the superior pulmonary vein. As the patient showed a usual right inferior pulmonary vein, formed by the union of the superior segment right lower lobe vein (V6) and the common basal vein joining the left atrium, the uncommon segmental pulmonary vein described was named: additional V6. It was identified preoperatively and recognized intraoperatively during thoracoscopic right lower lobectomy and lymph node dissection performed for lung cancer treatment. Diagnostic imaging and careful surgical dissection are helpful tools to avoid intraoperative bleeding and other complications during thoracic surgical procedures due to unrecognized vascular anomalies. [ABSTRACT FROM AUTHOR]

The key to avoid intraoperative complications due to failure in the preoperative detection of pulmonary vascular anomalies is to perform a careful hilar dissection. [ABSTRACT FROM AUTHOR]

A knowledge of pulmonary vein anatomy variants allows an appropriate preoperative radiological assessment and safe surgical management of vascular anomalies in patients undergoing major lung resections. In our case, multiple pulmonary vein variations were identified pre‐ and intraoperatively in a patient undergoing thoracoscopic right lower lobectomy and included superior and common basal veins from the right lower lobe draining separately into the left atrium, middle lobe veins joining the superior segment right lower lobe vein and additional superior segment right lower lobe vein draining directly into the left atrium. The recognition of these anatomical abnormalities in pulmonary veins may help thoracic surgeons avoid surgical complications in patients undergoing anatomical lung resections. [ABSTRACT FROM AUTHOR]

Perivascular fibrosis is technically one of the most challenging issue to manage during thoracoscopic lobectomy and it is associated with increased risk of hemorrhagic injury. Here we report a case of thoracoscopic right lower lobectomy performed with individual dissection of segmental arteries due to dense adventitial fibrosis around the right lower lobe pulmonary artery. This approach may be considered as an alternative to the so-called "en masse" lobectomy and a way to avoid conversion to thoracotomy. [ABSTRACT FROM AUTHOR]

Several factors as cultural factors and social class other than biological and genetic factor can affect symptom perception in patients with malignant airway obstruction. Poor perception of dyspnoea can result in the delayed seeking of medical care so increase access to intensive care due to impeding respiratory failure. In patients issued from malignant airway obstruction, therapeutic bronchoscopy procedure can not affect the endotracheal extubation although immediate airway patency can be obtained. We reported the outcome of two patients from lower social classes admitted in intensive care and underwent emergency rigid bronchoscopy for malignant complete pulmonary atelectasis. [ABSTRACT FROM AUTHOR]

Key message: We describe a patient with incidental endobronchial synchronous hamartoma and typical carcinoid with different management strategy. [ABSTRACT FROM AUTHOR]

Background: Bronchopleural fistulae represent a relatively rare complication of pulmonary resection. For inoperable patients, several endoscopic procedures have been described. In the presence of large and chronic bronchopleural fistulae, persistent air leaks require a surgical therapy, while endoscopic airway stent represents a useful palliative treatment. Objective: We describe the successful closure of large and chronic bronchopleural fistulae using an expandable polyvinyl alcohol (PVA) sponge and cyanoacrylate glue. Methods: In all patients, a rigid bronchoscope was used to insert a small cylinder of PVA sponge within the fistula. After releasing the patch, cyanoacrylate glue was applied directly on the PVA sponge using a channel catheter. This methodology induces an expansion of the clot and the closure of the air leak. The long-term outcome of treatment was checked by flexible bronchoscopy once every month for 3 months and every 6 months until 5 years. Results: We performed endoscopic treatment in 7 consecutive patients with bronchopleural fistula ranging from 4 to 8 mm. In 6 of 7 patients, the bronchial stump was the site of the fistula. In 1 patient, the fistula was visualized on the right wall of the distal trachea. A temporary complete occlusion of the fistula was achieved in 7 of 7 patients and a definitive result in 5 of 7 patients. Conclusions: The use of an expandable PVA sponge and cyanoacrylate glue is an available strategy for endobronchial closure of bronchopleural fistulae. [ABSTRACT FROM AUTHOR]

Highlights • The drainage pattern of the pulmonary veins presents a wide range of anatomical variations. • Identification of anatomical variations in pulmonary veins can help avoid intraoperative complications. • A careful dissection during VATS lobectomy is essential to avoid intraoperative complications. Abstract Introduction The anatomical abnormalities in pulmonary veins can have a serious impact on pulmonary resections. Presentation of case We report the case of a 70-year-old woman undergoing VATS right upper lobectomy for the treatment of non-small cell lung cancer. During subcarinal dissection, an anomalous vein draining from the superior segment of the right lower lobe into the left atrium and passing behind the bronchus intermedius was incidentally discovered. The patient had, in addition to the inferior pulmonary vein formed by the confluence of superior and common basal veins, a supernumerary vessel identified as: accessory right V6. Retrospective review of preoperative enhanced chest computed tomography confirmed the pulmonary vascular anomaly. Discussion/Conclusion A careful dissection during pulmonary resections can help to recognize variations of the pulmonary veins, avoiding unexpected intraoperative complications. [ABSTRACT FROM AUTHOR]

Highlights • Primary Spontaneus Pneumothorax is a common clinical problem. • The risk of recurrence is high. • The elective surgery treatment in patient with history of recurrent PSP remains questionable. • Bleeding or prolonged air leaks represent the most common complications following the lysis of multiple pleural adhesions. • We do not recommend the elective surgery treatment in patient living in rural area with recurrent primary spontaneous pneumothorax. Abstract Introduction Pneumothorax is defined as accumulation of air in the pleural space with secondary lung collapse resulting in dyspnea or chest pain. Currently the optimal management of spontaneous pneumothorax has been standardized, but the question of elective surgery treatment remains unresolved in patients living in rural area with history of recurrent Primary spontaneous pneumothorax [PSP]. Presentation of case A 41 years-old white man living in rural area, with a history of recurrent right spontaneous pneumothorax (three subsequent episodes) treated by positioning of chest tube, was admitted to our unit. No respiratory symptoms and normal physical exam were observed on admission although anxiety states was noted. Chest CT scan showed small apical bullae in the right upper lobe without cystic change in the pulmonary parenchyma. Discussion Recurrence of primary spontaneous pneumothorax represents a complication most frequently occurring within the first year. Among the treatment options, surgical management is needed in 25–50% of all patients suffering from PSP, due to persistent air leak or recurrence. We report the operative complications after elective surgery in a white man living in rural area with a history of recurrent right primary spontaneous pneumothorax. Conclusion This case report highlights that elective surgery in patients living in rural area with history of recurrence PSP can lead to post-operative complications as bleeding or prolonged air leaks following the lysis of multiple pleural adhesions. [ABSTRACT FROM AUTHOR]

A prompt diagnosis is mandatory to avoid fatal complications in case of pulmonary artery pseudoaneurysm. [ABSTRACT FROM AUTHOR]

A mediastinal mass in patients with a history of asbestos exposure should raise the suspicion of malignant mesothelioma. [ABSTRACT FROM AUTHOR]

Abstract: Background: Legionnaires disease is a potentially fatal infection often associated with permanent pulmonary fibrosis in survivors. Although neurological complications are not infrequent, chronic peripheral neuropathy in the absence of pulmonary abnormalities is an uncommon consequence of Legionnaires disease. Case Report: A 51-year-old woman was admitted to the Emergency Department due to acute respiratory failure. Chest computed tomographic (CT) scan revealed bilateral consolidation shadows suggestive of acute respiratory disease syndrome (ARDS). Urine culture was evaluated and empiric therapy was administered due to a clinical suspicion of acute legionella pneumonia. Acute flaccid paralysis of the limbs and cutaneous rash complicated the clinical course. Treatment with appropriate antibiotics and steroids resulted in complete recovery of pulmonary damage, whereas mild ataxic gait was present at 1-year follow-up. Conclusions: The outcome of this case confirms that the early exudative phase of ARDS in the absence of bronchial dilatation on chest CT scan is not always related to pulmonary fibrosis in survivors at follow-up. It also demonstrates that peripheral neuropathy can persist despite tailored treatment. [Copyright &y& Elsevier]

Benign endobronchial tumors are rare clinical entities characterized by considerable variability in etiology and clinical presentation. The authors report four cases of endobronchial hamartomas treated and followed up from 2018 to 2023. Three of these cases, with identical endobronchial localization in the right lower lobe, were radically treated in flexible bronchoscopy with the only use of biopsy forceps. Another case with a different localization in the left main bronchus was treated with a laser through rigid bronchoscopy. In addition, the authors outline the main interventional pulmonological strategies for the treatment of benign tumors with endobronchial growth based on the existing literature.

Dear Editor, we have read with interest the case reported by Rotolo et al.  (published in February 2023 as Early Access) concerning the surgical management of tracheoesophageal fistula (TEF) in a COVID-19 patient treated with prolonged mechanical ventilation for severe respiratory failure.

Alectinib is a highly selective tyrosine kinase inhibitor of anaplastic lymphoma kinase (ALK) that is approved as first-line treatment in adult patients with ALK-positive non-small cell lung cancer (NSCLC) and as second-line in patients previously treated with crizotinib, and has been shown in the literature to significantly prolong progression-free survival compared to chemotherapy in patients with advanced non-small cell lung cancer. The authors describe a clinical case of a 24-year-old woman with malignant massive pleural effusion caused by ALK rearranged pulmonary adenocarcinoma with pleural and pericardial metastasis, in which, despite a dramatic clinical debut, the correct and timely management of the diagnostic and therapeutic path allowed for extraordinary therapeutic success.

Anatomical variations of pulmonary venous drainage have been widely described in the literature in order to perform safe thoracic surgical procedures. We report a case of anomalous vein from the superior segment of the right lower lobe running in the posterior mediastinum and draining into the superior pulmonary vein. As the patient showed a usual right inferior pulmonary vein, formed by the union of the superior segment right lower lobe vein (V6) and the common basal vein joining the left atrium, the uncommon segmental pulmonary vein described was named: additional V6. It was identified preoperatively and recognized intraoperatively during thoracoscopic right lower lobectomy and lymph node dissection performed for lung cancer treatment. Diagnostic imaging and careful surgical dissection are helpful tools to avoid intraoperative bleeding and other complications during thoracic surgical procedures due to unrecognized vascular anomalies.

Background:  Postoperative bronchopleural fistula represents a challenging issue for thoracic surgeons. The treatment options reported include bronchoscopic or surgical procedures but the method yielding the best results remains unclear., Methods:  In our thoracic surgery department, between January 2011 and June 2020, 11 patients treated conservatively for early bronchopleural fistula after lobectomy or bilobectomy were reviewed. The fistula size ranged between 2 and 3 mm and complete suture dehiscence., Results:  In all 11 patients favorable conditions such as clinical stability, complete expansion of the remaining lung, and resolution of the pleural infection allowed a successful conservative treatment with chest tube drainage., Conclusion:  In selected cases, conservative management of early bronchopleural fistula after lobectomy or bilobectomy may be an alternative therapeutic option to bronchoscopic or surgical procedures, regardless of the fistula size., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction: The anatomical abnormalities in pulmonary veins can have a serious impact on pulmonary resections., Presentation of Case: We report the case of a 70-year-old woman undergoing VATS right upper lobectomy for the treatment of non-small cell lung cancer. During subcarinal dissection, an anomalous vein draining from the superior segment of the right lower lobe into the left atrium and passing behind the bronchus intermedius was incidentally discovered. The patient had, in addition to the inferior pulmonary vein formed by the confluence of superior and common basal veins, a supernumerary vessel identified as: accessory right V 6 . Retrospective review of preoperative enhanced chest computed tomography confirmed the pulmonary vascular anomaly., Discussion/conclusion: A careful dissection during pulmonary resections can help to recognize variations of the pulmonary veins, avoiding unexpected intraoperative complications., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

We report a case of anterior bronchogenic mediastinal cyst (ABMC) in old age patient underwent Robotic Thoracic Surgery (da Vinci Surgical System). Video-assisted thoracoscopic surgery (VATS) represents the routine approach in posterior bronchogenic mediastinal cyst, but some limitation for resection of mediastinal mass located in the anterior mediastinum has been reported. The introduction of da Vinci surgical system has overcome the surgical limits of VATS as two dimensional vision (2D) and the use of long rigid instruments with poor maneuverability in case of fine dissection., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

We show the use of a new endoscopic drill for the management of web-like tracheal stenosis. Our device creates radial holes within stenosis that facilitate the use of scissors for cutting the scar tissue and the subsequent mechanical dilatation., (© The Author 2017. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

We propose the use of a new endoscopic drill for management of web-like tracheal stenosis. Our device allows creating radial holes within stenosis that facilitates the use of the scissors for cutting the  scar and the subsequent mechanical dilatation., (© The Author 2016. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

We report a clinic case of patient in whom angiosarcoma of the heart presents as bilateral pulmonary nodular infiltrates. The cardiac tumor was clinically silent, the electrocardiogram was normal and the cough was the only symptom. Chest CT scan (Fig. 1) showed bilateral diffuse nodular infiltrates ranging. Clinical clues, the results of laboratory tests and all of the cultures obtained excluded an infectious etiologies; the findings of CT-guided needle biopsy was inconclusive for a definitive diagnosis. Thus, the patient was scheduled for a thoracoscopic biopsy. Surprisingly, the pre-operatory echocardiogram showed a soft tissue mass fixed to the posterior wall of the right atrium. On retrospective reviewing of chest CT scan, a tumor was evident in the right atrium, but it was missed initially. In theory, the lung lesions attract the attention of the observer who had not taken into account anything else as to say: "the brain knows what the eyes want". The diagnosis ofpulmonary metastases was obtained by means ofpleural biopsy during right thoracoscopy. Immunoistochemical staining revealed a CK-, CK7-, EMA-, ESA-, CEA-, TTF1-, Vimentina+, CD31+, CD117+ lesion. Because at the time of diagnosis our patient already had lung metastases, he underwent chemotherapy.