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COVID-19 has dramatically affected working forces. We aim to report our occupational medicine service's experience in managing suspected COVID-19 cases during the pandemic through a retrospec-tive observational study. We compared the number of days employees were absent from work due to flu-like symptoms from March 2020 to February 2021 to the same period the previous year (2019-2020). Two hundred thirty-four patients (+47.2% compared to the previous year) who tested negative for SARS-CoV-2 reported flu-like symp-toms; the number of days of absence from work was 2812 (+190.2% compared to the previous year). On average, employees with flu-like symptoms lost 12.07 working days compared to 6.12 in the previous year (p0.0001). In conclusion, in our sample COVID-19 has increased the number of working day loss. However, our approach proved to be important, especially during the first months of the pandemic, to limit SARS-CoV-2 spread in workplaces.

People experiencing homelessness have peculiar characteristics that make them more vulnerable to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission and to more serious forms of Coronavirus Disease 19 (COVID-19). The aim of this study was to evaluate the prevalence of SARS-CoV-2 infection in the homeless population assisted by the primary care services of the Eleemosynaria Apostolica, Vatican City.Persons experiencing homelessness and the volunteers assisting them were tested for COVID-19 through PCR and antigen rapid test between October 1st, 2020, and June 5th, 2021, in the clinical facilities of the Eleemosynaria Apostolica.A total of 1665 subjects from 96 different countries in five continents were included in the study; age range was 1-90 years. Overall, 2315 COVID-19 tests through nasopharyngeal swab were performed; 1052 Polymerase Chain Reaction (PCR) tests and 1263 antigen rapid tests. Nearly 40% of the subjects underwent both tests (n=650, 39.04%), 402 were tested with PCR test only (24.14%) and 613 with antigen test only (36.8%). PCR tests were negative in 966 cases and positive in 86 (8.17%), while antigen tests were negative in 1205 cases and positive in 58 (4.59%). The number of positive cases varied over time, with a drastic increase during the winter months of 2020 and a progressive decrease over 2021. Among positive cases, 24.41% were symptomatic; symptoms included fever, breathing difficulties, anosmia/hyposmia, cough, headache, and diarrhea.This study reported an overall prevalence of SARS-CoV-2 infection in our sample slightly above 8%. Additional data on viral genome through sequencing of SARS-CoV-2 in positive cases are of utmost importance to help identify variants and implement specific infection control measures.

In all animals, sleep pressure is under continuous tight regulation. It is universally accepted that this regulation arises from a two-process model, integrating both a circadian and a homeostatic controller. Here we explore the role of environmental social signals as a third, parallel controller of sleep homeostasis and sleep pressure. We show that, in Drosophila melanogaster males, sleep pressure after sleep deprivation can be counteracted by raising their sexual arousal, either by engaging the flies with prolonged courtship activity or merely by exposing them to female pheromones., eLife digest Humans spend one-third of their lifetime sleeping, but why we (and other animals) need to sleep remains an unresolved mystery of biology. Our desire to sleep changes depending on how much sleep we’ve already had. If we’ve had a long nap during the day, we may find it harder to fall asleep at night; conversely, if we stay up all night partying, we’ll have a difficult time staying alert the next day. This change in the pressure to sleep is known as “sleep homeostasis”. Can sleep homeostasis be suppressed? We know that some migratory birds are able to resist sleep while flying over the ocean. In addition, males of an Arctic bird species forgo sleep for courtship during the three-week window every year when females of its species are fertile. These examples suggest that some behavioral or environmental factors may influence sleep homeostasis. Beckwith et al. now show that sexual arousal can disrupt sleep homeostasis in fruit flies. In “blind date” experiments, young male fruit flies were kept in a small tube with female fruit flies, prompting a 24-hour period of courtship and mating. The males went without sleep during that period, and they did not make up for the lost sleep afterward. In other experiments, male fruit flies were kept awake by a robot that disturbed them every time they tried to sleep. After such treatment, the flies normally attempted to nap. But if the sleep-deprived flies were exposed to a chemical emitted by female flies that increased their sexual arousal, they no longer needed to sleep. Overall, the results presented by Beckwith et al. show that sleep is a biological drive that can be overcome under certain conditions. This will be important for sleep researchers to remember, because it means that it’s possible to affect sleep regulation (perhaps by making the animal stressed or aroused) without activating the brain circuits directly involved in regulating sleep.

Thymic tumors comprise a heterogeneous group of neoplasms with a wide spectrum of clinical presentations. The evolution of the disease is often unpredictable, ranging from an indolent attitude to the possibility of intra- and extrathoracic spread. From the histological point of view, thymoma and thymic carcinoma are the most frequent subtypes and arise only from thymic epithelial cells. Other histological types are even more rare and are usually considered separately. A number of prognostic factors have been validated as predictors of outcome: staging, World Health Organization histological classification, diameter of the tumor, associated paraneoplastic syndromes, completeness of resection, and early onset of recurrence. Complete surgical resection is the key factor for cure and should be considered the gold standard at any stage. Especially for more aggressive lesions, surgery should be considered with a multimodality approach, involving induction and adjuvant therapy according to the stage. Multimodality therapy protocols have been designed based on the integration of clinical staging and histology. Neoadjuvant therapy is now administered before surgical resection in patients with tumors considered inoperable as it improves resectability and survival and reduces the risk of recurrence. Adjuvant treatment has been extensively reported after both complete or partial resection. New targeted therapies are in the developmental stage, and in the future they will be part of the standard protocols. Integrated treatment modalities require strict cooperation between medical and radiation oncologists, thoracic surgeons, and pathologists.

Bronchoscopic lung volume reduction (BLVR) is a novel emphysema therapy. We evaluated long-term outcome in patients with heterogeneous emphysema undergoing BLVR with one-way valves. 40 patients undergoing unilateral BLVR entered our study. Pre-operative mean forced expiratory volume in 1 s (FEV(1)) was 0.88 L · s(-1) (23%), total lung capacity was 7.45 L (121%), intrathoracic gas volume was 6 L (174%), residual volume (RV) was 5.2 L (232%), and the 6-min walk test (6MWT) was 286 m. All patients required supplemental oxygen; the Medical Research Council (MRC) dyspnoea score was 3.9. High-resolution computed tomography (HRCT) results were reviewed to assess the presence of interlobar fissures. 33 patients had a follow-up of12 months (median 32 months). 37.5% of the patients had visible interlobar fissures. 40% of the patients died during follow-up. Three patients were transplanted and one underwent lung volume reduction surgery. Supplemental oxygen, FEV(1), RV, 6MWT and MRC score showed a statistically significant improvement (p ≤ 0.0001, p = 0.004, p = 0.03, p = 0.003 and p0.0001, respectively). Patients with visible fissures had a functional advantage. BLVR is feasible and safe. Long-term sustained improvements can be achieved. HRCT-visible interlobar fissures are a favourable prognostic factor.

An anterior approach affords the spine surgeon excellent visualization and access to the anterior thoracic spine, the vertebral bodies, intervertebral disks, spinal canal, and nerve roots. This approach is currently used in the surgical treatment of thoracic disk disease, vertebral osteomyelitis or discitis, fractures and tumors of the vertebral bodies, allowing for proper decompression of neural elements and spine stabilization. Over a 10-year period in a single institution, a total of 142 patients with a mean age of 49.6 years underwent anterior thoracic exposure of the spine. The indication for surgery was trauma fracture in 20 patients, malignancy in 35, degenerative disease in 29 and correction of scoliosis in 58. Surgical approaches were determined based on the location and length of spinal involvement, including cervico-thoracic approach (15) thoracotomic approach (85) video-assisted thoracoscopy (10) and thoracolumbar exposure (32). Mean operative time was 334 min (range from 256 to 410 min). There was no perioperative mortality. Thirty-one patients (21.8%) developed postoperative complications. The anterior approach to the thoracic spine is safe and effective and even the presence of complications can be appropriately managed. An adequate preoperative evaluation stratifying the risk and instituting measures to reduce it, accurate surgical planning and careful surgical technique are key to yielding a good outcome and to reduce the risk of complications.

Thymoma and thymic carcinoma are an extremely heterogeneous group of neoplastic lesions with an exceedingly wide spectrum of morphologic appearances. They show different presentations with a variable and unpredictable evolution ranging from an indolent non-invasive attitude to a highly infiltrative and metastasising one. Prognosis can be predicted on the basis of a number of variables, mainly staging, the WHO histological pattern and diameter of the tumour. Complete surgical resection is certainly the gold standard to achieve cure. However, especially in patients with lesions at advanced stage, complete resection may be difficult and recurrence often occurs; at these stages, disease-free long-term survival may be difficult to be accomplished. Chemo- and radiotherapy protocols have been designed to complete surgical treatment and improve results in inoperable patients as well, based on the reported sensitivity of thymic tumours to these treatment modalities. The integration of clinical staging and histology, with the new histogenetic morphological classification, has contributed to design multimodality treatment protocols that help to improve prognosis. Induction therapy can now be applied before surgery in patients with tumours considered inoperable, improving resectability and outcome without adding morbidity and mortality to the surgical procedure. This newly developed approach helps to reduce the recurrence rate and to ameliorate disease-free survival. New therapies are now being evaluated as for many other tumours; however, they still need confirmation in prospective randomised studies. In the future, integrated treatment modality should be incorporated in a standardised approach that goes from a careful assessment of histology, staging and lymph node status, and a constructive and non-empirical co-operation between medical and radiation oncologists, pathologists and thoracic surgeons.

Numerous endoscopic procedures have recently been studied and progressively introduced in clinical practice to improve mechanics and function in patients who have emphysema. Bronchoscopic lung volume reduction with one-way endobronchial valves facilitates deflation of the most overinflated emphysematous parts of the lung. These valves have been designed to control and redirect airflow by preventing air from entering the target parenchymal area but allowing air and mucus to exit. The preliminary results have shown that this procedure is safe and effective at medium term in a selected group of patients.

Combined modality therapy is gaining acceptance for treating stage 3 and 4A thymic tumors. Also, specific subsets of stage 2 tumors deserve particular attention. Single-center experiences demonstrate that there are some advantages in selected groups of patients. The overall relatively low complete response rate, however, imposes the search for better systemic therapy to optimize results. In fact, although thymic tumors are responsive to different cytotoxic regimens, none has been demonstrated to be the ideal one. New therapies and strategies should be designed and tested in large-scale multicenter prospective trials. Among the others, epidermal growth factor receptor inhibitors have shown some clinical response, because EGFR is overexpressed in thymoma. c-KIT is overexpressed in thymic carcinoma. Although in a recent study a clinical response to imatinib has been reported, results of a prospective study in patients who have thymic carcinoma are pending. Clinical responses have been reported also to other tyrosine kinase inhibitors, such as dasatinib. Other reports have stressed the presence of an up-regulation of COX-2 with a potential separate therapeutic pathway. Other markers, such as the expression of thymidine synthase and dihydropyrimidine dehydrogenase, which predict sensitivity to 5-fluoruracil-based chemotherapy, were not correlated with the clinicopathological characteristics in a series of thymomas. These new therapies should be incorporated in a standardized approach that goes from a careful assessment of histology, staging, and lymph node status, and a constructive and nonempiric cooperation between the oncologist, radiotherapist, pathologist, and thoracic surgeon.

Objective Air leakage after pulmonary lobectomy is a well-known problem often contributing to extended hospitalization. Many techniques have been proposed to prevent and treat air leakage, but none have been proved incontrovertibly effective. We evaluated the role of an autologous blood patch after pulmonary lobectomy. Methods Twenty-five patients with air leaks on the sixth postoperative day after lobectomy were enrolled in this study. They were randomly assigned to 2 groups: group A (12 patients), with 50 mL of autologous blood infused in the pleural cavity; and group B (13 patients), with 100 mL of blood infused. These 2 groups were retrospectively compared with the last 15 patients showing the presence of air leaks for at least 6 days (group C) (in this group the duration of leakage after the sixth postoperative day was compared). We recorded the duration of posttreatment air leaks and hospitalization. Results Air leaks stopped 2.3 ± 0.6 days after the procedure in group A, 1.5 ± 0.6 days after the procedure in group B, and after 6.3 ± 3.7 days in group C. The air leakage disappeared within 72 hours in all patients in groups A and B. There was a statistically significant difference in the duration of drainage between groups A and B ( P = .005), groups A and C ( P = .0009), and groups B and C ( P = .0001), showing the effectiveness of an autologous blood patch, particularly with 100 mL of blood. Conclusions Management of air leaks after lobectomy with an autologous blood patch is easy, safe, and effective, and does not add costs. It may become the gold standard treatment early in the postoperative course.

Neuroferritinopathy is a rare genetic disease with a dominant autosomal transmission caused by mutations of the ferritin light chain gene (FTL). It belongs to Neurodegeneration with Brain Iron Accumulation, a group of disorders where iron dysregulation is tightly associated with neurodegeneration. We studied the 498–499InsTC mutation which causes the substitution of the last 9 amino acids and an elongation of extra 16 amino acids at the C-terminus of L-ferritin peptide. An analysis with cyclic voltammetry on the purified protein showed that this structural modification severely reduces the ability of the protein to store iron. In order to analyze the impact of the mutation in vivo, we generated mouse models for the some pathogenic human FTL gene in FVB and C57BL/6J strains. Transgenic mice in the FVB background showed high accumulation of the mutated ferritin in brain where it correlated with increased iron deposition with age, as scored by magnetic resonance imaging. Notably, the accumulation of iron–ferritin bodies was accompanied by signs of oxidative damage. In the C57BL/6 background, both the expression of the mutant ferritin and the iron levels were lower than in the FVB strain. Nevertheless, also these mice showed oxidative alterations in the brain. Furthermore, post-natal hippocampal neurons obtained from these mice experienced a marked increased cell death in response to chronic iron overload and/or acute oxidative stress, in comparison to wild-type neurons. Ultrastructural analyses revealed an accumulation of lipofuscin granules associated with iron deposits, particularly enriched in the cerebellum and striatum of our transgenic mice. Finally, experimental subjects were tested throughout development and aging at 2-, 8- and 18-months for behavioral phenotype. Rotarod test revealed a progressive impaired motor coordination building up with age, FTL mutant old mice showing a shorter latency to fall from the apparatus, according to higher accumulation of iron aggregates in the striatum. Our data show that our 498–499InsTC mouse models recapitulate early pathological and clinical traits of the human neuroferritinopathy, thus providing a valuable model for the study of the disease. Finally, we propose a mechanistic model of lipofuscine formation that can account for the etiopathogenesis of human neuroferritinopathy., Highlights • We developed two new neuroferritinopathy mice models (NF). • NF brains are characterized by iron/ferritin accumulation and oxidative damage. • NF brains show granules of lipofuscine associated with iron. • A mechanism of lipofuscine formation is proposed. • NF mice show impaired motor coordination increasing with age.

Emphysema is a debilitating lung disease continuing to be a major source of morbidity and mortality in the developed countries. Medical treatment is the mainstay of therapy and consists of smoking cessation, pulmonary rehabilitation, administration of bronchodilators and, when indicated, steroids and supplemental oxygen. Various surgical procedures have been promoted in the past to relieve dyspnoea and improve quality of life in patients with advanced emphysema; whilst early results were often encouraging, a sustained objective functional improvement was rarely achieved and most of those procedures were progressively abandoned. Despite controversies, LVRS has been shown to be beneficial to selected patients with end-stage emphysema when medical therapy has failed. There is no doubt that LVRS allows a significative functional improvement in a selected group of patients; however, it still carries a substantial morbidity, even if mortality is low at the centres with the larger experience. Patients with a most advanced functional deterioration show a higher surgical mortality and less impressive functional results, suggesting that LVRS should be considered more carefully in these situations. Bronchoscopic alternatives to the surgical approach have been recently proposed and some of them may play an important role in the future; in particular, the airway bypass and bronchoscopic lung volume reduction with one-way valves are certainly one step beyond on their way to clinical application. We hereby report the initial experimental and clinical experience with these new treatment options.

We have previously shown that the expression of a semaphorin, known as a repelling cue in axon guidance, Sema3E, correlates with the ability to form lung metastasis in murine adenocarcinoma cell models. Now, besides providing evidence for the relevance of SEMA3E to human disease by showing that SEMA3E is frequently expressed in human cancer cell lines and solid tumors from breast cancer patients, we show biological activities of Sema3E, which support the implication of Sema3E in tumor progression and metastasis. In vivo, expression of Sema3E in mammary adenocarcinoma cells induces the ability to form experimental lung metastasis, and in vitro, the Sema3E protein exhibits both migration and growth promoting activity on endothelial cells and pheochromocytoma cells. This represents the first evidence of a metastasis-promoting function of a class 3 semaphorin, as this class of genes has hitherto been implicated in tumor biology only as tumor suppressors and negative regulators of growth. Moreover, we show that the full-size Sema3E protein is converted into a p61-Sema3E isoform due to furin-dependent processing, and by analyzing processing-deficient and truncated forms, we show that the generation of p61-Sema3E is required and sufficient for the function of Sema3E in lung metastasis, cell migration, invasive growth, and extracellular signal–regulated kinase 1/2 activation of endothelial cells. These findings suggest that certain breast cancer cells may increase their lung-colonizing ability by converting the growth repellent, Sema3E, into a growth attractant and point to a type of semaphorin signaling different from the conventional signaling induced by full-size dimeric class 3 semaphorins.

Background We evaluated the feasibility and short-term functional outcome after bronchoscopic lung-volume reduction performed with one-way valves in patients with severe heterogeneous emphysema. Methods Thirteen patients entered this pilot study. Endobronchial one-way valves were placed in the segmental bronchi supplying the most hyperinflated parts of the emphysematous lungs to allow lung deflation, reduce lung volume, and alleviate symptoms. The valves and delivery catheter were inserted under intravenous anesthesia and spontaneous assisted ventilation, with visual control through a flexible bronchoscope. We performed unilateral bronchoscopic lung-volume reduction in 11 patients and staged bilateral procedures in 2. Preoperative median forced expiratory volume in 1 second (FEV1) was 0.75 L/s (22%), residual volume was 5.3 L (233%), total lung capacity, 7.9 L (123%); intrathoracic gas volume, 6.5 L (176%); and 6-minute walk test, 223 meters. All patients required supplemental oxygen at rest (1.4 L/min). The median preoperative Medical Research Council (MRC) scale dyspnea score was 4. Results Six complications occurred in 3 patients: two bilateral and one contralateral pneumothorax, one pneumonia, and two episodes of bronchospasm. Functional results at 1 and 3 months showed a significant improvement in FEV1, residual volume, and 6-minute walk test; 43% of the patients were able to completely stop supplemental oxygen. The posttreatment MRC median dyspnea score at 1 and 3 months was 2. Bronchoscopic follow up at 1 and 3 months showed that the valves were correctly in place with no granulation. Conclusions Bronchoscopic lung-volume reduction with one-way valves can be performed with acceptable short-term safety and worthwhile functional benefits.

Standard immunosuppression after lung transplantation includes calcineurin inhibitors, azathioprine, and steroids. Calcineurin inhibitor administration is associated with an increased renal impairment. Sirolimus shows no renal toxicity and could be used in selected patients.We have prospectively administered sirolimus as an alternative to calcineurin inhibitors in 15 lung transplantation recipients with persistent drug nephrotoxicity. Eight patients had also bronchiolitis obliterans syndrome. The mean serum creatinine and azotemia were 2.7 +/- 1.1 mg/dL and 111 +/- 39 mg/dL. After starting sirolimus, azathioprine was reduced to 50%-25% of baseline, calcineurin inhibitors were gradually reduced and eventually stopped, and steroids were maintained stable. Patients started sirolimus with 2 to 5 mg/d orally; adjustments were made according to trough levels (4 to 12 ng/mL for combined sirolimus + calcineurin inhibitors; 12 to 20 ng/mL as monotherapy), toxicity, and perceived efficacy. Patients were monitored for renal and graft function and clinical status.A significant creatinine decrease was observed after 6 months of treatment (p0.02); azotemia decreased after 1 month and remained stable (p0.01). Pulmonary function tests did not show any significant modification from before sirolimus baseline in patients without bronchiolitis obliterans syndrome. There were eight infectious complications and 10 episodes of toxicity (4 dermatitis, 2 epistaxis, 1 headache, 1 diarrhea, 1 nausea, 1 laryngeal cancer). Moderate leukocytopenia (n = 3) and hypertriglyceridemia (n = 6) responded to dose reduction. One patient was lost to follow-up. Three patients died of complications related to bronchiolitis obliterans. One patient underwent transplantation again.Sirolimus administration allows amelioration of renal function with a relatively low morbidity and is useful for chronic renal impairment rescue after lung transplantation.

Semaphorins are a large family of molecular cues implicated in neural development and in a variety of functions outside the nervous system. Semaphorin 5A (Sema5A) is a transmembrane semaphorin, containing seven thrombospondin type-1 repeats, which was recently found to control axon guidance. Here we show that plexin-B3 is a high-affinity receptor specific for Sema5A. We further demonstrate that plexin-B3 activation by Sema5A mediates functional responses in plexin-B3-expressing cells (either fibroblasts, epithelial and primary endothelial cells). In addition, Sema5A can trigger the intracellular signalling of the hepatocyte growth factor/scatter factor receptor, Met, associated in a complex with plexin-B3. We thus conclude that Sema5A is able to elicit multiple functional responses through its receptor plexin-B3.

Background Surgery remains the cornerstone of therapy for thymic tumors, but the optimal treatment for advanced, infiltrative lesions is still controversial. The introduction of multimodality protocols has substantially modified survival and recurrence rate. We reviewed our 13-year prospective experience with multimodality treatment of stage III thymoma and thymic carcinoma. Methods Since 1989 we have prospectively used a multimodality approach in 45 stage III thymic tumors. Sixteen patients (35%) had myasthenia gravis. Twenty-three patients (51%) had pure or predominantly cortical thymoma (group 1), 11 (24.5%) had well-differentiated thymic carcinoma (group 2), and 11 (24.5%) had thymic carcinoma (group 3). Tumors that were not considered radically resectable at preoperative workup underwent biopsy and induction chemotherapy (15 patients, 33%) followed by surgical resection; all patients were referred for adjuvant chemoradiotherapy. Results No operative mortality was recorded; 1 treatment-related death during adjuvant chemotherapy was observed in group 1. Complete resection was feasible in 91% of patients in groups 1 and 2 and 82% in group 3. The overall 10-year survival was 78%. Ten-year survival for groups 1 and 2 was 90% and 85%, respectively; 8-year survival for group 3 was 56%. During follow-up, tumor recurrence was noted in 3 patients (13%) from group 1, 3 (27%) from group 2, and 3 (27%) from group 3. Conclusions Multimodality treatment with induction chemotherapy (when required) and adjuvant chemoradiotherapy offers encouraging results for stage III thymic tumors; the outcome is more favorable for cortical thymoma and well-differentiated thymic carcinoma.

Background . Thirty percent of patients with lung cancer have airway obstruction requiring palliation. In addition, endoscopic resection may be considered before surgery or induction therapy to improve quality of life and functional status, and to allow better staging. It may also help to prevent infectious complications during induction chemotherapy. Methods . Since 1993, 351 Nd:YAG laser resections were performed in 273 patients with lung cancer. The tumor involved the trachea in 36 patients, the carina in 28, the main bronchi in 154, the bronchus intermedius in 29, and the distal airway in 26. One hundred eight stents were placed. After the endoscopic treatment 36 patients were operated on (23 after induction chemotherapy) with 8 pneumonectomies (1 tracheal sleeve) and 28 lobectomies (15 bronchial sleeves). Spirometry, arterial blood gas analysis, and quality of life and performance status were recorded before and after laser treatment and after induction chemotherapy. Complications during chemotherapy, surgical morbidity and mortality, and survival were also recorded. Results . Major complications during laser resection were bleeding (7 patients) and hypoxia (5 patients). Three patients died within 24 hours after the procedure. No complications were observed in the group of patients who subsequently underwent induction chemotherapy or surgery. One patient developed pneumonia during induction chemotherapy. The airway caliber improved in 89% of patients undergoing palliation only. In the group of patients undergoing induction chemotherapy and/or surgery, the performance status, quality of life, and functional measurements significantly improved after endoscopic treatment (FEV 1 from 1.4 ± 0.5 L/s to 2.2 ± 0.6 L/s). Three-year survival after induction chemotherapy and surgery, was 52%. Median survival after palliation alone was 12.1 months. Conclusions . Nd:YAG laser resection is a safe and effective means of relieving airway obstruction. Before induction chemotherapy or surgery preliminary endoscopic palliation helps to improve evaluation and staging and contributes to reducing morbidity during chemotherapy without increasing surgical complications.

Bronchial and vascular reconstructive procedures are a technically feasible alternative to pneumonectomy and have the advantage of sparing functioning lung parenchyma. Between 1989 and 1999, we performed bronchovascular sleeve resection and reconstruction in 145 patients (109 men, 36 women; age range, 26 to 76 years, mean, 56 years) with non-small-cell lung cancer (NSCLCL). Forty-one patients had induction chemotherapy and 3 had pre-operative radiotherapy. Immediate and long-term postoperative evaluation included bronchoscopy, spirometry, electrocardiogram, Doppler echocardiography, and perfusion lung scans, computed tomography and, only recently, angio-magnetic resonance (MR) imaging. Follow-up ranged between 3 months and 10 years (mean, 3.7 years) and is complete for all patients. We report the results of this series and conclude that morbidity, mortality, and functional data indicate that bronchovascular reconstructions are equal to standard lobectomy in terms of pulmonary function. Long-term survival is comparable with that reported for standard resection (lobectomy-pneumonectomy). These findings suggest that even complex lung-sparing operations can be proposed as adequate procedures in the treatment of lung cancer as long as a complete anatomical resection is obtained.

Complications of the residual pleural space after pulmonary resection have been reported to be between 5% and 40% depending on the type of resection, and they increase morbidity, mortality, hospital stays, and costs. The therapeutic use of autologous prepared platelet leukocyte-enriched gel is a relatively new technology for the stimulation and acceleration of soft tissue and bone healing. This gel can be applied to a diversity of tissue. We describe the case of a successful application through a chest tube of platelet leukocyte gel to treat an infected residual pleural space that developed after pulmonary lobectomy for lung cancer.

Objective: Bronchogenic cysts are uncommon congenital anomalies of foregut origin usually located within the mediastinum and the lung and rarely diagnosed in adults. Surgical excision is recommended to establish diagnosis based on histologic examination, alleviate symptoms if present, and prevent future complications. Thoracoscopic approach is becoming the primary therapeutic option. Methods: Between January 1995 and July 2008, 30 patients with mediastinal bronchogenic cyst (MBC) underwent thoracoscopic operation (19 male, 11 female with a mean age of 39 years, range 19—59 years). Symptoms were present in 11 patients (37). Results: The cysts averaged 5.2 cm in their greatest diameter (range3—10.5 cm).Intwocasesthoracoscopywasconvertedto thoracotomybecauseofmajorpleuraladhesions.Therewerenooperativedeaths and no intra-operative complications. Postoperative course was uneventful in all cases and the 28 patients who underwent thoracoscopy were dischargedafter a meanof 3.7 days (range 2—5 days).Conclusions:Consideringthe low conversion and complication rate, thoracoscopic excision of bronchogenic mediastinal cyst should be considered the primary therapeutic option. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Several clinical forms of mucormycosis are recognized. The tendency of mucoraceous zygomycetes to invade the blood vessels often produces a disseminated infection. A case of a disseminated mucormycosis complicated by a haemophagocytic syndrome (HS) in a 32-year-old Caucasian male is reported in this article. Few cases of infection-associated HS (IAHS), involving infections caused by fungi, have been reported. In all the recorded cases, the fungal infection coexists with malignant lymphoma, immunodeficiency and a long-term steroid therapy for renal transplant or Crohn's disease. This is the second described case of the HS due to mucormycosis.

Hydrocarbon inhalation is seldom chosen as a means to commit suicide. This practice is exclusively a prerogative of the prison population; it is, however, only exceptionally found in this environment. The two cases of lethal inhalation of propane/butane gas observed by us over a very short time occurred in this context. Toxicologic analyses were performed by means of gas chromatography (head space) and revealed a propane/butane mixture in all specimens (heart blood, bile, and urine) except vitreous humor. Although fatal arrhythmia posthydrocarbon gas abuse is well known, the concentrations of the two hydrocarbons were sufficient to induce death by asphyxiation and were distributed (fairly) homogeneously in all biological fluids and organs examined, a parameter permitting one to assume that death occurred within a relatively short period of time. The absence of finding in vitreous humor and the trace amount in urine suggests that both men died very quickly.

Air leakage after pulmonary resections is considered the most prevalent postoperative problem, and it is often the only morbidity identified. Ideally, treatment begins with prevention; the onset of this complication should be anticipated and recognized during surgery, and intraoperative strategies should be attempted to avoid it and reduce the impact on the clinical course. Once an air leak develops, in most of the cases it seals spontaneously within 2 or 3 days of operation. When it persists, it might elicit the onset of other complications and increase costs and length of hospitalization. The postoperative approaches to a prolonged air leak include management of the pleural drainage and residual space, pleurodesis, pneumoperitoneum, endobronchial one-way valve placement, and potential reoperation.

Background: Chronic obstructive pulmonary disease (COPD) is the leading indication for lung transplantation; however, these patients rarely gain priority on the waiting list until very late. The clinical status can be improved by surgical lung volume reduction; this procedure, although carries significant morbidity, has been repeatedly advocated as a bridge. Recently, bronchoscopic lung volume reduction (BLVR) has been proposed to improve functional parameters in patients with emphysema; however, it has never been reported as a bridge to lung transplantation so far. Methods: We hereby report our experience with BLVR as a bridge to lung transplantation in four patients (males, mean age 51 years). Results: All patients underwent unilateral BLVR (two right upper lobe (RUL), one right lower lobe (RLL), and one left upper lobe (LUL); mean 3.5 valves per patient). No morbidity and mortality were observed.Three out of the four patients successfully reachedtransplantation after 6, 7, and 6 months, respectively. Two patients received single-lung transplantation and one sequential double-lung transplantation. The fourth patient died of respiratory failure 13 months after valve placement. BLVR was able to reduce the residual volume and improve the 6-min walking test and Medical Research Council (MRC) score. Conclusions: BLVR allowed to improve the functional status and quality of life of these patients. In a selected group of COPD patients awaiting lung transplantation, the reported short- to medium-term objective improvement may play an important role to ameliorate the clinical status and reach the time of surgery. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

This paper presents the results of an intensive monitoring activity of the particulate, fall-out and soil of selected living areas in Italy with the aim to detect the asbestos concentration in air and subsequent risk of exposure for the population in ambient living environments, and to assess the nature of the other mineral phases composing the particulate matrix. Some areas were sorted out because of the presence of asbestos containing materials on site whereas others were used as blank spots in the attempt to detect the background environmental concentration of asbestos in air. Because the concentration of asbestos in ambient environments is presumably very low, and it is well known that conventional low–medium flow sampling systems with filters of small diameter (25 mm) may collect only a very small fraction of particulate over a short period, for the first time here, an intense monitoring activity was conducted with a high flow sampling system. The high flow system requires the use of large cellulose filters with the advantage that, increasing the amount of collected dust, the probability to collect asbestos fibers increases. Both the protocol of monitoring and analysis are novel and prompted by the need to increase the sensitivity towards the small number of expected fibers. With this goal, the collection of fall-out samples (the particulate falling into a collector filled with distilled water during the monitoring shift) and soil samples was also accomplished. The analytical protocol of the matrix particulate included preliminary X-ray powder diffraction (XRPD), optical microscopy and quantitative electron microscopy (SEM and TEM). Correlations with climatic trends and PM10 concentration data were also attempted. The surprising outcome of this work is that, despite the nature of the investigated site, the amount of dispersed asbestos fibers is very low and invariably lower than the theoretical method detection limits of the SEM and TEM techniques for identification and counting of asbestos fibers. The results are compared to the literature data worldwide and an updated model for asbestos fibers dispersion in ambient environments is proposed.

Study objectives The reported 5-year survival rate after pulmonary metastasectomy from colorectal carcinoma, usually accomplished through thoracotomy or median sternotomy, ranges from 9 to 47%. Video-assisted thoracoscopy (VAT) is employed routinely for many thoracic surgical procedures, but the main concern about this approach for resection of lung metastases is that VAT does not allow complete lung palpation to identify and remove metastases not detected by preoperative radiologic examinations. Design In this study, we reviewed our experience with thoracoscopic resection of single peripheral lung metastases from colorectal carcinoma with potentially curative intent. Patients and interventions From July 1992 to September 1998, 24 patients (15 male, 9 female) with a mean age of 56 years, who previously had undergone resection for colorectal carcinoma and had a single limited and peripheral lung lesion identified by high-resolution CT, underwent thoracoscopic wedge resection of the lesions. Results No intraoperative complications developed. Three patients had minor postoperative complications successfully treated. In one case, we found a benign lesion, and this patient was excluded from the analysis. In the remaining cases, metastases from colorectal cancer were confirmed. The median follow-up was 29 months, ranging from 3 to 67 months. Thirteen patients (56.5%) developed recurrence of the disease, and 5 of them (21.7%) had local recurrence. Cumulative 5-year survival estimated by Kaplan-Meier method was 49.5%, not really different from the data reported in the literature. Conclusions Thoracoscopic resection of single peripheral lung metastases from colorectal cancer with potentially curative intent seems effective and justified since the ultimate outcome of this highly selected group of patients seems to be not different from that obtained after a more invasive approach.

Objective: The effects of major lung resections on cardiac function in the medium and long term have not been thoroughly evaluated. We have studied right heart function with serial Doppler echocardiography in patients undergoing lobectomy and pneumonectomy during 4 years of follow-up after surgery. Methods: Thirty-six patients undergoing lobectomy and 15 receiving pneumonectomy were evaluated with one- and two-dimensional Doppler standard transthoracic echocardiography before surgery and 1 week, 3 months, 6 months, 1 year, and 4 years postoperatively. We have studied the right midventricular diastolic diameter (RVDD), the right ventricle free wall thickness, the tricuspid valve insufficiency (TVI) and regurgitation jet (TRJ), and the pulmonary artery systolic pressure (PASP). Results: None of the patients died within the first postoperative year. After lobectomy there were no significant modifications of any variable at any time. RVDD progressively increased after pneumonectomy (26.5 2.2 mm preoperatively vs 34.3 7.6 at 4 years; p < 0.001). Four years after surgery all patients undergoing pneumonectomy had moderate TVI while only 55% of patients receiving lobectomy showed it (low grade in 50% and moderate in 5%). In this group of patients PASP increased from 26.1 2.6 mmHg preoperatively to 34.3 7.6 mmHg at 4 years (p < 0.00001). Conclusions: Right ventricle modifications are clearly evident after pneumonectomy and even if they do not show a clear clinical impact they should not be neglected.

Objective:Inductiontherapyfor advancedlungcancerallowsimprovementofcompleteness ofresectionandsurvival.However, predictiverisk factorsforpostoperativecomplicationsandearlymortalityremaincontroversial. Wereportour14-yearexperiencewiththiscombinedapproach. Methods: One hundred and thirty-nine patients (100 males and 39 females) underwent induction therapy and surgery for stage IIIA and B lung cancer. The mean age was 58.4 7.7 years. We retrospectively collected demographic data, preoperative functional parameters, type of operation, associated disorders, staging, induction regimen (chemotherapy alone or associated with radiotherapy). Univariate and multivariate analyses were performed to identify predictors of postoperative complications and early mortality. Results: One hundred and nine patients received chemotherapy (mainly based on cisplatin and gemcitabine) and 30 received chemoradiotherapy (median dose 50 Gy). Complications developed in 49 patients (35%). The most frequent was persistent air leakage (23—30% of the lobectomies), followed by cardiac complications, respiratory failure, and infections. Five patients (3.5%) died in the postoperative period and four of them had received pneumonectomy (mortality for pneumonectomy: 12.5%). The statistical analysis demonstrated that only pneumonectomy was associated with an increased mortality risk with no differences between intra- and extrapericardial dissection or right and left pneumonectomy. Conclusions: Induction therapy seems to be associated with an increased incidence of air leakage; the risk of other complications is acceptable. Pneumonectomy is associated with an increased risk of mortality and should be performed in selected patients. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Tracheopulmonary intubation is the most common misplacement site for narrow-bore feeding tube and it might be associated with severe pleuro-pulmonary complications. A 38-year-old female with a severe bilateral pneumonia and acute respiratory insufficiency was admitted in the ICU, intubated, and mechanically ventilated. Few hours after the insertion of a narrow-bore feeding tube the patient's oxygen saturation dropped with hypotension and tachycardia. A large left-side hydropneumothorax developed requiring a chest tube. Air-leakage was important and bronchoscopic implant of one-way endobronchial valve was accomplished. Immediate and substantial decrease of air-leakage was observed, and it completely stopped after 5 days; as soon as the patient was extubated. Endobrochial one-way valve, specifically designed for bronchoscopic lung volume reduction, resulted in being safe and effective to control a significant and prolonged air-leakage due to a malposition of a narrow-bore feeding tube.

Lung transplantation is currently a suitable option for patients with end-stage lung disease. Since the early 1980s the surgical technique and immunosuppressive protocols have been progressively modified to improve results and favor long-term survival. The original heart-lung transplantation under cardiopulmonary bypass is now rarely performed and single or bilateral lung transplantation is the procedure of choice. Bilateral transplantation is performed with two single lung transplants performed in sequence. Extracorporeal support is rarely employed and in most cases it is instituted through the femoral approach. Also, the surgical approach has been modified and the original clam shell incision has been replaced by two small anterior thoracotomies. The use of marginal donors has been increasingly proposed to enlarge the number of organs potentially available for transplantation. Immunosuppressive protocols have evolved to patient-specific regimens that can be quickly modified if required by the clinical status. Induction is now more aggressive and also rescue protocols for obliterative bronchiolitis can contribute to improved outcomes. Overall, lung transplantation is now performed with encouraging long-term results.

Objective: Fibrous stenosis of the esophagogastric cervical anastomosis remains a significant complication occurring in up to one-third of cases. Trying to reduce the incidence of this complication, we describe our technique of cervical esophagogastric anastomosis using endoscopic linear stapler which seems to reduce the incidence of fibrous stricture formation after resection of esophageal cancer. Methods: Between March 2000 and June 2003, 26 patients (15 males and 11 females) underwent esophagectomy using tubulized stomach for reconstruction. Cervical esophagogastric anastomosis using linear endoscopic stapler was performed in all cases. The occurrence of post-operative anastomotic leak and development of anastomotic stricture were recorded and analyzed. Results: All patients survived esophagectomy and were available for post-operative follow-up. Anastomotic leak developed in one case. No patient developed fibrous stenosis that required dilatation therapy. Conclusion: Complete mechanical esophagogastric anastomosis, using endoscopic linear stapler is effective and safe, even when a narrow gastric tube is used as esophageal substitute. This technique seems superior to other techniques to reduce the incidence of post-operative anastomotic complications. q 2004 Elsevier B.V. All rights reserved.

Objective: Surgery is the first line of treatment for laryngotracheal stenosis; Montgomery tube or permanent tracheostomy have been so far the only alternatives. Nd-YAG laser resection and indwelling endotracheal stents have rarely been used in subglottic stenosis for anatomic and technical reasons. We have used the latter approach to optimize the timing of surgery or to achieve palliation without tracheostomy. Methods: Between 1991 and 2001 we have treated 18 patients with subglottic stenosis (10 males, 8 females; age range 14‐78, mean 34). The upper margin of the stricture was 2 mm to 1 cm below the vocal cords; the stenotic segment extended from 1.5 to 5 cm. Three patients had tracheostomy done elsewhere. Four patients (Group I) had laser and stenting by a Dumon prosthesis as the only treatment; six had laser and stenting (#4) followed after 1‐6 months by laryngotracheal resection (Group II); eight had surgery alone (Group III). Results: In Group I, one patient required repositioning of the stent and in two the stent was removed; two patients died of their underlying disease; at a follow-up of 2‐9 years all living patients did well but required permanent aerosolized therapy and periodical bronchoscopy. In Group II, we had two wound infections due to airway colonization by staphylococcus aureus. In Group III, two patients developed anastomotic postoperative stenosis, treated by laser (#2) and stenting (#1), and one patient with previous tracheostomy had a wound infection. Overall, in the 14 surgical patients (Groups II and III) stenosis occurred in 14.2% and infection in 21.3%. After a follow up of 15 months to 12 years, all surgical patients breathe and speak well. Conclusions: Laser resection and endoluminal stenting can be a viable alternative to surgery or optimize the timing of operation in patients with subglottic stenosis. q 2004 Elsevier B.V. All rights reserved.

Background. Severely symptomatic arterial insufficiency of the hand and upper extremities requires adequate treatment. Medical therapy and local care are usually unsuccessful, and thoracic sympathectomy can represent an effective procedure to control pain, to help ulcer healing, and to prevent or delay amputation. Methods. We performed 20 thoracoscopic sympathectomies in 15 patients (13 men and 2 women) with upper extremity ischemia. Mean age was 47 years (range 21 to 72 years). All patients were thought to have organic block l age of digital arteries. The condition was unilateral in 10 patients and bilateral in 5. Primary diagnosis was digital arteriosclerosis in 8 patients, Buergerʼs disease in 4 patients and the remaining 3 were drug abusers with severe ischemia due to accidental intra-arterial injection of drugs. Eleven patients (73%) presented with terminal digital necrosis, gangrene, or ulceration of the fingers associated with severe pain. Four ~patients complained of coldness, pain, and some degree of soft tissue infection without permanent loss of tissue. Results. We performed 10 unilateral and five bilateral staged (mean interval was 3 months) thoracoscopic sympathectomies. We had two minor complications and no mortality. Mean duration of postoperative chest drainage was 2.5 + 0.4 days and mean postoperative hospital stay was 5.3 + 0.5 days. Follow-up ranged from 3 to 71 months, with a mean of 33 months. All patients demonstrated clinical benefit after operation. Conclusions. Thoracoscopic sympathectomy in patients with severe ischemia of upper limb extremities permits optimal symptomatic control and maximum tissue salvage. Because the procedure is minimally invasive, safe, and associated with a low rate of complications, it should be considered earlier the natural course of this disease. Thoracic sympathectomy has been substantially improved with the use of video-assisted thoracoscopy (VAT) because it offers better visualization of the anatomic structures with minimal invasiveness [1-3]. Major indications include hyperhidrosis [4], Raynaudʼs disease [5], causalgia [6], and reflex sympathetic dystrophy [7]. A less common indication is represented by symptomatic vascular insufficiency of the upper extremities due to arterial obstruction, when revascularization is not feasible because of the peripheral location of the lesions [8]. In this subset of patients, sympathectomy induces the release of vasomotor control and hyperactive tone of the small arteries and arterioles, improving circulation to the skin, peripheral extremities, and bone, allowing healing of ulcers and trophic lesions and limiting tissue necrosis [9]. Because little information is available in the literature about the efficacy of VAT sympathectomy in this subset of patients, we describe our initial experience. Patients and Methods

The use of pneumoperitoneum to treat prolonged air leaks or space problems, or both, after pulmonary resection has been recently resurrected and used successfully.During the last 3 years, 14 patients experienced short-term pleural space problems associated with prolonged air leaks after pulmonary resection for lung cancer. All patients, under sedation and local anesthesia, had a mean of 2,100 mL of air injected under the diaphragm, using a Veres needle after a mean time of 7 days (range, 5 to 10 days) from the operation. In 3 patients talc slurry was added to help control the air leak.No patients experienced complications during the induction of the pneumoperitoneum. No patients complained of dyspnea, although blood gas analysis showed a slight increment of carbon dioxide partial pressure (p0.0004). Obliteration of the pleural space was observed in all cases after a mean time of 4 days (range, 1 to 7 days). Air leaks stopped in all patients after a mean time of 8 days (range, 4 to 12 days). The mean postoperative hospital stay after lung resection was 18 days (range, 14 to 22 days). No patients had significant complications or long-term sequelae. We found that patients who had undergone induction chemotherapy had longer air leak durations than observed in noninduction patients (p = 0.03).Our experience supports the use of postoperative pneumoperitoneum whenever a space problem associated with prolonged air leaks is present. The procedure is effective, safe, and easy to perform.

Objective: Careful patient selection is vital when video-assisted thoracoscopic surgical (VATS) therapeutic pulmonary metastasectomy of colorectal carcinoma is considered. Complete resection of all metastatic disease remains a vital concept. We reviewed our VATS experience for therapeutic metastasectomy of peripheral colorectal pulmonary metastases. Methods: Over 90 months, therapeutic VATS metastasectomy was accomplished upon 80 patients with colorectal metastases. Thin cut computed tomography (CT) was central in identifying lesions. The mean interval from primary carcinoma to VATS resection was 41 months (1‐156 months; median, 33). A solitary lesion was resected in 60 patients and multiple (2‐7) lesions resected in 20 patients. Statistics were obtained using the Student’s t-test. Results: No operative mortality or major postoperative complications occurred. The hospital stay was 4.5 ^ 2.2 days (range, 1‐13). All lesions were resected by VATS, with four conversions to thoracotomy to improve the margins. The mean survival of patients with one lesion was 34.8 months compared with 26.5 months for patients with multiple lesions (Pa 0:37). The mean survival was 20.5 months when metastases occurred ,3 years vs. 28.1 months for .3 years from primary carcinoma resection (Pa 0:20). Twenty-five (31%) patients are disease free; with a mean interval of 38.7 (3‐84; median, 35) months. Sixty-nine percent (55/80) of patients developed a recurrence: 6/80 (8%) local; 19/80 (24%) regional (same hemithorax away from resection); and 30/80 (38%) distant. The overall survival at 1 year was 81.2%, 48.4% at 3 years and 30.8% at 5 years. Conclusions: Therapeutic VATS resection of colorectal metastases appears efficacious. Preoperative CT can identify peripheral colorectal metastases amenable to VATS. Conversion to thoracotomy is indicated when none of the lesions identified by CT are found or when clear surgical margins are jeopardized. q 2000 Elsevier Science B.V. All rights reserved.

Background . Diaphragmatic invasion from lung cancer (T3-diaphragm) is a rare occurrence reported to portend a poor prognosis. Methods . Fifteen patients with T3-diaphragm (14 males, 1 female; median age, 64 years) were surgically treated over a twenty-year period by en bloc resection (14 patients). One patient was only explored. Pathologic stage IIB (T3N0) was found in 11 patients. A partial infiltration of the diaphragm was observed in 3 patients, whereas full-depth invasion was found in 12. Diaphragmatic reconstruction was done primarily in 9 patients, and, by prosthetic material in 5. Results . Two patients are still alive without evidence of disease at 88, and, 114 months from surgery. Overall median survival was 23 months (range, 3 to 168). The actuarial 5-year survival was 20%, when all patients were considered, and, 27%, for T3N0 patients. Univariate analysis showed that prosthetic replacement of the muscle ( p = 0.018) was significantly related to survival. Conclusions . T3-diaphragm is best treated with en bloc resections with wide tumor-free margins and prosthetic replacement of the diaphragm.

Background . Lobectomy associated with reconstruction of the pulmonary artery (PA) is a technically feasible alternative to pneumonectomy in patients with lung cancer. However, concern about postoperative complications and long-term survival limited its acceptance so far. Methods . Between 1989 and 1996, we performed a PA reconstruction in 52 patients (41 men, 11 women; age range 35 to 75 years, mean 60 years) with lung cancer. Eleven patients had induction chemotherapy. We performed 15 PA sleeve resections, 34 PA reconstructions by a pericardial patch, and three PA reconstructions by a pericardial conduit, associated with a bronchial sleeve lobectomy or bilobectomy (33), or with standard lobectomy (19). Immediate and long-term postoperative evaluation included spirometry, echocardiography, perfusion lung scans, computed tomography, and PA angiography. The follow-up ranged between 27 and 96 months and is complete for all patients. Results . We had one specific postoperative complication (PA thrombosis) and no mortality. Perfusion scans and PA angiography were normal in all but the 1 patient having thrombosis. Mean forced expiratory volume (FEV) in 1 s and forced vital capacity (FVC) were, respectively, 72% and 80% preoperatively, 65% and 76% 1 month after surgery, and then they plateaued at 70% and 78% after 6 months. Echocardiography showed patterns in the normal range and normal estimates of PA pressures in all but 2 patients. Five-year survival was 38.3% for the entire group, 18.6% for stages IIIA and B, and 64.4% for stages I and II. Conclusions . Morbidity, mortality, and functional data do not differ from what is currently reported for standard lobectomy. Long-term survival is in line with that reported for standard resection. These data support PA reconstruction as a viable option in the treatment of lung cancer.

Objective: Retrograde pneumoplegia seems to improve early graft function in experimental and clinical lung transplantation. We evaluated the role of retrograde flushing in addition to antegrade pneumoplegia in clinical lung transplantation. Methods: Fourteen patients undergoing lung transplantation were randomized into 2 groups: in group I we performed antegrade pulmonary artery flushing with alprostadil (prostaglandin E 1 ) and modified Euro-Collins solution at the time of retrieval. In group II additional retrograde flushing through the pulmonary veins was performed at the back table, before reimplantation. Hemodynamic variables, mean airway pressure, and blood gas analysis were monitored at different time points. Postoperative volumetric monitoring was performed to assess extravascular lung water. The reimplantation response was assessed by a radiographic score; extubation time and intensive care unit stay were recorded. Results: During retrograde flushing, blood and clots coming out from the pulmonary artery were observed; 2 lungs harvested from a donor with multiple bone fractures had fat emboli in the retrograde perfusate. Hemodynamic monitoring did not demonstrate any difference between the 2 groups. The ratio of arterial oxygen tension to inspired oxygen fraction, extravascular lung water, duration of intubation, and length of stay in the intensive care unit were improved in group II, but the differences did not reach statistical significance. Intrapulmonary shunt fraction was significantly improved in group II at each time point ( P = .02), as well as indexed alveolar-arterial oxygen tension gradient ( P = .04), mean airway pressure ( P = .04), and chest x-ray score ( P = .03). Conclusions: Preimplantation retrograde flushing is not detrimental and helps to improve early graft function. (J Thorac Cardiovasc Surg 1999;118:107-14)

Objective: Surgical treatment of bullous emphysema has received renewed attention because of recent advances in minimally invasive techniques. We describe our experience in the thoracoscopic management of patients with bullous emphysema over the last 5 years. Methods: Twenty-five patients (24 male, one female) with a mean age of 57 years with giant bullae associated with various degree of underlying emphysema, were operated on thoracoscopically at our Institution. The severity of the emphysema was classified according to the criteria of the American Thoracic Society: five patients were in stage I (FEV1 . 50%), eight patients were in stage II (FEV1 35 to 49%) and 12 patients were in stage III (FEV1 , 35%). Nine patients underwent operation to treat complications related to bullae, 12 presented dyspnoea and four were asymptomatic. We performed 23 unilateral and two bilateral staged thoracoscopic procedures. Results: No intraoperative complications developed. Mean operative time was 107 ^ 25 min. No patient dead. Mean post-operative chest tube duration was 8 ^ 4:13 days and mean post-operative hospital stay was 11 ^ 5:76 days. The most frequent post-operative complication was air-leakage that in 12 patients lasted more than 7 days. Pulmonary function tests were obtained 3‐6 months after the operation and statistical comparison between pre-operative and post-operative data was performed using Student’s paired t-test. We observed best results in I and II stage patients, but also stage III patients experienced clinical improvement and better quality of life. Conclusions: Our experience supports the safety and effectiveness of video-assisted thoracoscopy for the treatment of giant bullae. Minimally invasive approach is fully justified especially in the group of patients with severe impairment of lung function. q 1999 Elsevier Science B.V. All rights reserved.

Lung volume reduction has been performed in patients with advanced emphysema to relieve dyspnea and improve exercise tolerance. Median sternotomy and video-assisted thoracoscopy have been proposed as equally adequate approaches; however, prolonged postoperative air leakage is the most prevalent complication in all series. For this reason, on the basis of the experience achieved with the median sternotomy approach, buttressing of the suture line with different materials and techniques for space reduction have been proposed. We describe a technique to create a pleural tent after thoracoscopic volume reduction. The thoracoscopic creation of a pleural tent is feasible and results in a duration of postoperative air leaks and hospital stays similar to that achieved with stapler line buttressing.

Air leakage is a relatively frequent complication after lobectomy; it can be expected in up to 15% of the patients, independently from the type of surgical approach (open or thoracoscopic). The risk increases when interlobar fissures are incomplete and in patients with emphysema; in nearly all series it contributes to increase the length of hospitalization and thus the costs. Prolonged air leaks is defined as a leakage persisting 7 or more days. Ideally, treatment begins with prevention: when fissures are incomplete, meticulous attention should be given to the anatomic planes of interlobar dissection. Several strategies can be employed to reduce the incidence of this complication: staplers and reinforcement materials could be used; a pleural tent or pneumoperitoneum could be performed if at the end of the operation the lung is not likely to reach the chest wall and fill the pleural space; also the use of surgical sealants and glues have been repeatedly proposed with encouraging results. However, none of these methods have definitively contributed to solve the problem and randomized studies are extremely rare. The aim of the present study was to evaluate the role of Coseal (Baxter Healthcare, Deerfield, IL) (a polymeric sealant) to reduce postoperative air leaks and hospital stay.

Bronchial dilation is usually required to treat a number of disorders; the most frequent are complications after airway surgery, including lung transplantation, stenosis after radiotherapy, and compression by an extraluminal mass. The procedure is performed by forcing the tip of a rigid bronchoscope through the stenosis using barrels of increasing size; however, when there is a clear discrepancy between the caliber of the rigid instrument and the stenosis, the first step may be difficult. In such cases, we have successfully employed two types of old-fashioned esophageal dilators rescued from the armamentarium of our endoscopy unit.

Objectives: The ‘clamshell incision’ is considered the standard approach for bilateral sequential lung transplantation (BSLT); however, a considerable morbidity may be related to this incision. The bilateral anterolateral thoracotomy without sternal division is an alternative approach that may contribute to avoid chest wall complications. Methods: We have employed this approach in a prospective series of 34 patients undergoing bilateral transplantation (Group I). The results were retrospectively compared with an historical control group of 37 patients (Group II) undergoing transplantation through the clamshell incision. Results: The operative time in Groups I and II were 228 ^ 32 and 293 ^ 37 min, respectively; the difference between the ischemic time of the first and second lungs were 68 ^ 20 and 73 ^ 15 min. Intensive care unit stay was 5 ^ 6 vs. 13 ^ 10 days and length of hospitalization was 25 ^ 16 vs. 32 ^ 10 days. Vital capacity measured 3 weeks after the transplant was significantly higher in Group I (65 ^ 13 vs. 45 ^ 8% predicted) as well as FEV1 (71 ^ 8 vs. 58 ^ 7% predicted). No wound related complication was observed in Group I; in Group II, there were 17 chest wall complications: sternal osteomyelitis in three patients (surgical debridement and closure with a muscle flap), migration of the Kirshner wire in three (removal of the wire), sternal override in three (surgical correction) and prolonged pain in eight. Conclusions: The bilateral anterolateral thoracotomy without sternal splitting is a safe and effective approach for BSLT; it allows to avoid sternal complications and contributes to improve respiratory function in the early postoperative period. q 2003 Elsevier Science B.V. All rights reserved.

Objective Reconstruction of the pulmonary artery in association with lung resection is technically feasible with low morbidity and mortality. To assess long-term outcome, we report our 20-year experience. Methods Between 1989 and 2008, we performed pulmonary artery reconstruction in 105 patients with non–small cell lung cancer (tangential resections not included). Twenty-seven patients received induction therapy. We performed 47 pulmonary artery sleeve resections, 55 reconstructions by pericardial patch (with 3 left pneumonectomies under cardiopulmonary bypass), and 3 by pericardial conduit. In 65 patients, a bronchial sleeve resection was associated; in 6 cases superior vena caval reconstruction was also required. Fifteen patients had stage IB disease, 37 stage II, 31 IIIA, and 22 IIIB. Sixty-one patients had epidermoid carcinoma, and 38 adenocarcinoma. Mean follow-up was 46 ± 40 months. Results The procedure–related complications were 1 pulmonary artery thrombosis requiring completion pneumonectomy and 1 massive hemoptysis leading to death (operative mortality, 0.95%); 28 patients had other complications, with the most frequent prolonged air leakage. Overall 5-year survival was 44%. Five- and 10-year survivals for stages I and II versus stage III were, respectively, 60% versus 28% and 25% versus 12%. Five-year survivals were 52.6% for N0 and N1 nodal involvement versus 20% for N2; 10-year survivals were 28% versus 3%. Multivariate analysis yielded induction therapy, N2 status, adenocarcinoma, and isolated pulmonary artery reconstruction as negative prognostic factors. Conclusions Pulmonary artery reconstruction is safe, with excellent long-term survival. Our results support this technique as an effective option for patients with lung cancer.

IMH: it reveals the involvement of adjacent structures and identifies focal calcifications (phleboliths) present in approximately 25% of cases. Differential diagnosis includes infection (which was unlikely in our patient because of the 5-year period of time and the lack of general signs), plasmacytoma or primary bone tumor (but there was no osseous involvement), lipoma (but lipoma has no heterogeneous nodular appearance), liposarcoma (but the phleboliths are unusual in liposarcoma), neurogenic tumor (which is located near the spine), desmoid tumor (which lacks phleboliths), and elastofibroma dorsi (which have a more compact tissue and usually are bilateral). In any case, the definitive diagnosis is made by histologic study of the surgical and/or biopsy specimen. Complete surgical excision with clear-cut margins is the best therapeutic approach, although every patient with IMH should be treated individually with consideration given to tumor location, surgical accessibility, depth of invasion, patient’s age, and cosmetic factors. Radiotherapy, cryotherapy, embolization, electrocoagulation, and injection of sclerosing agents may be beneficial in case of impractical and/or only partial surgical exeresis. A local recurrence in up to 18% of patients after surgical resection has been reported. In conclusion, the rarity of IMH of the chest wall may render an accurate preoperative diagnosis difficult. A high index of suspicion is required, and complete surgical excision is mandatory.