Search

Background: Intraoperative pulmonary artery (PA) bleeding is common during thoracic surgery. We investigated the efficacy of the gelatin matrix-thrombin solution FloSeal (Baxter International, Deerfield, IL, USA) for control of major PA bleeding., Methods: Retrospective data were collected on all intraoperative PA injuries during open or minimally invasive lobectomy or pneumonectomy between January 2000 and January 2014. Patients received either 4/0 prolene sutures (Standard) or the gelatin matrix-thrombin solution, plus sutures as needed (Matrix), with at least 6-month follow-up. Endpoints included time to hemostasis, total blood loss, transfusion and complications., Results: Of 2809 procedures, 39 (1.4%) had intraoperative PA injury, of which 21 received standard care and 18 the gelatin matrix-thrombin solution. Hemostasis was achieved in all Standard group patients after 2 minutes, and after 5 minutes in Matrix patients. Additional sutures were required in 4 (19.0%) Standard group patients. Three (16.7%) Matrix patients had a second solution application, while 17 (77.8%) received precautionary sutures. Mean blood loss on postoperative day 1 was 836.1±186.1 mL and 957.1±163.0 mL in the Matrix and Standard groups, respectively (P=0.003). Four (22.2%) Matrix patients received postoperative transfusions versus eight (38.0%) Standard patients (P=0.02). Two Standard and no Matrix patients underwent surgical revision. There were no complications and no mortalities., Conclusions: Our analysis suggests that the gelatin matrix-thrombin solution is safe and effective for the control of major bleeding following intraoperative PA injury, and may improve outcomes. Further prospective studies are required to confirm our findings.

Objective  We wanted to assess the prognostic factors and the efficacy of the treatment in patients who underwent lung resections for transitional cell carcinoma metastases. Materials and Methods  This is a retrospective, multicenter study. Between January 1995 and May 2014, 69 patients underwent lung metastasectomy with curative intent. We evaluated primary site of the tumor, the role of adjuvant chemotherapy after urological operation, disease-free interval (DFI; lower or higher than 24 months), type of lung resection, number of lung metastases, presence of metastatic lymph nodes, and diameter of the metastasis (less or more than 3 cm). Results  Among 69 patients, 55 (79%) had bladder as primary site of disease and 12 of them received a transurethral bladder resection. Fourteen (21%) patients developed primary tumor in the renal pelvis or ureter; 53 (76%) patients presented with a single metastasis, 16 (24%) with multiple metastasis. The median DFI was 37 months and the median follow-up was 50 months. Sampling lymphadenectomy was done in 42 patients and nodal metastases were found in 7 patients. The overall 5-year survival was 52%, median 62 months. At univariate analysis, the DFI had a significant impact on survival (5-year survival of 58% for patients with DFI ≥ 24 months vs. 46%; p  = 0.048) and diameter of metastasis (5-year survival of 59% for diameter less than 3 cm group vs. 33%; p  = 0.001). The multivariate analysis confirmed metastasis' diameter as an independent prognostic factor ( p  = 0.001). Conclusion  Our study found that, in addition to DFI that remains a common prognostic factor in patients with metastatic lung disease, in lung metastases by transitional cell carcinoma, the diameter of the lesion is another significant prognostic factor., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Bronchopleural fistulas are a major therapeutic challenge. We have reviewed our experience to establish the best choice of treatment., Methods: From January 2001 to December 2013, the records of 3,832 patients who underwent pulmonary anatomic resections were retrospectively reviewed., Results: The overall incidence of bronchopleural fistulas was 1.4% (52 of 3,832): 1.2% after lobectomy and 4.4% after pneumonectomy. Pneumonectomy vs lobectomy, right-sided vs left-sided resection, and hand-sewn closure of the stump vs stapling showed a statistically significant correlation with fistula formation. Primary bronchoscopic treatment was performed in 35 of 52 patients (67.3%) with a fistula of less than 1 cm and with a viable stump. The remaining 17 patients (32.7%) underwent primary operation. The fistula was cured with endoscopic treatment in 80% and with operative repair in 88.2%. Cure rates were 62.5% after pneumonectomy and 86.4% after lobectomy. The cure rate with endoscopic treatment was 92.3% in very small fistulas, 71.4% in small fistulas, and 80% in intermediate fistulas. The cure rate after surgical treatment was 100% in small fistulas, 75% in intermediate fistulas, and 100% in very large fistulas. Morbidity and mortality rates were 5.8% and 3.8%, respectively., Conclusions: The bronchoscopic approach shows very promising results in all but the largest bronchopleural fistulas. Very small, small, and intermediate fistulas with a viable bronchial stump can be managed endoscopically, using mechanical abrasion, polidocanol sclerosing agent, and cyanoacrylate glue. Bronchoscopic treatment can be repeated, and if it fails, does not preclude subsequent successful surgical treatment., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Pneumonectomy with en bloc chest wall resection is often denied because of the procedure-related high risk. We evaluated the short- and long-term outcome of this procedure., Methods: From January 1995 to October 2011, 34 patients (30 males and 4 females; mean age: 61.8 years) underwent pneumonectomy with en bloc chest wall resection for 33 non-small-cell lung cancer and 1 metastatic osteosarcoma in two institutions. Data were retrospectively reviewed., Results: Operative (30-day) mortality was 2.9% (1 of 34), and morbidity was 38.2% (13 of 34). There were 14 (41.1%) right-side procedures and 20 (58.8%) left-side procedures. Three (8.8%) patients developed bronchopleural fistulas. The mean number of resected ribs per patient was 2.7 ± 1.1. In 13 (38.2%) patients, a prosthetic reconstruction of the chest wall was needed. In 3 (8.8%) cases, the bronchial step was buttressed. Preoperative pain was statistically significantly related to the depth of chest wall invasion (P = 0.026). The N status was N0 in 18 (52.9%) cases, N1 in 9 (26.4%), N2 in 6 (17.6%) and Nx in 1 (metastatic osteosarcoma). Patients were followed-up for a total of 979 months. The median survival was 40 months. The overall 5-year survival was 46.8% (± 95% confidence interval [CI]: 0.2-0.6): 45.2 (± 95% CI: 0.03-0.8) for right-side and 48.4% (± 95% CI: 0.2-0.7) for left-side procedures, respectively. According to the N status, the 5-year survival was 59.7 (± 95% CI: 0.3-0.8) in N0, 55.5 (± 95% CI: 0.06-1) in N1 and 16.6% (± 95% CI: 0-0.4) in N2. The subgroup N0 plus N1 (27 patients) showed a 58.08% (± 95% CI: 0.3-0.8) 5-year survival compared with 16.6% (± 95% CI: 0-0.4) in N2 (χ(2): 3.7; P = 0.053)., Conclusions: Pneumonectomy with en bloc chest wall reconstruction can be safely offered to selected patients. The addition of en bloc chest wall resection to pneumonectomy does not affect operative mortality and morbidity compared with standard pneumonectomy. The pivotal additional effect of the chest wall resection should not be considered a contraindication for such procedures. Survival showed a clinically relevant difference by comparing N0 plus N1 with N2 (58.1 vs 16.6%), not confirmed by the statistical analysis (P = 0.053).

Objectives: We evaluated factors that influenced morbidity and mortality in patients undergoing completion pneumonectomy (CP)., Methods: A retrospective review of a consecutive series of patients who underwent CP at six international centres., Results: In total, 165 CP were performed between March 1990 and December 2009: 152 for malignant disease and 13 for benign disease. Forty-two patients (25.4%) underwent neoadjuvant therapy. Right CP was performed in 99 patients (60%) and left in 66 (40%). Thoracotomy was employed in 161 patients and median sternotomy in 4. Stapled closure of the bronchus was performed in 121 patients and hand closure in 44. The overall operative mortality was 10.3% (17 of 165). Operative mortality was 10.5% (16 of 152) in malignant diseases and 7.7% (1 of 13) in benign diseases. Complications occurred in 55.1% (91 of 165) of patients. Mean hospital stay was 16.02 ± 16.8 days (range: 3-151 days). Thirteen patients (7.9%) developed bronchopleural fistulas. No statistically significant relationship was found in mortality or morbidity according to side, gender, induction therapy and surgical approach. Stapled compared with hand closure for the bronchus did not affect the bronchopleural fistula rate (P = 0.4). The overall 5-year survival was 37.6%: 70.1% in benign disease (13 patients), 48.9% in squamous cell carcinoma of the lung (63 patients), 23.9% in primary lung adenocarcinoma (62 patients), 50% in grade 1 and grade 2 neuroendocrine carcinoma of the lung (4 patients), 54.7% in metastatic disease (14 patients) and 0% in primary lung sarcomas. A statistically significant better survival was observed in patients with squamous cell carcinoma versus adenocarcinoma (P = 0.04)., Conclusions: CP shows an acceptable operative mortality with a high morbidity rate. The overall 5-year survival is acceptable in properly selected patients (i.e. squamous cell carcinoma, metastatic disease). Side, gender, induction therapy and surgical approach did not influence mortality and morbidity.

Objectives: The safety of fibrin sealants (FS) has been questioned in the light of recent reports of adverse effects. We evaluated the safety of a new FS in a randomized controlled trial (RCT)., Methods: Multicentre, open-label Phase II/III RCT to evaluate the safety of the new FS. The trial was approved by the Ethic Committee of each three participating Centre. FS includes two components (component 1: fibrinogen; component 2: thrombin), each of them subjected to two viral inactivation procedures. Out of 200 screened patients, 185 eligible patients (49 females, 136 males), aged between 18 and 75 years, undergoing major thoracic surgery were randomized to receive FS (#91 patients) as an adjuvant for air leak control or no treatment (#94 patients, control group). Safety variables were: percentage of subjects with adverse events associated with the therapy; formation of antibodies against bovine aprotinin; vital signs (blood pressure, body temperature, heart and respiratory rate); laboratory parameters., Results: Overall operative mortality was 3.2% (6/185), 1.1% in the FS group and 5.3% in the control group, respectively. Twenty patients (22%) had adverse events in the FS group and 22 (23.4%) in the control group. Atrial fibrillation (five patients in the FS group and four in the control group) and hyperpyrexia (five and seven patients, respectively, in the two groups) were the most common adverse events. No patient reported thromboembolic events (pulmonary embolism or deep vein thrombosis) during the in hospital stay or within 1 month from discharge. None of the adverse events was considered as treatment related. The formation of bovine aprotinin antibodies was reported in a total of 34 patients (37.4%) in the FS group and was not related to any adverse effect., Conclusions: The present RCT did not show any increased risk of adverse events, and of surgical complications, related to the use of the new FS.

Background: This study evaluated the sealing capacity and safety of a new fibrin sealant (FS) to reduce alveolar air leaks (AALs) after pulmonary resections in a randomized controlled clinical trial conducted in 3 Italian centers., Methods: The study randomized (1:1) 185 patients with an intraoperative AAL graded 1 to 3 according to the Macchiarini scale: 91 received FS and 94 had standard lung closure. The primary outcomes were the length of postoperative AAL duration and the mean time to chest drain removal. Other end points included the percentage of patients without AAL, the development of serum antibodies against bovine aprotinin, and any adverse event related to FS. Chest drains were removed when fluid output was 100 mL/day or less, with no air leak., Results: The study groups were comparable with respect to demographic variables and surgical procedures. The FS group showed a statistically significant reduction in duration of postoperative AALs (9.52 vs 35.8 hours; p < 0.005) and in the percentage of patients with AALs at wound closure (81.11% vs 100%; p < 0.001); the difference in time to chest drain removal was not significant. Pleural empyema developed in 1 patient with FS treatment vs in 4 with standard treatment, and antibodies against bovine aprotinin were found in 34 of 91 FS-treated patients., Conclusions: The present study showed that the new FS is safe and effective in preventing AALs after lung resections and in shortening the duration of postoperative AALs., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)