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Patients with pulmonary metastases from colorectal cancer can benefit from surgical removal. However, the biological determinants of postsurgical outcome are not completely elucidated. We evaluated the role of host systemic inflammation status in this setting.The modified Glasgow prognostic score (based on serum C-reactive protein and albumin levels) and the neutrophil-to-lymphocyte (NTL) ratio were obtained from 44 patients who received curative-intent metastasectomy, and were used as indicators of systemic inflammation status. We tested the impact of both of these parameters on overall survival (OS) and progression-free survival (PFS), as well as their correlation with other well-known prognosticators.Five-year PFS and OS rates were 18% and 49%, respectively. At univariate analysis, multiple metastases, disease-free interval36 months, and a Glasgow score of 2 (P = 0.031) were significantly associated to a worse PFS rate. A NTL ratio3 predicted disease progression in the short-term (P = 0.036), but the effect on late events was weaker (P = 0.079). Factors associated with worse OS were multiple metastasis (P = 0.002), elevated carcinoembryonic antigen (P = 0.009), a Glasgow score of 2 (P = 0.029), and a faster metastasis growth (P = 0.008). At Cox regression analysis, neither a Glasgow score of 2, nor elevated NTL ratio showed an independent effect on survival rates.Systemic inflammation scores did not perform well as independent survival prognosticators in patients undergoing curative-intent pulmonary metastasectomy. Further investigation is warranted to evaluate whether these measurements could still be useful when restricting the analysis to specific patient subcategories or to diverse postoperative phases.

During the early twentieth century, thoracic surgery procedures were frequently attempted through local anesthesia, although the pneumothorax created after opening of the chest wall was deemed invariably fatal. During the ensuing decades, some surgeons started performing awake thoracic surgery procedures taking into account the experience matured during the World War I, which suggested that soldiers with severe open thoracic traumas could eventually survive. In the 1940s, a multi-step analgesia protocol entailing multiple local blocks with Novocaine was developed in Russia. Using this technique, hundreds of major thoracic surgery procedures including major lung resections and esophagectomies, were carried out. Subsequently, Buckingham first reported on major surgery procedures using sole thoracic epidural anesthesia in awake patients. The introduction of double-lumen tube ventilation in the 1950s led to the birth of modern thoracic surgery and general anesthesia with one-lung ventilation is still considered m andatory to allow accomplishment of more complex surgical procedures including lung resections. Awake thoracic surgery fell into disuse until recent years when, thanks to the better knowledge of potential adverse effects of general anesthesia, some surgeons again started to investigate the possibility of performing thoracic surgery operation in awake patients Awake thoracic surgery could not have been developed without the previous experience of pioneering thoracic surgeons. Moreover, continuing technological advances and the increased knowledge in cardiopulmonary physiology, are leading to a potentially revolutionary strategy capable of minimizing both surgical and anesthesiological trauma to eventually offer patients comprehensive non-invasive surgical management.

Aims and background The neodymium: yttrium-aluminium-garnet (Nd:YAG) laser has been successfully employed in parenchyma-sparing resection of pulmonary nodular lesions. We report our experience with limited resection using a noncontact Nd: YAG laser applied through a thoracotomic approach. Methods During the period March 1987-October 1993, we performed parenchyma-sparing resections of 66 pulmonary nodular lesions with a noncontact Nd:YAG laser in 47 patients. Nodules were approached through postero-lateral thoracotomy (n= 40), median sternotomy (n= 5) or staged bilateral thoracotomy (n= 2). Fifty-two lesions were located in a peripheral position and the others (n= 14) at various depths within the parenchyma. Results Fifteen lesions were benign: hamartoma (n= 5), chronic pneumonic infiltrate (n= 3), tuberculoma (n= 3), asbestosis (n= 2), Wegener's granuloma (n= 1). Twelve lesions were attributable to primary lung cancer and 33 were metastatic lesions. Another 6 lesions turned out to be necrotic metastases following chemotherapy. There were no perioperative deaths. Pulmonary re-expansion was shortly obtained: mean drainage time was 4.31 ± 3.9 days. Only one patient presented a prolonged drainage time (11 days); in this case, the air leak was successfully treated by tissue glue sealant trans-drainage infiltration. Follow-up ranged from 2 to 96 months. No case of relapse on the resection site has been observed. Conclusions The results suggest that Nd:YAG laser resection is safe and worthwhile in patients with multiple lesions and borderline pulmonary function.

To assess the long-term results and health-related quality of life in patients undergoing surgery for oesophageal achalasia.Thirty-nine patients with achalasia (25 males, mean age 42+/-13 years) underwent open-Heller myotomy and Dor fundoplication by the same surgeon. Long-term results were assessed by imaging, endoscopy, manometry, pH-metry, and Short Form 36 and Nottingham Health Profile questionnaires whenever applicable. Six patients were at radiological stage I, 20 were at stage II, 2 at stage III and 11 at stage IV. Dysphagia and regurgitation were scored according to the four-grade classification (1=no symptoms; 4=persistent symptoms). Pulmonary symptoms were present in six patients. Lower oesophageal pressure was 30+/-34 mmHg. Six patients had undergone previous pneumatodilation.No procedure related mortality was recorded. Mean follow-up was 107+/-30 months (54-177). Preoperative to 5-year postoperative mean decrement in lower oesophageal sphincter pressure was 12.3+/-8.3 mmHg (P0.001) in oesophageal width was 11.5+/-7.1 mm (P0.001) in dysphagia 1.8+/-0.8 (P0.001) and regurgitation 1.4+/-0.7 (P0.001) Four patients presented relapse dysphagia and two of those were re-operated upon. Three patients developed acid reflux, which was satisfactorily treated with proton-pump inhibitors. Preoperative to 4-year postoperative quality of life scores were available for 20 patients. Questionnaires showed a significant improvement (P0.001) especially in all psychosocial domains, which were correlated with postoperative dysphagia score and lower oesophageal sphincter pressure.Heller myotomy and Dor fundoplication is a safe and effective procedure that improves symptoms, functional status and especially psychosocial aspect of quality of life in the long term in oesophageal achalasia.

We prospectively analyzed the surgical and functional results of unilateral thoracoscopic reduction pneumoplasty which we performed by choice in patients with asymmetric emphysema.Between October 1995 and June 1997, 119 emphysematous patients were examined and 34 were operated upon. Among these, 14 selected patients with asymmetric distribution of emphysema in the lungs underwent unilateral reduction pneumoplasty (ten right, and four left). There were 13 males and one female, with a mean age of 62 years. Eligibility criteria included bullous and non-bullous end-stage emphysema with severe limitation to daily activity.No patient required conversion to thoracotomy. Mean operative time ranged between 70 and 240 min with a mean of 103 min. There was no postoperative mortality but five patients developed one or more complications: five prolonged air leaks (7 days); two pulmonary infections; one empyema. No patient required postoperative mechanical ventilation. Median hospital stay was 8 days. At the 3-month follow-up the mean FEV1 increased from 0.8 l to 1.2 l (P0.001). Mean FVC increased from 2.6 l to 2.9 l (P0.001). The Medical Research Council dyspnea score decreased from a mean of 3.2 to 1.8 (P0.001).Asymmetric distribution is a frequent finding in patients with severe emphysema. Unilateral thoracoscopic reduction pneumoplasty may represent an ideal approach in this selected group of patients.