Presence Of Pleural Adhesions Research Articles

VATS phrenic nerve harvesting for brachial plexus neurotization: literature review and our experience.

Brachial plexus traumatic lesions often lead to severe upper extremity deficits that dramatically compromise quality of life of mostly young patients. Optimal treatment aims to restore elbow flexion transferring various donor nerves. Phrenic nerve (PN) is a powerful source of transferable axons and, despite supraclavicular sectioning being the most used technique, it can be harvested through video-assisted thoracoscopic surgery (VATS). About PN harvesting, less than 20 articles were found in Literature. Most of them are clinical case-reports or case-series or expert opinions. Most of these studies are from China and East Asia and very rarely from Europe; none from Italy. Therefore, we present our experience in PN VATS harvesting in two patients, first cases reported in Italy. Few papers explore risks and benefits of PN as a donor site for brachial plexus reconstruction. There is no clear consensus in the literature whether a traditional approach or minimally invasive surgery is advisable to harvest PN for neurotization. Currently there's no clear indication nor a definitive contraindication about routine use of PN for surgical treatment of BPTLs, it's mostly a matter of choosing the best donor nerve for every single patient. This choice depends on the patient's characteristics, type of traumatic lesion, time from the traumatic event and on the center's experience. The only real concern about using PN as a donor is the potential loss of pulmonary function. In our center two patients with complete brachial plexus avulsion underwent PN transfer via VATS in 2021. Usually, recovery of muscle function depends on time between injury and surgical repair. A commonly accepted recommendation is to perform surgery within six months from the traumatic lesion12. In our experience, the time between trauma and surgery was five months for patient A and six months for patient B. Even if some authors13 consider previous thoracic trauma with rib fractures a major contraindication for homolateral PN harvesting, we believe that the presence of pleural adhesions should not exclude a patient from surgery. No intra or postoperative complications were observed. Both patients were discharged on IV postoperative day. An intense rehabilitation program within three months after surgery is mandatory and regular follow-up is needed to monitor any improvement. No respiratory symptoms or discomfort is recorded up to now. Nerve transfer is a safe and reliable surgical reconstructive procedure and phrenic nerve, due to its pure motor nature, is a very good donor for brachial plexus injuries14. VATS is a valid procedure to guarantee a much longer nerve, avoiding any graft use, and doesn't seem to determine significant pulmonary function loss. Previous thoracic trauma, rib fractures and pneumothorax are commonly considered contraindications for VATS harvesting. However, a major trauma leading to BPTL often implies homolateral thoracic trauma with or without rib fracture or pneumothorax. This could be a reasonable justification to reconsider those contraindications and extend the potential cohort of patients that could benefit from this technique.

Preoperative evaluation of pleural adhesions with dynamic chest radiography: a retrospective study of 146 patients with lung cancer

To assess the utility of dynamic chest radiography (DCR) during the preoperative evaluation of pleural adhesions. Sequential chest radiographs of 146 patients with lung cancer were acquired during forced respiration using a DCR system. The presence of pleural adhesions and their grades were determined by retrospective surgery video assessment (absent: 121, present: 25). The maximum inspiration to expiration lung area ratio was used as an index for air intake volume. A ratio of ≥0.65 was regarded as insufficient respiration. Two radiologists assessed the images for pleural adhesions based on motion findings. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were compared for each adhesion grade and patient group (patients with sufficient/insufficient respiration). Pearson's chi-squared test compared the group. Statistical significance was set at p<0.05. DCR correctly identified 22/25 patients with pleural adhesions, with 20 false-positive results (sensitivity, 88%; specificity, 83.5%; PPV, 52.4%; NPV, 97.12%). Although the diagnostic performances for the various adhesion grades were similar, specificity in patients with sufficient respiration increased to 93.9% (31/33), identifying all cases except for those with loose adhesions. DCR images revealed restricted and/or distorted motions in lung structures and structural tension in patients with pleural adhesions. DCR could be a useful technique for routine preoperative evaluation of pleural adhesions. Further development of computerised methods can assist in the quantitative assessment of abnormal motion findings.

УЛЬТРАЗВУКОВАЯ ДИАГНОСТИКА ПРИ ФОРМИРОВАНИИ ПИЩЕВОДНОПЛЕВРОКОЖНЫХ ФИСТУЛ

The aim of the study was to study the effectiveness of ultrasound diagnostics in the adhesion of pleural leaves in the formation of esophagopleurocutaneous fistulas. Material and methods. The data on treatment of 19 patients (9 - main group, 10 - control group) who were treated with esophageal perforation in the department of thoracic surgery of Brest Regional Clinical Hospital using diagnostic ultrasound were analyzed. Results. The technique of performing ultrasound examination was determined. The “zone of interest” was visualized in the B-mode with the definition of a hyperechoic line and drainage nearby. The displacement of the visceral pleura together with the lung tissue relative to the parietal pleura indicated the presence of pleural adhesions. Simultaneously detected sign "barcode" in the M-mode was a sign of pleural adhesion, which was maintained constantly during chest excursion. This method was used to determine the prevalence of the area of adhesions, and subsequently the issue of traction or removal of drainage in postoperative patients during the formation of a fistula was resolved. Conclusions. Ultrasound diagnostics in the formation of esophageal pleural fistula in patients with esophageal damage contributes to the detection of early complications, timely removal of drains and reduction of hospitalization time.

Prediction of preoperative intrathoracic adhesions for ipsilateral reoperations: sliding lung sign

IntroductionVideo-assisted thoracic surgery (VATS) for ipsilateral reoperations is controversial, because after the first surgical intervention, pleural adhesions occur frequently in the thoracic cavity and/or chest wall. This study assessed the usefulness of preoperative ultrasonography to reduce the incidence of lung injury at the time of the initial port insertion during secondary ipsilateral VATS.Materials and methodsThis was a retrospective, single-center study. Nine patients who underwent thoracic surgery at Vanvitelli Hospitalfrom September 2019 to February 2022, were scheduled for a second VATS surgeryon ipsilateral lung, because of inconclusive intraoperative histologic examination. All nine patients underwent preoperative ultrasonography to assess the possible presence of pleural adhesions. We evaluated the lung sliding, since the presence of pleural adhesions does not permit to appreciate it.Statistical analysisHard severe adhesions were observed in all nine patients without sliding lung sign (specificity 100%). In this series, the sensitivity, PPV, and NPV of the sliding lung sign were 93%, 100% and 94% respectively.ResultsThe presence of the lung respiratory changes can be evaluated as the “sliding lung sign” by chest ultrasonography; we believe that the sliding lung sign might also predict intrathoracic adhesion.ConclusionsPreoperative detection of pleural adhesions using transthoracic ultrasonography was useful for ipsilateral secondary pulmonary resection patients undergoing VATS. Using preoperative ultrasonography can improve the safety and feasibility of placing the initial port in VATS.

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

Poor ventilatory efficiency during exercise may predict prolonged air leak after pulmonary lobectomy.

ClinicalTrials.gov identifier: NCT03498352.

Usefulness of chest ultrasonography for prediction of pleural adhesion and postoperative severe pain in thoracoscopic surgery

Introduction Video-assisted thoracoscopic surgery (VATS) is the most widely used technique in thoracic surgery. However, preoperative pleural adhesion is a major obstacle in VATS and pleural adhesiotomy could aggravate a severe pain after surgery. In this study, we evaluated the usefulness of chest ultrasound to predict preoperative pleural adhesion and postoperative severe pain in VATS. Methods This study was a double blind observational study. Before induction of anaesthesia, 54 patients undergoing VATS were evaluated by using chest ultrasonography. During spontaneous and forced breathing, the sliding of visceral pleura was assessed by 7-Mhz linear transducer at three points (upper and lower blue points and phrenic point of the operating side). Presence of pleural adhesion was confirmed by surgeon through thoracoscopy at same points. Based on the existence of pleural adhesion in chest ultrasound, all of patients were assigned to two groups. Postoperative pain was assessed by numeric rating scale (NRS) and consumption of opioid until postoperative 24 hours. Results Preoperative chest ultrasonography to find pleural adhesion demonstrated a sensitivity of 53.3% [95% confidence interval; 0.38-0.68], a specificity of 96.5% [0.91-0.99], an accuracy of 84.3% [0.78-0.90], a positive predictive value of 85.7% [0.67-0.96], and a negative predictive value of 84.0% [0.77-0.90]. Patients with severe pain (NRS > 6) was not different significantly (adhesion group vs. free group; 57.9% vs. 64.7%; p = 0.624). Consumption of opioid did not show difference statistically (fentanyl equivalent dose, mcg; median [interquartile range], 530 [390-580] vs. 435 [375-570]; p = 0.594). Discussion Chest ultrasonography showed usefulness to predict pleural adhesion. It could help to decide an approach plan (VATS or open thoracotomy) in thoracic surgery. However, it would not be helpful to predict a postoperative severe pain.

Preoperative Detection of Pleural Adhesions Using Ultrasonography for Ipsilateral Secondary Thoracic Surgery Patients

Video-assisted thoracic surgery (VATS) for ipsilateral reoperations is challenging because of the potential for pleural adhesions. Insertion of the initial port can lead to lung injury because of the blinded intrathoracic area. We assessed the usefulness of ultrasonography before VATS to reduce the incidence of lung injury at the time of the initial port insertion during secondary ipsilateral VATS. Thirty-three patients who underwent repeat VATS for ipsilateral pulmonary lesions were included. All patients underwent preoperative ultrasonography to assess the possible presence of pleural adhesions using the lung sliding sign. Seven adhesions were found at the VATS ports. Two of these adhesions were not evaluated as pleural adhesions using ultrasonography; however, they were loose. All initial ports were inserted without lung injury. There were no major complications. Preoperative detection of pleural adhesions using ultrasonography can determine the best initial port for secondary ipsilateral VATS.

Uniportal thoracoscopic treatment in bronchiectasis patients: preliminary experience.

IntroductionBronchiectasis is defined as a permanent and abnormal dilation of the bronchi due to destruction of the bronchial wall. The thoracoscopic approach is represented in the literature by a few reports, and multiple port incisions are observed in these studies.AimTo investigate the effectiveness and outcomes of the single port video-assisted thoracoscopic surgery (VATS) method in the surgical treatment of bronchiectasis. To our knowledge, this is the first study reporting surgical treatment of bronchiectasis via the uniportal thoracoscopic approach.Material and methodsThe medical records of 15 patients undergoing surgery for bronchiectasis between 2013 and 2017 were reviewed. The patients were evaluated with regard to age, gender, duration of symptoms, localization, types and duration of the surgery, presence of pleural adhesion, intraoperative complications, amount of intraoperative bleeding, conversion to open surgery, postoperative drainage amount, chest tube removal time, length of hospital stay, mortality and morbidity, follow-up period, duration of narcotic analgesic usage, pain according to visual analog scale evaluation and satisfaction score.ResultsA total of 15 patients initially underwent single port thoracoscopic resection and 14 procedures were completed thoracoscopically. In terms of anatomic resections, 6 patients underwent left lower lobectomy, 4 right lower lobectomy, 1 right upper lobectomy, 1 left lower lobectomy + lingulectomy, 1 right basal segmentectomy and 1 patient underwent lingulectomy. The mean operative time was 137.1 ±24.5 min and the mean length of hospital stay was 4.78 ±1.52 days. The mean postoperative analgesic requirement was 2.85 ±0.66 days.ConclusionsWe believe that uniportal VATS is a safe, feasible, and effective technique for selected bronchiectasis patients.

Impact of bovine respiratory disease on lung lesions, slaughter performance and antimicrobial usage in French beef cattle finished in North-Eastern Italy

Bovine respiratory disease (BRD) is a major health concern in beef cattle, with several pathogens and environmental risk factors being involved. Clinical signs of BRD may remain undetected, preventing proper diagnosis. Yet, BRD-associated lung lesions can be detected at slaughter, providing a more sensitive way to estimate BRD prevalence, as these lesions are present also in subclinically affected animals. In April–August 2016, the lungs of 518 Charolaise males from 8 farms in North-Eastern Italy were scored at slaughter based on the presence of pleural adhesions and the percentage of affected parenchyma. Moreover, individual antimicrobial dosages were acquired from the farm registries. 64% of animals had at least one lung lesion; a negative association between lung lesions and carcass weight was found. No association between lung lesions and antimicrobial use was identified. The appropriateness of each antimicrobial treatment was evaluated based on the ratio between each actual daily dose used and the correspondent defined daily dose available in the Summary of Product Characteristics (SPC). Three methods based on different estimation of live-weight-at-treatment were applied and provided significantly different results for some antimicrobial classes. Aminoglycosides and high-priority critical antimicrobials like macrolides were those most frequently administered (20% and 42% of treatments, respectively). Evaluation of dosage appropriateness showed that aminoglycosides were administered properly in 60–75% of treatments, while macrolides were underdosed in 30–60% of treatments. In conclusion, this study shows a high prevalence of BDR-associated lung lesions at slaughter associated with carcass weight, and that antimicrobial use is frequently inconsistent with recommended doses.

Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: A single-centre experience.

Malignant pleurisy is associated with advanced oncological disease and dyspnoea is the most common presenting symptom. Pleurodesis is the preferred palliative and supportive treatment option, targeting symptom relief. The identification of clinical and endoscopic features that determine the success of talc pleurodesis in malignant pleurisy could guide clinical decision-making. All symptomatic patients with malignant pleurisy subjected to talc pleurodesis through medical thoracoscopy between January 2012 and December 2015 were included. Univariate and multivariate analyses were performed to identify factors associated with successful pleurodesis. Of the 155 patients, 122 (78%) were classified as having a successful pleurodesis based on clinical and radiological criteria. Factors associated with unsuccessful pleurodesis (univariate analysis) were the presence of pleural adhesions (odds ratio (OR): 0.43 (95% CI: 0.19-0.96); P = 0.04), extensive spread of pleural lesions (OR: 0.17 (95% CI: 0.05-0.59); P = 0.001), the use of systemic corticosteroids (OR: 0.28 (95% CI: 0.10-0.83); P = 0.02) and a prolonged time period between the clinical diagnosis of the pleural effusion and the moment of pleurodesis (OR: 0.14 (95% CI: 0.06-0.32); P < 0.0001). The latter being associated with failure of pleurodesis in a multivariate analysis (OR: 0.08 (95% CI: 0.01-0.25); P < 0.0001). Chest ultrasound prior to pleurodesis showed a sensitivity of 91% and a specificity of 88% in predicting the success of pleurodesis. The success rate of pleurodesis in malignant pleurisy could potentially be enhanced by correct patient selection and early referral for pleurodesis. Ultrasonic assessment of pleural adhesions and potential lung expansion prior to pleurodesis is useful in clinical decision-making.

Presence of pleural adhesions can predict conversion to thoracotomy and postoperative surgical complications in patients undergoing video-assisted thoracoscopic lung cancer lobectomy.

The purpose of our cohort study was to investigate the effects of pleural adhesions on perioperative outcomes in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for non-small-cell lung cancer (NSCLC). We performed a single-center retrospective analysis on the prospectively-maintained dataset at our unit from February 2014 to November 2015. Patients were divided into two groups (Group A: presence of pleural adhesions; Group B: absence of pleural adhesions) according to our grading system of pleural adhesions when entering the chest cavity. Demographic differences in perioperative outcomes between these two groups were initially estimated. A multivariate logistic-regression analysis was then performed to confirm the predictive value of the presence of pleural adhesions. A total of 593 NSCLC patients undergoing VATS lobectomy were enrolled. The conversion and postoperative morbidity rates were 3.2% and 29.2%, respectively. There were 154 patients with pleural adhesions (Group A) and 439 patients without pleural adhesions (Group B). Group A patients had significantly higher rates of conversion to thoracotomy (9.1% vs. 1.1%; P<0.001) and surgical complications (24.0% vs. 14.4%; P=0.006) than those of Group B patients. No significant difference was found in the overall morbidity and cardiopulmonary complication rates between these two groups. The presence of pleural adhesions was also significantly associated with the prolonged length of chest tube drainage (log-rank P<0.001) and length of stay (log-rank P=0.032). Finally, the presence of pleural adhesions was identified as an independent risk factor for conversion to thoracotomy [odds ratio (OR) =5.49; P=0.003] and surgical complications (OR =1.94; P=0.033) by multivariate logistic-regression analyses. Presence of pleural adhesions can predict conversion to thoracotomy and postoperative surgical complications in patients undergoing VATS lobectomy for NSCLC. Our study calls for an internationally accepted grading system for the presence of pleural adhesions to stratify the surgical risk.

PP37 - Nonintubated video-assisted thoracoscopic surgery: a report of five cases

In recent years, the performance of nonintubated video-assisted thoracoscopic surgery (NIVATS) has been expanding. It consists of video-assisted thoracoscopic surgery (VATS) under regional anaesthesia, with the patient awake or under sedation and with spontaneous ventilation. Its use is accepted to carry out simple interventions (drainage of pleural effusion, pneumothorax surgery or atypical lung resections), and aims to avoid the adverse effects of general anaesthesia and to accelerate postoperative recovery. We report the first 5 cases of patients undergoing NIVATS in our hospital. Five patients were selected for NIVATS, four men and one woman, aged between 31 and 72 years old. The selection of the patients excluded patient who were obese, predictors of a difficult airway, sleep apnoea syndrome and altered coagulation. Pulse oximetry, non-invasive blood pressure and electrocardiogram were monitored. In all patients, a thoracic epidural catheter was placed at T5-T6 level and 0.25% levobupivacaine was administered in bolus at doses of 8-10 ml h-1. Intravenous sedation was administered to achieve a 3-4 sedation level on the Ramsay scale. Remifentanil 0.05-0.1 μg kg-1 min-1 was used in all patients. In addition, propofol 2-3 mg kg-1 h-1 was used in three patients and the other two patients received dexmedetomidine 0.4-0.6 μg kg-1 h-1. Oxygen was administered through a face mask The interventions were performed by uniportal thocacoscopy. In three patients, lung biopsy was performed for the diagnosis of diffuse interstitial lung disease, and the other two patients underwent solitary pulmonary nodule resection. All patients adequately tolerated thoracoscopy in spontaneous ventilation, without refer pain or discomfort. Pulmonary collapse and vision were adequate in all cases. The intervention could be performed without any incident in all but one patient, in which conversion to general anaesthesia was necessary due to the difficulty in locating the nodule. Epidural anesthesia in NIVATS provides satisfactory analgesia of the chest wall and the parietal pleura. However, manipulation of the visceral pleura and hilar structures can trigger the cough reflex. In this case, some authors recommend the anaesthetic blockade of the vagus nerve at the intrathoracic level. In our patients there was no cough that interfered with the surgical procedure, and no blockage of the vagus nerve was required. The need to convert NIVATS to general anaesthesia ranges from 2.3% to 10% depending on the type of procedure and the experience, and may occur due to bleeding, presence of pleural adhesions, severe hypercapnia, insufficient pulmonary collapse and difficulties to perform the surgical technique. We had to perform general anaesthesia in one of the patients due to an inadequate visualisation of the pulmonary nodule. NIVATS is safe and feasible in simple interventions such as lung biopsies or atypical resections. Adequate patient selection is necessary.

Video-assisted thoracoscopic surgery is a safe option for benign lung diseases requiring lobectomy

Lobectomy for benign lung disease is renowned to be technically complex and to be subjected to an increased complication rate. The objective of this study was to evaluate whether the results obtained with video-assisted surgery (VATS) in benign disease are comparable to those obtained in oncologic surgery, where VATS has been validated. We have reviewed the files of 246 consecutive patients who underwent VATS lobectomy from January 2012 to August 2015. The cohort was divided into two groups according to pathology (benign or malignant). Outcome parameters on scrutiny were demographics, pathology, duration of air leak, drainage and hospital stay, conversion, and perioperative complication rate. Comparisons were made with the χ 2 test and Student's t test; any p value ≤0.05 was considered as significant. Group 1 (36 patients) included patients who underwent lobectomy for benign disease and group 2 (210 patients) patients affected by lung cancer or pulmonary metastases. The two groups differed with reference to age (p<0.001), history of cancer (p<0.001), history of stroke (p=0.05), and the presence of pleural adhesions (p=0.03). There was no difference for duration of air leaks, chest tube drainage and hospital stay, conversion rate, and perioperative complication rate. We conclude that pathology did not impact on outcomes after VATS lobectomy. This study suggests that VATS is as a safe option in selected patients with benign disease requiring lobectomy, despite a more complex technical context.

Ultrasound-Guided Medical Thoracoscopy in the Absence of Pleural Effusion

BACKGROUND: Medical thoracoscopy (MT) is a diagnostic and therapeutic procedure that permits the study of the pleural space. The presence of pleural adhesions is the most important contraindication to performing MT. Lesions of the pleura in absence of pleural effusion are usually studied in video-assisted thoracoscopic surgery (VATS) with preoperative ultrasound evaluation. No data are available about ultrasound-guided MT in the absence of pleural effusion.METHODS: From January 2007 to June 2013, 622 consecutive MTs were performed under ultrasound guidance without inducing a pneumothorax. A retrospective cohort of 29 patients affected by pleural diseases without fluid was reviewed. The fifth or sixth intercostal spaces along the midaxillary line with a good echographic “sliding sign” and normal appearance of the pleural line were chosen as the entry site. The pleural cavity was explored, and biopsies were performed.RESULTS: The mean age of the patient cohort was 62.8 years; there were 20 male patients and nine female patients. Pleural adherences were avoided, and adequate number of pleural biopsies were performed. No parenchymal lung injuries, bleeding, or hematoma occurred. Seventeen patients had a completely free pleural cavity, four patients had a single pleural adhesion, and eight had multiple pleural adhesions; in all cases, however, endoscopic exploration was possible and biopsy specimens were adequate. The most frequent histopathologic diagnosis was malignant pleural mesothelioma.CONCLUSIONS: We have shown that thoracic ultrasound accurately identifies intrathoracic adhesions and, in experienced hands, can guide MT access, replacing the VATS approach, even in the complete absence of pleural effusion.

Prevention and management of postoperative air leaks.

A contemporary, practical definition of prolonged air leak (PAL) is an air leak that lasts beyond postoperative day 5. This is consistent with the definition used in the Society of Thoracic Surgeons database and represents a leak whose duration exceeds the average length of stay (LOS) for lobectomy. The reported incidence of PAL ranges from 8% to 26% (1), but the definition of PAL has varied amongst reports. PAL increases the LOS, increases hospital costs, and is associated with elevated rates of empyema and other complications. The most consistently reported risk factors for PAL include poor pulmonary function, use of steroids, performance of an upper lobectomy, presence of a pneumothorax coinciding with an air leak, and the presence of pleural adhesions (1,2). With regard to sublobar resection, although it has yet to be studied scientifically, we believe that segmentectomy may have a higher risk of PAL compared to wedge resection due to the increased thickness of some intersegmental planes and the more extensive dissection involved.

Pleural tissue repair with cord blood platelet gel.

Prolonged air leak is the major cause of morbidity after pulmonary resection. In this study we used in vitro and in vivo experiments to investigate an innovative approach based on the use of human umbilical cord blood platelet gel. In vitro, a scratch assay was performed to test the tissue repair capability mediated by cord blood platelet gel compared to the standard culture conditions using human primary mesothelial cells. In vivo, an iatrogenic injury was made to the left lung of 54 Wistar rats. Cord blood platelet gel was placed on the injured area only in treated animals and at different times histological changes and the presence of pleural adhesions were evaluated. In addition, changes in the pattern of soluble inflammatory factors were investigated using a multiplex proteome array. In vitro, mesothelial cell damage was repaired in a shorter time by cord blood platelet gel than in the control condition (24 versus 35 hours, respectively). In vivo, formation of new mesothelial tissue and complete tissue recovery were observed at 45±1 and 75±1 hours in treated animals and at 130±2.5 and 160±6 hours in controls, respectively. Pleural adhesions were evident in 43% of treated animals compared to 17% of controls. No complications were observed. Interestingly, some crucial soluble factors involved in inflammation were significantly reduced in treated animals. Cord blood platelet gel accelerates the repair of pleural damage and stimulates the development of pleural adhesions. Both properties could be particularly useful in the management of prolonged air leak, and to reduce inflammation.

Characterization and Prediction of Prolonged Air Leak After Pulmonary Resection: A Nationwide Study Setting Up the Index of Prolonged Air Leak

The objective of this study was to better characterize prolonged air leak (PAL), defined as an air leak longer than 7 days, and to develop and validate a predictive model of this complication after pulmonary resection. All lung resections entered in Epithor, the French national thoracic database (French Society of Thoracic and Cardiovascular Surgery), were analyzed. Data collected between 2004 and 2008 (n=24,113) were used to build the model using backward stepwise variable selection, and the 2009 data (n=6,813) were used for external validation. The primary outcome was PAL. Results of the predictive model were used to propose a score: the index of PAL (IPAL). Prevalence of PAL after pulmonary resection was 6.9% (n=1,655) in the development data set. In the final model, 9 variables were selected: gender, body mass index, dyspnea score, presence of pleural adhesions, lobectomy or segmentectomy, bilobectomy, bulla resection, pulmonary volume reduction, and location on upper lobe. In the development data set, the C-index was 0.71 (95% confidence interval [CI], 0.70 to 0.72). At external validation, the C-index was 0.69 (95% CI, 0.66 to 0.72) and the calibration slope (ie, the agreement between observed outcomes and predictions) was 0.874 (<1). A score chart based on these analyses has been proposed. The formula to calculate the IPAL is the following: gender (F=0; M=4)-(body mass index-24)+2×dyspnea score+pleural adhesion (no=0; yes=4)+pulmonary resection (wedge=0; lobectomy or segmentectomy=7; bilobectomy=11; bulla resection=2; volume reduction=14)+location (lower or middle lobe=0; upper=4). Surgeons can easily use the well-validated model to determine intraoperative preventive measures of PAL.

A Scoring System to Predict the Risk of Prolonged Air Leak After Lobectomy

Prolonged air leak (PAL) remains a frequent complication after lung resection. Perioperative preventative strategies have been tested, but their efficacy is often difficult to interpret due to heterogeneous inclusion criteria. The objective of this study was to develop and validate a practical score to stratify the risk of PAL after lobectomy. Six hundred fifty-eight consecutive patients were submitted to pulmonary lobectomy (2000 to 2008) in center A and were used to develop the risk-adjusted score predicting the incidence of PAL (> 5 days). Exclusion criteria were chest wall resection and postoperative assisted mechanical ventilation. No sealants, pleural tent, or buttressing material were used. To build the aggregate score numeric variables were categorized by receiver operating curve analysis. Variables were screened by univariate analysis and then used in stepwise logistic regression analysis (validated by bootstrap). The scoring system was developed by proportional weighing of the significant predictor estimates and was validated on patients operated on in a different center (center B). The incidence of PAL in the derivation set was 13% (87 of 658 cases). Predictive variables and their scores were the following: age greater than 65 years (1 point); presence of pleural adhesions (1 point); forced expiratory volume in one second less than 80% (1.5 points); and body mass index less than 25.5 kg/m(2) (2 points). Patients were grouped into 4 risk classes according to their aggregate scores, which were significantly associated with incremental risk of PAL in the validation set of 233 patients. The developed scoring system reliably predicts incremental risk of PAL after pulmonary lobectomy. Its use may help in identifying those high-risk patients in whom to adopt intraoperative prophylactic strategies; in developing inclusion criteria for future randomized clinical trials on new technologies aimed at reducing or preventing air leak; and for patient counseling.

Totally videoendoscopic descending thoracic aorta-to-femoral artery bypass

Descending thoracic aorta to femoral artery bypass is an effective and safe procedure for the treatment of aortoiliac occlusive disease when an approach to the abdominal aorta is undesirable. The major limitation of this technique has resulted from the morbidity rate associated with thoracotomy in a relatively high-risk vascular surgery population. As a minimally invasive procedure, videoendoscopy has been shown to improve the patient postoperative course and comfort in the field of general and thoracic surgery. The same benefits could be expected from a videoendoscopic surgery involving the thoracic aorta. In 2003 we reported the first case of a totally videoendoscopic descending thoracic aorta-to-femoral artery bypass procedure. In this article we report our additional experience with and the modifications we have made to this technique.