Introduction:The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic has affected Italy since the beginning of 2020. Endotracheal intubation, prolonged mechanical ventilation, and tracheostomy are frequently required in patients with severe COVID-19. Tracheal stenosis is a potentially severe condition that can occur as a complication after intubation. The aim of this study was to evaluate the utility and safety of endoscopic and surgical techniques in the treatment of tracheal stenosis related to COVID-19. Materials and Methods:Between June 2020 and May 2022, consecutive patients with tracheal stenosis who were admitted to our surgical department were considered eligible for participation in the study. Results:A total of 13 patients were included in the study. They consisted of nine women (69%) and four men (31%) with a median age of 57.2 years. We included seven patients with post-tracheostomy tracheal stenosis. Bronchoscopy was performed to identify the type, location, and severity of the stenosis. All patients underwent bronchoscopic dilation and surveillance bronchoscopy at 7 and 30 days after the procedure. We repeated endoscopic treatment in eight patients. Three patients underwent tracheal resection anastomosis. Final follow-up bronchoscopy demonstrated no residual stenosis. Conclusions:The incidence of and risk factors associated with tracheal stenosis in critically ill patients with COVID-19 are currently unknown. Our experience confirms the efficacy and safety of endoscopic management followed by surgical procedures in cases of relapsed tracheal stenosis.

The aim of this study was to assess the impact of BMI on perioperative outcomes in patients undergoing VATS lobectomy or segmentectomy. Data from 5088 patients undergoing VATS lobectomy or segmentectomy, included in the VATS Group Italian Registry, were collected. BMI (kg/m2) was categorized according to the WHO classes: underweight, normal, overweight, obese. The effects of BMI on outcomes (complications, 30-days mortality, DFS and OS) were evaluated with a linear regression model, and with a logistic regression model for binary endpoints. In overweight and obese patients, operative time increased with BMI value. Operating room time increased by 5.54 minutes (S.E. = 1.57) in overweight patients, and 33.12 minutes (S.E. = 10.26) in obese patients (P < 0.001). Compared to the other BMI classes, overweight patients were at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications. In the overweight range, a BMI increase from 25 to 29.9 did not significantly affect the length of stay, nor the risk of any complications, except for renal complications (OR: 1.55; 95% CI: 1.07–2.24; P = 0.03), and it reduced the risk of prolonged air leak (OR: 0.8; 95% CI: 0.71–0.90; P < 0.001). 30-days mortality is higher in the underweight group compared to the others. We did not find any significant difference in DFS and OS. According to our results, obesity increases operating room time for VATS major lung resection. Overweight patients are at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications following VATS resections. The risk of most postoperative complications progressively increases as the BMI deviates from the point at the lowest risk, towards both extremes of BMI values. Thirty days mortality is higher in the underweight group, with no differences in DFS and OS.

Background Thymoma is an uncommon cancer often associated with myasthenia gravis, an autoimmune disorder of the neuromuscular junction characterized by muscular fatigability. In patients with advanced nonmetastatic thymoma, primary chemotherapy may be required to induce tumor shrinkage and to achieve radical resection. Cancer chemotherapy has been anecdotally reported as a trigger factor for worsening of myasthenia gravis in thymic epithelial cancers. The study of uncommon cases of chemotherapy-related myasthenic crisis is warranted to gain knowledge of clinical situations requiring intensive care support in the case of life-threatening respiratory failure. Case presentation We report a case of an 18-year-old Caucasian woman with advanced Masaoka-Koga stage III type B2 thymoma and myasthenia gravis on treatment with pyridostigmine, steroids and intravenous immunoglobulins, who developed a myasthenic crisis 2 hours after initiation of cyclophosphamide/doxorubicin/cisplatin primary chemotherapy. Because of severe acute respiratory failure, emergency tracheal intubation, mechanical ventilation, and temporary (2 hours) discontinuation of chemotherapy were needed. Considering the curative intent of the multimodal therapeutic program, we elected to resume primary chemotherapy administration while the patient remained on mechanical ventilation. After 24 hours, the recovery of adequate respiratory function allowed successful weaning from respiratory support, and no further adverse events occurred. After 3 weeks, upon plasma exchange initiation with amelioration of myasthenic symptoms, a second course of chemotherapy was given, and in week 6, having documented partial tumor remission, the patient underwent radical surgery (R0) and then consolidation radiation therapy with 50.4 Gy in 28 fractions in weeks 15–20. Conclusions This case report, together with the only four available in a review of the literature, highlights that chemotherapy may carry the risk of myasthenic crisis in patients affected by thymoma and myasthenia gravis. To our knowledge, this is the first reported case of chemotherapy continuation on mechanical ventilation in a patient with chemotherapy-induced myasthenic crisis requiring tracheal intubation. The lesson learned from the present case is that, in selected cases of advanced thymoma, the paradoxical worsening of myasthenia gravis during chemotherapy should not be considered an absolute contraindication for the continuation of primary chemotherapy with curative intent.

El tratamiento paliativo de la estenosis traqueobronquial maligna es difícil. Las experiencias publicadas con stent en Y autoexpandibles son escasas, por lo que es necesario evaluar si los resultados que ofrecen son mejores que los de otras prótesis alternativas.

Palliation of malignant tracheobronchial stenosis is challenging. Published experience with self-expanding Y-shaped stents is limited and it seems necessary to evaluate whether they improve clinical results with respect to alternative prostheses.

In right upper lobectomy, there are a variety of access incisions, surgical instruments, intraoperative strategies, and perioperative treatment approaches. We describe a safe, effective, and cost-saving technique to simultaneously staple the individually dissected right superior pulmonary vein and anterior trunk of the right main pulmonary artery during right upper lobectomy. Barring extremely unusual anatomy, this approach has wide indications. This technique may become an integral part of video- and robotic-assisted right upper lobectomies.

Pulmonary venous anastomotic thrombosis (PVT) is well recognized as a potentially fatal early complication of lung transplantation.1Schulman L.L. Anandarangam T. Leibowitz D.W. et al.Four-year prospective study of pulmonary venous thrombosis after lung transplantation.J Am Soc Echocardiogr. 2001; 14: 806-812Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 2Leibowitz D.W. Smith C.R. Michler R.E. et al.Incidence of pulmonary vein complications after lung transplantation: A prospective transesophageal echocardiographic study.J Am Coll Cardiol. 1994; 24: 671-675Abstract Full Text PDF PubMed Scopus (64) Google Scholar The delay in diagnosis postpones therapeutic intervention, resulting in irreversible lung damage and a poor outcome.3Huang Y.C. Cheng Y.J. Lin Y.H. et al.Graft failure caused by pulmonary venous obstruction diagnosed by intraoperative transesophageal echocardiography during lung transplantation.Anesth Analg. 2000; 91: 558-560Crossref PubMed Scopus (27) Google Scholar We read with interest the article by Mcllroy and colleagues4Mcllroy D.R. Cairo S.A. Buckland M.R. Pulmonary vein thrombosis, lung transplantation, and intraoperative transesophageal echocardiography.J Cardiothorac Vasc Anesth. 2006; 20: 712-715Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar entitled "Pulmonary Vein Thrombosis, Lung Transplantation, and Intraoperative Transesophageal Echocardiography." The authors report a series of cases of the intraoperative diagnosis and successful surgical management of PVT using intraoperative transesophageal echocardiography (TEE). This series of cases highlights the utility of intraoperative TEE in the early diagnosis of PVT. The use of intraoperative echocardiography is recommended as routine monitoring during lung transplantation because it allows the early detection of pulmonary venous anastomotic obstruction before the patient leaves the operating room and before clinical symptoms develop.5Cywinski J.B. Wallace L. Parker B.M. Pulmonary vein thrombosis after sequential double-lung transplantation.J Cardiothorac Vasc Anesth. 2005; 19: 225-227Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar A multiplane TEE probe allows visualization of all 4 pulmonary veins. In some rare cases, bidimensional images can be suboptimal,1Schulman L.L. Anandarangam T. Leibowitz D.W. et al.Four-year prospective study of pulmonary venous thrombosis after lung transplantation.J Am Soc Echocardiogr. 2001; 14: 806-812Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 2Leibowitz D.W. Smith C.R. Michler R.E. et al.Incidence of pulmonary vein complications after lung transplantation: A prospective transesophageal echocardiographic study.J Am Coll Cardiol. 1994; 24: 671-675Abstract Full Text PDF PubMed Scopus (64) Google Scholar and not all thrombi can be clearly visualized. Measured peak systolic flow velocity within the pulmonary veins is often used to give indirect evidence of PVT or significant pulmonary vein blood flow obstruction. Nevertheless, peak systolic flow velocity depends on left atrial pressure and mitral inflow velocities, and the presence of impaired systolic and/or diastolic function or mitral regurgitation can modify velocities and pressure gradients.5Cywinski J.B. Wallace L. Parker B.M. Pulmonary vein thrombosis after sequential double-lung transplantation.J Cardiothorac Vasc Anesth. 2005; 19: 225-227Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 6Cherqui M.M. Brusset A. Liu N. et al.Intraoperative transesophageal echocardiographic assessment of vascular anastomoses in lung transplantation.Chest. 1997; 111: 1129-1135Google Scholar Epicardial echocardiography may be considered another available diagnostic tool for the intraoperative visualization of pulmonary vein connections. We introduced in our department the use of the epicardial approach to study pulmonary veins during lung transplantation 2 years ago. We used the combination of transesophageal and epicardial echocardiography in 9 patients who underwent lung transplantation in this time. Epicardial echocardiography with a high-frequency linear probe was easily performed in all patients. When TEE showed suboptimal images (left lower pulmonary vein in 2 patients), the epicardial approach always allowed us to rapidly visualize all 4 pulmonary veins abutting on the left atrium (Fig 1) and pulmonary artery anastomoses. The favorable beam-vessel angle always allowed an optimal flow velocity pattern of all 4 pulmonary veins. To our knowledge, this is the first report describing the intraoperative epicardial approach to study pulmonary vein anastomosis during lung transplantation. Further investigations are necessary to clarify the advantages of this approach to detect PVT. Pulmonary Vein Thrombosis, Lung Transplantation, and Intraoperative Transesophageal EchocardiographyJournal of Cardiothoracic and Vascular AnesthesiaVol. 20Issue 5PreviewWITH 1-YEAR survival figures on the order of 70% to 80%,1,2 lung transplantation is an established and viable treatment option for a variety of end-stage lung diseases. Although primary graft failure and infection remain the greatest causes of early mortality in this group of patients,2,3 pulmonary venous anastomotic thrombosis (PVT) is well recognized as a potentially fatal early complication of lung transplantation.3-5 Full-Text PDF

Purpose: The risk of neoplasia is considered to be higher in solid-organ transplant recipients than in the general population. Lung cancer observed after heart transplantation is considered to have a poor prognosis. However, the results of surgical treatment have not yet been significantly evaluated.

Objective: We have analyzed our experience in a period ranging from January 1990 to December 1996, to confirm role of surgery in management of treatment of SCLC patients.Methods: The study was carried out on 55 patients(pts) undergone surgery for SCLC as resections or open lung biopsy. The median age of pts(49 males and 6 females) was 59 years(range 34 to 74 yrs). In 6 pts with pre-operatory diagnosis 3-5 cycles of neo-adjuvant chemotherapy(CEVE-CEV) were administered. In all remained pts adjuvant chemotherapy(CHT) after thoracic approach(3-5 cycles CEVE-CEV) and in few cases radiotherapy (RT)were performed. The surgical procedures included 7 pneumonectomy,28 lobectomy and 20 open lung biopsy and or segmental resections.Results: The median follow-up was 27.6 months(range 5-84mths). The 5 year actuarial survival rate was 23.3%(median 19.1 mths). Seventen pts are still alive(9 in stage I; il in stage II and 4 in stage III), 12 of them being disease free. No patients had a significantly better survival than N1-N2 patients.-Conclusions- Surgery,adjuvant CHT and RT represent a good option in treatment of limited SCLC desease. Neoadjuvant CHT consents to reconduce to surgery some excluded pts and permitts a satisfactory management also in extensive SCLC desease controll.