1,721,201 research outputs found
From “Awake” to “Monitored Anesthesia Care” Thoracic Surgery. a 15 Years Evolution
No full textDespite general anesthesia still represents the standard to perform thoracic surgery, the interest toward alternative methods is increasing. These has evolved from the employ of just local or regional analgesia technique in completely alert patients (awake thoracic surgery), to more complex protocols entailing conscious sedation and spontaneous ventilation. The main rationale of these methods is to prevent serious complications related to general anesthesia and selective ventlation, such as tracheobronchial injury, acute lung injury, and cardiovascular events. Also, trends toward shorter hospitalization and reduced overall costs have been indicated in preliminary reports. Monitored anesthesia care thoracic surgery can be successfully employed to manage diverse oncologic conditions, such as malignant pleural effusion, peripheral lung nodules, and mediastinal tumors. Main non-oncologic indications include pneumothorax, emphysema, pleural infections, and interstitial lung disease. Furthermore, as the familiarity with this surgical practice has increased, major operations are now being performed this way. Despite the absence of randomized controlled trials, there is preliminary evidence that monitored anesthesia care protocols in thoracic surgery may be beneficial in high-risk patients, with non-inferior efficacy when compared to standard operations under general anesthesia. Monitored anesthesia care thoracic surgery should enter the armamentarium of modern thoracic surgeons, and adequate training should be scheduled in accredited residency programs
Active ectopic thymus predicts poor outcome after thymectomy in class III myasthenia gravis
No full textOBJECTIVE:
The presence of ectopic thymic tissue has been considered one of the most significant predictors of poor outcome after thymectomy for myasthenia gravis, but the role of active ectopic tissue is unknown. The current study analyzed the importance of this factor on post-thymectomy outcome of patients with class III myasthenia gravis.
METHODS:
We retrospectively reviewed 106 patients with class III, anti-acetylcholine receptor antibody-positive, nonthymomatous myasthenia gravis (70 female, 36 male; mean age, 41 ± 17 years) who underwent transsternal extended thymectomy between 1980 and 2005. Quality of life was assessed from 1996 with the Short Form 36 questionnaire. Prognosticators were investigated using complete stable remission and normalized component summaries as end points.
RESULTS:
Major morbidity rate was 5% with no perioperative mortality. Ectopic thymic tissue was detected in 51 patients (48%), 34 of whom (67%) presented germinal centers. Complete follow-up was available in 96 patients (mean 160 ± 91 months). Fifty-two patients (54%) achieved complete stable remission, and 20 patients (21%) presented clinical and pharmacologic improvement. Lack of postoperative improvement in physical and psychosocial domains was significantly correlated with active ectopic thymus. At Kaplan-Meier evaluation, duration of symptoms (>12 months) (P = .04), oropharyngeal involvement (P = .02), germinal centers (P = .03), ectopic thymus (P = .001), and active ectopic thymus (P < .0001) were negative predictors of complete stable remission. The presence of active ectopic thymus was the most significant negative predictor of complete stable remission at Cox regression (P = .03).
CONCLUSIONS:
Extended thymectomy yields good outcome in patients with nonthymomatous class III myasthenia gravis. The presence of active ectopic thymus was the most significant predictor of poor outcome. These patients should be rigorously followed and undergo early aggressive therapy
Awake thoracic surgery: a historical perspective
No full textDuring 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
Role of systemic inflammation scores in pulmonary metastasectomy for colorectal cancer
Full text linkBackground: 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.
Methods: 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.
Results: Five-year PFS and OS rates were 18% and 49%, respectively. At univariate
analysis,multiple metastases, disease-free interval <36 months, and a Glasgow score
of 2 (P = 0.031)were significantly associated to aworse PFS rate.A NTL ratio >3 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 Glasgowscore 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.
Conclusions: 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
Early closure of the postpneumonectomy bronchopleural fistula by pedicled diaphragmatic flaps
No full textIn the past, several methods for closure of postpneumonectomy bronchopleural fistula have been proposed. Herein we describe a technique to close a bronchopleural fistula using a mobilized diaphragmatic flap sutured directly to the fistula edges. This maneuver improves the blood supply to the bronchial stump and may reduce residual pleural cavity. To prevent bacterial contamination of the pleural space, the procedure should be performed immediately after the diagnosis
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