Mr Andrea Bille
- London, United Kingdom
- En, En
- Best at: Surgery for thoracic conditions and lung cancer
Mr Andrea Bille is a Consultant Thoracic Surgeon at Guy’s and St Thomas’ NHS Foundation Trust and Honorary Senior Clinical Lecturer at Kings College University, London. He specialises in the treatment of thoracic conditions and in surgery and sees patients privately for a range of conditions: Pneumothorax, Pectus deformity, Infection of the pleura / empyema, Rib fractures, Pleural effusion, Lung cancer, Thymoma, Mesothelioma, Mass/lesion in the mediastinum. Mr Bille qualified in 2005 from the University of Turin and trained in Cardiothoracic Surgery in Italy and at Guy’s Hospital, London. He undertook a clinical fellowship at Guy’s Hospital focusing on mesothelioma surgery and minimally invasive thoracic surgery for the treatment of lung cancer and benign conditions. In 2013 he was appointed as a consultant at the National Institute of Cancer in Milan, focusing on surgical treatment of lung cancer, thoracic sarcoma and mediastinal tumour which require extensive resection and complex reconstruction. In 2014/15 Mr Bille undertook a clinical fellowship at Memorial Sloan Kettering Cancer Center in the US and trained in thoracoscopy and robotic surgery for the treatment of thoracic malignancies and advance technique with complex reconstruction for extensive thoracic malignancies. He completed his PhD in 2015 which focussed surgical treatment of mesothelioma. Mr Bille has published extensively and presented at conferences worldwide. He is Associate Editor of the thoracic section of the Tumori Journal and the Journal of Thoracic Disease. Mr Bille is involved a number of research projects on lung cancer, thymoma and mesothelioma analysing the role of surgery and new multimodality approaches. He is a member of the thymoma and mesothelioma international staging committee and he is chair of the mesothelioma database of the European Society of Thoracic Surgeons (ESTS).
Achievements of Mr Andrea Bille
Information about Mr Andrea Bille
- surgery - 59
lung cancer articles - Impact Factor
- respiratory tract neoplasms - 59
- surgery - 59
Treatment and prognostic factors of patients with thymic epithelial tumors at first recurrence or progression.
The treatment of patients with recurrent or progressive thymic epithelial tumors remains uncertain due to limited data in this rare disease.
Sternal resection represents a rare, peculiar subgroup of chest wall operations. Abdominal or lung hernia could be a serious complication after extended chest wall or sternal resection for cancer. We present a case of a late abdominal hernia in the chest underneath the skin, 7 years after a total sternal resection for a sarcoma.
Placental site trophoblastic tumor (PSTT) is a rare variant of gestational trophoblastic tumor (GTN), accounting for 1-2% of all GTNs. Primary testicular PSTTs are extremely rare. Thirty percent of patients with PSTT show multiple lung and brain metastases at the time of diagnosis. We present the first case of a synchronous single pulmonary trophoblastic placental tumor metastasis together with a teratoma and a mixed germinal tumor of the testis, treated with minimally invasive lung metastasectomy.
Bronchoscopic management of patients with symptomatic airway stenosis and prognostic factors for survival.
Interventional bronchoscopy is effective in the management of patients with symptomatic airway obstruction for both malignant and benign conditions. The main aim of this study is to report our experience with emergency interventional bronchoscopy in patients with symptomatic airway obstruction and identify prognostic factors for survival.
The aim of this study is to report the overall survival after pulmonary metastasectomy in patients with metastatic sarcoma and prognostic factors for survival.
Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy, and systemic chemotherapy in patients with malignant pleural mesothelioma: a 10-year experience.
We evaluated the long-term results of pleurectomy/decortication (P/D), hyperthermic pleural lavage with povidone-iodine, prophylactic chest wall radiotherapy (21 Gy), and systemic chemotherapy in patients with malignant pleural mesothelioma.
To evaluate the feasibility of training program in video assisted thoracic surgery (VATS) lobectomy comparing intraoperative and postoperative data of patients operated on by an established consultant and trainees.
In patients undergoing lung resection is it safe to administer amiodarone either as prophylaxis or treatment of atrial fibrillation?
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether the administration of amiodarone is safe in patients undergoing lung resection either for prophylaxis or treatment of de novo postoperative atrial fibrillation (POAF). A total of 30 papers were identified, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date, study type, country of publication, patient demographics, relevant outcomes and results were tabulated. Among the identified papers, there were 2 meta-analyses, 1 best evidence topic and 3 randomized studies, while the remainder were retrospective. When considering perioperative amiodarone for the prophylaxis of POAF, 3 randomized studies reported no significantly increased postoperative complications or amiodarone-related side effects. Mortality and length of hospital stay were similar in patients receiving amiodarone compared with either no amiodarone or other prophylactic antiarrhythmic medication. When considering amiodarone for the treatment of POAF, 1 study reported a significantly increased incidence of ARDS after anatomical lung resection (P < 0.001). Two case series reported that patients developing POAF after lung resection and managed with amiodarone also had either none or acceptable rates of side effects, with no serious respiratory complications. Two retrospective and 1 prospective observational study reported that amiodarone used either for the treatment of POAF, or for prophylaxis against it, had similar rates of postoperative respiratory complications, length of hospital stay and mortality, compared with either no treatment or treatment with other prophylactic or therapeutic agents. In accordance with the Society of Thoracic Surgeons guidelines on prophylaxis and management of POAF in general thoracic surgery, these data suggest that amiodarone is a safe agent for the management of POAF after lung resection. Careful monitoring in patients treated with amiodarone after pneumonectomy should be considered because development of acute lung toxicity can increase length of hospital stay, morbidity and mortality. Further studies may also be needed to identify the subset of pneumonectomy patients at risk of pulmonary toxicity after use of amiodarone.
Surgery for thymic epithelial tumours (TETs) with pleural involvement is infrequently performed. Thus, the value of surgical therapy for primary or recurrent TETs with pleural involvement is not sufficiently defined yet.
Malignant mesothelioma remains an incurable cancer. We demonstrated that mesotheliomas expressed EGFR (79.2%), ErbB4 (49.0%) and HER2 (6.3%), but lacked ErbB3. At least one ErbB family member was expressed in 88% of tumors. To exploit ErbB dysregulation in this disease, patient T-cells were engineered by retroviral transduction to express a panErbB-targeted chimeric antigen receptor (CAR), co-expressed with a chimeric cytokine receptor that allows interleukin (IL)-4 mediated CAR T-cell proliferation. This combination is referred to as T4 immunotherapy. T-cells from mesothelioma patients were uniformly amenable to T4 genetic modification and expansion/enrichment thereafter using IL-4. Patient-derived T4 T-cells were activated upon contact with a panel of four mesothelioma cell lines, leading to cytotoxicity and cytokine release in all cases. Adoptive transfer of T4 immunotherapy to SCID Beige mice with an established bioluminescent LO68 mesothelioma xenograft was followed by regression or eradication of disease in all animals. Despite the established ability of T4 immunotherapy to elicit cytokine release syndrome in SCID Beige mice, therapy was very well tolerated. These findings provide a strong rationale for the clinical evaluation of intracavitary T4 immunotherapy to treat mesothelioma.
Fractures of the medial clavicle are rare injuries but are associated with significant morbidity and mortality. The current trend is shifting from conservative treatment to surgical intervention to reduce long-term sequelae. We present an isolated medial clavicular fracture associated with significant displacement and demonstrate excellent results after open reduction and internal fixation.
Incidence of occult pN2 disease following resection and mediastinal lymph node dissection in clinical stage I lung cancer patients.
Early clinical stage (T1 and T2) non-small cell lung cancer (NSCLC) is commonly treated with anatomic lung resection and lymph node sampling or dissection. The aims of this study were to evaluate the incidence and the distribution of occult N2 disease according to tumour location and the short- and long-term outcomes.
New-onset atrial fibrillation after anatomic lung resection: predictive factors, treatment and follow-up in a UK thoracic centre.
Postoperative atrial fibrillation (POAF) increases morbidity, hospital stay and healthcare expenditure. This study aims to determine the perioperative factors correlating with POAF as well as to evaluate both treatment strategies and AF persistence beyond discharge.
The IASLC Mesothelioma Staging Project: Proposals for Revisions of the T Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Pleural Mesothelioma.
The current T component for malignant pleural mesothelioma (MPM) has been predominantly informed by surgical data sets and consensus. The International Association for the Study of Lung Cancer undertook revision of the seventh edition of the staging system for MPM with the goal of developing recommendations for the eighth edition.
We report the case of a 39-year-old man presenting with an acute right-sided traumatic pneumothorax secondary to migration of a hypodermic needle fractured during intravenous drug use. We discuss the unusual passage of this foreign body from the left groin to the right ventricular wall and into the mediastinum, ultimately presenting with a right pneumothorax 1 year later.
Detection of Recurrence Patterns After Wedge Resection for Early Stage Lung Cancer: Rationale for Radiologic Follow-Up.
Wedge resection for selected patients with early stage non-small cell lung cancer is considered to be a valid treatment option. The aim of this study was to evaluate the recurrence patterns after wedge resection, to analyze the survival of patients under routine follow-up, and to recommend a follow-up regimen.
Contemporary Analysis of Prognostic Factors in Patients with Unresectable Malignant Pleural Mesothelioma.
Previous prognostic scoring systems for malignant pleural mesothelioma (MPM) included patients managed surgically and predated the use of pemetrexed. We analyzed prognostic factors in a contemporary cohort of patients with unresectable MPM who received pemetrexed-based chemotherapy.
Unusual late presentation of metastatic extrathoracic thymoma to gastrohepatic lymph node treated by surgical resection.
In advanced stages, thymic tumors tend to spread locally. Distant metastatic disease is rare. We present the first report of single metastatic abdominal lymph node in a 37-year-old female patient and 5 years after an extrapleural pneumonectomy for stage IV thymoma followed by radiotherapy with no other evidence of abdominal disease successfully treated by robotic surgical resection.
Does Previous Surgical Training Impact the Learning Curve in Video-Assisted Thoracic Surgery Lobectomy for Trainees?
Background To analyze if the number of open lung resections performed by trainees before starting video-assisted thoracic surgery (VATS) lobectomy training program has any impact on intraoperative and postoperative outcomes. Materials and Methods Retrospective analysis of 46 consecutive patients who underwent VATS lobectomies between December 2011 and September 2012 by two trainees (A.B. and L.O.). The previous surgical experience of the two trainees was evaluated to assess for any difference in terms of learning curve. Group A comprised 25 VATS lobectomies performed by one trainee (A.B.) and group B comprised 21 VATS lobectomies performed by the other trainee (L.O.). Results There was no statistical difference in terms of operating time and intraoperative bleeding between the two groups (p = 0.16 and p = 0.6). The conversion rate was 8% (2 out of 25 cases) in group A and 23.8% (5 out of 21 cases) in group B (p = 0.002). Evaluation of vascular injury showed no difference in the conversion rate (p = 0.56). The median length of the drainage and of hospital stay were 4 days and 7 days in group A and 4 days and 8 days in group B, respectively (p = 0.36 and p = 0.24). The complication rate was 44% in group A and 47.6% in group B (p = 0.52). A.B. had performed 139 and L.O. 70 operations as first operator before starting their VATS lobectomy training; the surgical experience had an impact only on the conversion rate. Conclusion Our study showed that a training program in VATS lobectomy is feasible, and previous surgical training has a minimal impact on intraoperative and postoperative outcomes.
Tailored stent for bronchial stump fistula closure and omentoplasty for infection control: a combined approach with low morbidity.
Bronchopleural fistula (BPF) after pneumonectomy remains a dangerous complication with high mortality and morbidity. Primary closure of the fistula with muscle flaps and a thoracic window is generally used to treat BPF. New techniques for secondary stump closure including glues, stents and coils have been introduced recently. We report the use of a J-shaped tracheal stent device placed during bronchoscopy combined with omentoplasty to control the symptoms related to BPF and pleural space infection, respectively.
Gingival metastasis as first sign of multiorgan dissemination of epithelioid malignant mesothelioma.
Metastatic malignant mesothelioma to the oral cavity is extremely rare. They are more common in the jaw bones than the soft tissue. Occurrence of the malignant disease typically carries an average survival rate of 9-12 months
Thulium laser versus staplers for anatomic pulmonary resections with incomplete fissures: negative results of a randomized trial.
This randomized trial evaluated the feasibility and safety of thulium 2010-nm laser to perform anatomic lung resections in patients with incomplete fissures, as compared to mechanical staplers with or without sealants.
This study aimed to assess the efficacy of thoracotomy and decortication (T/D) in achieving lung re-expansion in patients with Stage III empyema and assess the impact of culture-positive empyema on the outcome of decortication.
Does surgery improve survival of patients with malignant pleural mesothelioma?: a multicenter retrospective analysis of 1365 consecutive patients.
Surgery with pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP) can be an option for selected patients with resectable malignant pleural mesothelioma (MPM). The aim of this study was to investigate the impact of surgical treatment on the outcome of patients with MPM.
Thoracoscopic lobectomy: comparison of intraoperative and postoperative outcomes between 3 and 4 incision accesses.
Several techniques have been proposed to perform a video-assisted thoracic lobectomy. We compared the results of a 3 versus 4-port procedure, analyzing intraoperative data, morbidity, and mortality.
Many surgical procedures are used to restore the defect of the alimentary tract after cervical oesophagectomy. We present a case of a 69-year old woman, affected by a G2 squamous cell carcinoma of retro-cricodeal hypopharynx extend to the cervical oesopaghus. She underwent a direct reconstruction with a direct trans-oral anastomosis by a mechanical device and without any interposition. No postoperative complication was observed and there was a good functional result at 24 months after surgery. In a few selected cases, this technique can be usefully performed, avoiding gastric or intestinal resection and improving the quality of life.
Patterns of disease progression on 18F-fluorodeoxyglucose positron emission tomography-computed tomography in patients with malignant pleural mesothelioma undergoing multimodality therapy with pleurectomy/decortication.
The aim of this study was to evaluate the patterns of disease progression in patients treated with pleurectomy/decortication (P/D), hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy and adjuvant chemotherapy, using F-fluorodeoxyglucose (18F-FDG) PET/computed tomography (PET/CT).
Does external pleural suction reduce prolonged air leak after lung resection? Results from the AirINTrial after 500 randomized cases.
External pleural suction is used after lung resection to promote lung expansion and minimize air leak duration. Published randomized trials failed to prove this advantage but they are limited in number and underpowered in many cases. The aim of the AirINTrial study was to test the hypothesis that external pleural suction may reduce the rate of prolonged air leak in a large, randomized cohort.
Intrathoracic infiltration of the inferior vena cava (IVC) is rare; mobilization and prosthetic replacement may increase the risk of cardiac arrest and postoperative complications. We report a case of a giant liposarcoma which elongated and grew around the IVC, invading both hemithoraces. The removal of this mass required a bypass between the left femoral and ipsilateral axillary vein to guarantee an adequate venous return. The IVC was replaced by a polytetrafluoroethylene prosthesis. A postoperative paralysis of patient's lower limbs occurred. Hypotension or involvement of aberrant medullary artery origin could be responsible for this complication.
A false positive fluorodeoxyglucose lymphadenopathy in a patient with pulmonary carcinoid tumor and previous breast reconstruction after bilateral mastectomy.
We present a case of a 60-year-old woman with a positive fluorodeoxyglucose integrated positron emission tomography and computed tomography (PET/TC) mammary chain lymphadenopathy and carcinoid tumor of the left lower lobe who had a previous bilateral mastectomy and breast reconstruction for breast cancer. She underwent a right muscle sparing mini-thoracotomy and mammary chain lymphadenectomy; the final histopathology showed granulomatous reaction to silicone.
Evaluation of long-term results and quality of life in patients who underwent rib fixation with titanium devices after trauma.
To describe the long-term results, quality of life and chronic pain after chest wall fixation for traumatic rib fracture using a quality of life (QOL) score and a numeric pain score.
Videothoracoscopic repair of diaphragm and pleurectomy/abrasion in patients with catamenial pneumothorax: a 9-year experience.
Catamenial pneumothorax (CP) is a cause of recurrent pneumothorax in women of child-bearing age. Surgical treatment has been associated with high recurrence rates. We report our experience with a totally videothoracoscopic approach involving diaphragmatic repair, pleurectomy/abrasion, and hormonal treatment in patients with proven CP.
To describe our experience with two new titanium-based devices for chest wall reconstruction and stabilization.
Recurrent pleural effusion in yellow nail syndrome successfully treated with video-assisted thoracic surgery: comparison of two surgical strategies in two cases.
Pleural effusions as part of the yellow nail syndrome (YNS) can often be recurrent, requiring multiple thoracocentesis. The optimal surgical treatment of such recurrent effusions remains unclear and various methods including thoracoscopic pleurodesis, pleuroperitioneal shunts and pleurectomy have been described. We report two cases of recurrent pleural effusions in YNS, the first case with bilateral effusions and the second with right-sided effusions treated 2 months apart from bilateral long-term tunnelled catheters and thoracoscopic pleurectomy and compare the results of the two treatment strategies.
Evaluation of integrated positron emission tomography and computed tomography accuracy in detecting lymph node metastasis in patients with adenocarcinoma vs squamous cell carcinoma.
The aim of our study was to analyze the specificity and sensitivity of integrated positron emission tomography and computed tomography (PET/CT) in detecting nodal metastasis according to histology (adenocarcinoma vs squamous cell carcinoma), and to identify the factors related to false-negative findings.
The prognostic significance of maximum standardized uptake value of primary tumor in surgically treated non-small-cell lung cancer patients: analysis of 413 cases.
Integrated PET/CT is widely used in the preoperative staging and prognostic assessment of non-small-cell lung cancer (NSCLC) patients. The aims of this study were to evaluate the prognostic significance of SUVmax of primary tumor in patients undergoing surgical treatment and, in order to minimize technical interferences, to verify whether SUVmax standardized by SUVmax liver or SUVmax blood pool provided additional prognostic information.
Mediastinoscopy still represents the gold standard in mediastinal lymph node staging in patients with lung cancer. It is an invasive procedure, where complications are unusual. This case report shows an uncommon complication after mediastinoscopy: pseudoaneurysm of the aortic arch and its minimally invasive endovascular stenting treatment in order to facilitate the recovery and to allow minimal delay to oncological treatment.
Vascular occlusion device closure of bronchial stump fistulae: a straightforward approach to manage bronchial stump breakdown.
Post lung resection surgery bronchopleural fistula (BPF) continues to be a dangerous complication associated with very high mortality and morbidity. Traditional treatments have included primary closure of the fistula with muscle flaps and thoracic window formation. New techniques for secondary stump closure have included glues, stents and coils. We report another bronchoscopic treatment of BPF using an atrial septal closure/vascular occlusion device combined with bioglue.
Tracheo-bronchial glomus tumours are rare, usually benign tumours of modified smooth muscle cells. They commonly present as non-specific respiratory symptoms of cough, dyspnoea or haemoptysis. Generally, glomus tumours are benign, but extension beyond the bronchial wall into surrounding soft tissues has been described. Surgical treatment remains the treatment of choice for tracheo-bronchial glomus tumours. Endobronchial therapy should be considered in patients unfit for surgical excision. We describe a patient with a glomus tumour of the left main bronchus, who presented with mediastinal shift and lung atelectasis, treated by left upper sleeve lobectomy. The resection was complete and the patient was discharged home after 8 days from surgery.
Surgical access rather than method of pleurodesis (pleurectomy or pleural abrasion) influences recurrence rates for pneumothorax surgery: systematic review and meta-analysis.
Surgery for recurrent spontaneous pneumothoraces is one of the most commonly performed procedures in thoracic surgery, but few studies have evaluated the efficacy of the surgical treatment options. We aimed to evaluate the influence of the type of pleurodesis on recurrence whilst adjusting for surgical access by systematic review and meta-regression of randomised and non-randomised trials.
Thymidylate synthase but not excision repair cross-complementation group 1 tumor expression predicts outcome in patients with malignant pleural mesothelioma treated with pemetrexed-based chemotherapy.
The relationship between thymidylate synthase (TS) expression and outcome in patients with malignant pleural mesothelioma (MPM) treated with pemetrexed (P) was retrospectively evaluated.
Preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer: accuracy of integrated positron emission tomography and computed tomography.
To evaluate the accuracy of integrated positron emission tomography with 18F-fluoro-2-deoxy-D-glucose (FDG) and computed tomography (PET/CT) in preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer (NSCLC) and to ascertain the role of invasive staging in verifying positron emission tomography (PET)/computed tomography (CT) results.
What is the optimum strategy for thromboembolic prophylaxis following extrapleural pneumonectomy in patients with malignant pleural mesothelioma?
Malignant pleural mesothelioma (MPM) increases the risk of venous thromboembolic (VTE) events. This risk is higher following extrapleural pneumonectomy (EPP) as part of trimodality therapy, where VTE can be catastrophic. In our series, the impact of warfarin in preventing a pulmonary embolus (PE) after neoadjuvant chemotherapy and EPP for MPM was analysed. A retrospective analysis of 21 consecutive patients undergoing EPP for MPM was conducted. The first 10 patients (Group A) had VTE prophylaxis by subcutaneous enoxaparin and compression stockings commenced a day prior to surgery, intraoperative pneumatic calf compression and early post-operative mobilization. Enoxaparin was continued for 30 days postoperatively. The following 11 patients (Group B) had the same VTE prophylaxis, together with warfarin, started prior to hospital discharge and continued for 6 months postoperatively. All patients had a computed tomography pulmonary angiogram within 8 weeks after surgery and a full examination at 1, 3, 6 and 12 months. Both groups were comparable for characteristics. Three patients in Group A suffered a PE at 4, 6 and 16 weeks postoperatively. One PE was fatal. No patient in Group B suffered VTE (P = 0.05, χ(2) test) or haemorrhagic complications. Warfarin anticoagulation following EPP is feasible and safe, and is associated with a significant reduction in VTE complications.
Induction chemotherapy, extrapleural pneumonectomy, and adjuvant radiotherapy for malignant pleural mesothelioma: experience of Guy's and St Thomas' hospitals.
The treatment of malignant pleural mesothelioma (MPM) remains controversial. We present a prospective study of patients treated at our institution with neoadjuvant chemotherapy, extrapleural pneumonectomy (EPP), and radical radiotherapy.
Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma.
To compare the outcomes of two different multimodality regimens involving neoadjuvant chemotherapy, extrapleural pneumonectomy (EPP) and adjuvant radiotherapy versus pleurectomy/decortication (P/D), hyperthermic pleural lavage with povidone-iodine, and adjuvant chemotherapy in patients with malignant pleural mesothelioma.
Cyberknife radiosurgery for focal paravertebral recurrence after radical pleurectomy/decortication in malignant pleural mesothelioma.
We present a case of malignant pleural mesothelioma with focal relapse in the Azygos arch region after radical pleurectomy/decortication and adjuvant chemotherapy. Tumour recurrence was successfully treated by Cyberknife radiosurgery (70 Gy in five fractions). Patient remains disease-free at 40 months without any other treatment.
Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine followed by adjuvant chemotherapy in patients with malignant pleural mesothelioma.
Malignant pleural mesothelioma is a fatal neoplasm related to asbestos exposure. We investigated the effects of pleurectomy/decortication (P/D), hyperthermic pleural lavage with povidone-iodine and adjuvant chemotherapy in patients with malignant pleural mesothelioma.
Chemical pleurodesis is widely used in symptomatic patients with malignant pleural effusion to relieve symptoms, prevent fluid recurrence, and improve quality of life. Talc has been repeatedly found to be the most effective sclerosant agent, and thoracoscopic talc poudrage has been found to be the most effective pleurodesis technique. A homogeneous talc distribution on the visceral and parietal pleura helps to achieve complete pleural symphysis. We have recently adopted a new suitable sterile device that delivers talc under low and constant pressure, facilitating uniform coating of the whole pleural surface and avoiding inappropriate deposition of talc clumps.
Air leaks following pulmonary resection for malignancy: risk factors, qualitative and quantitative analysis.
Air leaks are a common complication of pulmonary resection. The aims of this study were to analyze risk factors for postoperative air leak and to evaluate the role of air leak measurement in identifying patients at increased risk for cardiorespiratory morbidity and prolonged air leak. From March to December 2009, 142 consecutive patients underwent pulmonary resection for malignancy and were prospectively followed up. Preoperative and intraoperative risk factors for air leak were evaluated. Air leaks were qualitatively and quantitatively labeled twice daily. There were 52 (36.6%) patients who had an air leak on day 1, and 32 (22.5%) who had an air leak on day 2. Air leak was ≥180 ml/min in 12 (37.5%) of these patients. Independent predictors of air leak on day 2 included type of pulmonary resection, presence of adhesions, and incomplete fissures. Cardiorespiratory morbidity was significantly higher (34.4%) in patients who experienced air leak on day 2 than in those who did not (10.9%) (P=0.002). Nine (75%) out of 12 patients with air leak ≥180 ml/min on day 2 had prolonged air leak (greater than five days) (P=0.0001).
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted thoracic surgery (VATS) is the best treatment for paediatric pleural empyema. Altogether 274 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that early VATS (or thoracotomy if VATS not possible) leads to shorter hospitalisation. The duration of chest tube placement and antibiotic use is variable and does not correlate with treatment method. Patients who underwent primary operative therapy had a lower aggregate in-hospital mortality rate (0% vs. 3.3%), re-intervention rate (2.5% vs. 23.5%), length of stay (10.8 days vs. 20.0 days), duration of tube thoracostomy (4.4 days vs. 10.6 days), and duration of antibiotic therapy (12.8 days vs. 21.3 days), compared with patients who underwent non-operative therapy. Similar complication rates were observed for the two groups (5% vs. 5.6%). Moreover, median hospital charges for VATS were $36,320 [interquartile range (IQR), $24,814-$62,269]. The median pharmacy and radiological imaging charges were $5884 (IQR, $3142-$11,357) and $2875 (IQR, $1703-$4950), respectively, for VATS and tube drainage. Adjusting for propensity score matching, costs for primary VATS were equivalent to primary chest tube placement. Only one article found discordant results. Ninety-five children (52%) received antibiotics alone, and 87 (45%) underwent drainage procedures (21 chest tube alone, 57 VATS/thoracotomy, and eight chest tube followed by VATS/thoracotomy); only four received fibrinolytics. Mean (standard deviation) length of stay was significantly shorter in the antibiotics alone group, 7.0 (3.5) days vs. 11 (4.0) days. The strongest predictors of undergoing pleural drainage were admission to the intensive care unit and large effusion size (>1/2 thorax filled).
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether chemical pleurodesis is superior to catheter drainage or pleuroperitoneal shunts (PPS) in the management of patients with pleural effusions. Overall 161 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that chemical pleurodesis is superior to chronic catheter drainage and PPS in terms survival length and mortality rates but in patients with trapped lung syndrome chronic intrapleural catheter placement is indicated. Six studies reported patient outcomes after treatment with chemical pleurodesis. They report high success rates (89.4%) and low mortality rates (2%) without any need to convert to open thoracotomy. Mean hospital stay of 2.33 days, complication rates of 16.5% and mean survival length of 23.8 ± 16.3 months were observed. Five studies managed malignant pleural effusions (MPEs) using chronic indwelling catheters. They reported mean survival length of 126 days. Symptomatic relief was achieved in 94.2% of patients. There was a significant reduction in the Medical Research Council dyspnoea score (3.0-1.9, P < 0.001) and despite complication rates of 22%, comparable mortality rates (7.5%) were observed. Even in patients with trapped lung syndrome, mean survival length was 125 days with symptomatic improvement being achieved in 90.9% of patients. Three studies treated MPEs using PPSs. Mean hospital stay was 6.2 days (range 2-26) with a mean survival length of 11 months. Pleurodesis success rates varied from 57.1% to 95% with a complication rate of 14.8%. PPSs were shown to produce lower success rates (57.1% vs. 92.3%), shorter survival lengths (4.3 ± 1.9 vs. 6.7 ± 2.1 months) and higher complication rates (14.3% vs. 2.8%) than talc pleurodesis. Overall, chemical pleurodesis is the optimal treatment option for MPE with use of chronic intrapleural catheters reserved in cases where talc pleurodesis is not possible.
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether an open surgical approach is superior to minimally invasive surgery in patients with postpneumonectomy empyema (PPE). Overall 171 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that open surgical approaches are superior to minimally invasive surgery in terms of empyema recurrence rate, mortality and reintervention rate. Minimally invasive surgery includes chest tube drainage with or without chemical irrigation and video-assisted thoracoscopic surgery debridement. Whereas open surgery includes open debridement, open window thoracostomy (OWT) and thoracomyoplasty. To allow for an accurate comparison, success of an intervention was defined as prevention of empyema recurrence. Two studies reported surgical outcomes of patients treated with minimally invasive treatment options. They found high mortality rates (17.1%) and low success rates (31%) in patients treated by chest tube drainage with chemical irrigation. Five studies treated PPE using a combination of minimally invasive and open surgical approaches and reported a high reintervention rate of 3.5 (range 3-5) and an empyema recurrence rate of 13.3%. Higher success rates (6.7 vs. 95%), lower mortality rates (33 vs. 0%) and shorter hospital stay (47.5 vs. 17.6 days) were all noted with thoracomyoplasty compared to chest tube drainage therapy. Five studies managed PPE using OWT or thoracomyoplasty. The time between empyema diagnosis to resolution (3 vs. 38 months) was much shorter with immediate OWT than with delayed OWT therapy. The Clagett procedure resulted in a mean hospital stay of 12.9 days, an operative mortality rate of 7.1% and an overall success rate of 81%. Thoracomyoplasty led to a mean hospital stay of 34 days with a mortality rate of 6%. The shorter hospital stay, lower empyema recurrence rates and lower mortality rates may make open surgical approaches a more effective treatment option to minimally invasive options.
A suitable system of reconstruction with titanium rib prosthesis after chest wall resection for Ewing sarcoma.
The recent improvements in chemotherapy and surgical resection in Ewing sarcoma (ES) increased the overall survival as well as the importance of chest wall reconstruction. These improvements are in order to avoid asymmetrical growth, functional and cosmetic compromise after surgery. Chest wall reconstruction still remains a big issue in young patients with ES. We present a case of ES of the left chest wall, arising from a rib, in a 14-year-old patient. He was admitted after neoadjuvant chemotherapy and radiotherapy. The patient underwent a chest wall resection of three ribs and a wedge lung resection of the upper lobe followed by chest wall reconstruction with Stratos™ rib titanium prostheses. This new device is suitable for reconstruction after major chest wall resection with good cosmetic and functional results. During the follow-up, there was no evidence of local and distant recurrence, the pain was under control and there were no functional alterations in the chest wall.
The aim of this study is to investigate clinicopathologic characteristics and to identify prognostic factors in patients undergoing pulmonary metastasectomy for colorectal carcinoma.
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether blood pleurodesis is effective for cessation of persistent air leak (PAL). Altogether more than 43 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that autologous blood pleurodesis has superior outcomes when compared with conservative management for treatment of postoperative PAL. In addition, for PAL causing pneumothorax, blood pleurodesis [optimal volume 100 ml (from two studies)] should be considered in patients who are unsuitable for surgery, talc pleurodesis is ineffective or not viable (including cases complicated by acute respiratory distress syndrome) and a prompt resolution is required. Some 70-81% of patients treated for postoperative air leak resolved within 12 h and 95-100% within 48 h vs. a mean of 3-6.3 days (from two studies) with simple drainage. Resolution of pneumothorax with blood pleurodesis was also significantly shorter (P<0.01). Overall success rates (from all studies) were 92.7% (n=133) from patients having undergone pulmonary surgery (76.6% in one injection, n=111), and 91.7% (n=109) of patients with pneumothorax. Recurrence rates were between 0 and 29% compared with 35-41% for simple drainage, although one controlled study in which the recurrence rate was improved from 16% in controls to 0% in the blood pleurodesis group (at 12-48 months). Minor complication (empyema/fever/pleural effusion) rates varied between studies (0-18%), although they show reduced incidence in line with improving technique over time. A controlled study looking at acute respiratory distress syndrome complicated by pneumothorax showed a significant reduction in mortality (odds ratio 0.6), time to cessation of air leak (P<0.01), weaning time (P<0.01) and intensive treatment unit (ITU) stay (P<0.01) whilst another randomized control study showed significant reduction in hospital stay following pulmonary resection (P<0.001).
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether [surgery] has a role in [treatment of T4N0 and T4N1 lung cancer]. Altogether more than 151 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that upfront surgery for locally invasive T4 tumours without mediastinal lymph node involvement (T4N0 and T4N1 non-small cell lung cancer) is of benefit in terms of survival rates in carefully selected patients. Overall five-year survival rates following resection of T4N0-N2 tumours vary from 19.1% to 57% (from six studies), within which, involvement of certain structures were found to greatly affect prognosis. Pulmonary artery invasion has a good prognosis (five-year survival; 52.8%) relative to other mediastinal structures [five-year survival: left atrium; N0; 28.94%, N1; 27.92%, N2; 17.95% (three-year survival), aorta; N0; 100%, N1; 37.1%, N2; 0%, superior vena cava (SVC); 11%, -29.4% (from four studies), carina; 28-42.5% (two studies), veterbral bodies; 16%, oesophagus; 12%, pleural dissemination; 0%]. When considering isolated invasion of the pulmonary great vessels there are mixed outcomes, one study reporting reduced mortality (reduced risk -0.483, P=0.004) in contrast to another that found five-year survival of 35.7% with great vessel invasion vs. 58.3% for invasion of all other structures excluding the pulmonary great vessels. The prognostic variables found to be of greatest determinacy were; first, the completeness of resection, wherein five-year survival rates ranged from 37.5 to 46.2% (from three studies) with complete tumour removal, and 15.9-22.4% (from three studies) with incomplete resection, and second, nodal status of the patients, N0/N1 having five-year survival of 43-74% and N2 of 15.1-17.5% (P=0.022 and P=0.007, for two studies). Multiple intralobar lesions represent either multilobar metastasis or NSCLC with multifocal origin and have been found to behave differently to invasive T4 tumours. Reported five-year survival in NSCLC with satellite nodules is 48.2-57% compared with 18-30% from T4 invasive tumours (three studies), respectively (P=0.011) corroborating the change in TNM ipsilobar multifocal T4 disease to be recoded as T3.
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