To analyse HRV at rest in healthy people and in patients with acute myocardial infarction (AMI) and how it changes during aerobic exercise.The heartbeat signal was recorded beat to beat for 15 minutes at rest and 15 minutes while pedalling in 10 healthy and active men (H group) and 10 cardiac patients (C group). The statistical parameters in the time domain were calculated as well as the spectral analysis applying the Fast Fourier Transform (FFT) and Poincare's graphic analysis (PGA).At rest, H group have an average SDRR (standard deviation of RR intervals) of 71.24 msec, a pRR50 (percentage of differences higher than 50 msec in RR intervals) of 9.97% and a PGA called "comet-type". The C group have a SDRR of 36.69 msec, a pRR50 of 1.69%, and a PGA "torpedo-type". These data show a low or moderate risk for healthy people and a high risk for patients. The FFT analysis lies in the very-low-frequency (VLF) zone in both groups. During exercise, H group shows a significant decrease in all parameters; the PGA turns to "torpedo-type" and the FFT remains in the VLF zone. However, C group is characterised by the maintenance of pRR50, no change in PGA and a second peak in FFT in the high-frequency zone.The HRV at rest and during aerobic exercise follows a different pattern in healthy people and in patients and it provides further information about performance during exercise.
A tracheal perforation was discovered after Nd-YAG laser thermal ablation (LTA) of a thyroid nodule. The LTA is a relatively new method of treatment of thyroid nodules, which consists of delivering laser energy into the thyroid by means of two optical fibres. The patient presented with a multinodular goitre and initially refused surgery, then underwent an LTA of a thyroid nodule. Fifty days after the procedure she started to have symptoms related to a tracheal stenosis and, after tracheoscopy, a tracheal perforation was diagnosed and she underwent a total thyroidectomy plus tracheal repair. The results of the histological examination revealed a goitre with a focal area of papillary carcinoma. This particular complication is likely the first of its kind to be described after the LTA of a thyroid nodule.
In 2012, open procedures represented 63% of the total number of lobectomies performed in our unit; in 2015, video-assisted thoracoscopic surgery (VATS) lobectomy numbers increased up to 66% of the total number of lobectomies performed. When carrying out the procedures, we followed the guidelines presented by the International VATS Lobectomy Consensus Group regarding indications, contraindications, preoperative investigations and conversions. In view of 280 VATS major lung resections from May 2012 to May 2016, we describe some tips and tricks that can be useful in this surgical technique, from general principles to single operative procedures.
Objective. There are limited data for estimating the risk of early discharge following thoracoscopic lobectomy. The objective was to identify the factors associated with a short length of stay and verify the influence of these variables in uncomplicated patients. Methods. We reviewed all lobectomies reported to the Italian VATS Group between January 2014 and January 2020. Patients and perioperative characteristics were divided into two subgroups based on whether or not they met the target duration of stay (≤ or >4 days). The association between preoperative and intraoperative variables and postoperative length of stay (LOS) ≤4 days was assessed using a stepwise multivariable logistic regression analysis to identify factors independently associated with LOS and factors related to LOS in uncomplicated cases. Results. Among 10,240 cases who underwent thoracoscopic lobectomy, 37.6% had a hospital stay ≤4 days. Variables associated with LOS included age, hospital surgical volume, Diffusion Lung CO % (81 [69–94] vs. 85 [73–98]), Forced Expiratory Volume (FEV1) % (92 [79–106] vs. 96 [82–109]), operative time (180 [141–230] vs. 160 [125–195]), uniportal approach (571 [9%] vs. 713 [18.5%]), bioenergy sealer use, and pain control through intercostal block or opioids (p < 0.001). Except for FEV1 and blood loss, all other factors emerged significantly associated with LOS when the analysis was limited to uncomplicated patients. Conclusions. Demographic, clinical, and surgical variables are associated with early discharge after thoracoscopic lobectomy. This study indicates that these characteristics are associated with early discharge. This result can be used in association with clinical judgment to identify appropriate patients for fast-track protocols.
Abstract Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. Results Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. Conclusions These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.
Abstract Background: The usefulness of digital chest drain is still discussed. We are carrying out a study to determine if the use of a digital system compared with a traditional system reduces the duration of chest drainage. To evaluate safety, benefit, or futility of this trial we planned the current interim analysis. Methods: An interim analysis on preliminary data from ongoing investigator-initiated, multicenter, interventional, prospective randomized trial. Original protocol number: (NCT03536130). The interim main endpoint was overall complications; secondary endpoints were the concordance between the two primary endpoints of the RCT (chest tube duration and length of hospital stay). We planned the interim analysis when half of the patients have been randomised and completed the study. Data were described using mean and standard deviation or absolute frequencies and percentage. T-test for unpaired samples, Chi-square test, Poisson regression and absolute standardized mean difference (ASMD) were used. P-value <0.05 was considered significant. Results: From April 2017 to November 2018, out of 317 patients were enrolled by 3 centers, 231 fulfilled inclusion criteria and were randomized. Twenty-two of them dropped out after randomization. Finally, 209 patients were analyzed: among them 94 used the digital device and 115 the traditional one. The overall postoperative complications were 35 (16.8%) including prolonged air leak (1.9%). Mean chest tube duration was 3.6 days (SD=1.8), with no differences between two groups (p=0.203). The overall difference between hospital stay and chest tube duration was 1.4 days (SD=1.4). Air leak at first postoperative day detected by digital and traditional devices predicted increasing in tube duration of 1.6 day (CI 95% 0.8-2.5, p<0.001) and 2.0 days (CI 95% 1.0-3.1, p<0.001), respectively. Conclusions: This interim analysis supported the authors’ will to continue with the enrollment and to analyze data once the estimated sample size will be reached. Trial registration: Trial registration number NCT03536130, Registered 24 May 2018 - Retrospectively registered, https://clinicaltrials.gov/ct2/results?cond=&term=NCT03536130&cntry=&state=&city=& dist=
We report a technical modification of the classic transmanubrial osteomuscular sparing approach described by Grünenwald and Spaggiari for the treatment of a T1 vertebral tumor. The goal of the surgical treatment for spinal tumors of the cervico-thoracic area is to excise the vertebral tumor, reconstruct the spinal column, and place an internal fixation device to achieve immediate stabilization. The procedure was necessary for treating a patient who presented with an invasion of T1 vertebral body by multiple myeloma with initial neurological symptoms of epidural spinal cord compression. This approach requires a multidisciplinary team, essentially composed by the thoracic surgeon, who performs the anatomical dissection of the cervico-thoracic area, and the neurosurgeon, who performs the vertebrectomy and placement of a titanium prosthesis (Harm's cage). The operation was successful; the follow-up 6 months after the surgical procedure is normal.
Tumors of the cervical-thoracic area can be treated by the Grunenwald approach, which consists of an L-shaped cervical-manubrialthoracotomy without section of the clavicle. We used this access in three different tumors of the cervical-thoracic inlet: a tumor of T1 vertebral body, a tumor of the left superior sulcus, and a rare tumor originating from the root T1 of the brachial plexus. The first patient was a 39-years-old man with a somatic fracture of T1 and tumor invasion of the residual vertebral body by multiple myeloma. The 2nd patient was a 61-years-old man with a squamous cell carcinoma of S1 left upper lobe, infiltrating the parietal pleura and the chest wall, in the anterior-lateral part of the 2nd intercostal space. The 3rd patient was a 35-years-old woman with a glomic tumor originating from the T1 root of the right brachial plexus. The only post-operative complication was a modest diaphragm elevation in the 3rd patient, completely disappeared after 3-4 months. The 2nd patient is dead one year after the operation for cerebral metastases. The other two patients are presently in good conditions, without signs of relapse. Is our opinion the Grunenwald technique is technique for the treatment of tumors of the cervical-thoracic area allows a safe visibility of the anatomical structures without the necessity of a clavicle section.
