Napolitano AG, et al. Ann Surg Treat Res. 2023 Aug;105(2):76-81. https://doi.org/10.4174/astr.2023.105.2.76

Background: Oesophageal perforation (OP) is a life-threatening condition requiring prompt diagnosis and treatment. Mortality is influenced by several factors, such as aetiology, defect location, comorbidities, age, and delays in treatment. This study reviews patients with OP undergoing surgery, analysing mortality risks and the impact of timing on surgical outcomes. Methods: Medical records of 45 patients surgically treated for OP across three tertiary centers were analysed. Results: Of the 45 patients, 31 were male (68.88%) and 14 were female (31.11%), with a mean age of 66.00 ± 17.75 years. Pre-operative CT was performed in all patients, and 18 (40%) underwent oesophagogastroduodenoscopy. As many as 25 patients (55.55%) presented within 24 h, 10 (22.22%) within 24–72 h, and 10 (22.22%) after 72 h. Symptoms included pain, vomiting, fever, dysphagia, and subcutaneous emphysema. Foreign body ingestion and Boerhaave’s syndrome were the leading causes (33.33% each), followed by caustic ingestion (17.77%) and iatrogenic and traumatic cases. Treatments included primary repair, debridement, oesophagectomy, and oesophagogastrectomy. Primary repair was performed in 22 cases (48.88%), and muscle flaps reinforced 11 of these. Direct repair showed the highest success rate when performed within 24 h. Thirty patients (66.66%) experienced complications, including respiratory failure, oesophagopleural fistula, and sub-stenosis. The hospital stay average was 36.34 ± 35.03 days. Nine patients underwent same-session/two-stage gastroplasty or retrosternal coloplasty for reconstruction, with complications including stenosis and leaks. Six patients (13.33%) died within the first 24 h after surgery, primarily due to severe comorbidities (three (50%) were octogenarians). Conclusions: OP is a life-threatening condition with high mortality. Primary repair is the preferred treatment. Oesophagectomy and gastrectomy are reserved for extensive lesions. Muscle flaps can reinforce sutures in cervical and thoracic perforations. Mortality is mainly influenced by the severity of the patient’s clinical picture and comorbidities, rather than by time and type of treatment.

Massive hemoptysis may be related to a wide spectrum of diseases whose differential diagnosis can be challenging, also due to the medical emergency condition.We present a case of a 33-year-old woman presented to our department with sudden, life-threatening hemoptysis from unknown etiology, which required a rescue pulmonary lobectomy after resuscitation maneuvers. Histology proved to be a localized Wegener granulomatosis. Our case shows that granulomatosis should always be considered among the possible, although rarer, causes of massive hemoptysis.

Background: Primary and secondary tumors of the abdominal lower third of the bony thorax are relatively rare. Therefore, indications and techniques for chest wall reconstructions in this area are not well defined. Methods: The techniques for reconstructing basal chest wall defects using the diaphragm are described. Indications for phrenoplasty are limited to reconstruction after full-thickness resection of at least two of the last four ribs in the midaxillary line. The diaphragm can be used for reconstructive purposes both if it is intact and if it is partially involved in the resection of the chest wall. Results: At our institution, the abovementioned reconstructive technique was successfully performed in five patients with an uneventful post-operative course. Conclusions: The main advantages of these methods are the use of promptly available, high-quality autologous tissue and the exclusion of the pleural space from the defect area, thus transforming a thoracic defect into an abdominal one. The disadvantage is a variable reduction in the volume of the hemithorax. These techniques could be compared with other reconstruction techniques using pre-/post-operative respiratory functional tests.

Background: Contralateral recurrence following surgically treated primary spontaneous pneumothorax represents clinical concern yet remains poorly understood. This study aims to expand the current understanding by evaluating a large, multicenter cohort over a 10-year period and to determine the true incidence of contralateral recurrence assessing the potential role of clinical factors in risk stratification. Methods: A total of 479 patients surgically treated for PSP (2012–2024) across three Italian high-volume centers were retrospectively reviewed. Secondary pneumothorax, patients <18 years old, lung emphysema or intraparenchymal large bullae, and the thoracotomy approach were excluded. The association between categorical variables and contralateral recurrence was assessed using the chi-square (χ²) test, while the association with continuous variables was evaluated using the t-test. Time to recurrence was analyzed using Kaplan–Meier survival curves. Variables with a p-value < 0.05 were considered statistically significant. Results: We identified 59 patients who experienced contralateral recurrence: 45 were males, the mean age was 26.66 ± 12.32 and the mean BMI was 22.00 ± 2.92; only 13 were active smokers. Age (p < 0.001) and smoking history (p = 0.029) were significantly associated with contralateral recurrence in univariate analysis, though these were not confirmed in multivariate analysis. Among the cohort of recurrence, 53 patients only had a recurrence on the contralateral side, with a median time to recurrence of 139 days. The incidence rate ratio (IRR) of recurrence for patients with a mean age of <34 years was 1.23, which translates to a 23% increased risk. No significant impact of age (p = 0.25), sex (p = 0.67), or smoking (p = 0.59) on the time to recurrence on the other side was observed through Kaplan–Meier analysis. The peak incidence for the first episode of PNX surgically treated and contralateral recurrence was observed in October, November and January. Conclusions: This study highlights a 12% contralateral recurrence rate after PSP surgery. Younger age is associated with earlier contralateral recurrence. Seasonality may influence recurrence patterns. Further studies should explore underlying mechanisms and preventive strategies.

A 62-year-old man was diagnosed with an asymptomatic intralobar pulmonary sequestration supplied by a short-neck proximal 57×25 mm aneurysmal artery originating from the mid-descending aorta. The patient underwent thoracic endovascular aneurysm repair; an aortic endograft was released to entirely restore the aberrant vessel. Then, pulmonary resection was performed. A triportal video-assisted left lower lobectomy was carried out. The thoracic endovascular aneurysm repair minimized the risk of bleeding and allowed a safe pulmonary resection with a minimally invasive approach.