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The surgical treatment of locally advanced mediastinal tumors invading the great vessels and other nearby structures still represent a tricky question, principally due to the technical complexity of the resective phase, the contingent need to carry out viable vascular reconstructions and, therefore, the proper management of pathophysiologic issues. Published large-number series providing oncologic outcomes of patients who have undergone extended radical surgery for invasive mediastinal masses are just a few. Furthermore, the wide variety of different histologies included in some of these studies, as well as the heterogeneity of chemo and radiation therapies employed, did not allow for the development of clear oncologic guidelines. Usually in the past, surgical resections of large masses along with the neighbouring structures were not offered to patients because of related morbidity and mortality and limited information available on the prognostic advantage for long term. However, in the last decades, advances in surgical technique and perioperative management, as well as increased oncologic experience in this field, have allowed radical exeresis in selected patients with invasive tumors requiring resections extended to the surrounding structures and complex vascular reconstructions. Such aggressive surgical treatment has been proposed in association or not with adjuvant chemo- or radiotherapy regimens, achieving encouraging oncologic results with limited morbidity and mortality in experienced institutions. Congestive heart failure or impending cardiovascular collapse due to the compression by the large mass are the most frequent immediately life-threatening problems that some of these patients can experience. In this setting, medical palliation is usually ineffective and an aggressive salvage surgical treatment may remain the only therapeutic option., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: To evaluate the efficacy of Endo-Bronchial Valves in the management of persistent air-leaks (PALs) and the procedural cost., Methods: It was a retrospective multicenter study including consecutive patients with PALs for alveolar pleural fistula (APF) undergoing valve treatment. We assessed the efficacy and the cost of the procedure., Results: Seventy-four patients with persistent air leaks due to various etiologies were included in the analysis. In all cases the air leaks were severe and refractory to standard treatments. Sixty-seven (91%) patients underwent valve treatment obtaining a complete resolution of air-leaks in 59 (88%) patients; a reduction of air-leaks in 6 (9%); and no benefits in 2 (3%). The comparison of data before and after valve treatment showed a significant reduction of air-leak duration (16.2±8.8 versus 5.0±1.7 days; P<0.0001); chest tube removal (16.2±8.8 versus 7.3±2.7 days; P<0.0001); and length of hospital stay (LOS) (16.2±8.8 versus 9.7±2.8 days; P=0.004). Seven patients not undergoing valve treatment underwent pneumo-peritoneum with pleurodesis (n=6) or only pleurodesis (n=1). In only 1 (14%) patient, the chest drainage was removed 23 days later while the remaining 6 (86%) were discharged with a domiciliary chest drainage removed after 157±41 days. No significant difference was found in health cost before and after endobronchial valve (EBV) implant (P=0.3)., Conclusions: Valve treatment for persistent air leaks is an effective procedure. The reduction of hospitalization costs related to early resolution of air-leaks could overcome the procedural cost., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes., Methods: It is a retrospective multicenter study including all consecutive patients with severe heterogeneous emphysema undergoing BLVR with endobronchial valve treatment and developed any complications related to this procedure. The type of complication, the time of onset, the treatment required and the out-come were evaluated. Response to treatment was assessed according to the minimal clinically important difference (MCID) as follows: an improvement of ≥15% in forced expiratory volume in one second (FEV 1 ); of -8% in residual volume (RV); of ≥26 m in 6-minnute walking distance (6MWD); and of ≥4 points on the St. George's Respiratory Questionnaire (SGRQ). Target lobe volume reduction (TLVR) ≥350 mL was considered significant., Results: One hundred and seven out of 423 (25.3%) treated patients had complications related to valve treatment including pneumothorax (17.3%); pneumonia (1.7%), chronic obstructive pulmonary disease (COPD) exacerbation (0.9%), respiratory failure (1.4%), valve migration (2.1%), and hemoptysis (1.9%). In all cases complications resolved with appropriate treatment including removal of valves in 21/107 cases (19.6%). Patients with TLVR ≥350 mL (n=64) vs. those <350 mL (n=43) had a statistically significant higher improvement in FEV 1 (19.0%±3.9% vs. 3.0%±0.9%; P=0.0003); in RV (-10.0%±4.8% vs. -4.0%±2.9%; P=0.002); in 6MWD (33.0±19.0 vs. 12.0±6.3 metres; P=0.001); and in SGRQ (-15.0±2.9 vs. -8.0±3.5 points; P=0.01). Only patients with TLVR ≥350 mL met or exceeded the MCID cut-off criteria for FEV 1 (19.0%±3.9%), RV (-10.0%±4.8%), 6MWT (33.0±19.0 metres), and SGQR (-15.0±2.9 points). Five patients (1.2%) died during follow-up for causes not related to valves treatment neither to any of the complications described., Conclusions: Valve treatment is a safe and reversible procedure. The presence of complications seems not to have a significant impact on clinical outcome in patients with lobar atelectasis. Due to poor clinical conditions and possible complications, BLVR should be performed in high volume centers with a multidisciplinary approach., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: One-lung ventilation (OLV) is a ventilation procedure used for pulmonary resection which may results in lung injury. The aim of this study was to evaluate the local inflammatory cytokine response from the dependent lung after OLV and its correlation to VT. The secondary aim was to evaluate the clinical outcome of each patient., Methods: Twenty-eight consecutive patients were enrolled. Ventilation was delivered in volume-controlled mode with a VT based on predicted body weight (PBW). 5 cmH 2 O positive end-expiratory pressure (PEEP) and FiO 2 0.5 were applied. Bronchoalveolar lavage (BAL) was performed in the dependent lung before and after OLV. The levels of pro-inflammatory interleukins (IL-1α, IL-1β, IL-6, IL-8), tumor necrosis factor alpha (TNFα), vascular endothelial growth factor (VEGF), endothelial growth factor (EGF), monocyte chemoattractant protein-1 (MCP-1) and anti-inflammatory cytokines, such as interleukins (IL-2, IL-4, IL-10) and interferon (IFN-γ), were evaluated. Subgroup analysis: to analyze the VT setting during OLV, all patients were ventilated within a range of 5-10 mL/kg. Thirteen patients, classified as a conventional ventilation (CV) subgroup, received 8-10 mL/kg, while 15 patients, classified as a protective ventilation (PV) subgroup, received 5-7 mL/kg., Results: Cytokine BAL levels after surgery showed no significant increase after OLV, and no significant differences were recorded between the two subgroups. The mean duration of OLV was 64.44±21.68 minutes. No postoperative respiratory complications were recorded. The mean length of stay was for 4.00±1.41 days in the PV subgroup and 4.45±2.07 days in the CV group; no statistically significant differences were recorded between the two subgroups (P=0.511)., Conclusions: Localized inflammatory cytokine response after OLV was not influenced by the use of different VT. Potentially, the application of PEEP in both ventilation strategies and the short duration of OLV could prevent postoperative complications., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Tracheobronchial stents are a treatment option for inoperable benign or malignant tracheobronchial stenosis (TBS) or postoperative bronchopleural fistulas (POBPF). The present study evaluated the outcomes of patients with TBS and POBPF who were treated by placement of recent generation, fully covered, self-expanding metallic stents (SEMS) and determined stent efficacy relative to airway pathology., Methods: From January 2009 to January 2016, 68 patients with TBS or POBPF underwent rigid bronchoscopy, laser/mechanical debridement and placement of fully covered SEMS. Eighteen patients had benign stenosis, 38 had malignant stenosis, and 12 patients had POBPF., Results: Seventy-four SEMS were successfully placed in 68 patients. There were no perioperative deaths. Stent-related complications occurred in 20 (29.4%) patients: granulation tissue formation [TBS group, 10.7% (n=6); POBPF group, 8.3% (n=1)]; stent fracture [TBS group, 5.4% (n=3); POBF group, 8.3% (n=1)], stent migration [TBS group, 7.1% (n=4); POBF group, 0% (n=0)], severe secretions not removable by flexible bronchoscopy [TBS group, 7.1% (n=4); POBF group, 8.3% (n=1)]. No stent migration was observed in the POBPF group. Four patients (7.1%) in the TBS group had stent migration requiring stent replacement. After stenting, all TBS patients had a Hugh-Jones classification score improvement ≥1 grade and 42 patients (75%) had an improvement ≥2 grades. Logistic regression analysis showed that the disease (stenosis vs. fistula) did not influence the occurrence of stent complications [OR 0.96, 95% confidence interval (CI): 0.71-1.13, P=0.13]., Conclusions: Fully covered SEMS are effective and provide a versatile treatment option for patients with inoperable TBS and POBPF., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.