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Background: Completion thymectomy may be performed in patients with non-thymomatous refractory myasthenia gravis (MG) to allow a complete and definitive clearance from residual thymic tissue located in the mediastinum or in lower neck. Hereby we present our short- and long-term results of completion thymectomy using subxiphoid video-assisted thoracoscopy., Methods: Between July 2010 and December 2017, 15 consecutive patients with refractory non-thymomatous myasthenia, 8 women and 7 men with a median age of 44 [interquartile range (IQR) 38.5-53.5] years, underwent video-thoracoscopic completion thymectomy through a subxiphoid approach., Results: Positron emission tomography (PET) showed mildly avid areas [standardized uptake value (SUV) more than or equal to 1.8] in 11 instances. Median operative time was 106 (IQR, 77-141) minutes. No operative deaths nor major morbidity occurred. Mean 1-day postoperative Visual Analogue Scale value was 2.53±0.63. Median hospital stay was 2 (IQR, 1-3.5) days. A significant decrease of the anti-acetylcholine receptor antibodies was observed after 1 month [median percentage changes -67% (IQR, -39% to -83%)]. Median follow-up was 45 (IQR, 21-58) months. At the most recent follow-up complete stable remission was achieved in 5 patients. Another 9 patients had significant improvement in bulbar and limb function, requiring lower doses of corticosteroids and anticholinesterase drugs. Only one patient remained clinically stable albeit drug doses were reduced. One-month postoperative drop of anti-acetylcholine receptor antibodies was significantly correlated with complete stable remission (P=0.002)., Conclusions: This initial experience confirms that removal of ectopic and residual thymus through a subxiphoid approach can reduce anti-acetylcholine receptor antibody titer correlating to good outcome of refractory MG., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd.2020.03.81). The authors have no conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Background: More than ten years ago we started a program of video-assisted thoracic surgery (VATS) lung metastasectomy in non-intubated local anesthesia. In this study we investigated the effectiveness and long term results of this combined surgical-anesthesiological technique., Methods: Between 2005 and 2014, 48 patients (25 men and 23 women) with pulmonary oligometastases from colorectal cancer, at the first episode, underwent VATS metastasectomy under non-intubated local anesthesia. Three patients required intubation for intolerance. In the same period 13 patients scheduled for non-intubated metastasectomy refused awake surgery and were used as a control group., Results: The two groups were homogeneous for both demographic and pathological features. Mean number of lesions resected per patient were 1.51 (non-intubated) vs. 1.77 (control), respectively (P=0.1). The oxygenation was significantly lower in the non-intubated group especially at the end of the procedure, but the values inverted from the first postoperative hour. There was no mortality in any groups. The non-intubated group demonstrated a significant shorter overall operating time (P=0.04), better quality of recovery after both 24 (P=0.04) and 48 hours (P=0.04), shorter median hospital stay (P=0.03) and lower estimated costs (P=0.03), even excluding the hospital stay. Major morbidity rate was lower (6% vs. 23%) yet not significant (P=0.1). Both disease free survival and overall survival were similar between groups., Conclusions: VATS lung metastasectomy in non-intubated local anesthesia was safely performed in selected patients with oligometastases with significant advantages in overall operative time, hospital stay and economical costs. Morbidity rate was lower yet not significant. Long term results were similar., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.