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Background: Persistent air leak and the management of intraoperative blood loss are common threats in thoracic surgical practice. The availability of new procedures, technology and materials is constantly evolving topical hemostats and surgical sealants must be added to this toolkit. Topical hemostats and surgical sealants differ according to their chemical nature and physical characteristics, to their origin and mechanism of action, regulatory/registration and vigilance paths. A Delphi consensus was set to highlight the different points of view on the use of topical haemostatic products and sealants among the members of Italian Society of thoracic surgery., Methods: The board was formed by a group of five Italian experts; in the first phase after a careful review of the scientific literature and two rounds, the board finally generated 16 consensus statements for testing across a wider audience. During the second phase, the statements were collated into a questionnaire, which was electronically sent to a panel of 46 Italian surgeons, experts in the field., Results: Out of 46 Italian surgeons, 33 (72%) panel members responded to the Delphi questionnaire. All the items reached a positive consensus, with elevated levels of agreement, as demonstrated by the presence of a 100% consensus for nine items. For the remaining 7 statements the minimum level of consent was 88% (29 participants approved the statement and 4 disagreed) and the maximum was 97% (32 participants approved the statement and 1 was in disagreement)., Conclusions: The present Delphi analysis shows that air leak and intraoperative bleeding are clinical problems well known among thoracic surgeons. Nevertheless, the aim of the scientific societies and of the group of experts is to execute the education activities in the surgery community. This Delphi survey suggest the need of wider and updated scientific information about technical and registration characteristics of most recent technologic solutions, such as the of topical hemostats and surgical sealants to provide healthcare and administrative staff with the opportunity to work and interact through a common and shared language and eventually to guarantee minimal requirements of assistance., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-619/coif). PC serves as an unpaid editorial board member of Journal of Thoracic Disease from November 2020 to October 2022. GM serves as an unpaid editorial board member of Journal of Thoracic Disease from February 2021 to January 2023. LV serves as an unpaid editorial board member of Journal of Thoracic Disease from October 2022 to September 2024. GC participated on an Advisory Board supported by BD in the past 36 months. MN participated on an Advisory Board supported by Bard Limited in the past 36 months. MS received honoraria by J&J, Medtronic and Medela for speakers fee, and participated on an Advisory Board supported by BD, and he was a member of ESTS board of directors in the past 36 months. MT participated on an Advisory Board supported by BD in the past 36 months. GC is an unpaid member of the Oncologic network of Sicilian Region in the past 36 months. AI is an unpaid member of Editorial Board of the “Monaldi Archives for Chest Disease” and unpaid member of Editorial Board of the Video-Assisted Thoracic Surgery in the past 36 months. GLP is an unpaid Councillor of the Italian Thoracic Surgery Society from 2021 to 2023 and an unpaid Scientific Coordinator Pulmonary Nodule Recommendations Group PNR of Italian Thoracic Surgery Society from 2021 to 2023. RC participated on an Advisory Board supported by BD in the past 36 months. The other authors have no conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

Background: We previously showed that selected single-nucleotide-polymorphisms (SNPs) of genes involved in angiogenesis influence the aggressiveness of thymic epithelial tumors (TETs). This study analyzes their role in TETs and in thymic benign lesions, in order to investigate potential correlation with risk and outcome., Methods: Genomic DNA was extracted from paraffin-embedded tissue of 92 patients, undergoing surgery at our Institution. We investigated by Real-Time PCR the SNPs of the following genes: platelet-derived growth factor receptor - α ( PDGFR α), hypoxia-inducible factor-1α ( HIF-1 α), vascular endothelial growth factor A ( VEGF-A ), vascular endothelial growth factor receptor-2 and 3 ( VEGF-2, VEGFR-3 ), excision repair cross-complementation group-1 ( ERCC1 )., Results: Fifty-seven TETs and 35 thymic benign lesions were included into the study. Frequency of SNPs was as follows: rs2057482 C, rs11158358 C and rs11549465 C polymorphisms of HIF1-a : thymomas < general population (P=0.008, P=0.007, and P=0.044 respectively). HIF1-a alleles: general population > study groups, rs1951795C SNP (P=0.026 for benign lesions and P=0.0007 for thymomas), rs10873142T SNP (P=0.008 and P=0.001 respectively), rs12434438 A SNP (P=0.034 and P=0.0007) and rs2301113A SNP (P=0.027 and P=0.010). rs699947C polymorphism of VEGF-A: benign lesions > general population (P=0.012)., Conclusions: This is the first study investigating the angiogenetic polymorphisms in thymic benign lesions and TETs. SNPs analysis may represent a further asset in identification of patients who could benefit from anti-angiogenetic therapy., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-19-3720). CP serves as an unpaid editorial board member of Journal of Thoracic Disease from Sep 2020 to Aug 2022. The other authors have no conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Many studies have confirmed that the implementation of enhanced recovery after surgery (ERAS) protocols has the advantages of reducing the potential complications after thoracic surgery and the length of hospital stay. The ERAS program involves a multidisciplinary team, aimed at integrating evidence-based knowledge into clinical practice in order to reduce the patient's stress response to the surgical procedure and improve the response to stress, guaranteeing a combination of better outcomes and cost savings. All this would not be possible without the improvement of minimally invasive surgical techniques, progression of anesthesia, pain control, and careful patient preparation. In this setting, a preoperative personal counselling may play a key role to reduce stress, fear or anxiety and improve the morbidity of patients, enabling them to achieve functional and psychological compensatory mechanisms more quickly. Preoperative patient counselling, performed using verbal, written or multimedia materials, is crucial in order to achieve the goal of the ERAS project: making the patient a potentially active participant and the main character of his recovery, able to positively impact himself throughout the surgical and healing process. This report is aimed at evaluating patient information and care-plans in thoracic surgery, reviewing the available evidence on ERAS pathways, and demonstrating our ideal program as discussed and shared among the Italian Thoracic Surgery Units accredited in the video-assisted thoracic surgery (VATS) group., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

The Society for Translational Medicine and The Chinese Society for Thoracic and Cardiovascular Surgery conducted a systematic review of the literature in an attempt to improve our understanding in the postoperative management of chest tubes of patients undergoing pulmonary lobectomy. Recommendations were produced and classified based on an internationally accepted GRADE system. The following recommendations were extracted in the present review: (I) chest tubes can be removed safely with daily pleural fluid of up to 450 mL (non-chylous and non-sanguinous), which may reduce chest tube duration and hospital length of stay (2B); (II) in rare instances, e.g., persistent abundant fluid production, the use of PrR P/B <0.5 when evaluating fluid output to determine chest tube removal might be beneficial (2B); (III) it is recommended that one chest tube is adequate following pulmonary lobectomy, except for hemorrhage and space problems (2A); (IV) chest tube clearance by milking and stripping is not recommended after lung resection (2B); (V) chest tube suction is not necessary for patients undergoing lobectomy after first postoperative day (2A); (VI) regulated chest tube suction [-11 (-1.08 kPa) to -20 (1.96 kPa) cmH 2 O depending upon the type of lobectomy] is not superior to regulated seal [-2 (0.196 kPa) cmH 2 O] when electronic drainage systems are used after lobectomy by thoracotomy (2B); (VII) chest tube removal recommended at the end of expiration and may be slightly superior to removal at the end of inspiration (2A); (VIII) electronic drainage systems are recommended in the management of chest tube in patients undergoing lobectomy (2B)., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Clinical care pathways are developed to standardize postoperative patient care and the main impetus is to improve quality of care, decrease variation in care and reduce costs. We report the clinical pathway of care adopted at our centre since the introduction of Uniportal VATS program for major lung resections.

Objective: The Thoracic Morbidity and Mortality (TM&M) classification system is a method for univocally coding the postoperative adverse events by their complexity of management. The aim of the present study was to compare the distribution of the severity of complications according to the TM&M system versus the distribution according to the classification proposed by European Society of Thoracic Surgeons (ESTS) Database in a population of patients submitted to lung resection in our unit., Methods: 457 patients with any type of complications (326 lobectomy, 60 pneumonectomy, 71 wedge/segmentectomy) out of 1,518 patients submitted to pulmonary resections (January 2000-April 2011) were analyzed. Each complication was graded from I to V (TM&M system), reflecting an increasing severity of management. We verified the distribution of the different grades of complications and analyzed their frequency among those defined as "major cardio-pulmonary complications" by the ESTS Database., Results: According to the TM&M system, 0.6% of complications were regarded as grade I, 66.3% as grade II, 9.5% as grade IIIa, 4.4% as grade IIIb, 6.8% as grade IVa, 3.3% as grade IVb and 9.1% as grade V. According to the ESTS definitions, 290 complications were regarded as "major". Sixty two percent of them were reclassified as minor complications (grade I or II) by the TM&M classification system., Conclusions: The application of the TM&M grading system questions the traditional classification of complications following lung resection. This grading system may be used as an additional endpoint for outcome analyses.