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Background: Thoracotomy, video-assisted thoracoscopic surgery (VATS) and robotic assisted thoracoscopic surgery (RATS)-lobectomy are widely accepted procedures for the surgical treatment of clinical (c)stage I non- small cell lung cancer (NSCLC). In the current literature which procedure gives more benefits is still debated. We present a comparison between these three procedures in term of advantages and postoperative outcomes., Methods: A multicentric study about 259 lobectomies from 2013 to 2019: 128 patients underwent TL, 96 VATS and 35 RATS. Different variables were retrospectively analyzed among these three cohorts of patients with diagnosis of cStage I NSCLC., Results: Rate of major complications comparable in VATS, RATS and TL; Advantages for RATS in minor complications (TL 34.4% vs. VATS 18.75% vs. RATS 8.57%. P=0.0015), postoperative days in Intensive Care Unit, days to chest tube removal, length of postoperative hospitalization (P<0.0001) and number of lymph nodes dissected (P=0.0257). Operating times are shorter in VATS than RATS (P<0.05). Pain (NRS Scale) is comparable., Conclusions: TL remains the conventional approach for stage II-IIIA(N2) NSCLC. RATS showed great advantages, but its higher operating time and costs, mostly, today don't justify its adoption as gold standard for the surgical treatment of cStage I NSCLC, instead of VATS.

Aim: The present study aimed to demonstrate that computed tomography-guided transthoracic needle biopsy (TTNB) is a safe procedure that gives a more accurate pre-operative tissue diagnosis for peripheral lung nodules than transthoracic needle aspiration, obtaining suitable samples for molecular test in lung adenocarcinomas. Patients & methods: Between December 2016 and March 2018 at Thoracic Surgery Department of the University of Palermo - Policlinico Paolo Giaccone hospital, TTNB was performed in 42 patients with computed tomography-detected peripheral lung nodules >10 mm, using 16-18-Gauge Tru-Cut needles. Results: With TTNB, we have estimated an accuracy for tissue diagnosis of 97.6%. At the molecular test, EGFR overexpression and ALK mutation resulted positive for 12/23 patients with lung adenocarcinoma. Conclusion: TTNB has showed a low rate of complications and it is adoptable as standard diagnostic procedure for peripheral lung nodules.

Background: Quality of care and provider's experience seem to be strictly connected in any field of surgery. Aim of this study is to identify a method to classify the centers on the basis of the number of thyroidectomies and parathyroidectomies performed., Methods: We listed 666 centers performing endocrine neck surgery in 2015, from the database of the Italian Health Ministry. We performed a descriptive statistic analysis with a dedicated software. We identified the outliers, according to a previous literature review, in those centers performing >1000 and < 10 thyroidectomies, >100 and < 3 parathyroidectomies and we excluded them to our analysis. The remaining centers were grouped in a box-plot. Third quartile, median, procedures performed/3rd quartile value ratio (Standardized Hospitalization Ratio, SHR, superior cut-off), Romamedian/3rd quartile values ratio (inferior cut-off) were calculated. These centers were charted in a bar graph and three zones were identified: "excellence" (SHR>1.1), "SHR", "alert" (between the two cut-offs) and "risk" (under the lower cut-off)., Results: 35743 thyroidectomies and 2306 parathyroidectomies were performed in Italy in 2015. After the outliers' exclusion, 407 and 157 centers performing respectively thyroidectomies and parathyroidectomies were analysed. A median value of respectively 37 thyroidectomies and 6 parathyroidectomies, and a 3rd quartile cut-off of respectively 85 and 12 were calculated. Concerning all the 666 centers, we found: 95 excellence centers for thyroidectomy and 33 for parathyroidectomy, respectively 18 and 17 falling into superior cut-off line, 100 and 29 in the alert zone, 453 and 587 in the risk zone., Conclusions: Our method, according to the literature data, highlighted a number of thyroidectomies and parathyroidectomies performed in low volume centers. Looking for an optimization in health organization, we can consider some measures such as a net of tutorship of the "alert" hospitals by the excellence ones and a discouragement of the "risk" hospitals in performing endocrine neck surgery.

Background: Nowadays, minimally invasive video-assisted thyroidectomy (MIVAT) is considered a safe and effective option. However, its complication rate has not been specifically discussed yet. The aim of this systematic review was enrolling a large number of studies to estimate early and late complications (transient and definitive, uni- and bilateral laryngeal nerve palsy; transient and definitive hypocalcemia; cervical hematoma; hypertrophic or keloid scar) of MIVAT compared with conventional technique., Methods: The review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria in PubMed and Embase. Search terms were "minimally invasive," "video-assisted," and "thyroidectomy." We enrolled randomized clinical trials, nonrandomized trials, and noncontrolled trials., Results: Thirty-two articles were considered suitable. Complication rate of MIVAT was quite similar to conventional technique: only one randomized trial found a significant difference concerning overall skin complication, and a single trial highlighted hypocalcemia significantly increased in MIVAT, concerning serologic value only. No difference concerning symptomatic nor definitive hypocalcemia was found., Conclusions: We can confirm that MIVAT is a safe technique. It should be adopted in mean-high-volume surgery centers for thyroidectomy, if a strict compliance with indication was applied.

Introduction: Prolonged air leak (PAL) is one of the most common postoperative complications after lung surgery. It is associated with increased significant morbidity, lower quality of life, longer hospital stay and higher hospital costs. Since its great clinical and economic burden, it is important to establish the feasibility and the effectiveness of the routinary preventive use of a fibrin sealant in order to reduce the incidence of prolonged air leaks., Patients and Methods: This is a randomized study on 189 adult patients - 118 men (62.4%) and 71 women (37.6%) aged from 39 to 87 y.o. (mean age 68.3 y.o.) - who underwent lung surgery (lobectomy or bilobectomy) with intraoperatory detection of air leakage, from January 2013 to December 2017, at Department of Thoracic Surgery in "Ospedale Maggiore Carlo Alberto Pizzardi" (Bologna, Italy) and Department of Thoracic Surgery in "Paolo Giaccone" Teaching Hospital (Palermo, Italy). Patients were randomly assigned to the "Glue" arm (90 patients) or the "Control" group (99 patients). We only used stapler or manual suture to achieve aerostasis. In addition, we used a fibrin sealant ("glue") to cover the suture line on patients in the "Glue" arm. The primary endpoints were incidence of prolonged air leaks, days with chest tube and mean hospital stay., Results: In the "Glue" arm we experienced only 1 prolonged air leak (1.1%), while in the "Control" group there were 8 leaks (8.1%). Patients kept chest tube for average 4.15 days in the "Glue" arm and 4.45 days in the "Control" group. The mean hospital stay was average 7.4 days for the "Glue" arm, while 9.1 days in the "Control" group., Conclusions: According to our experience it seems that the routinary preventive use of a fibrin sealant results in a lower incidence of prolonged air leaks, a shorter hospital stay with lower hospital costs, representing a cost-effective, feasible and effective system to decrease morbility and mortality among surgical patients.

Primary leiomyosarcomas of the lung are tumors. We report a case of 49-year old female with history of cough, breathless at rest, right sided chest pain. Chest CT showed a huge (16 cm) mediastinal mass located on the right mediastinum encasing the right main pulmonary artery and infiltrating the main right bronchus and pericardium. The tumor was resected with combined pericardiectomy and pnemonectomy via hemiclamshell incision. This surgical access provided an adequate exposure of the chest "blind zones" and it allowed a radical and safe surgical resection of lung, pleura, pericardium and diaphragm. The final diagnosis showed a low grade differentiation leiomyosarcoma.

Aim: Thoracoscopic lobectomy is superior to thoracotomy, but the evidence for this assumption is low. We present a comparison between thoracotomy and thoracoscopy in term of postoperative complications, mortality, postoperative pain, hospital stay and quality of life., Patients and Methods: This is a retrospective analysis of 224 lobectomies in 24-months. 128 patients (57.1%) were operated by thoracotomy; 96 patients (42.9%) by videothoracoscopy., Results: Major complications were observed in 4/128 (3.1%) in thoracotomy group and in 1/96 (1%) in thoracoscopy. Minor complications were observed in 38/128 patients (29.7%) in the thoracotomy, and in 16/96 (16.7%) thoracoscopy. Thoracoscopy patients had a shorter hospital stay., Conclusion: Our study shows an advantage of thoracoscopy over thoracotomy but further studies are needed.

The choroid is the most common site for intraocular metastatic di sease. Orbital metastasis as metastatic site of lung adenocarcinoma is very rare and in literature a very exiguous number of cases is present. This is a case report of a woman with history of lung adenocarcinoma and, after surgery, detection of a choroidal mass described as lung metastasis, responding to Gefinitib therapy. However a biopsy was not performed. After two years there was a great dimension decrement of the lung metastasis but she is still suffering from recurrent pleural effusion, with pleural thickenings biopsied and diagnosed as recurrences of disease.

In the original article the credit line for the reuse of Fig. 1 from an article published in the open access journal, World Journal of Emergency Surgery is missing.

Background: Open abdomen (OA) permits the application of damage control surgery principles when abdominal trauma, sepsis, severe acute peritonitis and abdominal compartmental syndrome (ACS) occur., Methods: Non-traumatic patients treated with OA between January 2010 and December 2015 were identified in a prospective database, and the data collected were retrospectively reviewed. Patients' records were collected from charts and the surgical and intensive care unit (ICU) registries. The Acosta "modified" technique was used to achieve fascial closure in vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) patients. Sex, age, simplified acute physiology score II (SAPS II), abdominal compartmental syndrome (ACS), cardiovascular disease (CVD) and surgical technique performed were evaluated in a multivariate analysis for mortality and fascial closure prediction., Results: Ninety-six patients with a median age of 69 (40-78) years were included in the study. Sixty-nine patients (72%) underwent VAWCM. Forty-one patients (68%) achieved primary fascia closure: two patients (5%) were treated with VAWC (37 median days) versus 39 patients (95%) who were treated with VAWCM (10 median days) (p = 0.0003). Forty-eight patients underwent OA treatment due to ACS, and 24 patients (50%) survived compared to 36 patients (75%) from the "other reasons" group (p = 0.01). The ACS group required longer mechanical ventilator support (p = 0.006), length of stay in hospital (p = 0.005) and in ICU (p = 0.04) and had higher SAPS II scores (p = 0.0002)., Conclusions: The survival rate was 62%. ACS (p = 0.01), SAPS II (p = 0.004), sex (p = 0.01), pre-existing CVD (p = 0.0007) and surgical technique (VAWC vs VAWCM) (p = 0.0009) were determined to be predictors of mortality. Primary fascial closure was obtained in 68% of cases. VAWCM was found to grant higher survival and primary fascial closure rate.

Background: The lungs are among the first organ affected by remote metastases from many primary tumors. The surgical resection of isolated pulmonary metastases represents an important and effective element of therapy. This is a retrospective study about our entire experience with pulmonary resection for metastatic cancer using 1318-nm neodymium-doped yttrium-aluminum garnet laser., Method: In this single-institution study, we retrospectively analyzed a group of 209 patients previously treated for primary malignant solid tumors. We excluded 103 patients. The number and location of lesions in the lungs was determined using chest computed tomography and positron emission tomography-computed tomography. Disseminated malignancy was excluded. All pulmonary laser resections are performed via an anteroaxillary muscle-sparing thoracotomy. All lesions were routinely removed by laser with a small (5-10 mm) margin of the healthy lung. Patients received systematic lymph node sampling with intraoperative smear cytology of sampled lymph nodes., Results: Mortality at 2 years from the first surgery is around 20% (10% annually). This value increases to 45% in the third year. The estimated median survival for patients who underwent the first surgery is reported to be approximately 42 months., Conclusion: Our results show that laser resection of lung metastases can achieve good result, in terms of radical resection and survival, as conventional surgical metastasectomy. The great advantage is the possibility of limiting the damage to the lung. Stapler resection of a high number of metastases would mutilate the lung.

Parathyroid carcinoma (PC) is a very rare endocrine tumour, usually characterized by symptoms such as a neck mass, dysphonia, severe hypercalcemia exceeding 140 mg/L and elevated serum parathyroid hormone levels, even more than 5 times the upper limit of normal. Non-functioning parathyroid cancer is extremely rare and, in this case, its pre-operative diagnosis is often difficult. A 54-year old female patient, referring dysphagia and dysphonia, underwent neck ultrasound and neck CT. A left thyroid nodule, probably cystic, was found. It presented caudal extent on anterior mediastinum causing compression of the left lateral wall of the trachea. The preoperative calcemia was into the normal range. The patient underwent left thyroid lobectomy. Histological exam showed a cystic lesion, immunohistochemically originating from parathyroid that oriented for carcinoma. The 18 months follow-up did not show a residual-recurrent disease. The parathyroid origin of a neck lesion could not be suspected before surgery when specific laboratory tests are not available and clinical effects of hyperparathyroidism syndrome are not present. Histological features are not always sufficient for the differential diagnosis between the parathyroid adenoma and carcinoma. The immunohistochemistry is an useful tool that can aid to reach the definite diagnosis.

Background: Patients undergoing thyroidectomy often complain aerodigestive disorders. In a previous study we showed the associations between voice impairment and proximal acid reflux, swallowing impairment and Upper Esophageal Sphyncter (UES) incoordination and the decrease in UES pressure in thirty-six patients observed before and soon afterwards uncomplicated thyroidectomy. This study investigated the state of post-thyroidectomy esophageal motility changes and its associations with these disorders after 18-24 months., Patients and Methods: The thirty-six patients prospectively recruited according to selection criteria (thyroid volume ≤60 ml, benign disease, age 18-65 years, previous neck surgery, thyroiditis, pre- or postoperative vocal cord palsy) underwent voice (VIS) and swallowing (SIS) impairment scores, esophageal manometry and pH monitoring once again., Results: After 18-24 months, both VIS and SIS recovered (respectively: p=0,022; p=0,0001); UES pressure increased (p=0,0001) nearing the preoperative values. The persistence of swallowing complaints were associated with the persistence of esophageal incoordination (p=0,03); the association between voice impairment and proximal acid reflux was confirmed (p<0,001)., Conclusions: Our study confirms that aerodigestive disorders after uncomplicated thyroidectomy, largely transient, are strictly connected with upper esophageal motility changes. In this viewpoint, the innervation of upper aerodigestive anatomical structures (larynx, pharynx, upper esophagus) and its variations should be focused.

Background: Pleural angiosarcoma is a rare tumor that causes diffuse pleural thickening and effusion, mimicking mesothelioma. Immunohistochemistry is needed to highlight endothelial differentiation. We describe the first case of pleural angiosarcoma with lymphatic differentiation following radiometabolic therapy for thyroid carcinoma., Case Presentation: A 50-year-old man showed diffuse pleural thickening and effusion. Nine years earlier, he underwent thyroidectomy and radiometabolic therapy for thyroid carcinoma with lymph node metastases. Histologically, the tumor consisted of a solid proliferation of atypical epithelioid cells and anastomosed vascular spaces, lacking of red blood cells and containing Alcian blue positive material. The tumor showed positive immunostaining for Vimentin, CD31, CK7, D2-40, c-MYC, Ki67, focal positivity for PanCK, and negative immunostaining for Factor VIII, CD34, WT1, CK5/6, Calretinin, EMA, HBME-1, CEA, p63, EpCAM, Bcl-2, TTF1 and Thyroglobulin. CD99 showed a granular/paranuclear pattern of positivity. The histological and immunohistochemical features were consistent with "pleural angiosarcoma with lymphatic differentiation, epithelioid variant"., Discussion and Conclusions: Epithelioid angiosarcoma with lymphatic differentiation is very rare and aggressive. Moreover, the positivity for c-MYC suggests the relationship with radiometabolic therapy. To our knowledge, this is the first case of pleural c-MYC-positive angiosarcoma with lymphatic differentiation reported in the literature and the first one arisen after radiometabolic therapy for thyroid carcinoma.

Introduction: Dysphagia and hoarseness are possible complications that can be observed in patients undergoing thyroidectomy or other neck surgery procedures. These complaints are usually related to superior and inferior laryngeal nerves dysfunction, but these can appear even after uncomplicated surgical procedure., Methods: We reviewed the current literature available on MEDLINE database, concerning the swallowing disorders appearing after the thyroidectomy. The articles included in the review reported pathophysiology and diagnostic concerns., Results: Twenty articles were selected for inclusion in the review. Depends on the possible causes of the difficulty swallowing (related to nerve damage or appearing after uncomplicated thyroidectomy), different types of diagnostic procedures could be used to study patient discomfort, as well as intraoperative nerve monitoring, fiber optic laryngoscopy, endoscopy, pH monitoring, esophageal manometry and videofluorography. Among all these procedures, videofluorography is considered the gold standard to evaluate the entire swallowing process, since that allows a real-time study of all the three phases of swallowing: oral phase, pharyngeal phase and esophageal phase., Conclusion: The diagnostic procedures described can help to identify the mechanisms involved in swallowing disorders, with the aim to choose the best therapeutic option. More studies are needed for understanding the causes of the dysphagia appearing after thyroidectomy., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: The ideal surgical approach for pulmonary metastasectomy remains controversial. Thoracoscopic surgery may offer advantages in quality of life outcomes, with equivalent oncologic long-term results. This study aimed to demonstrate the validity of video-assisted thoracoscopic surgery (VATS) in the treatment of lung metastases., Methods: In all 224 patients who underwent 300 VATS metastasectomies from January 2000 to December 2013 were retrospectively reviewed. Sixty-nine patients underwent major resection (68 thoracoscopic lobectomies and one pneumonectomy) and 155 patients underwent a wedge resection/segmentectomy. Complete curative pulmonary resections were performed in 219 (97%) cases. The Kaplan-Meier method was used to estimate survival curves. Univariate and subsequent multivariate Cox model regression were performed to identify independent factors of overall survival., Results: One hundred eighty-six patients developed lung metastases from epithelial tumors, 28 from sarcomas, seven from melanomas, and three from germ cell tumors. The final pathological examination revealed no cases of R1 disease. After a mean follow-up of 40 months, 118 patients (53%) had died. According to a multivariate analysis, a better prognosis was not observed for patients with a particular histological type; in addition, disease-free interval time, age, number of metastases, and type of surgery did not have any statistical influence on long-term survival., Conclusions: Thoracoscopic surgery is a safe and efficacious procedure, with a five-year overall survival that is equivalent to open surgery.

Aim: Mesh-mediated groin hernia repair is considered the goldstandard procedure. It has low recurrence rate. Rarely a deep Surgical Site Infection (SSI) is seen when a synthetic prosthesis is used., Case Report: We describe a rare case of bilateral deep SSI after mesh-mediated groin hernia repair. Diagnosis was performed through the physical examination and radiological exams. Microbiological samples identified a methicillin-resistant Staphylococcus aureus responsible of the infection. Target therapy was performed and re-operation performed in order to remove the infected prosthesis and to apply a biological one to create the fibrous scaffold. During follow-up time, right side recurrence was observed. Tru-cut biopsy of fascia was obtained in order to identify the responsible of the recurrence., Conclusion: Combination of antibiotic therapy and surgical reoperation seems to be the correct way to approach the deep SSI after mesh-mediated groin hernia repair. The use of biological mesh after synthetic removal seems to improve the final outcome.

Although the surgical procedures concerning the thyroid and the parathyroid glands are considered safe, the possible occurrence of complications (mainly hematoma and hypocalcemia) limit the short stay surgery. At our institution a 23-hour-surgery with overnight hospital stay for endocrine neck surgical procedures was introduced since 2004. The present case series analyses the institutional results. Over 1913 endocrine neck surgery procedures, 1730 patients (90,2%) were managed according to this model. Among these patients, 92 suffered from hypocalcemia, 12 from airways obstruction due to the hematoma, 5 from bilateral nerve palsy. 15 more patients had unpredictable general disease compromising the short-stay surgery management. The goal of the discharge after 23 hours was achieved in 92,8% of cases with a mean hospital stay of 1,1days. The 23-hour observation with an overnight surgery is feasible and safe if the correct indications are observed. A considerable volume of specific activity is needed.

The typical complications of Crohn's disease concerns small and large bowel. The full thickness inflammation of the intestinal wall develops in strictures, fistulas and abdominal abscesses. Nowadays the most accepted therapeutic for intra-abdominal abscess option is antibiotic therapy and, in case of need, percutaneous drainage of the abscess. If the abscess passes through the pelvic foramen the abscess can involve the inferior limbs. We report a case a perforation of terminal ileum in Crohn's disease complicated by a large abscess of the right iliac fossa reaching the spaces between the anterior lateral muscles of the right thigh as far as the anterior lateral pre-tibial region. We discuss the diagnostic and therapeutic options in a multidisciplinary context.