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Background: Video-assisted thoracoscopic lobectomy (VATS-L) is a well-established approach for early-stage non-small cell lung cancer (NSCLC) with functional and oncological outcomes similar to thoracotomy. The role of VATS-L in locally advanced stage of NSCLC has not been well standardized. The objective of this study was to evaluate the state of the art in Italy of VATS-L for NSCLC advanced stages using the data from the Italian VATS Group Database. Methods: Between 1st January 2014 and 31th May 2017, 3,720 patients underwent VATS-L at VATS Group participating centres and included in the VATS Group database. Patients were divided into two groups: (A) early stages and (B) locally-advanced stages (tumours with dimension >5 cm (cT2b), cT3, cT4 and/or tumours that received neo-adjuvant chemotherapy). A retrospective study was performed, to evaluate the safety and the oncological adequacy of VATS-L comparing peri-operative outcomes and pathological data. Results: A total of 3,266 (87.7%) patients were included into the group A, while 454 (13.3%) patients formed the group B. VATS-L for locally advanced-stage NSCLC is associated with a longer procedure, a higher estimated blood loss, an increased incidence of conversion (9.3% vs . 13.0%, P=0.018) and a significant higher number of total, hilar and mediastinal dissected lymph nodes. The mortality rate (1.6% vs . 1.5%), the proportion of patients who suffered any complication (24.8% vs . 29.1%) and the hospitalization were not statistically different between the two groups (P=0.880, 0.057 and 0.660, respectively); the overall complication rate was statistically higher in group B (30.4% vs . 37.0%; P=0.04). Patients of group B who required conversion had a statistically significantly higher operative time (P vs . 28.0%) compared with patients completely operated by VATS. Conclusions: VATS-L for locally advanced-stage NSCLC in Italy is a safe and effective procedure when performed in appropriately selected patients, ensuring peri-operative results similar to those obtained in early-stage tumours.

In the article that appeared on page 2061-2070, Vol 9, No 7 (July 2017) Issue of the Journal of Thoracic Disease (1), there are some mistakes in the presented authors information. In the list of collaborators of the Italian VATS Group are not included the following author names: Alessandro Bertani, Alessandro Gonfiotti, Mario Nosotti, Paolo Albino Ferrari, Lavinia De Monte, Emanuele Russo, Gioacchino Di Paola, Piergiorgio Solli, Andrea Droghetti, Luca Bertolaccini, Roberto Crisci. The correct list of collaborators of the Italian VATS Group should have been shown as below. Alessandro Bertani, MD (IRCCS ISMETT, Palermo); Alessandro Gonfiotti, MD (Careggi Hospital, Firenze); Mario Nosotti, MD (Policlinico Ca'Granda, Milano); Paolo Albino Ferrari, MD (IRCCS ISMETT, Palermo); Lavinia De Monte, MD (IRCCS ISMETT, Palermo); Emanuele Russo, MD (IRCCS ISMETT, Palermo); Gioacchino Di Paola, MD (IRCCS ISMETT, Palermo); Piergiorgio Solli, MD PhD (AUSL Romagna Teaching Hospital, Forlì); Andrea Droghetti, MD (ASST Mantova-Cremona, Mantova); Luca Bertolaccini, MD PhD (AUSL Romagna Teaching Hospital, Forlì); Roberto Crisci, MD PhD (Università dell'Aquila, L'Aquila); Carlo Curcio, MD (Monaldi Hospital, Napoli); Dario Amore, MD (Monaldi Hospital, Napoli); Giuseppe Marulli, MD (University of Padova); Samuele Nicotra, MD (University of Padova); Andrea De Negri, MD (San Martino Hospital, Genova); Paola Maineri, MD (San Martino Hospital, Genova); Gaetano di Rienzo (Vito Fazzi Hospital, Lecce); Camillo Lopez, MD (Vito Fazzi Hospital, Lecce); Angelo Morelli, MD (S. Maria delle Misericordia Hospital, Udine); Francesco Londero, MD (S. Maria delle Misericordia Hospital, Udine); Lorenzo Spaggiari, MD (IEO Hospital, Milano); Roberto Gasparri, MD (IEO Hospital, Milano); Guido Baietto, MD (Maggiore della Carità Hospital, Novara); Caterina Casadio, MD (Maggiore della Carità Hospital, Novara); Maurizio Infante, MD (Borgo Trento Hospital, Verona); Cristiano Benato, MD (Borgo Trento Hospital, Verona); Marco Alloisio, MD (IRCCS Humanitas, Milano); Edoardo Bottoni, MD (IRCCS Humanitas, Milano); Giuseppe Cardillo, MD (Forlanini Hospital, Roma); Francesco Carleo, MD (Forlanini Hospital, Roma); Franco Stella, MD (S. Orsola Hospital, Bologna); Giampiero Dolci, MD (S. Orsola Hospital, Bologna); Francesco Puma, MD (University of Perugia); Damiano Vinci, MD (University of Perugia); Giorgio Cavallesco, MD (University of Ferrara); Pio Maniscalco, MD (University of Ferrara); Luca Ampollini, MD (University of Parma); Paolo Carbognani, MD (University of Parma); Alberto Terzi, MD (Negrar Hospital, Verona); Andrea Viti, MD (Negrar Hospital, Verona); Giampiero Negri, MD (S. Raffaele Hospital, Milano); Alessandro Bandiera, MD (S. Raffaele Hospital, Milano); Reinhold Perkmann, MD (Bolzano Hospital, Bolzano); Francesco Zaraca, MD (Bolzano Hospital, Bolzano); Claudio Andretti, MD (S. Andrea Hospital, Roma); Camilla Poggi, MD (S. Andrea Hospital, Roma); Felice Mucilli, MD (S. Maria Annunziata Hospital, Chieti); Pierpaolo Camplese, MD (S. Maria Annunziata Hospital, Chieti); Luca Luzzi, MD (University of Siena); Marco Ghisalberti, MD (University of Siena); Andrea Imperatori, MD (University of Varese); Nicola Rotolo, MD (University of Varese); Luigi Bortolotti, MD (Humanitas Gavazzeni Hospital, Bergamo); Giovanna Rizzardi, MD (Humanitas Gavazzeni Hospital, Bergamo); Massimo Torre, MD (Niguarda Hospital, Milano); Alessandro Rinaldo, MD (Niguarda Hospital, Milano); Armando Sabbatini, MD (Ospedali Riuniti, Ancona); Majed Refai, MD (Ospedali Riuniti, Ancona); Mauro Roberto Benvenuti, MD (Spedali Civili, Brescia); Diego Benetti, MD (Spedali Civili, Brescia); Alessandro Stefani, MD (Ospedale Policlinico, Modena); Pamela Natali, MD (Ospedale Policlinico, Modena); Paolo Lausi, MD (Ospedale Molinette, Torino); Francesco Guerrera, MD (Ospedale Molinette, Torino).

Decellularized tissues and organs represent a suitable option for tissue engineering when specific scaffolds are needed. However, the optimal conditions to completely remove all the cellular components and minimally affect the biochemical and structural properties of the extracellular matrix are still to be found. For this aim, bioreactors could be an alternative means to dynamically treat the biological samples, automatically controlling all the variables involved in the process and speeding up the entire procedure in order to deal with a suitable scaffold within a limited time period. This paper presents the characterization of rat tracheae decellularized in dynamic conditions, implementing a detergent-enzymatic method, previously considered. Only 6 cycles were enough to generate a tracheal matrix that was histologically and structurally similar to the native one. The network of collagen, reticular and elastic fibers was well preserved, such as the epithelial cilia, the luminal basement membrane and the main matrix components. The elastin content decreased, even if not significantly, after the decellularization protocol. Mechanical properties of the treated tissues were slightly affected by the procedure, and were partially recovered after crosslinking with genipin, a naturally-derived agent. The use of bioreactors could enhance the decellularization procedure of tissues/organs, but a careful selection of the processing parameters is needed in order to prevent large modifications compared to the native condition.

Summary Background In 2008, the first transplantation of a tissue-engineered trachea in a human being was done to replace an end-staged left main bronchus with malacia in a 30-year-old woman. We report 5 year follow-up results. Methods The patient was followed up approximately every 3 months with multidetector CT scan and bronchoscopic assessment. We obtained mucosal biopsy samples every 6 months for histological, immunohistochemical, and electron microscopy assessment. We also assessed quality of life, respiratory function, cough reflex test, and production and specificity of recipient antibodies against donor human leucocyte antigen. Findings By 12 months after transplantation, a progressive cicatricial stenosis had developed in the native trachea close to the tissue-engineered trachea anastomosis, which needed repeated endoluminal stenting. However, the tissue-engineered trachea itself remained open over its entire length, well vascularised, completely re-cellularised with respiratory epithelium, and had normal ciliary function and mucus clearance. Lung function and cough reflex were normal. No stem-cell-related teratoma formed and no anti-donor antibodies developed. Aside from intermittent bronchoscopic interventions, the patient had a normal social and working life. Interpretation These clinical results provide evidence that a tissue-engineering strategy including decellularisation of a human trachea, autologous epithelial and stem-cell culture and differentiation, and cell-scaffold seeding with a bioreactor is safe and promising. Funding European Commission, Knut and Alice Wallenberg Foundation, Swedish Research Council, ALF Medicine.

Pectus excavatum (PE) is also known as funnel or sunken chest. PE is the most common type of chest wall malformation, indeed occurs in about 1 of 300–400 births with a male predominance (M:F =3:1). It is featured of a depression of the body of the sternum and in association abnormalities of the costal cartilages. The aspect of the defect variant from mild to very severe. PE is frequently asymptomatic during childhood, but symptoms like easy tiredness and decreased hardiness often appear when patients become teenager or are involved in competitive sports. Surgical correction for PE has become rifer thanks to development of the mini-invasive repair (MIRPE), described for the first time by Nuss in 1989. MIRPE consists in a thoracoscopic fixing of at least one metal bar, which is maintained in the chest at least 2 years.

Recent advances in the field of minimally invasive surgery for the treatment of lung cancer and, in particular, the emergence of the uniportal approach alongside the more “traditional” multiportal approach, have generated an interesting debate. Supporters of the two different techniques have been on the field with the intent of trying to determine what is the best approach to offer to their patients to guarantee them, not only the best technical result, but above all the lower functional impact and effective oncological results. This article explores the necessary and rigorous scientific path to be followed to ensure adequate clinical trials to support one or the other technique to try to reach an objective conclusion of the current debate.

Objectives The surgical approach to chronic pleural empyema is still controversial. Video-assisted thoracic surgery (VATS) debridement and decortication has shown favourable outcomes, while the uniportal VATS (U-VATS) approach is still anecdotal. We report our experience with ultrasonographic (US) preoperative staging followed by U-VATS decortication for pleural empyema. Methods We performed a retrospective analysis of patients who underwent surgical treatment of stage II and stage III pleural empyema from 2012 to 2015. Pre-, intra- and postoperative data were investigated to evaluate outcomes including postoperative complications and disease recurrence. Results were analysed according to preoperative US appearance of pleural space (stages A-E) and surgical approach (thoracotomy vs U-VATS). Results We performed 30 (47%) uniportal thoracoscopic pleural decortication and 34 (53%) open decortication for empyema in stage II (40%) or III (60%) obtaining a complete debridement and decortication in all patients. In-hospital mortality was zero and overall morbidity was 29%. U-VATS was associated with lower blood loss (118 ± 80 ml vs 247 ± 140 ml P

Background The development of a video assisted thoracic surgery lobectomy (VATS-L) program provides a dedicated surgical team with a recognized learning curve (LC) of 50 procedures. We analyse the results of our program, comparing the LC with subsequent cases. Methods From June 2012 to March 2015, we performed n = 146 VATS major pulmonary resections: n = 50 (Group A: LC); n = 96 (Group B). Pre-operative mediastinal staging followed the National Comprehensive Cancer Network guidelines. All procedures were performed using a standard anterior approach to the hilum; lymphadenectomy followed the NCCN recommendations. During the LC, VATS-L indication was reserved to clinical stages I, therefore evaluated case by case. Results Mean operative time was 191 min (120-290) in Group A and 162 min (85-360) in Group B (p

As part of the third Mediterranean Symposium in Thoracic Surgical Oncology, we introduce the Italian VATS Group ( http://vatsgroup.org/sito/index.php ). This national collaborative initiative was established in 2013 and started to recruit patients in January 2014; as of July 2016, 3680 patients have been enrolled in the database. Three different video-assisted thoracic surgery approaches have been predominantly used by Italian thoracic surgery centers, 71% of them preferentially adopting a multi-portal approach, with a 20% recorded morbidity. The majority of the cases were stage I adenocarcinomas of the lung. Conversion to open surgery occurred in 9% of the cases. The study suggests video-assisted thoracic surgery lobectomy as a ‘gold standard’ for the surgical treatment of early-stage lung cancer in Italy.

Background. We prospectively evaluated a clinical and endoscopic score, the tracheal endoscopic clinical score (TECS), developed as a disease-specified outcome measure in adult patients undergoing operation for subglottic stenosis. We also performed a retrospective chart review to identify preoperative and intraoperative risk factors for worse TECS. Methods. The TECS includes endoscopic (vocal cord and glottic function, anastomotic healing, and patency) and interview (respiration, voice, swallow) variables, and was administered at 6-month follow-up. Endoscopic and subjective domains were weighted to obtain a continuous TECS index ranging from 0 (best) to 1 (worse). The TECS and preoperative variables relationships were evaluated by univariate and multivariate analysis. Results. We collected data (January 2009 to December 2010) from 30 patients (mean age, 48.3 19 years) undergoing subglottic resection and primary reconstruction. Stenosis etiology was postintubation (n 8), idiopathic (n 2), tracheostomy (n 18), and malignant (n 2). Surgery included Pearson operation with (n 7) or without (n 23) a Liberman-Mathisen cricoplasty. Mean length of resected trachea was 30.5 13.5 mm, and mean hospital stay was 7.4 days. Mortality rate was 1 patient (3.3%). The univariate analysis showed positive correlation between 6-month TECS and degree of stenosis (McCaffrey and Cotton scale 0 to 4) stage 4, tracheostomy or T-tube at surgery, bottleneck-type transition stenosis, and resection length. At multivariate analysis, the presence of tracheostomy, bottleneck-type transition stenosis and resection length were indicators of worse postoperative functional result. Conclusions. The TECS seems to be a valid and simple instrument to identify preoperative variables predicting worse results and to assess postoperative outcome. Validation on larger series is necessary. (Ann Thorac Surg 2012;94:1065‐72) © 2012 by The Society of Thoracic Surgeons

Bioengineered tissues created for transplant will be expected to survive and contribute to function over the lifetime of the individual. To evaluate potential intrinsic changes and degradation of the extracellular matrix of decellularized human tissue scaffolds, human decellularized tracheas were evaluated over a one year period in vitro . Human tracheas were decellularized and stored for one year in phosphate-buffered saline at 4 °C in the presence of antibiotics and anti-mycotics, and their structural, mechanical, and angiogenic properties compared to baseline values. Results showed that stored human decellularized tracheas were increasingly degraded resulting in a loss of extracellular matrix architecture – in particular of collagenous and elastic fiber structure –and decreased mechanical and angiogenic properties. The mechanical alterations of the extracellular matrix but not the deterioration and microstructure were not improved by using a natural cross-linking agent. These findings demonstrate that human decellularized tracheas, stored for one year in phosphate-buffered saline solution at 4 °C, would not meet the demands for a tissue engineering matrix and likely would not yield a suitable graft for lifelong implantation. The degradation phenomenon observed in vitro may be further enhanced in vivo , having clinical relevance for tissues that will be transplanted long-term and this should be carefully evaluated in pre-clinical settings.

Nowadays the treatment of patients with non-small cell lung cancer (NSCLC) that invades the chest wall is still questioned. The classic approach is a lobectomy that requires chest wall resection through thoracotomy, but thanks to the progress in the field of thoracoscopic surgery, this procedure can be performed by video-assisted thoracoscopic surgery (VATS). Major advances have been made in recent years both in the surgical technique associated with thoracoscopy and in the instrumentation available today. This has allowed the use of thoracoscopic technique even in advanced disease. To choose to perform complex surgery in assisted video surgery, considerable experience is needed to avoid making mistakes and giving up a better approach for the patient only for any technical difficulties. Thoracoscopy is not currently the preferred intervention for patients with chest wall invasion because there are insufficient studies on the feasibility of lobectomy with thoracoscopic wall resection, although the thoracoscopic approach has reduced mortality and morbidity in lung cancer cases not in advanced stage. We discuss our experience in three patients using hybrid approach with assisted video thoracoscopic lobectomy and a chest wall en-block resection with an alternative method of estimating thoracic wall resection that uses assisted video surgery and hypodermic needles (minimally invasive posterior approach).

We used the Tuscan Cancer Registry archives to retrieve records of 2,896 patients with a histological diagnosis of lung tumor from January 1996 to December 2000. Of 2,410 patients with non-small-cell lung cancer, 767 (31.8%) underwent complete resection. The following variables were analyzed for their influence on survival in the 157 patients with pathologic N1 status: sex, age, cell type, pathologic tumor status, number and level of involved lymph nodes, tumor grade, and type of surgery. Overall 5-year survival rates were 43.9% for 417 patients with pN0 disease, 10.8% for 176 with pN2 disease, and 31.6% for those with pN1 disease. In pN1 disease, the overall 5-year survival rates for patients with hilar and non-hilar lymph node involvement were 27.4% and 39.6%, respectively. Univariate analysis demonstrated that pathological T status and level of N1 involvement weresignificant prognostic factors. Cox proportional hazards analysis indicated that hilar lymph node involvement was an independent prognostic factor. N1 lymph node status was identified as an independent prognostic factor in a combination of subgroups with different prognoses.

Objective: Our aim was to evaluate the best intrathoracoscopic localization technique between hookwire and radio-guided surgery, in patients with pulmonary nodule. Methods: From January 2000 to January 2005 we enrolled in this study 50 patients with a solitary pulmonary nodule, prospective randomized in two groups, well matched for diameter and depth of the pulmonary lesion. In 25 patients we performed the hookwire technique (Group A), whereas in the other 25 patients radio-guided localization was adopted (Group B). In both groups the localization technique was compared with finger palpation. In Group A, 9 lesions were in the left and 16 in the right lung; in Group B, 14 nodules were in the left lung and 11 in the right one. In both groups, the distance of the nodule from the pleural surface with lung inflated was 2.5 cm (1.5-2.5 cm in 12 patients, and >2.5 cm for the remaining 13). The mean size of the nodules in both groups was 1.1, range 0.6-1.9 ( 1 cm n = 7 patients). Results: All patients underwent thoracoscopic wedge resection, and 23 patients with a primary pulmonary lesion underwent thoracotomy for lobectomy and radical mediastinal lymphadenectomy. In Group A the hookwire technique localized the nodule in 21 of 25 patients (84%) whereas finger palpation localized it in 7 of 25 patients (28%). In Group B, radio-guided surgery localized the nodule in 24 of 25 patients (96%) whereas finger palpation localized it in 6 of 25 (24%). In Group A we registered 6 cases of pneumothorax compared to 1 case observed in the radio-guided group. Postoperative hospital stay required an average of 4 days in both groups. Conclusions: In our experience radio-guided surgery has therefore been proven efficacious in the diagnosis of solitary pulmonary nodule and video-assisted thoracoscopic surgery allows the removal of pulmonary nodules without complications. Hookwire was also shown to be efficacious but demonstrated complications linked primarily to external technical factors.

Robot-assisted minimally invasive esophagectomy with intra-thoracic anastomosis showed encouraging results but there is a lack of data to demonstrate the safety and feasibility.The aim of this study is to report our experience in RA-ILE (robotic-assisted Ivor-Lewis esophagectomy) with robotic hand-sewn anastomosis.This is a retrospective study of patients who underwent robotic-assisted esophagectomy in prone position with intrathoracic anastomosis for malignant neoplasm of the esophagus or esophago-gastric junction.From January 2012 to December 2014 we performed eight completely robot-assisted esophagectomy without intra-operative complication. The mortality rate at 30-day was zero. In two patients we observed a partial leakage of the gastric tube that required revision. The mean operative time was 499 ± 46 min including robotic set up and patient positioning. The median hospital-stay was 10 days. Complete (R0) resection was accomplished in all patients and the mean number of lymph nodes removed was 37.6 ± 14 .7.This preliminary experience suggests that robotic-assisted RA-ILE for malignant lesions is a real surgical option compared with conventional surgery with satisfactory results. Copyright © 2015 John WileySons, Ltd.

Carinal resections and reconstructions, with or without lung resection, are challenging operations that may be indicated in less than 1% of operable patients with NSCLC or benign lesions involving the carina. These operations are completed in only a few centers worldwide, likely because of their technical complexity and the general opinion about their limited patient benefit. However, good survival results can be expected in pN0 or pN1 patients so that, in experienced hands, these operations are effective options. The risk of postoperative complications can be minimized by several intraoperative and postoperative precautions.

Objective: Video-assisted thoracic surgery (VATS) is an interesting and emerging procedure for diagnosis and treatment of peripheral pulmonary nodules. However, thoracoscopy has limits in the detection of small nodules, below the pleural surface, deep in the lung parenchyma, which cannot be seen as much as palpated. Methods to localize such lesions, including the methylene blue injection or the introduction of a hooked-wire under the radiological vision, have some advantages but a lot of limitations. We are developing a new technique for the detection of pulmonary nodules smaller than 2 cm, deep in the lung parenchyma. Methods: The technique consisted of a intra-lesional injection of 0.3 ml of solution of 99m Tc-labelled human serum albumin microspheres (5-10 MBq) under the CT-scan guide, 2 h before surgery. During thoracoscopy a 11 mm diameter-collimated probe connected to a gamma ray detector (Scinti Probe MR 100 - Pol.hi.tech., Aquila - Italy), is introduced by a 11.5 mm trocar and the pleural surface of the suspected area was scanned. A hot-spot indicated the presence of the injected nodule and as a consequence, the area to be resected. Results: from June 1997 to June 1999 we treated 39 patients with small pulmonary nodules. The patients were 27 men and 12 women with a mean age of 60.8 years (range: 13-80). In 19 cases the anamnesis was positive for synchronous or metachronous malignant neoplasm. The mean surgical procedure length was 50 min (range 20- 100 min). In all the cases the nodule was resected and the resection margins were pathologically free of tumour. The mean post-operative hospital stay was 3 days (range 2-6 days). Histological examination showed 21 benign lesions and 18 malignant lesions (seven metastases and 11 primary lung cancers). Nine pts with primary lung carcinoma underwent a completion lobectomy by open surgery. Conclusions: Radiolocalization by gamma-probe allows the detection and exeresis of small nodules in a easy and safe way. Future and predictable advances in radio-marked monoclonal antibodies, as well as in the development of endoscopic beta-detector probe, will offer a more effective method for detection of primary and metastatic tumours, targets of thoracoscopic resections. q 2000 Elsevier Science B.V. All rights reserved.

Methods From April 2012 to date, we performed 42 completely thoracoscopic lobectomies (non rib-spreading) with anterior approach to the pulmonary hilum. Clinical stages I were included and T3 or T4 tumors, central tumors, cN1-N2, previous ipsilateral thoracotomy were excluded. Whenever possible, we have obtained a preoperative diagnosis with CT-guided needle biopsy (n = 35, 83%); otherwise lobectomy was preceded by atypical resection and extemporaneous examination. A preoperative mediastinoscopy was performed following the guidelines of the National Comprehensive Cancer Network, 2013 (n = 18, 43%), in the same operative time with extemporaneous examination of the lymph nodes. Lung resection was always associated with a lymphadenectomy of at least 4 ilo-mediastinal stations.

We prospectively evaluated a clinical and endoscopic score, the tracheal endoscopic clinical score (TECS), developed as a disease-specified outcome measure in adult patients undergoing operation for subglottic stenosis. We also performed a retrospective chart review to identify preoperative and intraoperative risk factors for worse TECS.The TECS includes endoscopic (vocal cord and glottic function, anastomotic healing, and patency) and interview (respiration, voice, swallow) variables, and was administered at 6-month follow-up. Endoscopic and subjective domains were weighted to obtain a continuous TECS index ranging from 0 (best) to 1 (worse). The TECS and preoperative variables relationships were evaluated by univariate and multivariate analysis.We collected data (January 2009 to December 2010) from 30 patients (mean age, 48.3±19 years) undergoing subglottic resection and primary reconstruction. Stenosis etiology was postintubation (n=8), idiopathic (n=2), tracheostomy (n=18), and malignant (n=2). Surgery included Pearson operation with (n=7) or without (n=23) a Liberman-Mathisen cricoplasty. Mean length of resected trachea was 30.5±13.5 mm, and mean hospital stay was 7.4 days. Mortality rate was 1 patient (3.3%). The univariate analysis showed positive correlation between 6-month TECS and degree of stenosis (McCaffrey and Cotton scale 0 to 4) stage 4, tracheostomy or T-tube at surgery, bottleneck-type transition stenosis, and resection length. At multivariate analysis, the presence of tracheostomy, bottleneck-type transition stenosis and resection length were indicators of worse postoperative functional result.The TECS seems to be a valid and simple instrument to identify preoperative variables predicting worse results and to assess postoperative outcome. Validation on larger series is necessary.

OBJECTIVES: The safety of fibrin sealants (FS) has been questioned in the light of recent reports of adverse effects. We evaluated the safety of a new FS in a randomized controlled trial (RCT). METHODS: Multicentre, open-label Phase II/III RCT to evaluate the safety of the new FS. The trial was approved by the Ethic Committee of each three participating Centre. FS includes two components (component 1: fibrinogen; component 2: thrombin), each of them subjected to two viral inactivation procedures. Out of 200 screened patients, 185 eligible patients (49 females, 136 males), aged between 18 and 75 years, undergoing major thoracic surgery were randomized to receive FS (#91 patients) as an adjuvant for air leak control or no treatment (#94 patients, control group). Safety variables were: percentage of subjects with adverse events associated with the therapy; formation of antibodies against bovine aprotinin; vital signs (blood pressure, body temperature, heart and respiratory rate); laboratory parameters. RESULTS: Overall operative mortality was 3.2% (6/185), 1.1% in the FS group and 5.3% in the control group, respectively. Twenty patients (22%) had adverse events in the FS group and 22 (23.4%) in the control group. Atrial fibrillation (five patients in the FS group and four in the control group) and hyperpyrexia (five and seven patients, respectively, in the two groups) were the most common adverse events. No patient reported thromboembolic events (pulmonary embolism or deep vein thrombosis) during the in hospital stay or within 1 month from discharge. None of the adverse events was considered as treatment related. The formation of bovine aprotinin antibodies was reported in a total of 34 patients (37.4%) in the FS group and was not related to any adverse effect. CONCLUSIONS: The present RCT did not show any increased risk of adverse events, and of surgical complications, related to the use of the new FS.

This study evaluated the sealing capacity and safety of a new fibrin sealant (FS) to reduce alveolar air leaks (AALs) after pulmonary resections in a randomized controlled clinical trial conducted in 3 Italian centers.The study randomized (1:1) 185 patients with an intraoperative AAL graded 1 to 3 according to the Macchiarini scale: 91 received FS and 94 had standard lung closure. The primary outcomes were the length of postoperative AAL duration and the mean time to chest drain removal. Other end points included the percentage of patients without AAL, the development of serum antibodies against bovine aprotinin, and any adverse event related to FS. Chest drains were removed when fluid output was 100 mL/day or less, with no air leak.The study groups were comparable with respect to demographic variables and surgical procedures. The FS group showed a statistically significant reduction in duration of postoperative AALs (9.52 vs 35.8 hours; p0.005) and in the percentage of patients with AALs at wound closure (81.11% vs 100%; p0.001); the difference in time to chest drain removal was not significant. Pleural empyema developed in 1 patient with FS treatment vs in 4 with standard treatment, and antibodies against bovine aprotinin were found in 34 of 91 FS-treated patients.The present study showed that the new FS is safe and effective in preventing AALs after lung resections and in shortening the duration of postoperative AALs.

To date, only two human laryngeal allotransplants have been reported and, although they were successful, both patients required life-long immunosuppression. A bioengineered human larynx could represent a possible alternative to allotransplantation. Human larynxes were decellularized enzymatically to obtain acellular matrices. Histological and molecular analysis demonstrated that all cellular components and nuclear material were removed. SEM showed that decellularized matrices retained the hierarchical structures of the native larynx, and mechanical tests demonstrated that the decellularization did not significantly impaired the biomechanically properties of the obtained matrices. Immunohistochemical staining found residual angiogenic factors after decellularization, and CAM analysis demonstrated that acellular laryngeal scaffolds induce a strong in vivo angiogenic response. Using a decellularization method, we are now able to obtain, in a short and clinically useful time, natural bioengineered laryngeal scaffolds which could be use for partial or total implantation in humans.

Video-assisted thoracic surgery (VATS) is an interesting and emerging procedure for the diagnosis and treatment of peripheral pulmonary nodules. We developed a new radioguided surgical technique for the detection during VATS of pulmonary nodules smaller than 2 cm, situated deep in the lung parenchyma and neither visible nor palpable with endoscopic instruments. The procedure is divided into two phases. Two hours before surgery 0.3 ml of a solution composed of 0.2 mL of 99mTc-labeled human serum albumin microspheres (5–10 MBq) and 0.1 mL of non-ionic contrast is injected into the lesion under CT guidance. Then the patient is submitted to VATS. During thoracoscopy a collimated probe of 11 mm diameter connected to a gamma ray detector is introduced via an 11.5 mm trocar and the pleural surface of the suspected area is scanned. A hot spot indicates the presence of the radiolabeled nodule and hence the area to be resected. We treated 39 patients with small pulmonary nodules (mean size, 8.3 mm; range, 4–19 mm). The patients were 27 men and 12 women (mean age, 60.8 years; range, 13–80 years). Nineteen patients had a history of synchronous or metachronous malignancy. In all cases the nodule was detected and resected and the resection margins were pathologically free of tumor. Histological examination showed 21 benign and 18 malignant lesions (7 metastases and 11 primary lung cancers). Nine patients with a frozen section-based histopathological diagnosis of lung cancer without functional contraindications underwent a completion lobectomy by open surgery in the same surgical session. In conclusion, the radiolocalization of small pulmonary nodules by gamma probe during VATS is a safe and easy procedure, with fewer complications and a lower failure rate than other localization techniques.

Objectives: We analysed our experience in primary malignant chest-wall tumours (PMCWTs) with an emphasis on a new reconstruction technique and on survival. Methods: From 1998 to 2008, 41 patients (23 (56%) male, mean age 48 years) with PMCWTwere operated in our unit: chondrosarcoma n = 25; osteosarcoma n = 8; Ewing’s sarcoma n = 2; other n = 6. We performed nine sternectomies and 32 lateral chest-wall resections (median number of ribs resected = 3.5). Resections were extended to the lung (n = 2), diaphragm (n = 3), vertebral body (n = 3), scapula (n = 1) and upper limb (n = 1). Stability was obtained by a prosthetic material, rigid and non-rigid and a muscular flap. As non-rigid material, we mostly used a polytetrafluoroethylene patch (n = 24). In the past 2 years, two patients (one total sternectomy and one wide anterior chest-wall resection) were reconstructed with a rigid system composed of mouldable titanium connecting bars and rib clips (Strasbourg Thoracic Osteosyntheses System — STRATOS, MedXpert GMbH, Heitersheim, Germany). A muscular flap was added in 12 patients (29.3%). Results: There was no perioperative mortality or significant morbidity and all patients were extubated within first 24 h. At a mean follow-up of 60.5 months (range 4—130 months), the overall 5- and 10-year survival was 61% and 47%, respectively. In the chondrosarcoma group, 5- and 10-year survival was 80%. Conclusions: Wide resection with tumour-free margins is necessary in PMCWT to minimise local recurrence and to contribute to longterm survival. The STRATOS system, developed for chest-wall replacement, allows a firm reconstruction, simple to handle and to fix, avoiding instability or paradoxical movement also in wide chest-wall resections. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

echocardiography revealed no paradoxical motion of the interventricular septum and a left ventricular ejection fraction of 47%. Cardiac magnetic resonance imaging revealed a left ventricular ejection fraction of 35.8% and left ventricular end-diastolic volume of 124.6 mL (Figure 2). There was no arrhythmia on 24-hour Holter monitor. Eight months after the operation, the patient was in New York Heart Association functional class I with digoxin and angiotensin-converting inhibitor medication. Measured values by echocardiography and cardiac magnetic resonance imaging are shown in Table 1.