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The aim of this study was to assess the impact of BMI on perioperative outcomes in patients undergoing VATS lobectomy or segmentectomy. Data from 5088 patients undergoing VATS lobectomy or segmentectomy, included in the VATS Group Italian Registry, were collected. BMI (kg/m 2 ) was categorized according to the WHO classes: underweight, normal, overweight, obese. The effects of BMI on outcomes (complications, 30-days mortality, DFS and OS) were evaluated with a linear regression model, and with a logistic regression model for binary endpoints. In overweight and obese patients, operative time increased with BMI value. Operating room time increased by 5.54 minutes (S.E. = 1.57) in overweight patients, and 33.12 minutes (S.E. = 10.26) in obese patients (P < 0.001). Compared to the other BMI classes, overweight patients were at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications. In the overweight range, a BMI increase from 25 to 29.9 did not significantly affect the length of stay, nor the risk of any complications, except for renal complications (OR: 1.55; 95% CI: 1.07-2.24; P = 0.03), and it reduced the risk of prolonged air leak (OR: 0.8; 95% CI: 0.71-0.90; P < 0.001). 30-days mortality is higher in the underweight group compared to the others. We did not find any significant difference in DFS and OS. According to our results, obesity increases operating room time for VATS major lung resection. Overweight patients are at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications following VATS resections. The risk of most postoperative complications progressively increases as the BMI deviates from the point at the lowest risk, towards both extremes of BMI values. Thirty days mortality is higher in the underweight group, with no differences in DFS and OS., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Till now there are very few reports about surgical results of Uniportal-VATS esophagectomy and no one about long-term outcomes. This study is the first comparing surgical and oncological outcomes of Uniportal-VATS with open McKeown esophagectomy, with the largest reported series and longest oncological follow-up., Methods: The prospectively collected clinical, surgical and oncological data of 75 patients, undergone McKeown esophagectomy at our Thoracic Surgery Department, from January 2012 to August 2022, were retrospectively analyzed. Nineteen patients underwent esophagectomy by thoracotomy and reconstruction according to McKeown technique while 56 by Uniportal-VATS approach. Gastric tubulization was performed totally laparoscopic or through a mini-laparatomic access and cervical anastomosis was made according to Orringer's technique., Results: The mean operative thoracic time was similar in both accesses (102.34 ± 15.21 min in Uniportal-VATS vs. 115.56 ± 23.12 min in open, p : 0.646), with a comparable number of mediastinal nodes retrieved (Uniportal-VATS:13.40 ± 8.12 vs. open:15.00 ± 6.86, p : 0.275). No case needed conversion from VATS to open. The learning curve in Uniportal-VATS was completed after 34 cases, while the Mastery was reached after 40. Both approaches were comparable in terms of minor post-operative complications (like pneumonia, lung atelectasis, anemization, atrial fibrillation, anastomotic-leak, left vocal cord palsy, chylothorax), while the number of re-operation for major complications (bleeding or mediastinitis) was higher in open group (21.0% vs. 3.6%, p : 0.04). Both techniques were also effective in terms of surgical radicality and local recurrence but VATS approach allowed a significantly lower chest tube length (11.89 ± 9.55 vs. 25.82 ± 24.37 days, p : 0.003) and post-operative stay (15.63 ± 11.69 vs. 25.53 ± 23.33, p : 0.018). The 30-day mortality for complications related to surgery was higher in open group ( p : 0.002). The 2-, 5- and 8-year survival of the whole series was 72%, 50% and 33%, respectively. Combined 2- and 5-year OS in Uniportal-VATS group was 76% and 47% vs. 62% and 62% in open group, respectively (Log-rank, p : 0.286; Breslow-Wilcoxon: p : 0.036). No difference in DFS was recorded between the two approaches (5 year-DFS in Uniportal-VATS: 86% vs. 72%, p : 0.298). At multivariate analysis, only pathological stage independently affected OS ( p : 0.02), not the surgical approach ( p : 0.276)., Conclusions: Uniportal-VATS seems to be a safe, feasible and effective technique for performing McKeown esophagectomy, with equivalent surgical and long-term oncological results to standard thoracotomy, but with a faster and unharmed recovery, and a quite short learning curve., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Nachira, Congedo, Calabrese, Tabacco, Petracca Ciavarella, Meacci, Vita, Punzo, Lococo, Raveglia, Chiappetta, Porziella, Guttadauro, Cioffi and Margaritora.)

Introduction: Stage Ia presents an optimal survival rate after surgical resection, but the type of lymphadenectomy to use in these patients is still debated. The aim of this study is evaluate if one type of lymphadenectomy adopted influences survival in patients who underwent VATS lobectomy for stage Ia NSCLC., Methods: Clinical and pathological data from pIa patients in the prospective VATS Italian nationwide registry were reviewed and analysed. Patients and tumour characteristics,type of lymphadenectomy (sampling or radical nodal dissection,MRLD), were collected and correlated to Overall Survival(OS) and Disease free Survival(DFS). The Kaplan-Meier product-limit method was used to estimate OS and DFS and the log-rank test was adopted to evaluate the differences between groups. A propensity match was performed to reduce bias due to the retrospective study design., Results: The final analysis was conducted on 2039 patients, 179 died during follow-up,recurrence rate was 13%. MRLD was performed in 1287(63.1%)patients. The univariable analysis identified as favourable prognostic factors for OS the female sex(p = 0.023), low ECOG-score(0.008),low SUVmax(p < 0.001), GGO appearance(p < 0.001), pT < 2 cm(p = 0.002) and low tumour grading(p = 0.002). The multivariable analysis confirmed as independent prognostic factors low ECOG-score(p = 0.012), low SUVmax(p < 0.001) and low tumour grading(p < 0.001). Analysing survival in patients with solid/sub-solid nodules and after propensity score matching for pTdimension and number of N2 resected lymphnodes, no OS differences were present comparing sampling vs MRLD., Conclusion: Survival in pIa patients seems to be determined by patient and tumour characteristics such as performance status,grading and SUVmax. Type of lymphadnectomy did not seem to be correlated with OS in these patients., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

BACKGROUND: The aim of this study is to analyze the prognostic factors in patients that underwent induction therapy and surgery for clinical stage III NSCLC. METHODS: Clinical and pathological characteristics of stage III NSCLC patients for N2 involvement that underwent neoadjuvant treatment (NAD) and surgery from 1/01/1998 to 31/12/2017 were collected and retrospectively analyzed. Tumor characteristics, yClinical, yPathological stage and lymph node characteristics were correlated to Overall Survival (OS). RESULTS: The analysis was conducted on 180 patients. Five-year OS (5YOS) was 50.9%. Univariable analysis results revealed old age (p = 0.003), clinical N2 post-NAD (p = 0.01), pneumonectomy (0.005), persistent pathological N2 (p = 0.039, HR 1.9, 95% CI 1.09−2.68) and adjuvant therapy absence (p = 0.049) as significant negative prognostic factors. Multivariable analysis confirmed pN0N1 (p = 0.02, HR 0.29, 95% CI 0.13−0.62) as a favorable independent prognostic factor and adjuvant therapy absence (p = 0.012, HR 2.61, 95% CI 1.23−5.50) as a negative prognostic factor. Patients with persistent N2 presented a 5YOS of 35.3% vs. 55.8% in pN0N1 patients. Regarding lymph node parameters, the lymph node ratio (NR) significantly correlated with OS: 5YOS of 67.6% in patients with NR < 50% vs. 29.5% in NR > 50% (p = 0.029). CONCLUSION: Clinical response aided the stratification of prognosis in patients that underwent multimodal treatment for stage III NSCLC. Adjuvant therapy seemed to be an important option in these patients, while node ratio was a strong prognosticator in patients with persistent nodal involvement.

Background: Descending necrotizing mediastinitis (DNM) is a severe, life-threatening complication of oropharyngeal infections with cervical necrotizing fasciitis. In this study, we aimed to identify any possible factors that correlate with favorable outcomes., Methods: We retrospectively analyzed our series of 18 patients who underwent surgical treatment for DNM from a cervical abscess. Gender, age, symptoms, etiopathogenesis, comorbidities, time to surgery from diagnosis, degree of diffusion, identified microorganisms, surgical procedure, days in the intensive care unit, need for tracheostomy, complications, and surgical outcomes were reviewed., Results: The main type of surgery was thoracotomy + cervicotomy in eight cases (50.0%), followed by cervicotomy +VATS in four (22.2%). Seven patients (38.9%) had two or more surgeries; a bilateral operation was necessary for four patients. Evaluating the risk factors associated with post-operative complications, age ≥ 60 years ( p :0.031), cervicotomy alone as surgical approach ( p = 0.040), and the bilateral approach ( p = 0.048) resulted in significance in terms of the univariate analysis; age ≥ 60 years ( p = 0.04) and cervical approach ( p = 0.05) maintained their significance in terms of the multivariate analysis., Conclusions: The low mortality of our series emphasizes the importance of an extensive and immediate surgical drainage of both the neck and the mediastinum. Mediastinal drainage from cervicotomy seems to be a risk factor for post-operative complications. Minimally invasive surgery on the chest cavity, such as with Uniportal-VATS, could be a good approach above all in elderly patients and all those cases where bilateral access is required.

Background: Robot-assisted thymectomy (RAT) has rapidly emerged as the preferred approach over open trans-sternal or video-assisted thoracoscopy for the surgical treatment of thymomas and non-thymomatous myasthenia gravis (MG). The aim of this study was to describe and discuss the learning curve (LC) of a single surgeon performing 113 consecutive RATs., Methods: A single-center retrospective analysis of prospectively collected clinical data was performed on all patients who had been operated on by the same surgeon in an RAT setting between October 2013 and February 2020. The cumulative sum (CUSUM) analysis of the operative time was used to define the completion of the learning curve (CLC) in RAT. The CLC was separately calculated for myasthenic patients, non-myasthenic patients, and docking time., Results: In myasthenic patients, the CLC cut-off was found in 19 patients. Considering the CLC cut-off of 19 patients, the mean operative time in phase 1 (first 19 cases) was 229.79 ± 93.40 min, while it was 167.35 ± 41.63 min in phase 2 (last 51 cases), p ≪ 0.001 . In non-myasthenic patients, the CLC cut-off was found in 16 cases. The mean operative time in phase 1 (first 16 cases) was 277.44 ± 90.50 min, while it was 169.63 ± 61.10 min in phase 2 (last 27 cases), p  = 0.016. The LC for docking time was reached at 46 cases, recording a significant reduction of time after the first phase (28.09 ± 5.37 min vs. 19.75 ± 5.51 min, p ≪ 0.001 ). The intraoperative and 30-day mortality were null in all phases of the LC in both myasthenic and non-myasthenic patients. There were no differences between the two phases of the LC in terms of blood loss, duration of postoperative drainage, and postoperative stay in both myasthenic and non-myasthenic groups. However, significantly higher hospital readmission at 30 days post surgery was recorded for myasthenic patients operated on during the first phase of the LC (2 cases vs. 0, p  = 0.02)., Conclusions: According to our data, LC in RAT seems to be steep, and RAT confirms to be safe even before reaching CLC., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Meacci, Nachira, Congedo, Petracca-Ciavarella, Vita, Porziella, Chiappetta, Lococo, Tabacco, Triumbari and Margaritora.)

Background: Although the feasibility and safety of Uniportal-Video-Assisted thoracic surgery (U-VATS) has been proven, its surgical effectiveness is still debated. The aim of this study is to assess the equivalence of the U-VATS approach compared with an open technique in terms of surgical (nodal-upstaging, complications, and post-operative results) and short-term survival outcomes., Methods: The clinical data of patients undergoing lobectomy for NSCLC at our center, from January 2014 to December 2019, were analyzed retrospectively. All patients undergoing open or U-VATS lobectomy with lymphadenectomy for early-stage lung cancer (cT1-T3N0, stages IA-IIB) were included in the study. Only 230 patients satisfied the inclusion criteria. Group bias was reduced through 1:1 propensity score matching, which resulted in 46 patients in each group (open surgery and U-VATS)., Results: The intra- and post-operative mortality were null in both groups. There was no difference in the post-operative complications ( p : 1.00) between U-VATS and open lobectomy. There was also no recorded difference in the pathological nodal up-staging [11 (23.9%) after thoracotomy vs. 8 (17.4%) after U-VATS, p : 0.440). The chest tube duration was longer in the open group ( p : 0.025), with a higher post-operative pain ( p: 0.001). Additionally, the 3-year overall survival (OS) was 78% after U-VATS lobectomy vs. 74% after open lobectomy ( p : 0.204), while 3-year disease-specific survival (DSS) was 97 vs. 89% ( p : 0.371), respectively. The 3-year disease-free survival (DFS) was 62% in the U-VATS group and 66% in the thoracotomy group, respectively ( p : 0.917)., Conclusions: Uniportal-VATS lobectomy for the treatment of early-stage lung cancer seems to be a safe and effective technique with similar surgical and short-term survival outcomes as open surgery, but with lower post-operative pain and shorter in-hospital stay., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Nachira, Congedo, Tabacco, Sassorossi, Calabrese, Ismail, Vita, Petracca-Ciavarella, Margaritora and Meacci.)

Objectives: The study aimed to assess the feasibility of radical surgical treatment for selected bone-oligometastatic non-small cell lung cancer (NSCLC) patients and to identify prognostic factors associated with survival., Materials and Methods: The clinical records of 27 patients with bone synchronous oligometastatic NSCLC were retrospectively analyzed., Results: Thirteen (48.1%) bone metastases were treated by surgery and 14 (51.9%) by local radiotherapy. Eighteen (66.7%) patients underwent induction chemotherapy before lung surgery, and 3 (11.1%) concurrent radiotherapy. Pulmonary surgery was a major lung resection in 23 (85.2%) cases. Intraoperative and 30-days mortality was null. Only one major (ARDS) and 10 (37.04%) mild complications (like air leakage, arrhythmia, and mucus retention) were recorded. 1-year and 5-years OS from the diagnosis and 1-year, 3- years disease-free survival (DFS) were 96%, 38%, and 66%, 30%, respectively. After stepwise Cox regression analysis, local recurrence (p = 0.05) and metachronous metastases (p = 0.04) maintained their independent prognostic value as overall survival negative determinants. Nodal upstaging (p = 0.04) and nonsurgical treatment of bone lesion (p = 0.03) turned out to be independent risk factors for shorter DFS; the vertebral localization of bone metastases showed only a remarkable trend towards significance (p = 0.06) as a risk factor for a worse DFS., Conclusions: In selected patients, surgical treatment of primary NSCLC and bone synchronous metastasis seems to be safe and feasible and rewarding survivals may be expected., (© 2021 Wiley Periodicals LLC.)

Introduction: The International Thymic Malignancy Interest Group (ITMIG) classifies thymoma recurrences on the basis of the topographic location, but its effectiveness in prognosis prediction has not been well investigated yet. Aims of this study are to analyze survival outcome of patients surgically treated for thymoma recurrence according to the ITMIG recurrence classification and to investigate possible alternatives., Methods: From January 1, 1990, to January 7, 2017, data on 135 surgically treated patients for thymoma recurrence from three high-volume centers were collected and retrospectively analyzed. Patients were classified according to the ITMIG classification as local, regional, and distant. The ITMIG classification and alternative classifications were correlated to overall survival (OS)., Results: According to the ITMIG classification, recurrence was local in 17 (12.5%), regional in 97 (71.8%), and distant in 21 (15.7%) patients, with single localization in 38 (28.2%) and multiple localizations in 97 (71.8%). The 5- and 10-year OS were 79.9% and 49.7% in local, 68.3% and 52.6% in regional, and 66.3% and 35.4% in distant recurrences, respectively, but differences were not statistically significant (p = 0.625). A significant difference in survival was present considering single versus multiple localizations: 5- and 10-year OS of 86.2% and 81.2% versus 61.3% and 31.5% (p = 0.005, hazard ratio = 7.22, 95% confidence interval: 0.147-0.740), respectively. Combining the localization number with the recurrence site, ITMIG locoregional single recurrence had a statistically significant better survival compared with patients with ITMIG locoregional multiple recurrence or ITMIG distant recurrence (p = 0.028). Similarly, a significant difference was present considering intrathoracic single versus intrathoracic multiple versus distant recurrence (p = 0.024)., Conclusions: The ITMIG classification for thymoma recurrence did not have significant survival differences comparing local, regional, and distant recurrences. Integrating this classification with the number of the localizations may improve its effectiveness in prognosis prediction., (Copyright © 2021. Published by Elsevier Inc.)

Background: The aim of this study was to evaluate the Masaoka-Koga and the tumor node metastases (TNM) staging system in thymic epithelial tumors (TET) considering possible improvements., Methods: We reviewed the data of 379 patients who underwent surgical resection for TET from 1 January 1985 to 1 January 2018, collecting and classifying the pathological report according to the Masaoka-Koga and the TMN system. The number of involved organs was also considered as a possible prognostic factor and integrated in the two staging systems to verify its impact., Results: Considering the Masaoka-Koga system, 5- and 10-year overall survival (5-10YOS) was 96.4% and 88.9% in stage I, 95% and 89.5% in stage II and 85.4% and 72.8% in stage III ( p = 0.01), with overlapping in stage I and stage II curves. Considering the TNM system, 5-10YOS was 95.5% and 88.8% in T1, 84.8% and 70.7% in T2 and 88% and 76.3% in T3 ( p = 0.02), with overlapping T2-T3 curves. Including the number of involved structures, in Masaoka-Koga stage III, patients with singular involved organs had a 100% and 76.6% vs. 87.7% 5-10YOS, which was 76.6% in patients with multiple organ infiltration. Considering the TNM, T3 patients with singular involved structures presented a 5-10YOS of 100% vs. 62.5% and 37.5% in patients with multiple organ involvement ( p = 0.07)., Conclusion: The two staging systems present limitations due to overlapping curves in early Masaoka-Koga stages and in advanced T stages for TNM. The addition of the number of involved organs seems to be a promising factor for the prognosis stratification in these patients.

Background and Objectives: The Masoka-Koga and tumor node metastases staging systems for thymoma are based on structures involved, but the prognostic role of the number of infiltrated/involved structures is still debated. We analyzed the prognostic role of involved structures and their combinations in locally advanced thymomas patients., Methods: Data on 174 surgically treated locally advanced thymoma patients from 1/01/1990 to 31/12/2015 were reviewed. Clinical and pathological characteristic, involved structures, number of involved structures and different combinations were correlated to cancer specific survival (CSS) using Kaplan-Meier product-limit method., Results: Five and 10-year CSS was 92% and 87%. Masaoka Stage 3 (p < 0.001), absence of pericardial involvement (p = 0.001), number of involved structures (p = 0.018), R0 (p < 0.001) and adjuvant radiotherapy (p = 0.008) were favorable prognostic CSS factors. A significant better prognosis was present in ≤2 involved structures vs >2 involved structures (5- and 10-year CSS: 95% and 93% vs. 80% and 51%). Multivariable analysis confirmed as independent prognostic factor R0 (p = 0.033, hazard ratio [HR]: 0.093, 95% confidence interval [CI] 0.010-0.827) and number of involved structures (p = 0.046, HR: 0.187, 95% CI: 0.036-0.968). In Masaoka Stage 3, patients with ≤2 involved structures had a significant better CSS than patients with >2 (10-year CSS: 98% vs. 73%, p = 0.008)., Conclusions: The number of involved structures and the concomitant involvement of the pericardium seems to be associated with a poor prognosis in surgically treated advanced thymoma patients., (© 2021 Wiley Periodicals LLC.)

In this paper we aimed to address the role of pulmonary metastasectomy (PM) in patients affected by Lung Metastases (LM) from Renal Cell Carcinoma (RCC) and to analyse prognostic factors affecting overall survival (OS), disease-free interval (DFI) between primary RCC and first LM, and disease-free survival (DFS) after PM and before lung recurrence. Medical records of 210 patients who underwent PM from RCC in 4 Italian Thoracic Centres, from January 2000 to September 2019, were collected and analysed. All patients underwent RCC resection before lung surgery. The main RCC histology was clear cells (188, 89.5%). The 5- and 10-year OS from the first lung operation were 60% and 34%, respectively. LM synchronous with RCC ( p = 0.01) and (Karnofsky Performance Status Scale) KPSS < 80% ( p < 0.001) negatively influenced OS. Five- and 10-year DFI were 54% and 28%, respectively. The main factors negatively influencing DFI were: male gender ( p = 0.039), KPSS < 80% ( p = 0.009) and lactate dehydrogenase > 1.5 times 140 U/L ( p = 0.001). Five- and 10-year disease-free survival were 54% and 28%, respectively; multiple LM ( p = 0.036), KPSS < 80% ( p = 0.001) and histology of RCC other than clear cells negatively influenced disease-free survival. Conclusions: patients with KPSS > 80%, single metachronous LM with a long DFI from RCC diagnosis, and clear cell histology, benefit from pulmonary metastasectomy.

Background: Accurate assessment of regional lymph node (LN) status is essential for the treatment of head and neck squamous cell carcinoma (HNSCC) patients. In this study, we aimed to compare the difference between intravenous injection of indocyanine green (ICG) and peritumoral injection of ICG in the location of metastatic LNs., Methods: Twenty-nine patients were enrolled in this study with 13 patients receiving intravenous injection of ICG and 16 patients receiving peritumoral injection of ICG. During the surgery, the fluorescence-positive LNs in vivo were sent to undergo frozen section after fluorescence intensity was recorded. After the cervical LN dissection, all LNs were sorted by region, and the fluorescence intensity was recorded before the LNs were sent for paraffin section., Results: During the surgery, both intravenous or peritumoral injections with near-infrared (NIR) fluorescence imaging of ICG had their respective pros and cons in vivo , with the sensitivity and specificity being 62.5%/75% and 98.1%/89.1% respectively. After the surgery, both methods could reduce the pathological workload by preselecting the LNs at-risk in the premise of accurate assessing the cervical LN stage. However, intravenous ICG administration was more valuable in determining all types of LN status according to the fluorescence intensity [area under the curve (AUC): 0.91 vs. 0.78, P<0.001]., Conclusions: With the assistance of NIR fluorescence imaging using ICG, both administration methods could reduce the postoperative complication and the pathological workload, whereas the intravenous mode of ICG administration is superior in application value., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-21-392). Dr. Hu reports grants from Nanjing Clinical Research Center for Oral Diseases, during the conduct of the study; Dr. Cai reports grants from the State Commission of Science & Technology of China, during the conduct of the study; Dr. Wang reports grants from the Jiangsu Province Science & Technology Department, grants from Nanjing Clinical Research Center for Oral Diseases, during the conduct of the study. The other authors have no conflicts of interest to declare., (2021 Annals of Translational Medicine. All rights reserved.)

Background: The optimal thoracoscopic sympathetic surgery for primary palmar and/or axillary hyperhidrosis (PPAH) is still unclear because of lack of uniform technique and qualitative/quantitative scales for definition of results. The aims of this study were to compare long-term outcomes based on the surgical technique and the level of sympathetic trunk interruption by clipping and to assess postoperative compensatory sweating (CS), patients' satisfaction, and quality of life (QoL)., Materials and Methods: Between September 2009 and April 2016, 94 patients who underwent 2-stage bilateral thoracoscopic rib-oriented (R) sympathetic clipping were prospectively followed up through the administration of standardized preoperative and postoperative questionnaires.Thirty-four (36.2%) patients underwent single-port transaxillary access instead of the standard two 5-mm incisions. The level of sympathetic clipping for PPAH was R3+4(top and bottom); in patients who complained associated facial or plantar hyperhidrosis R2-bottom and R5-top were clipped, respectively. Seventy-five patients completed bilateral surgery., Results: There were no significant differences between single-port and biportal video-assisted thoracoscopic surgery in terms of operative times and postoperative results. At a mean follow-up of 72 (SD: 26) months, CS was reported in 42 (56%) patients, severe only in 6 (8%). It was higher in the case of R2-bottom clipping (P=0.03). Thirty-one of 60 (51.6%) patients who had a plantar hyperhidrosis declared an improvement of feet sweating after surgery. Postoperative satisfaction was excellent (86.11% on a 0 to 100 scale) and 95.4% of patients declared an improvement in QoL, which was statistically significant in all evaluated parameters. These results were not related to the level of clipping., Conclusion: Thoracoscopic R3 to R4 clipping appears to be a safe and effective treatment for PPAH. Although postoperative CS was common and higher after R2-bottom clipping, this did not seem to affect patients' satisfaction and improvement in QoL., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

Background:  The aim of this study was to identify prognostic factors in patients affected by non-small cell lung cancer (NSCLC) with chest wall (CW) involvement, analyzing different strategies of treatment and surgical approaches., Methods:  Records of 59 patients affected by NSCLC with CW involvement underwent surgery were retrospectively reviewed, from January 2000 to March 2013., Results:  Induction therapy was administered to 18 (30.5%) patients while adjuvant treatment to 36 (61.0%). In 36 (61%) patients, lung resection was associated only with a parietal pleural resection while in 23 (39%) with CW en-bloc resection. Overall 5-year survival was 34%. Prognostic factors were evaluated in the 51 (86.4%) completely resected (R0) patients.Five-year survival was 60% in patients undergoing induction therapy followed by surgery and 24% in those who underwent surgery as first treatment ( p =  0.11). Five-year survival was better in the neoadjuvant group than that in the surgery group in IIB (T3N0) p-stage (100 vs 28%, p =  0.03), while in the IIIA (T3N1-2,T4N0) p-stage it was of 25 vs 0%, respectively ( p  = 0.53).No 5-year survival difference was found in case of parietal pleural resection versus CW en-bloc resection ( p =  0.27) and in case of only parietal pleural involvement versus soft tissue ( p  = 0.78).In case of incomplete resection (R1), patients undergoing adjuvant radiotherapy had better 2-year survival than patients untreated: 60% vs 0% ( p =  0.025)., Conclusions:  Type of surgical resection and the deep of infiltration of disease do not influence survival in this subset of patients. Integrated treatments seem to be suitable: neoadjuvant therapies ensure a better survival rate than surgery alone in IIB and IIIA patients, instead adjuvant radiotherapy proves a fundamental option in incomplete resections., Competing Interests: The authors declared that they have no conflicts of interest or financial ties to disclose., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Data on high-flow nasal oxygen after thoracic surgery are limited and confined to the comparison with low-flow oxygen. Different from low-flow oxygen, Venturi masks provide higher gas flow at a predetermined fraction of inspired oxygen (FiO 2 ). We conducted a randomized trial to determine whether preemptive high-flow nasal oxygen reduces the incidence of postoperative hypoxemia after lung resection, as compared to Venturi mask oxygen therapy., Methods: In this single-center, randomized trial conducted in a teaching hospital in Italy, consecutive adult patients undergoing thoracotomic lung resection, who were not on long-term oxygen therapy, were randomly assigned to receive high-flow nasal or Venturi mask oxygen after extubation continuously for two postoperative days. The primary outcome was the incidence of postoperative hypoxemia (i.e., ratio of the partial pressure of arterial oxygen to FiO 2 (PaO 2 /FiO 2 ) lower than 300 mmHg) within four postoperative days., Results: Between September 2015 and April 2018, 96 patients were enrolled; 95 patients were analyzed (47 in high-flow group and 48 in Venturi mask group). In both groups, 38 patients (81% in the high-flow group and 79% in the Venturi mask group) developed postoperative hypoxemia, with an unadjusted odds ratio (OR) for the high-flow group of 1.11 [95% confidence interval (CI) 0.41-3] (p = 0.84). No inter-group differences were found in the degree of dyspnea nor in the proportion of patients needing oxygen therapy after treatment discontinuation (OR 1.34 [95% CI 0.60-3]), experiencing pulmonary complications (OR 1.29 [95% CI 0.51-3.25]) or requiring ventilatory support (OR 0.67 [95% CI 0.11-4.18]). Post hoc analyses revealed that PaO 2 /FiO 2 during the study was not different between groups (p = 0.92), but patients receiving high-flow nasal oxygen had lower arterial pressure of carbon dioxide, with a mean inter-group difference of 2 mmHg [95% CI 0.5-3.4] (p = 0.009), and were burdened by a lower risk of postoperative hypercapnia (adjusted OR 0.18 [95% CI 0.06-0.54], p = 0.002)., Conclusions: When compared to Venturi mask after thoracotomic lung resection, preemptive high-flow nasal oxygen did not reduce the incidence of postoperative hypoxemia nor improved other analyzed outcomes. Further adequately powered investigations in this setting are warranted to establish whether high-flow nasal oxygen may yield clinical benefit on carbon dioxide clearance., Trial Registration: ClinicalTrials.gov, NCT02544477 . Registered 9 September 2015.

[This corrects the article DOI: 10.1186/S12957-018-1434-2.].

The aim of this study was to analyze the information from post-operative chest ultrasound (CU) to evaluate the possibility to use this method instead of chest X-ray (CXR) after thoracic surgery. Patients who underwent thoracic surgery were evaluated with CU blinded to CXR after surgery, deciding if it was useful or CU was exhaustive. Twenty-four patients were enrolled prospectively. The CU allowed a further discrimination of the lung abnormalities, discriminating between atelectasis, infections or hematoma. CXR was required in only 5 cases due to the presence of massive subcutaneous emphysema or absence of lung point. In the remaining 19 cases, CU was considered exhaustive and effective. In particular, CU was considered exhaustive in 67% of cases after open surgery and in 85% of cases after video-assisted thoracic surgery. In conclusion, CU appears to be effective in post-operative management after thoracic surgery and it can increase the diagnostic accuracy reducing any unnecessary X-ray exposure., (Copyright © 2018 World Federation for Ultrasound in Medicine and Biology. Published by Elsevier Inc. All rights reserved.)

Background: We report our experience and outcomes about the management of Askin's tumors [AT], which are rare primitive neuroectodermal tumors (PNETs) that develop within the soft tissue of the thoracopulmonary region, typically in children and adolescents., Methods: We retrospectively analyzed the charts of 9 patients affected by AT (aged 6-15 years), treated at the Paediatric Oncology Unit of Gemelli University Hospital in Rome between January 2001 and December 2016., Results: All nine patients underwent to biopsy followed by neoadjuvant chemotherapy. At the end of the neoadjuvant chemotherapy, they underwent to surgical removal of the residual tumor. Five patients with positive tumor margins and/or necrosis< 90% received local radiotherapy. Two patients with metastasis received an intensified treatment, with the addition of high dose adjuvant chemotherapy followed by peripheral blood stem cells rescue. No statistically significant correlation was found between outcome and gender; the presence of any metastasis and the radiotherapy. The overall survival was 65.14 months (95% confidence interval [95%CI], 45.81-84.48), and the 5 years survival was 60%, at a median follow-up of 53.1 months., Conclusion: Our study confirms that a multimodal treatment with surgery, chemotherapy, and radiotherapy may increase the survival in AT pediatric patients.

Objective: Despite the intense debate concerning the prognostic impact of fissure involvement (FI) in patients with non-small-cell lung cancer, no specific surgical strategies have been yet recommended when this condition occurs. In this setting, we report our monocentric 10-years experience to investigate this issue., Methods: From January 2000 to January 2010, the clinical data of 40 non-small-cell lung cancer patients with FI undergoing curative resection were retrospectively reviewed. The sample was stratified according to the type of resection: group A (28 patients): anatomical resection (bilobectomy [21 patients], pneumonectomy [7 patients]); group B (12 patients): nonanatomical resection (lobectomy plus wedge resection [LWR]). The end-points were (1) impact of different surgical approach on the pulmonary function (measured before surgery and 1 month after discharge); (2) disease-specific survival; and (3) tumor recurrence.The t test, χ, and log-rank tests, Kaplan-Meier method, and Cox and logistic regression analyses were used for the statistical analysis., Results: No differences between the two groups were found when comparing the clinical characteristics, histology, pN or pT status, p-stage, residual (R1) disease, tumor grading, or tumor size. Similarly, the baseline preoperative function (tested as forced expiratory volume in 1 second-%-predicted, FEV1%) was likewise comparable (92.5% ± 21.0% in group A versus 85.2% ± 20.0% in group B; p = not significant). The decline of FEV1% after surgery was slightly higher in group A (-24.9% ± 13.5%) when compared with that in group B (-19.5% ± 13.3%), but this difference was not statistically significant (p = ns). Nevertheless, the 5-year disease-specific survival was 56% for group A and 47% for group B (p = ns). The recurrence rate did not differ between the patients undergoing a LWR (3 of 12 patients) and those undergoing a bilobectomy or pneumonectomy (9 of 28 patients) (p = ns). The presence of FI extended for more than 3 cm was found to be the most significant prognostic factor when analyzing survival (p = 0.002) and recurrence rate (p< 0.001)., Conclusions: Our results suggest that nonanatomical resection (LWR) could be considered as a feasible surgical option (especially in "frail" patients with an extent of FI less than 3 cm) in the light of the similar oncological and functional outcome compared with anatomical resection. Further studies based on larger series are needed to confirm these preliminary data and also to investigate the impact on the postoperative quality of life.

Skeletal muscle metastasis is a very rare event in patients with oesophageal cancer. We herein report and discuss a case of a 65 years old man with history of gastro-esophageal reflux disease referred to our department for pyrosis associated to persistent low back pain. Oesophageal endoscopy and transesophageal endo-sonography showed a tumour localized in the lower third of the esophagus, histologically proved to be adenocarcinoma. Clinical staging procedures detected a two centimetres vascularized nodular lesion placed into right para-vertebral muscles at the level of L4 as the only sign of potential distant disease (versus a differential diagnosis of primitive sarcoma). The muscle lesion was completely removed and confirmed as secondary adenocarcinoma. Due to this evidence a chemotherapy protocol was initiated. After nine months the patient underwent transhiatal oesophagectomy. To the best of our knowledge this is the first reported case of a soft tissue metastasis from oesophageal cancer resected with radical intent.

Objective: Esophageal anastomotic leaks are associated with significant morbidity and mortality. The purpose of this study was to retrospectively assess the role of the anastomotic positioning (thoracic or cervical) on the incindence of the anastomotic leak and its severity., Methods: In the period 2002-07, we have performed extended esophagectomy with a curative-intent in 63 patients with esophageal cancer. The clinical outcome of the 46 patients where a cervical anastomosis was performed (Group A) has been compared with that of the 17 with thoracic anastomosis (Group B), in terms of leak incidence, pattern of healing, morbidity, and mortality., Results: Leaks occurred in 11% patients of the in group A and in 8% of the group B. When the dehiscence has occurred in the cervical region 1/4th of patients died before the 30th post-operative day compared to the 3/5th of those where the leak occurred at the level of the thorax., Conclusions: On the basis of our findings we suggest the adopt the cervical anastomosis due to lower mortality rate related when leaks occur.

Background: The determinants and predictors of QOL in lung cancer survivors who have received surgery remain defined vaguely and still debated. We evaluate clinical, surgical, and pulmonary function characteristics as predictors of QOL in long-term lung cancer survivors who received surgery., Methods: Quality of life was evaluated 5 years after surgery in 67 lung cancer patients using the European Organization for Research and Treatment of Cancer (EORTC) QOL Core Questionnaire, its lung cancer-specific module QLQ LC-13, and the Hospital Anxiety and Depression Scale questionnaire. Preoperative clinical, surgical, and pathologic data were matched with the questionnaire scores., Results: Sex was associated with role functioning and symptoms, with males more often reporting fatigue and pain, appetite loss, coughing, and hemoptysis (P < .05). Lower education was associated with better cognitive functioning (P < .05). Symptoms were worse for younger patients and for those with major comorbidity. Histology marginally influenced the global health status (P < .10) and the cognitive functioning (P < .05). Patients receiving complementary therapy more easily suffered from fatigue and insomnia (P < .05), and to a lesser extent from nausea and vomiting, constipation, and stress related to financial difficulties (P < .10). Higher values of forced expiratory volume at the first second (FEV(1)) and forced vital capacity (FVC) were significantly (P < .05) associated with a lower frequency of nausea and vomiting and appetite loss, while low percentage levels of FEV(1) and FVC were associated with lower global function and a greater severity of specific and nonspecific symptoms (P < .10 and P < .05)., Conclusions: Several preoperative features, particularly those reflecting pulmonary function, were moderately associated with QOL in long-term survivors and may be useful to address therapeutic strategies in lung cancer patients after surgery., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Diaphragmatic hernias occurring during pregnancy are an uncommon event. In very rare occasions, the clinical situation can suddenly worsen due to obstruction, torsion or infarction of the herniated viscera. Here, we describe a challenging case of a post-partum diaphragmatic hiatus hernia complicated by intrathoracic gastric perforation. A 23-year old woman was admitted at our hospital with a syndrome characterized by epigastralgy, dyspnoea and fever. She had previously undergone a laparoscopic antireflux surgery for hiatus hernia (6 years before) and a recent (4 months) unremarkable vaginal delivery. Due to the persistence of a pelvic pain after the delivery, she had been taking pain-killers as a self-administered medication. A CT scan showed a massive left pleural effusion and a complete herniation of the stomach into the left hemithorax. After placing a chest drainage and removing up to 3000 ml of brownish purulent fluid, a repeat CT scan (with water soluble contrast swallow) showed a leak at the level of the stomach. At surgery, we observed a complete intrathoracic herniation through a large diaphragmatic hiatal defect and a small well-defined gastric ulcer. A primary repair of both the stomach and the diaphragm was performed. We take the opportunity presented by this report to briefly discuss the patho-physiological mechanisms underlying this unusual complication.

Background: The aim of this study was to analyze the impact of the induction chemoradiotherapy (IT) on the survival pattern in T3/T4-N0 non-small cell lung cancer (NSCLC) patients., Methods: The data of 71 patients treated from January 1992 to May 2007 were reviewed. Of these, 31 patients received IT prior to surgery (IT group: T3, 20 patients; and T4, 11 patients), and 40 directly underwent surgery (S group: T3, 34 patients; and T4, 6 patients). Survival rates were compared using the Kaplan-Meier analysis and the Cox proportional hazards models., Results: Mean ages were 62.5±9.9 years in the IT group and 67.7±7.1 in the S group. All patients but 1 completed the IT treatment and 27 patients (87%) were operated. A radical resection was possible in 21 patients (78%). In the IT group a complete pathologic response was obtained in 6 patients (22%), where 8 patients ended up in pI stage, 7 in pII stage, and 6 in pIII stage. The overall 5-year survival (long-term survival [LTS]) and disease-free 5-year survival (DFS) for the entire cohort were 40% and 34%, respectively. No significant differences were found when LTS in the IT group (44%) and in the S group (37%) were compared. At multivariate analysis, the completeness of resection was the only independent predictive factor (hazard ratio [HR]=5.18; 95% confidence interval [CI]=2.55 to 10.28) while Cox multivariate analysis (on the IT group only) confirmed the critical role of the pathologic downstaging (HR=4.62; 95% CI=1.54 to 13.89)., Conclusions: A multimodal strategy with IT treatment followed by surgery is a safe and reasonable treatment in T3/T4-N0 NSCLC patients, but no clear evidence of prognostic improvement may be assumed at the present time. Nevertheless, patients with radical resection and complete pathologic response have a very rewarding survival., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The impact of myasthenia gravis on patients with thymoma is still controversial when perioperative and long-term outcomes are analyzed. With the unique opportunity of a 35-year follow-up in a single institution, thymomatous myasthenia gravis cohort, we investigated the influence of early and long-term clinical predictors., Methods: We reviewed a surgical series of 317 (1972 to 2007) patients with thymoma: clinical and pathologic features were analyzed as prognostic factors matched against the short- and long-term survival and recurrence rates., Results: Male to female ratio was 153:164; median age, 49 years. Myasthenia gravis coexisted in 276 patients (87.1%). Thymomas were classified according to the Masaoka (42.0% stage I, 32.2% stage II, 21.5% stage III, and 4.4% stage IV) and the World Health Organization (3.5% type A, 9.5% type AB, 19.2% type B1, 57.7% type B2, 8.2% type B3, and 1.9% thymic carcinoma) staging systems. The resection was complete in 295 patients (93.1%). Operative mortality and morbidity were respectively 1.6% and 7.6%. No differences were recorded in postoperative outcome stratifying for myasthenia gravis or comorbidities. Mean follow-up was 144.7 +/- 104.4 months. The overall 5-, 10-, 20-, and 30-year survival rates were 89.9%, 84.1%, 73%, and 58.6%, respectively. The completeness of resection (p < 0.001), the Masaoka staging (p = 0.010), and the World Health Organization classification (p < 0.001) all significantly influenced the long-term survival (univariate analysis). Only completeness of resection was significantly correlated with a better prognosis (p < 0.001) in multivariate analysis. Masaoka staging (p < 0.001) and World Health Organization classification (p < 0.001) significantly correlated with the disease-free survival in the univariate and multivariate analyses as significant prognostic factors (Masaoka, p < 0.001; World Health Organization, p = 0.011). Myasthenia gravis patients showed a better prognosis in terms of long-term survival (p = 0.046) and disease-free survival (p = 0.012) in the univariate analysis., Conclusions: We confirm the evidence that the clinical staging and the histologic classification influence long-term survival. The presence of myasthenia gravis was not significantly related to operative outcome, but prolongs both long-term survival and disease-free survival., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: The treatment of recurrent thymomas remains still controversial., Patients and Methods: From 1972 to 2006, 265 (114 males and 118 females ) patients with thymoma underwent surgery at Catholic University of Sacred Heart. Twenty of these 265 patients developed a recurrence of the initial thymoma, and they represent the population of the present study., Results: One patient died of sudden death related to respiratory failure. The overall morbidity rate was 33% and the morbidity rate among myasthenic patients was 60%. 10 patients died during the follow-up; 2 of unrelated diseases, 2 of myasthenia gravis, and 6 of tumor growth. The overall actuarial survival rates were 43% and 37% at 5 and 10 years, respectively. Recurrences never appeared in patients with I stage of Masaoka and in type A and AB., Conclusions: Considering the particular spread of thymoma and the encouraging results of the aggressive surgical approach, re-resection should be recommended in respectable recurrent thymomas.

Objective: We describe the technique, the benefits and the drawbacks of an original video-assisted thymectomy (VAT), performed through an inframammary cosmetic incision and median sternotomy in myasthenia gravis (MG) patients. This procedure is clinically valuable and cosmetically satisfactory so as to be very well accepted by patients, especially by young women. Minimal-access thymectomy has become increasingly popular as surgical treatment for patients with nonthymomatous myasthenia gravis because of its comparable efficacy, safety, and lesser degree of tissue trauma with conventional open surgery., Methods: We report a review/interview of 180 MG patients treated between 1993 and 2005. According to Myasthenia Gravis Foundation of America (MGFA), complete stable remission (CSR) and pharmacologic remission (PR) were calculated at the end of a minimal period of 12 months., Results: A clinical remission was obtained in 41.1% (CR 27.8%, PR 13.3%), who had been followed for at least 12 months from surgery. 95% of these patients judged their cosmetic results to be excellent or good., Conclusions: Thymectomy in MG video-assisted infra-mammary cosmetic incision has shown to be a useful surgical approach as demonstrated by the good functional and very good aesthetic results, associated with a very low morbidity and no mortality.

Malignant pleural effusion is a frequent condition with important prognostic repercussions on duration and quality of life. The neoplasms that more frequently determine pleural effusion are lung and breast cancer and pleural mesothelioma. Lymphomas, tumours of the genitourinary tract and gastrointestinal tract as a group account for a further 25%. Surgical treatment has palliative purposes and finalized to reduction symptoms and to improve quality of life. More frequent clinical presentation is a massive pleural efusion associated to dyspnoea and cough. Pleural aspiration is the first choice treatment but the recurrence rate equals to 100% within 1 month. Repeated pleural aspirations are indicated in those patients that have lower expectation of life. The recurrence risk can be reduced with chemical pleurodesis that allows the adhesion between pleural surfaces. Pleurodesis can be realized by the instillation of several substances by the tube of drainage (slurry) or during thoracoscopy (poudrage). Video Assisted Thoracoscopy (VATS) is a safe and well tolerated technique, a complication rate is lower than 0.5%, VATS can be used to obtain diagnosis and to treat patients with malignant pleural effusion and better expectation of life.

In Transhiatal Esophagectomy(THE) two approaches can be used by the surgeon: abdominal and cervical, without thoracotomy. A pioneer of this technique was Orringer, with the largest experience world-wide (1085 patients). THE is associated with a lower morbidity compared with the transthoracic approach, but much controversy exists on whether THE is a suitable operation for cancer, because it is not combined with en-bloc lymphadenectomy. However, overall, there are no statistical differences between the two. Frequently esophageal carcinoma is a systemic disease and thus, the biological behavior and the stage of tumor rather than the technique, play a major role.

Esophageal carcinoma is often diagnosed at an advanced, non resectable stage. Only early stages show a better prognosis. Surgical treatment represents the gold standard. The various surgical techniques do not seem to affect survival. Based on the severity of esophageal cancer and on poor outcome achievable with surgery alone, multimodality treatments are the most suitable. The possible negative impact on the complication rate after neoadjuvant therapy is still debated. Most randomized trials have not demonstrated as yet an improvement in prognosis in patients undergoing a three-modality treatment. However, patients with complete pathologic response after surgical resection were shown to have a better prognosis. In conclusion, additional randomized trials are required, aimed at evaluating all technical and therapeutic variables which affect prognosis.

Esophageal cancer ranks sixth among the causes of death from cancer worldwide. Patients undergoing surgery have a median survival ranging from 13 to 19 months; 2-year survival rates range from 35 to 42 percent, and 5-year survival rates from 15 to 24 percent. In particular, the 3 year survival (= SVV) is about 26%, with a median survival of 17 months. An interesting point is that about 20-25% of the patients has only locoregional involvement as pattern of failure. At least two randomized studies reported about the combined use of radiotherapy and chemotherapy as sensibilization. They assessed that patients treated with chemoradiation had a longer median survival compared to patients receiving radiation therapy alone, both in early and advanced stages. Moreover radiochemotherapy seems able of achieving high rates of downstaging and of increasing overall and disease-free survival.

The effectiveness of lymph node dissection in the treatment of non-small cell lung cancer is evaluated. The extent of lymphadenectomy in the treatment of NSCLC is still controversial. Although some centers perform only mediastinal lymph node sampling with resection of suspicious lymph nodes, others recommend radical, systematic mediastinal lymph node dissection to improve survival and achieve a better staging. Reports of the literature on the subject are reviewed and the results achieved with the various procedures are analyzed. A personal technique to perform mediastinal lymph node dissection is described.

Large studies have demonstrated that TNM staging system is the most consistent prognostic factor in patients with non small cell lung carcinoma. However, because patients within the same stage may have very different survival, better prognostic information is needed. The recent progress in molecular biology has allowed the analysis of proteins and genes involved in cancer development. To date, more than 150 different prognostic factors affecting survival in patients with lung cancer have been discovered and extensively studied. Despite the encouraging prognostic results in angiogenesis markers, there is not yet a molecular marker validated in large prospective trials that has major independent predictive prognostic value.