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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: Catamenial pneumothorax (CP) is defined as a recurrent, spontaneous pneumothorax occurring within a day before or 72 h after the onset of menstruation. Most first episodes go undiagnosed and treated as primary spontaneous pneumothorax, and only after recurrence is the clinical suspicion of CP raised. No gold-standard management approach exists, especially in terms of managing diaphragmatic involvement., Methods: This study is a single-centre cohort retrospective study of 24 female patients who underwent surgery for pneumothorax due to diaphragmatic endometriosis between January 2008 and December 2016. Two groups were compared: a group that underwent pleurodesis alone (8 patients) and a group that underwent diaphragmatic surgery and pleurodesis (16 patients)., Results: There were differences in BMI and smoking habits between the two groups. The right diaphragm was involved more often (6vs15, p = 0.190). VATS was the preferred surgical approach and only one conversion occurred in the diaphragmatic surgery group (p = 0.470). Diaphragmatic abnormalities were present in all the patients, brown/violet spots (100%) in the pleurodesis group and perforations (100%) in the diaphragmatic surgery group (p < 0.001). There were no differences in days of chest tube removal and length of stay. The recurrence rate was 100% in the pleurodesis alone group while it was only 12.5% in the diaphragmatic surgery group (< 0.001)., Conclusions: In our experience, diaphragmatic surgery and pleurodesis followed by hormonal therapy was an effective approach in preventing recurrence in patients with catamenial pneumothorax and diaphragmatic involvement., (© 2022. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Background: Minimally invasive surgery is considered the gold standard approach for early stage lung cancer. Techniques range from a standard three-port approach to uniportal lobectomies, with no technique emerging as superior thus far. We retrospectively compared the pain outcomes of a standard approach using a utility incision with a totally thoracoscopic technique., Methods: Between January 2015 and December 2019, 168 patients received a VATS lobectomy in our centers. Two groups were created, Group A (82 patients, totally thoracoscopic approach) and Group B (86 patients, standard approach with utility incision). Perioperative outcomes, such as operative time, complications, length of stay, perioperative and chronic pain using visual analog scale (VAS), and rescue doses of painkillers were examined. A one-way analysis of covariance (ANCOVA) was conducted to investigate the impact of surgical time and days of drainage on VAS score., Results: Pain was less on postoperative day (POD) 1 and 2 (p = 0.025 and p = 0.020, respectively) in Group A. No differences were found in the baseline and perioperative characteristics of the two groups, in the mean VAS score at 1 month (p = 0.429), 1 year (p = 0.561), doses of NSAIDs (p = 0.609), and chronic pain (3vs7 patients, p = 0.220). The ANCOVA test showed no significant effect of surgical time and days of drainage on VAS score (p > 0.05)., Conclusions: In our experience, a totally thoracoscopic approach may improve acute postoperative pain without compromising the oncological results of the procedure and the safety of the patients., (© 2022. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Malignant pleural mesothelioma (MPM) is an aggressive asbestos-related tumour with poor prognosis. To date, a multimodality treatment, including chemotherapy and surgery, with or without radiotherapy, is the gold standard therapy for selected patients with epithelioid and early-stage MPM. In this setting, the goal of surgery is to achieve the macroscopic complete resection, obtained by either extrapleural pneumonectomy or pleurectomy/decortication. Failure, in local and/or distant sites, is one of the major concerns; in fact, there has been no established treatment for the recurrence of MPM after the multimodal approach, and the role of surgery in this context is still controversial. By using electronic databases, studies that included recurrent MPM patients who underwent a second surgery were identified. The endpoints included were: a pattern of recurrence, post-recurrence survival (PRS), and the type of second surgery. When available, factors predicting better PRS and perioperative mortality and morbidity were collected. This systematic review offers an overview of the results that are currently obtained in patients undergoing a second surgery for relapsed MPM, with the aim to provide a comprehensive view on this subject that explores if a second surgery leads to an improvement in survival.

Background: Bronchoplastic procedures have become the reference standard in the lung parenchyma-sparing treatment of centrally located bronchopulmonary tumors. Two schools of thought exist regarding performing a bronchial sleeve resection: those who wrap the anastomosis with a pedicled flap and those who leave the anastomosis unprotected. We performed a study comparing these 2 methods., Methods: This study was a retrospective multicenter observational analysis of 90 consecutive patients undergoing bronchial sleeve resections for neoplastic disease between June 2009 and July 2019. Group A (60 patients) underwent bronchial wrapping and group B (30 patients) did not undergo wrapping., Results: The only difference between group A, which had 5 patients (8.3%), and group B, which had 10 patients (33.3%), regarding general characteristics was the presence of diabetes (P = .003). There were no differences in surgical, postoperative, and follow-up characteristics. There was no statistically significant difference between groups (group A, 9 patients [15%]; and group B, 6 patients [20%]) in terms of anastomotic complications at 1 year (P = .425). Diabetes was an independent predictive factor for anastomotic complications at 1 year (P = .035). The number of postoperative complications (P < .001) was an independent risk factor for length of hospital stay., Conclusions: We found no differences between groups in terms of postoperative complications and length of hospital stay, which confirmed previous reports that sleeve resections may be performed safely without bronchial wrapping., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Eso-SPONGE® has proved to be an excellent method for the treatment of persistent dehiscence of the intrathoracic esophagogastric anastomosis during the operation of subtotal esophagectomy sec. Ivor Lewis., Clinical Case Presentation: The case presented is of a 72-year-old patient with esophageal adenocarcinoma (ADK) who underwent sub-total esophagectomy and esophagoplasty sec. Ivor Lewis complicated by an esophageal leak. The Eso-SPONGE® therapy has been successful halving the index of inflammation after the first two sessions and generation of a neowall after seven sessions., Discussion: Eso-SPONGE® therapy has proven to be a valuable resource as a treatment for esophageal anastomotic dehiscences because it is easily repeatable in suburban centers, provided that they have a digestive endoscopy specialized in the positioning process., Conclusions: Eso-SPONGE® is a minimally invasive method that delivers excellent results in the treatment of fragile patients, such as those who have post-esophageal anastomotic dehiscence., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Left ventricular penetrating injuries are rare but often lethal. Transport times greater than 30 min have been shown to increase the injury severity; thus early recognition of cardiac tamponade, prompt pericardial decompression, and control of cardiac hemorrhage are mandatory., Methods: We retrospectively reviewed our record to include patients with penetrating trauma of the heart., Results: Four hemodynamically unstable young male patients with left ventricular penetrating injury of the heart were referred to our unit between January 2007 and December 2015. Median time from trauma to surgery was 16 min (range 14-21). A cardiorrhaphy through sternotomy with no extracorporeal support was performed. We had no in-hospital mortality., Conclusion: According to our experience, in patients with hemodynamic shock and penetrating cardiac injury, a timely recognition of injuries and referral to the closest thoracic surgery unit may increase patient survival if it is located closer than a level I trauma center., (© 2021. The Japanese Association for Thoracic Surgery.)

Foreign bodies in the pulmonary circulation have been documented in the literature, with almost all cases being iatrogenic, involving venous catheters, or due to penetrating foreign body emboli. Foreign body pulmonary emboli are often difficult to diagnose due to their varied clinical presentation, the nature of the embolizing material and dubious radiological features. We describe the case of a patient who experienced episodes of massive hemoptysis with inconclusive radiological findings, who underwent a thoracotomy with the discovery of a wooden object of 7 cm in length in the right lower lobe artery, with no apparent mechanism of injury.

Objectives: Vascular injuries are among the most severe causes of unplanned conversion during VATS lobectomies. The study aimed to analyse the incidence of vascular injuries and their risk factors during VATS lobectomy., Methods: The Italian VATS lobectomy Registry was used to collect data from 66 Thoracic Surgery Units. From 2013 to October 2016 (out of more than 3,700 patients enrolled) only information from Units with an enrollment >100 VATS lobectomies were retrospectively analysed. Logistic regression analysis was performed on selected variables of the univariate analysis., Results: Ten institutions contributed a total of 1,679 patients. Vascular injuries leading to conversion occurred in 44 (2.6%) patients. Years of experiences were inversely related to the risk of vascular injuries. Univariate analysis showed age, gender, surgical activity, Charlson Index Score and number of resected lymph nodes like significantly associated variables. Multivariate analysis revealed that number of resected lymph nodes, VATS experience ratio (number of VATS lobectomies/total lobectomies performed in the same year at same centre), and surgical activity of the centre were significantly associated with the risk of conversion. Unplanned thoracotomy was correlated with postoperative morbidity., Conclusion: Vascular injuries in VATS lobectomies represented a rare complication which could directly affect the postoperative outcomes. The predictive factors for conversion were multifactorial and depended on characteristics of centres and surgeons' seniority. Minimally invasive VATS lobectomy approaches did not influence the risk of vascular damages., (Copyright © 2019 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: The expertise curve of video-assisted thoracoscopic surgery (VATS) lobectomies still stirs debate and controversy both because of the number of procedures to carry out and of the evaluation of the learning threshold. The purpose of our study was the examination of the variables related to the learning curve of the video-assisted approach, to establish what may be an expression of the technical maturity of the surgeon., Methods: The National Register for VATS lobectomy built in 2013 was used to collect data from 65 Thoracic Surgery Units. Out of more than 3,700 patients enrolled, only information from Units with ≥100 VATS lobectomies were retrospectively analysed. Unpaired Student's t -tests, Fisher's exact tests, Pearson's χ 2 were applied as needed. Cumulative summative analysis and one-way ANOVA were used to identify the expertise curve of VATS lobectomy., Results: Ten institutions contributed a total of 1,679 patients, who were divided into three uniform groups according to the chronological sequence of surgery. The length of utility incision, the number of dissected lymph nodes and the operative time were not statistically significant (P=0.999, P=0.972 and P=0.307, respectively) among groups. Conversion to thoracotomy and postoperative air leaks occurred in 125 (7.44%) and 109 (6.49%) patients, gradually declined in Group 3 with statistical significance (P=0.048 and P=0.00086)., Conclusions: The conversion rate and the percentage of air leaks seem to define the expertise of VATS lobectomy, being linked to the ability to manage more complicated surgical cases or intraoperative adverse events., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

The management of hemothorax (spontaneous or, more often, due to thoracic trauma lesions), follows basic tenets well-respected by cardiothoracic surgeons. In most, a non-operative approach is adequate and safe, with a defined group of patients requiring only tube thoracostomy. Only a minority of patients need a surgical intervention due to retained hemothorax, persistent bleeding or incoming complications, as pleural empyema or entrapped lung. In the early 1990s, the rapid technological developments determined an increase of diagnostic and therapeutical indications for multiport video-assisted thoracoscopic surgery (VATS) as the gold standard therapy for retained and persistent hemothorax, allowing an earlier diagnosis, total clots removal and better tubes placement with less morbidity, reduced post-operative pain and shorter hospital stay. There is no consensus in the literature regarding the timing for draining hemothorax, but best results are obtained when the drainage is performed within the first 5 days after the onset. The traditional multi-port approach has evolved in the last years into an uniportal approach that mimics open surgical vantage points utilizing a non-rib-spreading single small incision. Currently, in experienced hands, this technique is used for diagnostic and therapeutic interventions as hemothorax evacuation as like as the more complex procedures, such as lobectomies or bronchial sleeve and vascular reconstructions., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Extensive chest wall resection and reconstruction are a challenging procedure that requires a multidisciplinary approach, including input from thoracic surgeon, plastic surgeon and oncologist. In particular chest wall neoplastic pathology is associated with high surgical morbidity and can result in full thickness defects hard to reconstruct. The goals of a successful chest wall reconstruction are to restore the chest wall rigidity, preserve pulmonary mechanic and protect the intrathoracic organs minimizing the thoracic deformity. In case of large full thickness defects synthetic, biologic or composite meshes can be used, with or without titanium plate to restore thoracic cage rigidity as like as more recently the use of allograft to reconstruct the sternum. After skeletal stability is established full tissue coverage can be achieved using direct suture, skin graft or local advancement flaps, pedicled myocutaneous flaps or free flaps. The aim of this article is to illustrate the indications, various materials and techniques for chest wall reconstruction with the goal to obtain the best chest wall rigidity and soft tissue coverage., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Introduction: We report the case of a patient who presented with subcutaneous emphysema, dyspnea and cough 7 days after total thyroidectomy for cancer. In addition we review the Literature and discuss the therapeutic challenges as well as management options., Case Report: A 17-year old female patient underwent a total thyroidectomy with right cervical lymph adenectomy for papillar cancer. Lung metastases are present. On postoperative day 7 she presented with face and neck swelling due to subcutaneous emphysema, dyspnea and persistent cough. The radiological evaluation revealed a tear on the right antero-lateral wall of the trachea. The patient underwent surgical exploration of the neck which confirmed the tracheal rupture and showed an important tracheal necrosis all around the tear. Due to the impossibility to make primary closure of the trachea or a tracheal resection, the tear was repaired with muscular flap interposition, (around the trachea as a scarf ), using the contralateral clavicular part of sternocleidomastoid muscle and prethyroid muscles bilaterally. The postoperative course was uneventful and the patient is alive 20 months after surgery and iodine induced adjuvant therapy., Conclusion: Delayed tracheal rupture should be suspected in all patients who present subcutaneous emphysema after thyroid surgery. The lesion should be promptly treated with primary closure or tracheal resection when possible. Muscular flap interposition could be a safe alternative option when the other procedures are contraindicated.

Introduction: Esophageal perforation has been considered a catastrophic and often life-threatening event, with very high mortality rates. Most of the cases are due to a complication in endoscopic manouvers and the best treatment, conservative rather than aggressive, remains a controversial topic., Material and Methods: In 1995-2005 period we observed 7 cases of esophageal perforation, 5 women and 2 men mean age 73.2 y (range 60-87). Three cases are due to foreign body ingestion, 2 cases to endoscopic manoeuvres, 2 cases were spontaneous. In 3 cases the lesion was in the cervical tract of the esophagus, in the thoracic tract the others. All the patients were admitted very early to our Unit and presented disphagia, vomiting and dyspnoea, 2 out of them also a pleural effusion. In iatrogenic perforation we performed a cervicotomy and a drainage of mediastinic abscess, while in spontaneous lesions mono (one case) or bipolar esophageal exclusion (one case) with primary suture, jujunostomy and drainage of pleural effusion were the treatment. In foreign body perforation we performed thoracotomic and cervicotomic esophagotomy, extraction of the foreign body, direct suture with pleural or muscle protection. We didn't observe any intra or post-operative mortality. About the complications, we observed a bilateral pleural empyema, a chylous fistula, a digestive bleeding due to gastric ulcer, a laparotomic infection, a parossistic FA and a persistent esophageal fistula. Mean hospital stay was 24.3 days (range 10-43). All the patients were discharged to the hospital in good conditions., Conclusions: In conclusion in most of the cases of esophageal perforation the surgical treatment is the treatment of choice for its lower morbidity and mortality and good functional results.