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Objective We present our experience with uniportal videothoracoscopic surgery (VATS-U), examining its indications, limits, and results. Methods Since January 2009, 66 patients underwent VATS-U for the following indications: pneumothorax (n = 25), lung nodule (n = 15; n = 10 with preoperative radiolocalization), wedge biopsy (n = 15), hyperhidrosis (n = 10), and chest wall schwannoma (n = 1). The conversion rate to conventional video-assisted thoracic surgery (VATS), postoperative pain, complications, residual paraesthesia, and hospitalization were analyzed. Operative time, postoperative pain, and paraesthesia were retrospectively compared with a cohort of 172 cases of conventional multiportal VATS, performed in the same period. Results Conversion to traditional VATS was necessary in two cases (pulmonary nodule, n = 1; pneumothorax, n = 1). The mean pain score was 0.8, the mean operation time was 42 minutes, and 10 patients had postoperative paraesthesia that lasted a mean of 7 days. No postoperative complications were reported, and the mean postoperative hospital stay was 3 days (range, 1–6 days). The comparison between the VATS-U and the standard multiportal VATS group showed in the VATS-U group a lower but not statistically significant pain score and paraesthesia as well as a lower and statistically significant operative time. Conclusions Uniportal videothoracoscopic surgery has a wide range of indications: lung apex resections and pleurodesis for spontaneous pneumothorax treatment; pulmonary nodule assessment with or without preoperative localization; lung biopsy for interstitial diseases; unilateral or bilateral sympathectomy to treat hyperhidrosis; benign chest wall tumor evaluation. The limits of this technique are linked to pleural adhesions or lung nodules in difficult positions. In our experience, VATS-U results in minimal postoperative pain, allowing for fast functional recovery and a consequent short hospital stay; thus, we suggest that VATS-U is a valid alternative to traditional multiportal VATS for indications beyond cosmetic benefits. Prospective randomized trials are necessary to validate the advantages of uniportal VATS.

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.

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

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.

Aim: Stages I and II malignant pleural mesothelioma (MPM) can be satisfactorily treated with extended extrapleural pneumonectomy (EPP). We modified our diagnostic methods and surgical techniques to improve outcome. Methods: 74 patients were treated with EPP, 33 from 1988 to May 2000 (first group), and 41 from June 2000 to 2010 (second group) and all underwent thoracoscopy without mediastinoscopy or laparoscopy prior to EPP. We began to make changes in surgical management in group 2 (2000-2010). Staging was improved using 3D CT scan and Standard Uptake Values (SUV) provided by 2-(Fluorine-18)fluro-2-deoxy-D-glucose positron emission tomography (FDG PET) scan. Talc pleurodesis was used preoperatively in 15 cases. Double unilateral thoracotomy, performed on 24 patients, facilitated dissection of the diaphragm and made alterations in the reconstructive phase possible. Polytetrafluoroethylene (PTFE) prostheses were used instead of biological materials. In 10 cases the pericardium was not reconstructed on the left side after the previous negative experience of functional pericardial concretio that needed the prosthesis removal (Table 1). Topical thrombin was used to reduce postoperative complications whereas posterior prosthetic packing was used to prevent paraprosthetic evisceration and reduce postoperative bleeding. Results: Patients of group 2 experienced less morbidity. Fourteen of the 71 patients who survived beyond the immediate postoperative period lived at least 3 years. Potential positive prognostic factors were identified at follow-up. Conclusions: The innovations we adopted, especially the reconstruction procedures, improved the outcome for our series of patients who underwent extended EPP for MPM. Follow-up results suggest that the MIB-1 index, stage 1 disease, prosthetic diaphragmatic replacement, adjuvant radiotherapy and control are important positive prognostic factors.

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.

In this study, the obtainment and characterization of decellularized rat tracheal grafts are described. The detergent-enzymatic method, already used to develop bioengineered pig and human trachea scaffolds, has been applied to rat tracheae in order to obtain airway grafts suitable to be used to improve our knowledge on the process of tissue-engineered airway transplantation and regeneration. The results demonstrated that, after 9 detergent-enzymatic cycles, almost complete decellularized tracheae, retaining the hierarchical and mechanical properties of the native tissues with strong in vivo angiogenic characteristics, could be obtained. Moreover, to improve the mechanical properties of decellularized tracheae, genipin is here considered as a naturally derived cross-linking agent. The results demonstrated that the treatment increased mechanical properties, in term of secant modulus, without neither altering the pro-angiogenic properties of decellularized airway matrices or eliciting an in vivo inflammatory response.