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Background: Completion thymectomy may be performed in patients with non-thymomatous refractory myasthenia gravis (MG) to allow a complete and definitive clearance from residual thymic tissue located in the mediastinum or in lower neck. Hereby we present our short- and long-term results of completion thymectomy using subxiphoid video-assisted thoracoscopy., Methods: Between July 2010 and December 2017, 15 consecutive patients with refractory non-thymomatous myasthenia, 8 women and 7 men with a median age of 44 [interquartile range (IQR) 38.5-53.5] years, underwent video-thoracoscopic completion thymectomy through a subxiphoid approach., Results: Positron emission tomography (PET) showed mildly avid areas [standardized uptake value (SUV) more than or equal to 1.8] in 11 instances. Median operative time was 106 (IQR, 77-141) minutes. No operative deaths nor major morbidity occurred. Mean 1-day postoperative Visual Analogue Scale value was 2.53±0.63. Median hospital stay was 2 (IQR, 1-3.5) days. A significant decrease of the anti-acetylcholine receptor antibodies was observed after 1 month [median percentage changes -67% (IQR, -39% to -83%)]. Median follow-up was 45 (IQR, 21-58) months. At the most recent follow-up complete stable remission was achieved in 5 patients. Another 9 patients had significant improvement in bulbar and limb function, requiring lower doses of corticosteroids and anticholinesterase drugs. Only one patient remained clinically stable albeit drug doses were reduced. One-month postoperative drop of anti-acetylcholine receptor antibodies was significantly correlated with complete stable remission (P=0.002)., Conclusions: This initial experience confirms that removal of ectopic and residual thymus through a subxiphoid approach can reduce anti-acetylcholine receptor antibody titer correlating to good outcome of refractory MG., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd.2020.03.81). The authors have no conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Objectives: The aim of this study is to collate multi-institutional data to determine the value by defining the diagnostic performance of fluorodeoxyglucose positron emission tomography (FDG PET)/CT for malignancy in patients undergoing surgery with an anterior mediastinal mass in order to ascertain the clinical utility of PET/CT to differentiate malignant from benign aetiologies in patients presenting with an anterior mediastinal mass SETTING: DECiMaL Study is a multicentre, retrospective, collaborative cohort study in seven UK surgical sites., Participants: Between January 2002 and June 2015, a total of 134 patients were submitted with a mean age (SD) of 55 years (16) of which 69 (51%) were men. We included all patients undergoing surgery who presented with an anterior mediastinal mass and underwent PET/CT. PET/CT was considered positive for any reported avidity as stated in the official report and the reference was the resected specimen reported by histopathology using WHO criteria., Primary and Secondary Outcome Measures: Sensitivity, specificity, positive and negative predicted values of [18F]-FDG PET in determining malignant aetiology for an anterior mediastinal mass., Results: The sensitivity and specificity of PET/CT to correctly classify malignant disease were 83% (95% CI 74 to 89) and 58% (95% CI 37 to 78). The positive and negative predictive values were 90% (95% CI 83% to 95%) and 42% (95% CI 26% to 61%)., Conclusions: The results of our study suggest reasonable sensitivity but no specificity implying that a negative PET/CT is useful to rule out the diagnosis of malignant disease whereas a positive result has no value in the discrimination between malignant and benign diseases of the anterior mediastinum., Competing Interests: Competing interests: Outside this work, EL reports personal fees from Abbott Molecular, personal fees from Glaxo Smith Kline, personal fees from Pfizer, personal fees from Novartis, personal fees from Covidien, personal fees from Roche, personal fees from Lily Oncology, personal fees from Boehringer Ingelheim, personal fees from Medela, grants and personal fees from ScreenCell, personal fees from Ethicon, outside the submitted work, and is the founder of Informative Genomics, a blood-based molecular diagnostic company in London., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: More than 15 years ago, we started a program of uniportal video-assisted thoracoscopies (VATS) lung metastasectomy in non-intubated local anesthesia. Hereby we present the short and long-term results of this combined surgical-anesthesiological technique., Methods: Between 2005 and 2015, 71 patients (37 men and 34 women) with pulmonary oligometastases, at the first episode, underwent uniportal VATS metastasectomy under non-intubated anesthesia., Results: Four patients (5.6%) required intubation for intolerance. Mean number of lesions resected per patient was 1.51. There was no mortality. The study group demonstrated a significant reduction of operative time from the beginning of the experience (P=0.001), good level of consciousness at Richmond scale and quality of recovery after both 24 and 48 hours. Median hospital stay was 3 days and major morbidity rate was 5.5%. Both disease-free survival and overall survival were similar to those achieved with intubated surgery., Conclusions: VATS lung metastasectomy in non-intubated local anesthesia was safely performed in selected patients with oligometastases with significant advantages in overall operative time, hospital stay and economical costs. Long-term results were similar., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: We hypothesized that video-assisted thoracic surgery (VATS) lung metastasectomy under non-intubated anesthesia may have a lesser immunological and inflammatory impact than the same procedure under general anesthesia., Methods: Between December 2005 and October 2015, 55 patients with pulmonary oligometastases (at the first episode) successfully underwent VATS metastasectomy under non-intubated anesthesia. Lymphocytes subpopulation and interleukins 6 and 10 were measured at different intervals and matched with a control group composed of 13 patients with similar clinical features who refused non-intubated surgery., Results: The non-intubated group demonstrated a lesser reduction of natural killer lymphocytes at 7 days from the procedure ( p = 0.04) compared to control. Furthermore, the group revealed a lesser spillage of interleukin 6 after 1 ( p = 0.03), 7 ( p = 0.04), and 14 ( p = 0.05) days. There was no mortality in any groups. Major morbidity rate was significantly higher in the general anesthesia group 3 (5%) vs. 3 (23%) ( p = 0.04). The median hospital stay was 3.0 vs. 3.7 ( p = 0.033) days, the estimated costs with the non-intubated procedure was significantly lower, even excluding the hospital stay., Conclusions: VATS lung metastasectomy in non-intubated anesthesia had significantly lesser impact on both immunological and inflammatory response compared to traditional procedure in intubated general anesthesia., Competing Interests: The authors declare no conflict of interest. The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

Background: More than ten years ago we started a program of video-assisted thoracic surgery (VATS) lung metastasectomy in non-intubated local anesthesia. In this study we investigated the effectiveness and long term results of this combined surgical-anesthesiological technique., Methods: Between 2005 and 2014, 48 patients (25 men and 23 women) with pulmonary oligometastases from colorectal cancer, at the first episode, underwent VATS metastasectomy under non-intubated local anesthesia. Three patients required intubation for intolerance. In the same period 13 patients scheduled for non-intubated metastasectomy refused awake surgery and were used as a control group., Results: The two groups were homogeneous for both demographic and pathological features. Mean number of lesions resected per patient were 1.51 (non-intubated) vs. 1.77 (control), respectively (P=0.1). The oxygenation was significantly lower in the non-intubated group especially at the end of the procedure, but the values inverted from the first postoperative hour. There was no mortality in any groups. The non-intubated group demonstrated a significant shorter overall operating time (P=0.04), better quality of recovery after both 24 (P=0.04) and 48 hours (P=0.04), shorter median hospital stay (P=0.03) and lower estimated costs (P=0.03), even excluding the hospital stay. Major morbidity rate was lower (6% vs. 23%) yet not significant (P=0.1). Both disease free survival and overall survival were similar between groups., Conclusions: VATS lung metastasectomy in non-intubated local anesthesia was safely performed in selected patients with oligometastases with significant advantages in overall operative time, hospital stay and economical costs. Morbidity rate was lower yet not significant. Long term results were similar., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Up to 25% of patients with primary hyperparathyroidism have ectopic parathyroid adenoma. A 45-year-old formerly obese woman underwent extended thymectomy for a parathyroid adenoma located in hyperplastic thymic tissue, associated with primary hyperparathyroidism and severe vitamin D deficiency, but normal bone mineral density. At nine months follow-up, all laboratory test results were within normal limits and she presented no symptoms and no recurrence of disease. In this case, autonomous growth of a parathyroid adenoma was reasonably secondary to chronic calcium and vitamin D malabsorption, which often occurs after bariatric surgery for pathologic obesity.

Simultaneous bilateral spontaneous pneumothorax is a very rare clinical event, comprising approximately 1% of all spontaneous pneumothoraces. Clinical signs and symptoms may vary from mild chest pain and dyspnea to severe respiratory failure; nevertheless immediate treatment is mandatory as this condition can deteriorate and progress to tension pneumothorax. An underlying lung disease has been commonly described; in most istances primary or secondary tumors, interstitial diseases, and infectious diseases. Birt-Hogg-Dubè syndrome is a rare inherited disorder clinically characterized by multiple fibrofolliculomas, renal tumors, lung cysts, and, in ~24% of the patients, occurrence of spontaneous pneumothorax. In this case, we firstly report the concurrence of these rare conditions, as a patient presenting a simultaneous bilateral spontaneous pneumothorax was diagnosed with Birt-Hogg-Dubè syndrome based on the typical radiological findings and genetic testing of the folliculin gene located on chromosome 17.

Background: Malignant pleural effusion can be treated successfully by video-assisted thoracic surgery (VATS) talc pleurodesis. This procedure can also be performed using local anesthesia on nonintubated patients., Objectives: To evaluate quality of life and major outcomes after VATS talc pleurodesis performed under local anesthesia in nonintubated patients with malignant pleural effusion., Design: Retrospective, nonrandomized case-matched comparison (nonintubated versus intubated) pairing the patients by computer according to their clinical features., Setting/subjects: Since 2002, 231 consecutive patients underwent uniport VATS talc pleurodesis under local anesthesia (nonintubated group). These patients were case matched with 231 homogeneous subjects, selected from a larger group that preferred general anesthesia (intubated group) in the same period., Measurements: Quality of life (European Organization for Research and Treatment of Cancer QLQ-C30 core questionnaire) and other major outcomes were considered., Results: Pleurodesis was successful in 198 (85.7%) nonintubated and 193 (83.5%) intubated patients, but the former group showed shorter total operating room time (65.8±7.5 versus 84.9±13.3 minutes, p<0.0001), duration of postoperative pleural fluid leakage (2.5±1.0 versus 4.0±1.5 days, p=0.014), postoperative hospital stay (3.1±2.5 versus 4.9±2.8 days, p=0.011), as well as lower perioperative mortality (0% versus 2.3%, p=0.017), morbidity (5.2% versus 9.0%, p=0.042), and costs (6,090±517 versus 9,660±713€, p=0.015). Quality of life presented a similar evolution between groups, however, the early postoperative improvement in physical function (p<0.05), global health (p<0.05), and dyspnea (p<0.01) was significantly greater in nonintubated patients. Significant improvements in respiratory exchanges, postoperative acute stress markers, and mental confusion were also documented. Effusion-free (p=0.35) and overall (p=0.52) survival was similar between groups., Conclusion: Nonintubated VATS talc pleurodesis can achieve similar results in pleural effusion to the same operation performed under general anesthesia but with earlier improvement of some quality-of-life domains as well as better mortality, morbidity, hospital stay, and costs.

Objectives: Alteration of erythrocyte osmotic resistance, with increment of reticulocytes, is common in emphysema. This fragility is probably due to an altered fatty acid membrane composition from lipid peroxidation, a reaction triggered by the disease-related increment of reactive oxidative species. We analysed the effects of lung volume reduction surgery (LVRS) on this anomaly compared with respiratory rehabilitation (RR) therapy., Methods: We retrospectively compared 58 male patients with moderate-to-severe emphysema who underwent LVRS with 56 similar patients who underwent standardized RR. Respiratory function parameters, erythrocyte osmotic resistance and antioxidant enzymes levels were evaluated before and 6 months after treatments., Results: Significant improvements in respiratory function, exercise capacity, unsaturated fatty acid content (+10.0%, P = 0.035), erythrocyte osmotic resistance (hyperosmolar resistance -21.0%, P = 0.001; hyposmolar resistance -18.0%, P = 0.007) and erythrocyte antioxidant enzymes [superoxide dismutase (SOD) +60.0%, P < 0.001; glutathione peroxidase +39.0%, P = 0.004 and glutathione reductase +24.5%, P = 0.008] were observed after surgery. In the RR group, we did not find any significant improvements in osmotic resistance, although respiratory and functional parameters were significantly improved. Correlation analysis in the surgical group showed that the reduction in residual volume (RV) significantly correlated the normalization of hyperosmotic (P = 0.019) and hyposmotic resistances (P = 0.006), the decrease in the absolute number of reticulocytes (P = 0.037) and increase in SOD (P < 0.001)., Conclusions: LVRS improved unsaturated fatty acid content, erythrocyte osmotic resistance and levels of erythrocyte antioxidant enzymes compared with RR. Correlations between erythrocyte osmotic resistance and antioxidant intracellular enzymes with RV suggest that reduction in lung hyperinflation with the elimination of inflammatory emphysematous tissue may explain such improvements after surgery.

Background:   Substernal hand-assisted thoracoscopy (HATS) has been proposed as a reliable surgical method with which to perform a bilateral lung metastasectomy. Herein, we review our 15-year experience with this approach for the purpose of understanding the long-term results in a large study cohort., Methods:   The study cohort was a series of 87 patients that underwent a HATS lung metastasectomy between 1995 and 2010. We focused on the main surgical findings including the ability of this approach to facilitate the detection of unexpected pulmonary lesions. Overall and disease-free survival rates were analyzed in a long-term follow up using the Kaplan-Meier method., Results:   A total of 219 lesions were removed. Of these, 191 proved to be malignant. This figure accounted for 31 (19.3%) unexpected lung metastases not previously identified at imaging work-up. Eighteen nodules previously suggested as metastatic lesions proved to be benign. On the basis of these findings sensitivity, specificity, positive and negative predictive values for imaging work-up in detecting lung metastases were 79.6%, 41.3%, 86.4%, and 30.5%, respectively. Lesions sized <7 mm showed the highest false negative rate. Postoperatively no major complications occurred. Overall survival rates at 3 and 5 years were 57.9% and 38.4%, respectively. Disease-free interval after primary cancer removal, but not all metastases nor bilateral spread, was related to survival (P = 0.015)., Conclusions:   In our experience, HATS resulted in a considerable percentage of resected lung metastases not previously detected at imaging work-up. We recommend this approach whenever feasible as it can conciliate low invasiveness and completeness of surgical resection. Substernal HATS makes it possible to detect a considerable number of unexpected lesions in patients undergoing lung metastasectomy with low surgical trauma. This study reinforces the role of this approach in the setting of lung metastasectomy, due to the large patient series and long-term follow-up., (© Tianjin Lung Cancer Institute and Blackwell Publishing Asia Pty. Ltd.)

Background: Surgical stress and general anesthesia can have detrimental effects on postoperative immune function. We sought to comparatively evaluate postoperative lymphocytes response in patients undergoing video-assisted thoracoscopic surgery (VATS) under thoracic epidural or general anesthesia., Methods: Between October 2008 and June 2009, 50 patients with nonmalignant pulmonary conditions were randomized to undergo VATS through either sole epidural anesthesia and spontaneous ventilation (awake group, n = 25) or general anesthesia with one-lung ventilation (control group, n = 25). In both groups, assessment of total lymphocytes count and changes in proportion of lymphocyte subsets including CD19+, CD3+, CD4+, CD8+, CD4+:CD8+ ratio, and CD16+CD56+ (natural-killer cell) were evaluated by two-way analysis of variance test for repeated measures at baseline and postoperative days 1, 2, and 3. The Mann-Whitney test was performed at each time point only for significant parameters at between-group analysis of variance., Results: Comparisons of baseline data showed relatively homogeneous groups. Between-group analysis of variance was significant for proportion of natural-killer cells (p = 0.01). In particular, the control group disclosed a significantly lower median proportion of natural-killer cells as compared with the awake group on postoperative day 1 (5% interquartile range [IQR]: 3% to 8%] vs 12% [IQR: 8% to 14%], p = 0.003) and 2 (7% [IQR: 4% to 10%] vs 11% [IQR: 8% to 21%], p = 0.02). Total lymphocyte count was significantly decreased in the control group only (p < 0.00001). No difference was found between groups in the remaining lymphocyte subsets., Conclusions: In this randomized study, awake VATS resulted in a lesser impact on postoperative lymphocyte responses than procedures performed under general anesthesia, as shown by the significant difference in postoperative proportion of natural-killer cells., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

This study was undertaken to assess stress hormones response after awake videoassisted thoracoscopic surgery (VATS). Plasma levels of adrenal-corticotropic hormone (ACTH), cortisol, epinephrine, norepinephrine, and glucose were assessed at baseline, 3 h postoperatively (T1), and on postoperative mornings 2 (T2) and 3 (T3) in 21 patients undergoing awake VATS with epidural anesthesia for non-malignant conditions (n=11) or equivalent procedures performed with general anesthesia. Epinephrine level peaked in both groups at T1, although significant change from baseline values occurred in the control group only [median-Delta: 6 ng/l (IQR: 4-6), P=0.005]. Cortisol level was lower in the study group at T1 (15.5 microg/dl vs. 23.0 microg/dl, P=0.001) and T2 (15.2 microg/dl vs. 19.2 microg/dl, P=0.002). In the control group, peak cortisol level proved not to be related to changes in ACTH (R=0.23, P=0.46). At T2, glucose (137 mg/dl vs. 98 mg/dl, P=0.01) and C-reactive protein (P=0.04) were higher in the control group. No other clinically relevant between-groups differences were found in aspecific acute-response factors. Overall, these preliminary findings suggest attenuated stress response after awake VATS in comparison with equivalent procedure performed under general anesthesia and one-lung ventilation., (2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.)

A 79-year-old woman had a primary tumor of the pulmonary artery, which was initially diagnosed as chronic pulmonary thromboembolism. Multislice angio-computed tomography showed a solid mass in the right pulmonary artery. Radical resection of the tumor was achieved by right pneumonectomy via a transsternal transpericardial approach. The patient was alive and free of disease 36 months after surgery.

Solitary fibrous tumors of the pleura are very rare neoplasms that can sometimes present with malignant features. Between 1984 and 2007, 18 cases were treated in our institution. There were 7 men and 11 women, with a median age of 56 years (range, 33-77 years). All patients underwent surgical treatment. Except for one case with hemangiopericytic features, all tumors were histologically the fibrous type of pleural mesothelioma. Resections were radical and there were no recurrences. There was no perioperative mortality. The outcome was excellent, and all patients have been followed up continuously. Survival rates at 3, 5, and 10 years were calculated as 86.7%, 75%, and 66.7%. One patient died after 18 months (malignant type of solitary fibrous tumor), and 2 died of unrelated disease after 24 and 53 months. Surgery is the treatment of choice, and careful long-term clinical follow-up is required.

Background: The aim of our study was to test the aerostatic validity of a cyan-acrylic glue (Glubran 2), applied by means of a spray catheter, on an experimental pig model., Materials and Methods: 15 young pigs were divided into three study groups of 5 based on surgical techniques: (1) atypical pulmonary resection with mechanical suturing and reinforcement with continuous suturing; (2) resection of the pulmonary parenchyma with a cold scalpel, followed by local application of Glubran 2; (3) atypical pulmonary resection with mechanical suturing followed by application of Glubran 2., Results: The mean aerostasis time was calculated at 3.5 +/- 1.26 s. The histopathological analysis did not show any particular differences when comparing the effects of the treatments carried out with Glubran 2 spray glue and the standard treatments. No statistically significant differences were recorded in the short- and medium-term survival of pigs treated with Glubran 2 compared with the respective control groups., Conclusions: The application of Glubran 2 spray on wounds caused by pulmonary resections in pigs proved to have a rapid and effective influence for the purposes of aerostasis without significant differences in air losses and survivals., (2009 S. Karger AG, Basel.)

Pulmonary carcinoids are rare malignant neoplasms, accounting for 2-5% of all lung tumors, with an approximate annual incidence of 2.3-2.8 cases per million of the population. We relate our experience of 54 patients (21 male, 33 female, mean age 53+/-15 years) treated between July 1986 and April 2006. All the patients underwent preoperative fibrobronchoscopy: preoperative diagnosis was made in 28 patients (52%). Surgical treatment consisted of: 31 standard lobectomies, 6 pneumonectomies, 5 bilobectomies, 2 sleeve lobectomies, 2 anatomic segmentectomies, 6 wedge resections; two patients were managed with sleeve bronchial procedure of the left main bronchus without lung resection. Fifty-four patients were followed with a mean time of observation of 67 months: 6 (11%) deaths occurred, at a mean period of 49 months after surgery; there were no postoperative deaths. Overall, 5-year survival was 91%, 10 years 83%: 5-year survival was 91% for typical carcoinoids (TC) vs. 88% for atypical (AC), 10 years 91% for TC and 44% for AC (significant value, P=0.0487). Carcinoid tumors are a distinct group of neuroendocrine tumors with a good prognosis in most cases. Surgery currently represents the best treatment with good results at mid- and long-term survival, according to an acceptable risk.

Aim: To re-evaluate the use of CT-guided needle biopsy and VATS, as our combined approach protocol for the diagnosis and treatment of peripheral pulmonary nodules., Methods and Results: We describe the case of a male smoking patient, 50-year-old, who came to our service for the histological diagnosis of a right pulmonary lesion incidentally revealed. He was submitted to our diagnostic and therapeutic protocol for peripheral pulmonary nodules, that is a combined approach of CT-guided needle biopsy, anchorage of the lesion and VATS resection. Difficulties with this technique can raise when: 1. the cytological CT-guided needle biopsy is not diagnostic, 2. the anchorage is not successful, 3. the malignancy of the lesion cannot be surely determined by the extemporary histological examination. In this patient all these difficulties were encountered., Conclusions: We conclude that our diagnostic and therapeutic protocol for peripheral pulmonary nodules is not invalidated by this experience, even in consideration of the fact that we applied successfully the protocol in several previous cases.

Aim: To re-evaluate the use of 111In-pentetreotide scintigraphy (Octreoscan) in the follow-up of patients operated for carcinoids, as second-step investigation, after chest X-ray, CT-scan and serological marker' levels., Methods and Results: We describe the case of a female patient, 58-year-old, operated on for a non-secretory lung carcinoid. Five years after surgery, the CT-scan showed the enlargement of the bilateral hylo-mediastinal lymph nodes, suggestive for carcinoid recurrences. In order to confirm that, the patient was submitted to an Octreoscan that showed the presence of enlarged hylo-mediastinal adenopathies matching with the lesions observed at the CT-scan. Because the serological examination of NSE, chromogranin and serotonin, and the 5-HIIA were in the normal range, the patient was submitted to a lymph node biopsy through a mediastinoscopy. The histological examination of the specimens revealed a sarcoidosis and the patient was started on steroid therapy with good outcome., Conclusions: We conclude that: 1. the octreoscan scintigraphy in the follow-up of resected carcinoids can give false-positive results and 2. in consequence, the mediastinoscopy is a discriminating investigation in case of mediastinal lymph nodes disease.