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Background/Objectives : The surgical resection of pulmonary metastases is considered a therapeutic option in selected cases. In light of this, we present the results from a national multicenter prospective registry of lung metastasectomy. Methods : This retrospective analysis involves data collected prospectively and consecutively in a national multicentric Italian database, including patients who underwent lung metastasectomy. The primary endpoints were the analysis of morbidity and overall survival (OS), with secondary endpoints focusing on the analysis of potential risk factors affecting both morbidity and OS. Results : A total 470 lung procedures were performed (4 pneumonectomies, 46 lobectomies/bilobectomies, 13 segmentectomies and 407 wedge resections) on 461 patients (258 men and 203 women, mean age of 63.1 years). The majority of patients had metastases from colorectal cancer (45.8%). In most cases (63.6%), patients had only one lung metastasis. A minimally invasive approach was chosen in 143 cases (30.4%). The mean operative time was 118 min, with no reported deaths. Morbidity most frequently consisted of prolonged air leaking and bleeding, but no re-intervention was required. Statistical analysis revealed that morbidity was significantly affected by operative time and pulmonary comorbidities, while OS was significantly affected by disease-free interval (DFI) > 24 months ( p = 0.005), epithelial histology ( p = 0.001) and colorectal histology ( p = 0.004) during univariate analysis. No significant correlation was found between OS and age, gender, surgical approach, surgical extent, surgical device, the number of resected metastases, lesion diameter, the site of lesions and nodal involvement. Multivariate analysis of OS confirmed that only epithelial histology and DFI were risk-factors, with p -values of 0.041 and 0.031, respectively. Conclusions : Lung metastasectomy appears to be a safe procedure, with acceptable morbidity, even with a minimally invasive approach. However, it remains a local treatment of a systemic disease. Therefore, careful attention should be paid to selecting patients who could truly benefit from surgical intervention.

Background: Surgery for thymic cancers is considered the key of curative treatment. Preoperative patients' characteristics and intraoperative features might influence postoperative outcome. We aim to verify short-term outcomes and possible risk factors for complications after thymectomy., Methods: We retrospectively investigated patients undergoing surgery for thymoma or thymic carcinoma in the period between January 1, 2008, and December 31, 2021, in our department. Preoperative features, surgical technique (open, bilateral VATS, RATS), intraoperative characteristics and incidence of postoperative complications (PC) were analyzed., Results: We included in the study 138 patients. Open surgery was performed in 76 patients (55.1%), in 36 VATS (26.1%) and in 26 RATS (36.1%). Resection of one or more adjacent organs due to neoplastic infiltration was required in 25 patients. PC appeared in 25 patients (52% Clavien-Dindo grade I, 12% grade IVa). Open surgery had a higher incidence of PC (p < 0.001), longer postoperative in-hospital stay (p = 0.045) and larger neoplasm (p = 0.006). PC were significant related to pulmonary resection (p = 0.006), phrenic nerve resection (p = 0.029), resection of more than one organ (p = 0.009) and open surgery (p = 0.001), but only extended surgery of more organs was confirmed as independent prognostic factor for PC (p = 0.0013). Patients with preoperative myasthenia symptoms have a trend toward stage IVa complications (p = 0.065). No differences were observed between outcomes of VATS and RATS., Conclusions: Extended resections are related to a higher incidence of PC, while VATS and RATS guarantee a lower incidence of PC and shorter postoperative stay even in patients that require extended resections. Symptomatic myasthenia patients might have a higher risk toward more severe complications., (© 2023. The Author(s).)

A Correction has been published | View Neurogenic tumors represent 10 to 34% of all mediastinal tumors and among them, neurofibroma originating from the vagus nerve are rare entities. We present a case of a neurofibroma with cystic degeneration originating from the left branch of the vagus nerve in a 27-year-old man without von Recklinghausen disease. A complete robotic resection of the mediastinal mass has been performed, with amputation of the vagus nerve enclosed in the mass. The postoperative course was uneventful and the patient was discharged in two days.

Mesothelioma is an aggressive disease arising from parietal pleura. Surgery is a valuable option in the frame of a multimodality treatment. Several surgical approaches have been standardized with the aim of a macroscopic complete resection; these often require homolateral diaphragm and pericardial resection and reconstruction. Extrapleural pneumonectomy (EPP) and extended pleurectomy decortication (EPD) have been recognized as radical surgical procedures. Nevertheless, both operations are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. Moreover, in the case of localized chest wall recurrence, surgery might be considered a valuable therapeutical option for highly selected and fit patients. All the technical aspects of the resection and reconstruction of the diaphragm, pericardium, and chest wall are described as well as the possible use of new minimally invasive techniques. In addition, the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.

Residual masses in patients with mediastinal lymphoma may be positron emission tomography (PET) positive during follow-up also in cases of complete response. The aim of this retrospective study is to verify the reliability of mediastinal PET-positive findings in suggesting disease relapse or progression during follow-up by histological verification. From January 2002 to March 2016, 96 patients with mediastinal lymphoma underwent PET follow-up after front-line treatment. A surgical biopsy was performed to confirm the suspected relapse (for a total of 113 procedures). A lymphoma relapse was diagnosed in 66/102 successful procedures (64.7%). Diagnosis at relapse was concordant with the initial diagnosis in all but 3 cases. Standardized uptake value was significantly higher among patients with relapse than among those who remained in remission (10 versus 5, p  < .05). PET scan helps individuate patients with a high suspect of lymphoma relapse and may guide the surgeon to the most suitable target.

Broncho-pleural fistula (BPF) is an atypical communication between the tracheobronchial tree and the alveolar/pleural space, with prolonged air leak (PAL). BPF is frequent and related to significant morbidity, prolonged length of hospital stay, and mortality. Nevertheless, in about 10%, more than 5 days of an air leak is considered a PAL, accounted for significant morbidity. Endobronchial valve is a novel device for the PAL management with minimal morbidity if related to surgical repairs. While it is suggested that surgical treatment should be undertaken when possible, endobronchial valves should be recommended as a therapeutic choice in high-risk patients. Placement techniques remain operator and patient friendly and allow the procedure to be performed with relative ease. Prospectively conducted, randomised, controlled clinical trials are needed where valve treatment is compared with other bronchoscopic techniques, surgical procedures, or both., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

In recent years, retrospective analyses have suggested that an oligometastatic state could exist, but the best evidence to date that a temporary oligometastatic disease exists for lung cancer mainly derives from the survival data on retrospective patients underwent surgical resection of a single M1 site and all intrathoracic disease. The critical determinates of long-term survival include definitive treatment of the primary non-small cell lung cancer (NSCLC), a single organ site of synchronous or metachronous disease, a long disease-free interval between treatment of the primary NSCLC and development of metastases, and the absence of intrathoracic lymph node (N0) disease. The ongoing development of innovative approaches to local therapy and treatment directed to the oligometastatic sites should be defined in future studies., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Synchronous cancers are not such rare clinical conditions. Nevertheless, even after the 8th edition of the TNM classification of the lung cancer, the surgical approach for patients presenting with synchronous bilateral lung cancer is still under debate. The resection of both lesions in the case of synchronous bilateral lung cancer is reasonable, but, on the other hand, is the lobectomy the correct choice in the event of the single primary with a contralateral metastatic lesion? In this case report, we describe how the molecular analysis and the detection of the EGFR, KRAS and TP53 mutations in both tumours have determined in a patient the two tumours as primary and both the right surgical approach. We also discuss how molecular analysis found differences in all the three genes examined in the two lesions and allowed to exclude the clonal nature of the two tumours. In conclusion, genetic studies help to offer a more radical surgical treatment to this patient., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare disorder which can be an incidental finding in imaging tests performed during the investigation of another condition, or is the final diagnosis in patients evaluated for chronic obstructive complaints. To explore the possible association between specific histopathology features and the mode of clinical presentation, we retrieved the clinical, functional, radiological, and pathological data of all 13 patients diagnosed with DIPNECH at our Institution over a 14-year period (2000-2014). As compared to patients with incidental disease (6/13, 46 %), patients with symptomatic disease were younger [mean (SD): 57.7 vs. 68.7 years, p = 0.046], were more likely to have mosaic attenuation (100 vs. 0 %, p = 0.001) and small multiple nodules (100 vs. 17 %, p = 0.005) at CT, and showed a significantly higher number of foci of linear neuroendocrine proliferation [median (IQR): 28 (13-37) vs. 6 (5-13), p = 0.018] and of tumorlets [median (IQR): 10 (8-20) vs. 1 (1-1), p = 0.002] at histology. Incidental disease was found in association with pulmonary adenocarcinoma in five out of six patients (83.3 %). The results of our study provide preliminary evidence that symptomatic patients with DIPNECH represent a specific subset characterized by younger age and a higher burden of foci of neuroendocrine proliferation.

Purpose: The aim of this article is to present a clinical case of severe descending mediastinitis following the insertion of three dental implants in the mandible., Materials and Methods: A 64-year-old female was treated with an implant-supported rehabilitation for her mandibular missing teeth in positions 36, 45 and 46., Results: Three days after the dental implant surgery, the patient complained of malaise, shiver and fever (38°C) with dysphagia and swelling of the mouth floor. The following day the patient was admitted to the hospital with a diagnosis of larynx oedema. Due to the worsening clinical conditions on day 5, she was transferred to the Thoracic Surgery Division with a diagnosis of left neck phlegmon and underwent cervicotomy. A CT scan at day 9 showed mediastinal extension of the phlegmon with initial pleural reaction. The patient then underwent cervicotomy again for drainage. On day 16, she underwent videothoracoscopy to drain a left pleural effusion. The patient was discharged on day 31., Conclusions: Despite the fact that descending mediastinitis has a very high mortality rate, in the present case proper treatment was able to resolve this serious complication. It is likely that the early diagnosis and prompt treatment prevented neck and mediastinal infection diffusion. Clinicians should always keep in mind that a potential fatal infection complication may arise after routine dental implant surgery in the mandible.

Background and Objective: Transbronchial needle aspiration (TBNA) is useful for diagnosing peripheral pulmonary lesions (PPL). However, TBNA is largely underused and the variables that may be related to its diagnostic usefulness have not been specifically studied. The aim of the present study was to evaluate the performance characteristics and predictors of yield from TBNA of PPL, and to compare the performance characteristics of different bronchoscopic sampling methods., Methods: Consecutive patients with PPL were prospectively enrolled, and during the same examination, TBNA, transbronchial lung biopsy (TBLB) and bronchial washing (BW) were performed., Results: Two hundred and eighteen PPL in 218 patients were sampled. TBNA was more sensitive (65%) than either TBLB (45%, P<0.001) or BW (22%, P<0.001). TBNA was the only diagnostic procedure in 42/196 patients (21%) with malignant lesions, and was more likely to be the only diagnostic procedure for lesions lacking (23/85 patients, 27%) than for lesions with the bronchus sign (19/111 patients, 17%). In multivariate analysis, a lesion size >2cm, malignancy and location in the middle lobe were independent predictors of a positive TBNA result., Conclusions: TBNA is the single best contributor to the success of bronchoscopy in the diagnosis of PPLs, and should be routinely used especially in the presence of lesions lacking the bronchus sign. Lesion size of > 2cm, location in the middle lobe, and malignant nature are strong predictors of a positive TBNA result., (© 2011 The Authors. Respirology © 2011 Asian Pacific Society of Respirology.)

We report on the successful surgical treatment of an esophageal-bibronchial fistula originating from an iatrogenic mediastinal abscess. Endoscopic treatment had been excluded due to the extensive damage to the right main stem bronchus wall. The surgical treatment was carried out as follows: 1) Endoscopic stenting of the left main bronchus with a self-expanding metallic stent followed by selective left main bronchus intubation; 2) Laparotomic harvesting of the omentum pedicled on both gastro-epiploic vessels; 3) Right thoracotomy, complete dissection of both main bronchi and esophageal wall at the site of the leakage; 4) Harvesting of a pericardial vascularized graft; 5) Deployment of a self-expanding metallic stent from the surgical field into the right main stem bronchus; 6) Reconstruction of the right bronchus wall with the pericardial patch; 7) Positioning a T-tube in the esophageal leak; and 8) Intrathoracic transposition of the omental graft for buttressing all sutures and potential leakage points. The postoperative course was uneventful from a surgical point of view and the patient recovered completely.

Purpose: To evaluate the status of limited upper sternal split in general thoracic surgery., Methods: We reviewed the clinical files of 100 consecutive patients operated on through limited upper sternotomy at a hospital in Italy during the 10 years between January 1995 and December 2004., Results: Thymus surgery represented the main indication for this approach (n = 51): for myasthenia without thymoma in 28 patients, for thymus neoplasms with or without myasthenia in 22, and for intrathymic parathyroid adenoma in 1. Thyroid surgery constituted the second main indication for upper sternal split (n = 32) for benign retrosternal goiter in 18 patients, for mediastinal nodal metastasis of thyroid cancer in 11, and for malignant retrosternal goiter in 3. The remaining indications were as follows: to assess residual disease following chemotherapy for Hodgkin's disease in 7 patients and for non-Hodgkin lymphoma in 1; for tracheal surgery in 7; and for excision of nodal mediastinal metastasis of non-thyroid cancer in 2. All operations were completed through the upper sternal split. There was no surgical mortality but complications developed in eight patients., Conclusion: The upper sternal split provides a satisfactory access to perform a surgical procedure in the superior mediastinum in most diseases. The procedure is safe and involves minimal surgical trauma.

Background: Idiopathic spontaneous pneumothorax (ISP) results from rupture of blebs, bullas, or diseased alveolar walls. Initiating mechanisms may relate to increased transpulmonary pressure. The possible impact of changes in atmospheric pressure (Patm) on the occurrence of ISP remains uncertain., Methods: We studied the relationship between the occurrence of ISP and meteorological conditions during a 4-year period in the urban area of Bologna, Italy, in which all cases of pneumothorax can be exhaustively identified. For each day of the study period, Patm and ambient temperature were obtained from the local meteorological institute. A cluster was defined as the admission of at least two patients with pneumothorax within 3 days of each other., Results: There were 294 episodes of ISP; 247 (84%) occurred in 76 clusters. Clusters were significantly associated with wider differences in Patm between the index day (ie, the first day of the cluster) and the previous day (ie, the difference in mean [+/- SEM] Patm, -1.23 +/- 0.45 vs + 0.04 +/- 0.12 mm Hg, respectively; p = 0.01[analysis of variance]). Similarly, pneumothorax and storms (but not temperature) were significantly associated (p < 0.0001 [chi(2) test])., Conclusions: This large-scale study shows that patients with ISP are hospitalized in clusters and suggests that important variations in Patm may be involved. The knowledge of this relationship may help to understand the pathophysiology of the disease.

Background: The consequence of the low rate of penetrating injuries in Europe and the increase in non-operative management of blunt trauma is a decrease in surgeons' confidence in managing traumatic injuries has led to the need for new didactic tools. The aim of this retrospective study was to present the Corso di Chirurgia del Politrauma (Trauma Surgery Course), developed as a model for teaching operative trauma techniques, and assess its efficacy., Method: the two-day course consisted of theoretical lectures and practical experience on large-sized swine. Data of the first 126 participants were collected and analyzed., Results: All of the 126 general surgeons who had participated in the course judged it to be an efficient model to improve knowledge about the surgical treatment of trauma., Conclusion: A two-day course, focusing on trauma surgery, with lectures and life-like operation situations, represents a model for simulated training and can be useful to improve surgeons' confidence in managing trauma patients. Cooperation between organizers of similar initiatives would be beneficial and could lead to standardizing and improving such courses.

Background: There are no recommendations about admission to an ICU after a major lung resection and there are considerable differences among institutions in this respect., Objectives: To audit the practice of admission to an ICU after a major lung resection and evaluate factors predicting the need for intensive care., Methods: Clinicalrecords of all patients who underwent major pulmonary resections in a 14-month period were reviewed retrospectively. The criteria for postoperative admission to the ICU were: (1) standard pneumonectomy if comorbidity index (CI) >0 and/or ASA score >1, and/or abnormal spirometry or arterial gas analysis; (2) extended pneumonectomy; (3) lobectomy if CI >or=4 and/or ASA >or=3; (4) lobectomy if FEV(1) <60% of predicted; (5) lobectomy if FEV(1) is between 60 and 80% and hypercapnia., Results: Among the 49 patients postoperatively admitted to the surgical ward, only 1 needed late intensive care. Among the 55 patients admitted to the ICU, 25 did not require specific intensive care and were discharged 24 h postoperatively, whereas the remaining 30 patients required specific intensive care. Multivariate analysis identified ASA score, predictive postoperative DL(CO), and predictive postoperative product (PPP) as independent predictors of a need for admission to an ICU., Conclusion: This empirical protocol was useful in identifying patients not likely to need admission to the ICU. ASA score, predictive postoperative DL(CO), and PPP are independent predictors of a need for admission to an ICU.

Background: The aims of the present study were: 1) to study the type and extent of resection in patients with pathological stage I lung cancer; 2) to evaluate the results of surgical treatment; 3) to assess prognostic factors., Setting: a tertiary referral general hospital., Methods: Retrospective review of clinical records of 296 patients operated on for pathologic stage I lung cancer between 1989 and 1998. Mean follow-up period was 33.1+/-28.1 months. Survivals were calculated by the actuarial method and compared by the long-rank test. Age, sex, tumor size, type and extent of resection and histologic type were evaluated by univariate and multivariate analisis., Results: Two hundred and forty-five lobectomies, 39 pneumonectomies, 5 segmental resections and 7 wedge resections were performed. Overall actuarial 5- and 10-year survivals were 62 and 49%, respectively. Stage Ia patients showed significantly better 5- and 10-year survivals (76 and 54%, respectively) as compared to Stage Ib patients (57 and 46%, p=0.007). Univariate analysis showed no significant difference in survival according to the age, the sex or the extent of resection. The histological type influenced the outcome (p=0.05): 5-year survival rate were 57, 67, 75% in squamous cell carcinoma, adenocarcinoma and bronchoalveolar carcinoma, respectively. At multivariate analysis stage and histology were identified as independent prognostic factors., Conclusions: Satisfactory results in terms of suvival can be achieved following surgery for stage I lung cancer. The T status and the histologic type significantly influence survival.

We report the case of a 15-year-old boy with primary high grade angiosarcoma of the 6th rib. The patient underwent chest wall resection (3 ribs) and reconstruction by using a sandwich of Marlex mesh with strips of methyl methacrylate. No adjuvant treatment was administered. A favourable outcome was observed, with no recurrence at 6-year follow-up. Functional results were excellent as well, with complete return of the patient to normal activities.