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OBJECTIVES Only few studies compared the surgical morbidity and mortality of thoracoscopic segmentectomy versus lobectomy for non-small-cell lung cancer, in particular, by relating the segmental resections with the corresponding anatomical lobes. METHODS We enrolled a total of 7487 patients who underwent VATS lobectomy (7269) or segmentectomy (218) from January 2014 to July 2019. A propensity score matching approach was used to account for potential confounding factors between the 2 groups. After matching, 349 lobectomies and 208 segmentectomies were included in the analysis. We analysed the operative and postoperative outcomes of video-assisted anatomical segmentectomy compared with video-assisted lobectomy and, in details, the results of segmentectomy with its corresponding lobectomy in a large cohort of patients from the Italian VATS Group Registry. RESULTS The overall conversion rate to thoracotomy was not statistically different between the groups (27 patients 8% vs 7 patients 3%, P = 0.1). The lobectomy group had a greater number of resected lymph nodes (median 11 vs 8, P = 0.006). No significant differences were detected in 30-day mortality (1.4%, 5 patients vs 0.9%, 2 patients), overall complications (18%, 62 patients vs 14%, 29 patients) and prolonged air leakage (31 patients, 9% vs 12 patients, 6%) between lobectomy and segmentectomy, respectively. No statistical differences were found regarding the median duration of drainage (3.2 days, P = 1) and the overall median length of hospital stay (6.4 days, P = 0.1) between the 2 groups. In the context of segmentectomy versus corresponding lobectomy, the right upper lobectomy compared with right upper segmentectomy showed a higher number of resected lymph nodes (P = 0.027). No statistical differences were reported in terms of conversion rate and postoperative complication and mortality. CONCLUSIONS Segmentectomy could be considered a safe procedure without significant differences compared to thoracoscopic lobectomy in terms of postoperative morbidity and mortality.

OBJECTIVES This study compares the uniportal with the 3-portal video-assisted thoracic surgery (VATS) by examining the data collected in the Italian VATS Group Database. The primary end point was early postoperative pain; secondary end points were intraoperative and postoperative complications, surgical time, number of dissected lymph nodes and length of stay. METHODS This was an observational, retrospective, cohort, multicentre study on data collected by 49 Italian thoracic units. Inclusion criteria were clinical stage I–II non-small-cell lung cancer, uniportal or 3-portal VATS lobectomy and R0 resection. Exclusion criteria were cT3 disease, previous thoracic malignancy, induction therapy, significant comorbidities and conversion to other techniques. The pain parameter was dichotomized: the numeric rating scale ≤3 described mild pain, whereas the numeric rating scale score >3 described moderate/severe pain. The propensity score-adjusted generalized estimating equation was used to compare the uniportal with 3-portal lobectomy. RESULTS Among 4338 patients enrolled from January 2014 to July 2017, 1980 met the inclusion criteria; 1808 patients underwent 3-portal lobectomy and 172 uniportal surgery. The adjusted generalized estimating equation regression model using the propensity score showed that over time pain decreased in both groups (P CONCLUSIONS Data from the Italian VATS Group Database showed that in clinical practice uniportal lobectomy seems to entail a higher risk of moderate/severe pain on second and third postoperative days.

OBJECTIVESInherent technical aspects of pulmonary lobectomy by video-assisted thoracoscopic surgery (VATS) may limit surgeons’ ability to deal with factors predisposing to complications. We analysed complication rates after VATS lobectomy in a prospectively maintained nationwide registry.METHODSThe registry was queried for all consecutive VATS lobectomy procedures from 49 Italian Thoracic Units. Baseline condition, tumour features, surgical techniques, devices, postoperative care, complications, conversions and the reasons thereof were detailed. Univariable and multivariable regressions were used to assess factors potentially linked to complications.RESULTSFour thousand one hundred and ninety-one VATS lobectomies in 4156 patients (2480 men, 1676 women) were analysed. The median age-adjusted Charlson index of the patients was 4 (interquartile range 3–6). Grade 1 and 2 and Grade 3–5 complications were observed in 20.1% and in 5.8%, respectively. Ninety-day mortality was 0.55%. The overall conversion rate was 9.2% and significantly higher in low-volume centres (CONCLUSIONSVATS lobectomy is a safe procedure even in medically compromised patients. An improved classification system for conversions is proposed and prevention strategies are suggested to reduce conversion rates and possibly complications in less-experienced centres.

Accurate staging of early non-small cell lung cancer is fundamental for selecting the best treatment. The aim of this study was to identify risk factors for nodal upstaging after video-assisted thoracoscopic lobectomy for clinical T1-3N0 tumors.From 2014 to 2017, 3276 thoracoscopic lobectomies were recorded in the prospective database "Italian VATS Group". Linear and multiple logistic regression models were adapted to identify independent predictors of nodal upstaging and factors associated with progression in postoperative N status.Nodal upstaging was found in 417 cases (12.7%), including 206 cases (6.2%) of N1-positive nodes, 81 cases of N2 nodes (2.4%), and 130 cases (4%) of involvement of both N1 + N2 nodes. A total of 241 (7.3%) patients had single-station nodal involvement, whereas 176 (5.3%) had multiple-station involvement. In the final regression model, the tumor grade, histology, pathologic T status, and 12 resected nodes were independent predictors of nodal upstaging.The number of resected lymph nodes seems to predict nodal upstaging better than the type of intraoperative lymph node management. Other preoperative risk factors correspond to those for which the current guidelines of the European Society of Thoracic Surgery recommend more extensive preoperative mediastinal staging.

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 signi cance (P=0.048 and P=0.00086). Conclusions: The conversion rate and the percentage of air leaks seem to de ne the expertise of VATS lobectomy, being linked to the ability to manage more complicated surgical cases or intraoperative adverse events.

Background: the case of an oldest-old woman with severe hypercalcemia and hyperparathyroidism due to left parathyroid adenoma. Case presentation: An 85-year-old woman, hospitalized for rapid loss of functional abilities, mental confusion, worsening of depression, anorexia and incontinence. In the medical history, she had depression, hypertension, osteopenia and osteoarthritis. Blood examinations showed high levels of calcium and intact parathyroid hormone (PTHi), severe renal failure with hyperphosphoremia. After hydration and loop diuretic administration, renal function improved and pamidronate and calcimimetic treatments were followed by reduction of calcium levels. The ultrasound of neck identified a possible parathyroid adenoma; 99Tc-sestamibi scintigraphy and CT scan with contrast confirmed the diagnosis. The surgical left hemithyroidectomy was the treatment of choice and the PTHi and calcium reached normal circulating levels immediately post-surgery. At the 3-month clinical follow-up from surgery, the functional, psychological and cognitive functions improved substantially, although mood disorder secondary to disability persisted. Conclusions: Hypercalcemia due to primary hyperparathyroidism is a low prevalence condition among older adults. However, we should keep in mind whenever we find ourselves facing a sudden and unjustified physical, psychological and cognitive deterioration in such a clinical condition old and oldest-old persons.

OBJECTIVES: Inherent technical aspects of pulmonary lobectomy by video-assisted thoracoscopic surgery (VATS) may limit surgeons’ ability to deal with factors predisposing to complications. We analysed complication rates after VATS lobectomy in a prospectively maintained nationwide registry. METHODS: The registry was queried for all consecutive VATS lobectomy procedures from 49 Italian Thoracic Units. Baseline condition, tumour features, surgical techniques, devices, postoperative care, complications, conversions and the reasons thereof were detailed. Univariable and multivariable regressions were used to assess factors potentially linked to complications. RESULTS: Four thousand one hundred and ninety-one VATS lobectomies in 4156 patients (2480 men, 1676 women) were analysed. The median age-adjusted Charlson index of the patients was 4 (interquartile range 3–6). Grade 1 and 2 and Grade 3–5 complications were observed in 20.1% and in 5.8%, respectively. Ninety-day mortality was 0.55%. The overall conversion rate was 9.2% and significantly higher in low-volume centres (

Introduction: A rare tumour of the lung (RTL) is defined as neoplasm whose incidence is lower than 2% of all pulmonary tumours. Such group includes different benign and malignant lesions with variable occurrence rate. Aim of this study was to retrospectively analyze a single centre surgical experience and com- pare it with the literature. Patients and Methods: From February 2002 to April 2009 twenty-four patients underwent resection for RTL. Different procedures were utilized, including operative rigid bronchoscopy, wedge resection, lobectomy, pneumonectomy, and bronchoplastic procedures. All patients entered a follow-up program (median 22, range1-79 months). Results: According to the 2004 WHO classification 6 patients had benign (Group A) and 18 malignant (Group B) RTL. Group A: endobronchial hamartoma (n=1) endobronchial lipoma (n=1), endobronchial fibroepithelial polyp (n=1), benign fibrous hystiocitoma (n=1) and sclerosing hemangioma (n=2). Group B: pulmonary blastoma (B1, n=1), mucoepidermoid carcinoma (B2, n=1), adenoid cystic carcinoma (B3, n=3), inflammatory myofi- broblastic tumour (B4, n=1), pulmonary synovial sarcoma (B5, n=3), dendritic follicular cells sarcoma (B6, n=1), pleomorphic carcinoma (B7, n=2) spindle cell carcinoma (B8, n=2), and carcinosarcoma (B9, n=4). Symptoms were present mostly in centrally- located neoplasms (10/24, n=3 Group A and n=7 Group B). Two patients were lost at follow-up. Three patients with B9 died of the disease (median 14 months, range 4-15), one B8 immunocompromised patient had progressive disease after 3 months, the remaining are present alive without evidence of disease. Conclusions: Our results substantially reflect the literature data. A multicentre study would add to the knowledge of this heterogeneous group of tumours.

Background: The clinical significance of lymph-node metastases, multicentric forms, and tumorlets in bronchial carcinoids is still a matter of debate. Aim of this study was to analyze their prevalence and clinical significance in a series of 123 bronchial carcinoids. Patients and Methods: Nodal dissection and serial sections of resected lung parenchima for research of multicentric forms and tumorlets were performed in most patients. Survival curve was produced using the Kaplan-Meyer method and multivariate analysis by the Cox proportional hazard model. Results: Lymph-node involvement was present in 14% of typical (14 of 100) and 13.04% of atypical carcinoids (3 of 23). Multicentric forms (syncronous carcinoids or tumorlets) were found in 11.3% of the total with a negative impact on survival (p = 0.021). Multiple tumorlets were found in 7.3% of all cases at the standard pathologic examination, but whenever accurate palpation and serial sections of the surgical specimen were performed, the percentage reached 24% of the cases. Overall survival was 98.2%, 95.8%, and 83.9% for typical and 71.6%, 57.3%, and 24% for atypical carcinoid respectively at 5, 10, and 15 years. Time from surgery was significantly directly correlated with recurrences (p < 0.0001) and disease related death (p = 0.0002). Conclusions: A high prevalence of tumorlets, multiple carcinoids, and lymph-nodal involvement was found in our series. On the basis of these observations bronchial carcinoids always require major surgical procedures with systematic nodal dissection, and a careful search for multifocal lesions should always be performed. Follow-up should always be accurate and protracted, due to the frequency of very long-term relapses (often more than 10 years after surgery). © 2009 by the International Association for the Study of Lung Cancer

Introduction: Talc is currently the most common agent used for pleurodesis. Despite its role acknowledged as an effective bed side strategy primarily in neoplastic pleural effusion, recently it has been introduced in the treatment of benign diseases such as spontaneous pneumothorax. Aim of this study is to investigate side effects and results of different concentrations of talc pleurod- esis (TP) in rabbits. Materials and Methods: Twenty-six New Zealand rabbits were randomly injected intrapleurally with saline (n=6) or talc slurry at usual dosage 40mg/kg (T40, n=10) and 200mg/kg (T200, n=10). Chest tube was opened at day1 post-operative and removed in day4. Clinical signs and symptoms, fluid lactate dehydrogenase and protein levels were measured daily after the injection until drainage removal, then on day7 and before sacrifice. All groups were equally divided in two endpoints: day14 and day28. At post- mortem examination, pleurodesis was graded, according to Light criteria, from 1(none) to 8(>50% symphysis), by two observers blinded to treatment groups. Results: Adverse reactions were discovered with fever and weight loss in T200 group at 14 and 28 days. Pleurodesis score in the control Saline was negative while it did not differ significantly between T200 (4.0±1.4 at 14 days, 4.2±1.6 at 28 days) and T40 (2.8±2.0 at 14 days, 3.6±1.9 at 28 days) at days 14 and 28 (p=0.25 and p=0.56 respectively). Microscopically several granulomas, moderate localized pleural thickness, few areas of neoangiogen- esis and mediastinal lymphathic tissue infiltration were present in both study groups. Conclusions: TP at usual clinical dosage is well tolerated with acceptable clinical results. By increasing the concentration we observed severe side-effects with only mild improvement of pleurodesis.

Introduction: Different etiologies are responsible for a wide spectrum of tracheal injuries. Some of these, such as cicatricial laryngo-tracheal stenosis and tracheoesophageal fistula (T-E) not rarely represent a challenge in tracheal surgery. Aim of this study is to retrospectively review the pattern of post-intubation lesions, extension of surgery and long term results in 49 patients. Methods: From December 1987 to February 2007, 49 patients (23 males and 26 females), mean age 50 (range 15–78), were submit- ted to surgical treatment: cicatricial tracheal stenosis (Group A), T-E fistula (Group B), and tracheal tear (Group C). All patients were symptomatic. Results: No post-operative deaths. In Group A (n = 34) the stricture was considered moderate (residual lumen:30–50%) in 27 patients, and severe (

Cricopharyngeal foreign bodies (FBs) impaction in adults is a common clinical problem; without treatment, the sequelae may be lethal due to local and/or mediastinal infection. When direct laryngoscopy and flexible fiberoptic endoscopy are ineffective, rigid endoscopy is the method of choice requiring general anesthesia. The new video laryngoscopes represent a great advancement in the assessment of the laryngeal inlet. Aim of the study was to assess the feasibility of identifying and removing FBs impacted at crycofaringeal and upper oesophageal sphincter by the video laryngoscope.In a period of 30 months, on an urgent basis, we systematically assessed by GlideScope® video laryngoscope all adult patients with a diagnosis of impacted crycofaringeal upper esophageal FB, after unsuccessful removal attempts in the otolaryngology or gastroenterology unit.Twenty-six consecutive patients were evaluated. In conscious sedation by video laryngoscope 17 FBs were identified and removed from the hypopharynx or upper esophageal sphincter. In 9 patients rigid endoscopy in general anesthesia and tracheal intubation was necessary to remove FBs impacted beyond the upper esophageal sphincter.In our experience video laryngoscope, because of the magnified vision, the better patient comfort and no requirement of general anesthesia, represents a great improvement in identifying and removing in conscious sedation even small and thin foreign bodies not recognized by radiological and otolaryngology examination and not readily detected by direct endoscopy.