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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.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).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).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.

Introduction Achalasia with megaesophagus is a pathology characterized by widespread and irregular dilation of the esophageal lumen. In most cases, this dilation is caused by contraction and subsequent failed relaxation of the lower esophageal sphincter (LES). It may be associated with a partial or complete slowing of the esophageal peristalsis. Case overview We present the case of a 58-year-old woman who developed dysphagia, regurgitation, and substantial weight loss (11 kg) over a span of 1 year. Symptomatic achalasia with megaesophagus was diagnosed following chest and abdominal computed tomography (CT) with contrast and transit RX with gastrografin and esophageal manometry. The patient refuse all minimally endoscopic treatments and opted straightly for the treatment with esophagectomy sec. Ivor–Lewis. At the 6-month follow-up, the patient appeared in excellent general clinical condition and oral gastrografin radiography (OGR) showed good channeling. Discussion Patients require medical attention when presenting with achalasia that has eroded the esophageal wall enough to form a megaesophagus. Early and minimally invasive treatments (i.e., medical therapy, endoscopic dilation, and myotomy) are insufficient at this stage, and thus esophageal surgery is required. Among the most common surgical approaches, we must mention esophagectomy sec. McKeown and esophagectomy with interposition of a colic loop sec. Wilkins; however, based on our experience, esophagectomy sec. Ivor–Lewis with intrathoracic anastomosis leads to excellent results and can therefore be considered a valid alternative for treating complex cases. Conclusions Subtotal esophagectomy sec. Ivor–Lewis with intrathoracic anastomosis is effective in treating achalasia with megaesophagus.

Extensive chest wall resection and reconstruction is a challenging procedure that requires a multidisciplinary approach, including input from thoracic surgeons, plastic surgeons and oncologists. Neoplastic chest wall pathologies are associated with a high surgical morbidity and can result in full thickness defects which are complicated to reconstruct. The goals of a successful chest wall reconstruction is to restore the chest wall rigidity, preserve ventilatory mechanics and protect the intrathoracic organs. Large full thickness defects require reconstruction with synthetic, biologic or composite meshes with or without titanium plate to restore thoracic cage rigidity. After skeletal stability is established full tissue coverage can be achieved using direct sutures, skin grafts or local advancement flaps, pedicled myocutaneous flaps or free flaps. The aim of this chapter is to illustrate the indications and the various materials and techniques for chest wall reconstruction with the goal of obtaining the best chest wall rigidity and soft tissue coverage.

Hemothorax, whether spontaneous or related to thoracic trauma lesions, is treated using basic principles that are well-accepted by trauma and cardiothoracic surgeons. Only a small percentage of patients require a tube thoracostomy; for the rest, a nonoperative technique is appropriate and safe. Only a small percentage of patients require surgical intervention due to retained hemothorax, persistent bleeding or incoming complications (i.e. pleural empyema or entrapped lung). Early in the 1990s, significant technological advancements led to an increase in diagnostic and therapeutic indications for Multi-port Video-assisted thoracoscopic surgery (VATS) as the gold standard therapy for retained and persistent hemothorax, allowing for earlier diagnosis, total clot removal, and better tube placement, with less morbidity, reduced post-operative pain, and a shorter hospital stay. Even if there is no agreement in the Literature about the timing for draining hemothorax, best results are obtained when the drainage is performed within the first five days after the onset. An important evolution of traditional multi-port approach is represented by uniportal approach, with the same results of open surgical technique and the real advantage of 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. Many authors have confirmed the advantages of single-port technique compared with multi-port in term of better post-operative pian control, easier surgical approach and better cosmetic results, but longer and harder learning curve.

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. Supplementary Information The online version contains supplementary material available at 10.1007/s11748-020-01570-5.

Background: Many new surgical techniques and materials have been introduced in the last decade for chest wall reconstruction or stabilization with the purpose of improving the incorporation, maintaining chest wall stability with reduction of infections. However, none of them are yet considered a gold standard procedure. The aim of this work is to evaluate the initial experience using a new titanium mesh for chest wall reconstruction in four Italian Thoracic Surgery Departments. Methods: A review was performed of all patients undergoing chest wall reconstruction using a new titanium mesh between January 2014 and September 2018. Surgical indications, the location and size of the chest wall defect, intraoperative variables and postoperative complications were analyzed. Results: A total of 26 consecutive patients were included. The most common indications for surgery were primary or secondary chest wall tumors (38%) followed by lung cancer invading chest wall (31%). The most common localization of chest wall defect was anterolateral (46%). Sternal reconstruction was required in 3 patients (12%). The average size of the defect was 9.3×7.8 cm. The median number of resected ribs was 3.6. No perioperative deaths occurred. Mean hospital stay was 11.9 days. Overall morbidity was 19%. One failure of reconstruction (4%) was reported during follow up. Conclusions: In our early clinical experience chest wall reconstruction using titanium mesh can be performed as a safe and effective surgical procedure. This mesh has excellent biomechanical characteristics between rigid and malleable materials, it’s easy to trim and fix for optimal adaptation without necessity of dedicated instruments. The early and mid-term results are satisfactory with low incidence of complications related to the titanium mesh implant.

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.

Introduction Smooth muscle tumours of uncertain malignant potential (STUMP) are mesenchymal uterine tumours with a malignant potential found somewhere between that of benign leiomyomas and leiomyosarcomas. Only three cases of STUMP pulmonary metastasis exist in the literature. Case presentation We report the case of a 63 year-old female patient presenting with dysphonia secondary to recurrent laryngeal nerve paralysis due to an enormous mediastinal STUMP metastasis, 14 years after having undergone a total hysterectomy with bilateral salpingo-oophorectomy. A successful left pneumonectomy was performed and the mass weighing 1570 g was histologically confirmed as a STUMP metastasis. Discussion Only three cases of pulmonary metastasis from STUMP have been reported in the recent literature and no robust information exists about the metastatic nature of STUMP. No cases exist in the literature of a successful pneumonectomy performed for a STUMP metastasis of such large dimensions presenting after many years from the diagnosis of the primary uterine lesion. Physicians should keep in mind that the finding of a smooth muscle tumour in the lung of a woman should promptly raise the suspicion of a metastatic uterine malignancy, even several years after diagnosis of the primary lesion. Conclusion Despite the size, invasiveness and late presentation of the STUMP metastasis, the surgery was successful and the patient no longer requires oxygen therapy., Highlights • Smooth muscle tumours of uncertain malignant potential (STUMP) are mesenchymal uterine tumours with malignant potential. • Pulmonary metastasis from STUMP is very rare, with only 3 cases found in the recent literature. • These tumours have a malignant potential somewhere between that of benign leiomyomas and leiomyosarcomas. • Smooth muscle tumours may metastasize several years after removal of the primary uterine lesion.

Purpose The role played by radiation therapy after pleurectomy/decortication or surgical biopsy in malignant pleural mesothelioma is uncertain. We treated patients with accelerated hypofractionated radiotherapy using helical tomotherapy and intensity-modulated arc therapy in an attempt to keep lung toxicity to a minimum. The present study reports the feasibility and toxicity of this approach. Material and Methods Between 2008 and 2012, 36 patients with malignant pleural mesothelioma underwent accelerated hypofractionated radiotherapy to the hemithorax after pleurectomy/decortication (19 patients) or biopsy (17 patients). The prescription dose was 25 Gy in five fractions over 5 consecutive days. Results We observed three patients with G3 pneumonitis, five cases of grade 2 dyspnea and six cases of grade 2 cough. The median follow-up was 37 months (range: 3–54 months). The median overall survival for patients who underwent pleurectomy/decortication followed by radiotherapy was 21.6 months [95% confidence interval (95% CI): 15.5–24.1] compared to 19.4 months for patients not submitted to surgery. Conclusion Treatment of intact lung with pleural intensity-modulated arc irradiation in malignant pleural mesothelioma patients with malignant pleural mesothelioma proved safe and feasible, with an acceptable rate of pneumonitis. Survival rates were encouraging for both biopsy-only and pleurectomy/decortication groups. We are currently conducting a phase II dose escalation trial in a similar patient setting to prospectively evaluate the impact of radiotherapy on toxicity, disease-free survival and overall survival.

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., Highlights • Anastomotic dehiscence is an adverse event in esophageal surgery. • Eso-SPONGE® is an excellent method to treat the esophageal post-surgery dehiscence. • Eso-SPONGE® has provided better results than previous methods. • Eso-SPONGE® is easily repeatable even in not-expert centers.

Background Single site studies in male Veterans in the U.S. reported increased detection of presumptive cancer precursors (adenomas, hyperplastic polyps) in the proximal colon (cecum-splenic flexure) by water exchange. Aims Assess the reproducibility of the observation. Methods Analysis of secondary outcomes collected prospectively in 3 similarly designed randomized controlled trials using water exchange, water immersion and insufflation (air or carbon dioxide). Main outcome: detection rates of adenomas and hyperplastic polyps in proximal, transverse and right colon (cecum-ascending). Results 704 males (173 screening) were evaluated. In the proximal colon, WE showed increased detection of small adenomas ( p = 0.009) and adenomas plus hyperplastic polyps ( p = 0.015) (vs insufflation); increased detection of adenomas plus hyperplastic polyps of any size ( p = 0.045) and of small size ( p = 0.04) (vs water immersion). In the right colon water exchange increased detection of small adenomas (19% vs 12.1%, p = 0.04) (vs insufflation); small adenomas (19% vs 12%, p = 0.038), adenomas plus hyperplastic polyps of any size (25% vs 16.7%, p = 0.028) and of small size (23.7% vs 14.6%, p = 0.012) (vs water immersion). Water exchange significantly improved bowel cleanliness. Sedation had no impact on lesion detection. Conclusions Water exchange is a superior insertion technique for detection of adenomas and hyperplastic polyps primarily in the right colon, especially those of small size.

Background A recent American Society for Gastrointestinal Endoscopy Technology Status Evaluation Report recommended comparative studies of water-aided colonoscopy methods to refine the optimal insertion technique. Objective Air insufflation (AI), water immersion (WI), and water exchange (WE) were compared head-to-head to test the hypothesis that WE produces the least insertion pain. Design Patient-blinded, prospective, randomized, controlled trials. Setting Two community hospitals in Italy. Patients First-time diagnostic or screening colonoscopy in unsedated patients with the option of on-demand sedation. Intervention Colonoscopy with AI, WI, or WE. Main Outcome Measurements Real-time maximum insertion pain (0 = none, 10 = worst). To avoid interventional bias, the timing of recording was at the discretion of the nurse assistant. Adjunct measures were implemented to ensure patient perception of minimal discomfort. Recalled pain and patients' guess of insertion methods were recorded after colonoscopy. Results Results were merged for 576 randomized patients. Correct patient guesses lower than 33% confirmed adequate blinding. Significant correlation (Pearson coefficient 0.6, P P P = .009; vs AI, 65.3%; P = .04). WE required the least implementation of adjunct maneuvers. Limitations Unblinded colonoscopists. Conclusion The current findings with an internally validated primary outcome in adequately blinded patients support the hypothesis that WE is superior to WI in attenuating real-time insertion pain and enhancing completion of unsedated colonoscopy.

Background: Postoperative (PO) anastomotic leak(AL) is life-threatening condition. Primary repair of defect with reinforcement of suture line by vascularized tissue has been advocated in treatment of intrathoracic oesophagal AL Aim: Describe use of diaphragmatic flap for closure of intrathoracic oesophagal AL after esophagectomy for cancer Method: 61 ys old man underwent Ivor-Lewis esophagectomy with esophagogastroplasty for oesophagal cancer. In 10th postoperative day, contrast studies revealed extravasation of intrathoracic anastomosis (Fig1a). Endoscopy confirmed significant AL with ischemia of gastric mucosa. Right redo thoracotomy was performed. Anastomotic dehiscence was directly sutured with interrupted monofilament resorbable stitches(Fig1b).Diaphragmatic flap was wrapped around anastomosis and gastric conduit and fixed to cover and buttress the suture line(Fig1c).Bovine pericardium patch was used to repair the diaphragmatic defect. Upper intrathoracic oesophagus was isolated and excluded by absorbable linear staple suture. Result: Enteral nutrition, through feeding jejunostomy, was administered from PO day-1 until restoration of intestinal integrity (Fig1d).Patient recovered well and was discharged on 29 th PO day Conclusion: Temporary oesophagal exclusion and primary repair, reinforced by diaphragmatic flap, represent efficient alternative technique in management of mediastinal and systemic sepsis due to intrathoracic oesophagal AL

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.

Consensus exists as to the concept that surgical therapy should not be denied based on older age alone. Elderly lung cancer patients with multiple morbidities are increasingly referred for surgical care. The aim of this study was to evaluate the surgical outcomes and the long-term survival in octogenarians with early-stage non-small cell lung cancer.Between January 2000 and December 2010, we identified 73 octogenarians who underwent intended curative lung resection for lung cancer in three different thoracic surgery departments. Two surgical groups were defined: patients who underwent lobar resection (group A) and patients who underwent sub-lobar resection (group B).The in-hospital mortality was 2.7% without difference between groups. Group B had a lower incidence of post-operative complications, in particular respiratory complications. Chronic renal failure, multi pre-operative comorbidities and type of resection were risk factors for post-operative morbidity. After a mean follow-up time of 63.8 months, the overall survival at 1, 3 and 5 years was 96, 83 and 60%, respectively. The low-respiratory reserve was associated with worse long-term survival. The intra-operative and post-operative factors able to influence survival were: the cN status, recurrence of disease and local versus systemic recurrence. The type of operation did not influence survival.In our experience, surgery is a safe and justifiable option for octogenarian patients with early stage NSCLC. Sublobar resection provides an equivalent in-hospital mortality and long-term survival in comparison with open lobectomy but with less postoperative morbidity. Further large-scale randomized studies are necessary to confirm our results.

RATIONALE: Angiosarcomas are rare, malignant vascular tumors.PATIENT CONCERNS: They represents about 2% of all soft tissue sarcoma, which can often metastasize through the hematogenous route. The radiological features have been analyzed in 4 patients with metastatic angiosarcoma in the chest.DIAGNOSES: The main radiologic findings included nodules, cysts, nodules with halo sign, and vascular tree-in-bud. Morphologic features, as observed in the histologic specimen, have been correlated with radiologic appearance.LESSONS: Metastatic angiosarcomas to the lung are characterized by a wide variety of radiologic appearances that can be very characteristic. Computed tomographic findings observed include bilateral solid nodules, cystic, and bullous lesions sometimes associated with spontaneous hemopneumothoraces.

To determine whether observations were reproducible among investigators.From March 2013 through June 2014, 18-85-year-old diagnostic and 50-70-year-old screening patients were enrolled at each center to on-demand sedation colonoscopy with water exchange (WE), water immersion (WI) and insufflation with air or CO2 for insertion and withdrawal [air or carbon dioxide (AICD)]. Data were aggregated for analysis.Variations in real-time maximum insertion pain (0 = none, 1-2 = discomfort, 10 = worst).One thousand and ninety-one cases analyzed: WE (n = 371); WI (n = 338); AICD (n = 382). Demographics and indications were comparable. The WE group had the lowest real-time maximum insertion pain score, mean (95%CI): WE 2.8 (2.6-3.0), WI 3.8 (3.5-4.1) and AICD 4.4 (4.1-4.7), P0.0005. Ninety percent of the colonoscopists were able to use water exchange to significantly decrease maximum insertion pain scores. One investigator had high insertion pain in all groups, nonetheless WE achieved the lowest real-time maximum insertion pain score. WE had the highest proportions of patients with painless unsedated colonoscopy (vs WI, P = 0.013; vs AICD, P0.0005); unsedated colonoscopy with only minor discomfort (vs AICD, P0.0005), and completion without sedation (vs AICD, P0.0005).Aggregate data confirm superiority of WE in lowering colonoscopy real-time maximum insertion pain and need for sedation. Ninety percent of investigators were able to use water exchange to significantly decrease maximum insertion pain scores. Our results suggest that the technique deserves consideration in a broader scale.

Malignant pleural mesothelioma (MPM) is a rare and aggressive tumor with generally disappointing results in terms of survival, however, there are occasional long-term survivors probably due to the biologic characteristics of the disease. Standard uptake value (SUV) of [18F] Fluorodeoxyglucose (FDG) evaluated by photon emission tomography (PET) is now widely accepted as an indicator of biologic behavior in several malignancies. The aim of this study was to verify whether SUVmax and SUVmean are inversely associated with the prognosis of patients with MPM and whether there was a correlation between grading/disease stage and SUV value. Patients with histologically proven MPM underwent integrated PET and computed tomography (CT) scanning. Patients fasted and received 5.18 MBq of FDG per kilogram of body weight. Based on the maximum Chi-Square method, a SUVmax of 4.21 (range: 2.30–14.74) and a SUVmean of 2.78 (range: 1.80–7.00) were used to classify patients as having a good or poor prognosis, respectively. From January 2004 to March 2010, 27 patients were analyzed: median age was 65 years (range: 54–77) and histologic MPM subtypes were epithelioid (23 patients) and biphasic (4 patients). At a median follow-up of 23 months (range: 1–52), there was no difference in median survival for either high or low SUVmax [26 months (range: 11-not reached) vs.19 months (range: 12-not reached); p = 0.811] or for high or low SUVmean [26 months (range: 8-not reached) vs.19 months (range: 11-not reached); p = 0.831]. High SUVmax (p = 0.018) was statistically correlated with high-stage disease. There was only a trend towards statistical significance between high-grade disease and high SUVmean (p = 0.083); no such trend was found between advanced stages and SUVmax (p = 0.268). We observed a significant correlation only between high SUVmax and high-grade disease. No other relationships between SUVmax and SUVmean with biologic and clinical parameters were found. This is probably due to the patient characteristics and to the non-routine use of 18F-FDG PET/CT to stage rare tumors such as MPM.

Purpose: Talc pleurodesis (TP) is employed worldwide for the management of persistent pneumothorax or pleural effusion, particularly of malignant origin. However, there are very little available data on 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F FDG PET/CT) response evaluation in malignant pleural mesothelioma (MPM) patients treated with TP and chemotherapy.Methods: Patients with histologically confirmed MPM underwent TP and FDG PET/CT staging and restaging after 3-4 courses of chemotherapy. All patients fasted and received a dose of 5.18 MBq 18F-FDG per kilogram of body weight. Whole-body emission scans were acquired with and without Ordered Subset Expectation Maximization (OSEM) iterative reconstruction algorithm.Results: From January 2004 to March 2010, 8 patients with biopsy confirmed MPM (7 epithelial, 1 biphasic), with a median age of 65 years (range: 54-77), were evaluated. Median follow-up was 31 months (range: 4-44). After TP treatment, there was a mean interval of 14 days (range: 9-22) and 125 days (range: 76-162) between FDG PET/CT staging and restaging. According to modified RECIST and EORTC criteria, there was a concordance between the radiologic and metabolic SUVmean and SUVmax responses in 6 (75%) and 3 (37.5%) patients, respectively.Conclusion: TP produces an increased FDG PET uptake which may interfere with the post-chemotherapy disease evaluation. In our case series, the metabolic response measured by SUVmean seems to be in better agreement with the radiologic response compared to the SUVmax.

Purpose: Talc pleurodesis (TP) is employed worldwide for the management of persistent pneumothorax or pleural effusion, particularly of malignant origin. However, there are very little available data on 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F FDG PET/CT) response evaluation in malignant pleural mesothelioma (MPM) patients treated with TP and chemotherapy. Methods: Patients with histologically confirmed MPM underwent TP and FDG PET/CT staging and restaging after 3-4 courses of chemotherapy. All patients fasted and received a dose of 5.18 MBq 18F-FDG per kilogram of body weight. Whole-body emission scans were acquired with and without Ordered Subset Expectation Maximization (OSEM) iterative reconstruction algorithm. Results: From January 2004 to March 2010, 8 patients with biopsy confirmed MPM (7 epithelial, 1 biphasic), with a median age of 65 years (range: 54-77), were evaluated. Median follow-up was 31 months (range: 4-44). After TP treatment, there was a mean interval of 14 days (range: 9-22) and 125 days (range: 76-162) between FDG PET/CT staging and restaging. According to modified RECIST and EORTC criteria, there was a concordance between the radiologic and metabolic SUVmean and SUVmax responses in 6 (75%) and 3 (37.5%) patients, respectively. Conclusion: TP produces an increased FDG PET uptake which may interfere with the post-chemotherapy disease evaluation. In our case series, the metabolic response measured by SUVmean seems to be in better agreement with the radiologic response compared to the SUVmax.

Low adenoma detection rate (ADR) predicts development of interval cancers, found mainly in the right (cecum-ascending) colon, where poor bowel preparation is an associated factor. Single-site studies reported increased detection of adenomas in the proximal colon segments by water exchange (WE). Data about colon cleansing revealed that WE had the greatest impact in the right colon.To test the hypothesis that WE had the greatest impact on ADR in colon segments with the most favorable bowel cleanliness scores, namely the right colon.We pooled right colon and overall ADR data of three similarly designed colonoscopy trials that compared WE, water immersion (WI) and insufflation of air or carbon dioxide (AICD) in a mixed gender European population.In this study, 1200 (704 males) subjects and were included. 288 were screening cases. Demographic and procedural data were comparable. Water exchange achieved significantly higher right colon10 mm ADR (11.9 %, vs WI 6.9 %, p = 0.016; vs AICD 7.2 %, p = 0.025). Water exchange achieved the lowest proportions of poor bowel preparation and the highest right colon and overall Boston bowel preparation scale scores (p range 0.003,0.0005). In patients with right colon excellent bowel cleanliness, water exchange was the only method significantly associated with right colon adenoma detection. One of the limitations is unblinded colonoscopists.In a mixed gender European population, water exchange is confirmed to be a superior insertion technique showing a significant increase in10 mm right colon adenoma detection, achieving the cleanest colon and lowest proportions of poor bowel preparation requiring repeat procedures. CLINICALTRIALS.NCT01781650, 01954862, 01780818.

Background: A diagnosis of interstitial lung diseases (ILDs) may include surgical lung biopsy (SLB), which is associated with significant morbidity and mortality and also appreciable costs. Transbronchial lung cryobiopsy (TBLC) is adopting an important role. Objectives: The aim of this study was to compare the diagnostic yield (DY) and safety of TBLC and SLB in a large cohort of patients and to perform a systematic review of the literature as well as a meta-analysis. Methods: We performed a retrospective analysis of 447 cases with ILD undergoing TBLC and/or SLB and a systematic review of the literature (MEDLINE and Embase for all original articles on the DY and safety of TBLC in ILDs up to July 2015). Results: A total of 150 patients underwent SLB and 297 underwent TBLC. The median time of hospitalization was 6.1 days (SLB) and 2.6 days (TBLC; p < 0.0001). Mortality due to adverse events was observed for 2.7% (SLB) and 0.3% (TBLC) of the patients. Pneumothorax was the most common complication after TBLC (20.2%). No severe bleeding was observed. TBLC was diagnostic for 246 patients (82.8%), SLB for 148 patients (98.7%, p = 0.013). A meta-analysis of 15 investigations including 781 patients revealed an overall DY of 0.81 (0.75-0.87); the overall pooled probability of developing a pneumothorax, as retrieved from 15 studies including 994 patients, was 0.06 (95% CI 0.02-0.11). Conclusion: Cryobiopsy is safe and has lower complication and mortality rates compared to SLB. TBLC might, therefore, be considered the first diagnostic approach for obtaining tissue in ILDs, reserving the surgical approach for cases in which TBLC is not diagnostic.

Background: diagnosis of interstitial lung disease (ILD) includes surgical lung biopsy (SLB) when clinical and radiological data are inconclusive, but transbronchial cryobiopsy (TBCB) is acquiring an important role. The main purpose of this study retrospective observational was to investigate the differences in mortality and complications between TBCB and SLB performed with VATS. Methods: we evaluated all patients with ILD from January 2004 to August 2014 at our Institution; 155 patients underwent SLB and 241 TBCB. All values were described as mean ±standard deviation; a chi-square statistics test was used for categorical data and an unpaired Student9s t test for continuous data. Results: The mean age of the patients was similar in the two groups (57,74 ± 11,29 in SLB group vs 56,70 ± 11,29 years in TBCB group). Mortality and complications were evaluated at 30 and 90 days. In the SLB group mortality was observed in 3,9 % of patients and minor complications were experienced in 10,6 % of patients. In the TBCB group the most frequent complication was pneumothorax (19,9%) but only 20% required drainage; we observed prolonged bleeding only in one case and only one patient died (0,41%), who was HIV-positive and died of acute exacerbation of IPF. Chest tube drainages after VATS were maintained for 3,6 days (2-9 days) and duration of hospitalization was 5,2 days; in case of iatrogenic pneumothorax in the TBCB, drainage was maintained for 4,1 days and mean hospitalization after bronchoscopy was 2,9 days. Conclusion: TBCB has advantages of decreased mortality and complication and can be safer than SLB in the diagnosis of ILDs, with also a shorter mean hospitalization.

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.

BACKGROUND AND STUDY AIM Water-aided colonoscopy includes water immersion and water exchange. Several small single-center studies have suggested that the use of water rather than air insufflation during colonoscopy reduces pain on insertion. The aim of this study was to investigate whether water-aided colonoscopy is less painful than air insufflation in a large cohort of patients. PATIENTS AND METHODS This was a two-center, randomized controlled trial. Consecutive patients who agreed to start colonoscopy without premedication were included. Sedation was administered on demand. Water-aided colonoscopy was performed using water immersion in the early phase of the study, and subsequently water exchange was used. The primary endpoint was cecal intubation with pain scores of ≤ 2 and sedation with no or ≤ 2 mg midazolam. Secondary outcomes were pain score at discharge, cecal intubation rate and time, and adenoma detection rate (ADR). RESULTS A total of 672 patients were randomized to water exchange (n = 338) or air insufflation (n = 334). The primary endpoint was achieved in more patients in the water exchange group (83.8 % vs. 62 %; P

Background Non-invasive early detection of lung cancer could reduce the number of patients diagnosed with advanced disease, which is associated with a poor prognosis. We analyzed the diagnostic accuracy of a panel of peripheral blood markers in detecting non small cell lung cancer (NSCLC). Methods 100 healthy donors and 100 patients with NSCLC were enrolled onto this study. Free circulating DNA, circulating mRNA expression of peptidylarginine deiminase type 4 (PAD4/PADI4), pro-platelet basic protein (PPBP) and haptoglobin were evaluated using a Real-Time PCR-based method. Results Free circulating DNA, PADI4, PPBP and haptoglobin levels were significantly higher in NSCLC patients than in healthy donors (p

OBJECTIVES: Older lung cancer patients with multiple morbidities are increasingly referred to thoracic surgery departments. The aim of this multicenter study was to analyse the prognostic factors for in-hospital morbidity and mortality and to elucidate the predictors of long-term survival and oncological outcomes. METHODS: We identified 319 patients aged ≥ 75 years who underwent intended curative lung resection for lung cancer in three different thoracic surgery departments between January 2000 and December 2010. RESULTS: Seventy-one patients underwent limited resection, 202 had lobectomy, 16 had bilobectomy and 30 had pneumonectomy. The in-hospital mortality was 6.6%. Chronic renal failure, low respiratory reserve and pneumonectomy were predictors of in-hospital mortality. The mean follow-up time was 3.9 years, ranging from 1 month to 10.4 years. The disease-free survivals at 1, 3 and 5 years were 82, 60 and 47%, respectively. The overall survivals at 1, 3 and 5 years were 86, 59 and 38%, respectively. The long-term overall survival was negatively influenced by pneumonectomy, extended resection, N(1-2) subgroups and pathological TNM stage. CONCLUSIONS: Nowadays, we can consider surgery a safe and justifiable option for elderly patients. Careful preoperative work-up and selection are mandatory to gain satisfactory results. Good long-term results were achieved in elderly patients with early stage who underwent lobar or sublobar lung resection. The role of surgery or other alternative therapies, in patients with advanced stages, extensive nodal involvement and/or requiring extensive surgical resection for curative intent, is still unclear and further studies are certainly needed.

This multicenter analysis evaluated patient outcome and clinical pathologic features of thymic epithelial tumors after complete surgical resection and adjuvant treatment. Histologic classification and clinical staging were performed according to WHO classification and Masaoka staging system, respectively. We analyzed 62 patients, 20 (32 %) of whom had myasthenia at diagnosis. Clinical and pathologic staging was as follows: 31 (50 %) and 30 (48 %) patients had stage I disease, 19 (30 %) and 22 (35 %) stage II, 5 (8 %) and 3 (6 %) stage III, 2 (4 %) and 2 (3 %) stage IVa, and 5 (8 %) and 5 (8 %) stage IVb, respectively. Histologic examination revealed 11 (19%) type A tumors, 19 (30%) type AB tumors, 7 (12 %) type B1 tumors, 11 (17 %) type B2 tumors, 11 (17 %) type B3 tumors, and 3 (5 %) type C tumors. Adjuvant therapies comprised chemotherapy in 3 (5 %) patients and radiotherapy in 16 (26 %) patients. Median follow-up was 71 months (range 1–145). DFS and OS at 48, 60, and 72 months were 89 and 89 %, 86 and 97 %, and 95% and 92%, respectively. Myasthenia at the onset of disease (P = 0.18 for DFS; P = 0.97) and tumor size >5 cm (P = 0.94 for DFS; P = 0.56) were not prognostic factors. TETs are rare and indolent tumors. Complete surgical resection followed by adjuvant therapies, such as chemotherapy and/or radiotherapy, in patients at risk of recurrence show very good DFS and OS results, even in cases with radically resected pleural-pulmonary metastases.

Isolated unilateral pulmonary artery agenesis is a rare congenital abnormality. We report a case of right pulmonary artery agenesis in an adult female without other cardiovascular anomalies. The patient presented with massive haemoptysis four years after the original diagnosis. The patient underwent right pneumonectomy with stapled suture of the main bronchus covered by an intercostal muscle flap. The clinical course was complicated by a bronchopleural fistula one month after the first operation. The fistula was successfully treated with a videothoracoscopic omentoplasty and serratus muscle flap. In these patients the surgical approach can be particularly complex because of the high risk of bleeding from the highly vascularised and extensive adhesions between the lung and the chest wall, associated with hyperplasia of the bronchial and intercostal arterial trees. In spite of these difficulties, access to the pulmonary veins and the main bronchus during pneumonectomy is not challenging.

We retrospectively evaluated elderly patients with advanced non-small cell lung cancer (NSCLC) treated with carboplatin (AUC 4-5) and gemcitabine (1,000-1,200 mg/m²). Thirty-six patients with performance Status (pS) 0-1 and median age 73 (range 70-78 years) were considered. Histology was squamous cell carcinoma (8 patients), adenocarcinoma (22) and NSCLC not otherwise specified (6). 149 cycles of chemotherapy were administered with a median of 3 per patient (range 3-6). Grade 3 non-hematologic toxicities were dyspnea (1 patient) and fever (1). Grade 3/4 hematologic toxicities were anemia (6), neutropenia (6) and thrombocytopenia (10), with dose reduction required in 13 patients. The overall disease control rate was 44.4%. We recorded no complete response, 8 partial response, 8 stable disease and 20 progressive disease. After a medium follow-up of 11 months, median progression- free survival and median survival were 5 and 11 months, respectively. Carboplatin and gemcitabine is a safe and active regimen in elderly advanced NSCLC patients with good PS.