Introduction:The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic has affected Italy since the beginning of 2020. Endotracheal intubation, prolonged mechanical ventilation, and tracheostomy are frequently required in patients with severe COVID-19. Tracheal stenosis is a potentially severe condition that can occur as a complication after intubation. The aim of this study was to evaluate the utility and safety of endoscopic and surgical techniques in the treatment of tracheal stenosis related to COVID-19. Materials and Methods:Between June 2020 and May 2022, consecutive patients with tracheal stenosis who were admitted to our surgical department were considered eligible for participation in the study. Results:A total of 13 patients were included in the study. They consisted of nine women (69%) and four men (31%) with a median age of 57.2 years. We included seven patients with post-tracheostomy tracheal stenosis. Bronchoscopy was performed to identify the type, location, and severity of the stenosis. All patients underwent bronchoscopic dilation and surveillance bronchoscopy at 7 and 30 days after the procedure. We repeated endoscopic treatment in eight patients. Three patients underwent tracheal resection anastomosis. Final follow-up bronchoscopy demonstrated no residual stenosis. Conclusions:The incidence of and risk factors associated with tracheal stenosis in critically ill patients with COVID-19 are currently unknown. Our experience confirms the efficacy and safety of endoscopic management followed by surgical procedures in cases of relapsed tracheal stenosis.

The aim of this study was to assess the impact of BMI on perioperative outcomes in patients undergoing VATS lobectomy or segmentectomy. Data from 5088 patients undergoing VATS lobectomy or segmentectomy, included in the VATS Group Italian Registry, were collected. BMI (kg/m2) was categorized according to the WHO classes: underweight, normal, overweight, obese. The effects of BMI on outcomes (complications, 30-days mortality, DFS and OS) were evaluated with a linear regression model, and with a logistic regression model for binary endpoints. In overweight and obese patients, operative time increased with BMI value. Operating room time increased by 5.54 minutes (S.E. = 1.57) in overweight patients, and 33.12 minutes (S.E. = 10.26) in obese patients (P < 0.001). Compared to the other BMI classes, overweight patients were at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications. In the overweight range, a BMI increase from 25 to 29.9 did not significantly affect the length of stay, nor the risk of any complications, except for renal complications (OR: 1.55; 95% CI: 1.07–2.24; P = 0.03), and it reduced the risk of prolonged air leak (OR: 0.8; 95% CI: 0.71–0.90; P < 0.001). 30-days mortality is higher in the underweight group compared to the others. We did not find any significant difference in DFS and OS. According to our results, obesity increases operating room time for VATS major lung resection. Overweight patients are at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications following VATS resections. The risk of most postoperative complications progressively increases as the BMI deviates from the point at the lowest risk, towards both extremes of BMI values. Thirty days mortality is higher in the underweight group, with no differences in DFS and OS.

Video description: A 34-year-old male patient presented at the emergency department with fever, dysphagia and thoracic pain. His previous medical history consisted of caustic ingestion 18 years before, resulting in oesophageal-aorta fistula treated by aortic endograft placement and oesophageal exclusion with retrosternal colonic interposition. Diagnosis of thoracic stent graft infection was made based on clinical, microbiological and radiological criteria. After multidisciplinary consultation which involved thoracic surgery unit, the patient was considered eligible for aortic endoprosthesis explantation. The video shows the surgical intervention of removal of the aortic endograft and aortic reconstruction with homograft conduit by extrapleural approach in thoraco-phreno-laparotomy.

Background: Persistent air leak and the management of intraoperative blood loss are common threats in thoracic surgical practice. The availability of new procedures, technology and materials is constantly evolving topical hemostats and surgical sealants must be added to this toolkit. Topical hemostats and surgical sealants differ according to their chemical nature and physical characteristics, to their origin and mechanism of action, regulatory/registration and vigilance paths. A Delphi consensus was set to highlight the different points of view on the use of topical haemostatic products and sealants among the members of Italian Society of thoracic surgery. Methods: The board was formed by a group of five Italian experts; in the first phase after a careful review of the scientific literature and two rounds, the board finally generated 16 consensus statements for testing across a wider audience. During the second phase, the statements were collated into a questionnaire, which was electronically sent to a panel of 46 Italian surgeons, experts in the field. Results: Out of 46 Italian surgeons, 33 (72%) panel members responded to the Delphi questionnaire. All the items reached a positive consensus, with elevated levels of agreement, as demonstrated by the presence of a 100% consensus for nine items. For the remaining 7 statements the minimum level of consent was 88% (29 participants approved the statement and 4 disagreed) and the maximum was 97% (32 participants approved the statement and 1 was in disagreement). Conclusions: The present Delphi analysis shows that air leak and intraoperative bleeding are clinical problems well known among thoracic surgeons. Nevertheless, the aim of the scientific societies and of the group of experts is to execute the education activities in the surgery community. This Delphi survey suggest the need of wider and updated scientific information about technical and registration characteristics of most recent technologic solutions, such as the of topical hemostats and surgical sealants to provide healthcare and administrative staff with the opportunity to work and interact through a common and shared language and eventually to guarantee minimal requirements of assistance.

Background Rare diseases are chronic and life-threatening disorders affecting < 1 person every 2,000. For most of them, clinical symptoms and signs can be observed at birth or childhood. Approximately 80% of all rare diseases have a genetic background and most of them are monogenic conditions. In addition, while the majority of these diseases is still incurable, early diagnosis and specific treatment can improve patients’ quality of life. Transplantation is among the therapeutic options and represents the definitive treatment for end-stage organ failure, both in children and adults. The aim of this paper was to analyze, in a large cohort of Italian patients, the main rare genetic diseases that led to organ transplantation, specifically pointing the attention on the pediatric cohort. Results To the purpose of our analysis, we considered heart, lung, liver and kidney transplants included in the Transplant Registry (TR) of the Italian National Transplantation Center in the 2002–2019 timeframe. Overall, 49,404 recipients were enrolled in the cohort, 5.1% of whom in the pediatric age. For 40,909 (82.8%) transplant recipients, a disease diagnosis was available, of which 38,615 in the adult cohort, while 8,495 patients (17.2%) were undiagnosed. There were 128 disease categories, and of these, 117 were listed in the main rare disease databases. In the pediatric cohort, 2,294 (5.6%) patients had a disease diagnosis: of the 2,126 (92.7%) patients affected by a rare disease, 1,402 (61.1%) presented with a monogenic condition. As expected, the frequencies of pathologies leading to organ failure were different between the pediatric and the adult cohort. Moreover, the pediatric group was characterized, compared to the adult one, by an overall better survival of the graft at ten years after transplant, with the only exception of lung transplants. When comparing survival considering rare vs non-rare diseases or rare and monogenic vs rare non-monogenic conditions, no differences were highlighted for kidney and lung transplants, while rare diseases had a better survival in liver as opposed to heart transplants. Conclusions This work represents the first national survey analyzing the main genetic causes and frequencies of rare and/or monogenic diseases leading to organ failure and requiring transplantation both in adults and children.

Lung cancer is one of the leading causes of cancer-related mortality around the world. A prompt diagnosis and accurate staging are of the essence in order to establish the appropriate treatment plan. Mediastinal lymph nodes involvement is the most important parameter to define the therapeutic path, and particularly to decide whether a patient can be offered a potentially curative surgery. Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA), together with oesophageal ultrasound (EUS), has a pivotal role in the diagnosis and staging of lung cancer. These procedures have excellent diagnostic performances, can be performed without requiring general anaesthesia, and are far less invasive than mediastinoscopy and video-assisted thoracic surgery (VATS). Moreover, EBUS-TBNA allows to biopsy intrapulmonary lymph nodes. Different studies have been investigated the diagnostic accuracy of EBUS-TBNA for the diagnosis and staging of lung cancer, with always good but heterogeneous results. In some studies, EBUS-TBNA has shown to yield adequate samples for molecular testing and immunocytochemistry too. Rapid on site cytologic evaluation (ROSE) can be used to assess the adequacy of samples during the endoscopic procedure. The aim of this review article is to describe the current evidence on the diagnostic accuracy of EBUS-TBNA for the diagnosis of lung cancer. We also reported our centre's experience and the results of 456 EBUS-TBNA performed between April 2016 and March 2020.

Background Thymoma is an uncommon cancer often associated with myasthenia gravis, an autoimmune disorder of the neuromuscular junction characterized by muscular fatigability. In patients with advanced nonmetastatic thymoma, primary chemotherapy may be required to induce tumor shrinkage and to achieve radical resection. Cancer chemotherapy has been anecdotally reported as a trigger factor for worsening of myasthenia gravis in thymic epithelial cancers. The study of uncommon cases of chemotherapy-related myasthenic crisis is warranted to gain knowledge of clinical situations requiring intensive care support in the case of life-threatening respiratory failure. Case presentation We report a case of an 18-year-old Caucasian woman with advanced Masaoka-Koga stage III type B2 thymoma and myasthenia gravis on treatment with pyridostigmine, steroids and intravenous immunoglobulins, who developed a myasthenic crisis 2 hours after initiation of cyclophosphamide/doxorubicin/cisplatin primary chemotherapy. Because of severe acute respiratory failure, emergency tracheal intubation, mechanical ventilation, and temporary (2 hours) discontinuation of chemotherapy were needed. Considering the curative intent of the multimodal therapeutic program, we elected to resume primary chemotherapy administration while the patient remained on mechanical ventilation. After 24 hours, the recovery of adequate respiratory function allowed successful weaning from respiratory support, and no further adverse events occurred. After 3 weeks, upon plasma exchange initiation with amelioration of myasthenic symptoms, a second course of chemotherapy was given, and in week 6, having documented partial tumor remission, the patient underwent radical surgery (R0) and then consolidation radiation therapy with 50.4 Gy in 28 fractions in weeks 15–20. Conclusions This case report, together with the only four available in a review of the literature, highlights that chemotherapy may carry the risk of myasthenic crisis in patients affected by thymoma and myasthenia gravis. To our knowledge, this is the first reported case of chemotherapy continuation on mechanical ventilation in a patient with chemotherapy-induced myasthenic crisis requiring tracheal intubation. The lesson learned from the present case is that, in selected cases of advanced thymoma, the paradoxical worsening of myasthenia gravis during chemotherapy should not be considered an absolute contraindication for the continuation of primary chemotherapy with curative intent.

Background and aim: Liver transplantation (LT) is a validated treatment for hepatocellular carcinoma (HCC). HCC recurrence occurred between 8 and 20% of patients and lung is the most frequent site. Pulmonary metastases resection (PMR) prolongs survival, however in LT-setting the impact on survival is unclear. To give new lights on this issue, we report the experience of three Italian LT Centers.Methods: All consecutive HCC transplanted patients in three Italian LT Centers, who developed pulmonary metastasis from HCC (PM-HCC), as first metastasis, from 2008 to 2018, were included whenever treated with PMR.Results: Twenty-five patients were enrolled (median age 58 yrs, 84% male, 3% cirrhotics). HCC recurred after 34 months (9–306) since LT and PMR was performed after 2.4 months (0–43.1). A total of 28 PMR (19 single resections; 9 multiple resections; 16 right; 2 left) have been performed on 24 patients while in one case percutaneous microwave ablation (MWA) was preferred. Four patients have been re-operated due to pulmonary HCC-recurrence after surgery. The majority of surgical resection type was wedge resection (26, 89%). Surgical access was: video-assisted thoracic surgery (VATS) in 17 cases (59%); thoracotomy in 11 (38%); MWA in 1 (3%). The 48% of nodule was in right lower lobe. Perioperative in-hospital mortality and 30 days mortality were nil; median surgical time 90 min (50–365); median post-operative overall stay 5 days (2–11). Post-operative ICU treatment was necessary in 1 case (3%) for 3 days; blood transfusions in 2 cases (7%). Overall, 5 complications (2 bleeding; 1 AKI; 1 major cardiac; 1 wound dehiscence) occurred, with an overall complications rate of 23%. Eight (32%) patients died during a follow-up after HCC recurrence of 32 months (7–213): 7 for HCC progression, 1 for severe liver failure due to chronic rejection. The 1 and 5 year cumulative probability of OS from recurrence were 100 and 43% (95%CI 12–74), respectively, with a median OS of 51 months (95%CI 24–78).Conclusion: Selected patients with isolated pulmonary HCC-recurrence after LT and with preserved hepatic function showed that a pulmonary metastasectomy could be efficacious in managing a PM-HCC and could give an opportunity for long-term survival.

The current coronavirus disease 2019 (COVID-19) pandemic has made us aware of the weaknesses and often the inadequacies of our current technologies and practices and has presented us with a huge challenge: to reorganize the way we work and sometimes even think, in order to ensure the safety of our patients. The Italian Society of Thoracic Surgery has launched various initiatives in response to the COVID-19 pandemic, aimed at facilitating the exchange of information, strategies and personal experiences between institutions. This article presents the results of a survey amongst all Italian thoracic surgery units accredited to SICT, with the aim of providing a glimpse of the current working conditions in these units, and an understanding of the impact of COVID-19 on their daily activities and patient care.

Epidermal growth factor receptor (EGFR) gene mutations are strong oncogenic drivers in a subset of non–small-cell lung cancer (NSCLC). Their inhibition with specific tyrosine kinase inhibitors (TKIs) represents a successful example of precision medicine. Nevertheless, disease progression almost invariably occurs after 9-14 months of treatment with either gefitinib, erlotinib, or afatinib (firstand second-generation TKIs) and after 19 months with osimertinib (a thirdgeneration TKI) because of the development of acquired therapeutic resistance.

Pectus carinatum (PC) is the one of the most frequent deformity of the chest wall and it occurs mostly in young males. The pathology is often caused by the overgrowth of the costal cartilages and the anterior displacement of the sternum. PC can be associated to other pathologies or syndromes; in most cases is asymptomatic but with important impact on social life and self-esteem. The treatment can be performed either through non-invasive methods (brace) or surgical ones (open or minimally invasive procedures), considering the age of the patient, the malformation severity and the patient’s compliance. The most used bracing device is the Dynamic Compression System (DCS), that permit to measure the pressure necessary for the correction. They have considered the chest wall compliance, related to the age and the pressure can be modified during the treatment based on the results. Surgery is dedicated to the patients who don’t tolerate the brace or who don’t have a good chest wall compliance. In literature both open and minimally invasive procedures have been proposed. The best therapeutic choice depends on characteristic of the single patient and his motivation.

Introduction: European Organisation for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ) is integrated system for assessing health-related quality of life (HRQL) of lung cancer (LC) patients participating in clinical trials. EORTC developed QLQ-instrument for cancer patients (QLQ-C30) and LC-specific (QLQ-LC13) that assesses specific LC symptoms/treatments. Aim: To validate national versions of EORTC LC-specific questionnaires. Methods: Patients completed instruments before/after LC surgery (24 hours, 15 days and 30 days). Internal reliability (Cronbach’s α)+Kaiser-Meyer-Olkin (KMO) sampling adequacy ratio were used. Areas under receiver operating characteristic (ROC) curves estimated discriminating value. Statistical analyses were made using R 3.5.2 (standard, rcmdr, EZR, scoring.QLQLC29, scoring.QLQLC13, scoring.QLQL30 packages). Results: 51 patients completed questionnaires with high compliance rates. Homogeneity of questionnaires showed high correlation with total scale. ROC (Figure 1) showed no significative differences between questionnaires (p=0.862). KMO ratio (Figure 2) was 0.7477 (QLQ-C30), 0.863 (QLQ-LC29), 0.8793 (QLQ-LC13). Reliability (Cronbach’s α) reaches 0.5988 (QLQ-C30), 0.8755 (QLQ-LC29), 0.8020 (QLQ-LC13). Conclusion: EORTC questionnaires are reliable and valid for HRQL evaluation in LC patients and can be widely employed in national clinical studies.

Dysphagia in patients with lung cancer is usually due to direct invasion from bronchogenic carcinomas or nodal localizations, while metastases from distant lung neoplasms are considered rare. We report a case of a smooth esophageal narrowing secondary to intramural metastasis from pulmonary adenocarcinoma in a patient with no previous history of neoplasia. Since standard linear echoendoscope could not overpass the malignant stricture, we obtained a histological diagnosis by fine-needle aspiration biopsy using an echobronchoscope (EBUS), due to its lower diameter. The EBUS scope represents a valuable tool to obtain cytological specimens in patients with esophageal strictures.

Deepened flow cytometry (FCM) analysis of bronchoalveolar lavage fluid (BALF) cells can disclose clonal B and abnormal T lymphocytes in case of lung involvement in non Hodgkin lymphoma (NHL). The possible role of routine FCM BALF analysis in diagnosing NHL involving the lungs is largely undetermined. To evaluate whether differences exist, within FCM screening of lymphocyte subsets, between BALFs from lung NHL and BALFs from reactive diseases. We compared alveolar leukocyte and lymphocyte data obtained using flow cytometry in 17 lung NHL cases with the median corresponding data detected in 208 controls, matched with cases for computed tomography findings. Absolute leukocyte counts did not differ significantly between cases and controls. As calculated within leukocytes, percentages of total, B, T, CD4+ and CD8+ T lymphocytes, respectively, were significantly higher in B cell NHL cases than in their controls (P = .003, .023, .009, .004, and .020, respectively). Similarly, percentages of total, and CD8+ T lymphocytes, respectively, were significantly higher in T cell NHL cases than in their controls (P = .046 and .027, respectively). Huger BALF lymphocytosis occurs in pulmonary NHLs than in other lung diseases. Possible lymphocyte cutoffs, that could indicate lung NHL and the subsequent need of a second-step BALF staining shortly following the initial screening, should be prospectively attempted.

BACKGROUND:Despite advances in perioperative care and surgical techniques, patients undergoing pulmonary lobectomy are still at high risk for postoperative complications. Among interventions expected to reduce complications, continuous positive airway pressure (CPAP) is a discussed option. This trial aims to test the hypothesis whether prophylactic application of CPAP following pulmonary lobectomy can reduce postoperative complications.METHODS:The study was designed as a prospective, randomized, controlled trial. Patients with clinical stage I non-small cell lung cancer scheduled for pulmonary lobectomy were eligible and were trained for the use of CPAP interface. The control group received standard postoperative pain management and physiotherapy; in addition, the study group received CPAP (PEEP 8-12 cmH2O, 2 hours thrice daily for three days).RESULTS:After the appropriate selection, 163 patients were considered for the analysis: 82 patients constituted the control group, 81 the study group. The two groups were substantially comparable for preoperative parameters. The rate of postoperative complications was lower in the study group (24.7% vs. 43.9%; P=0.015) as well as the hospital stay (6 vs. 7 days; P=0.031). The stepwise logistic regression model identified: CPAP [odd ratio (OR): 0.3026, CI: 0.1389-0.6591], smoke habits [OR: 2.5835, confidence interval (CI): 1.0331-6.4610] and length of surgery in minutes (OR: 1.0102, CI: 1.0042-1.0163) as regressors on postoperative complications.CONCLUSIONS:The present trial demonstrated that prophylactic application of CPAP during the postoperative period after pulmonary lobectomy for stage I non-small cell lung cancer was effective in prevent postoperative complications.

El tratamiento paliativo de la estenosis traqueobronquial maligna es difícil. Las experiencias publicadas con stent en Y autoexpandibles son escasas, por lo que es necesario evaluar si los resultados que ofrecen son mejores que los de otras prótesis alternativas.

Palliation of malignant tracheobronchial stenosis is challenging. Published experience with self-expanding Y-shaped stents is limited and it seems necessary to evaluate whether they improve clinical results with respect to alternative prostheses.

A 47-year-old male was admitted to hospital for severe pericardial effusion; he had undergone surgical removal of cutaneous melanoma 10 years before. Echocardiography-guided pericardiocentesis revealed the presence of intramyocardial masses, which were better defined and characterized, together with pericardial involvement, by cardiac magnetic resonance. Pericardial fluid drained was negative for malignant cells, so video-assisted thoracoscopy was performed and pathologic tissue was biopsied, leading to the diagnosis of metastatic melanoma. Multidisciplinary approach and multimodality imaging played a key role in allowing the diagnostic workup in this complex case. .

In right upper lobectomy, there are a variety of access incisions, surgical instruments, intraoperative strategies, and perioperative treatment approaches. We describe a safe, effective, and cost-saving technique to simultaneously staple the individually dissected right superior pulmonary vein and anterior trunk of the right main pulmonary artery during right upper lobectomy. Barring extremely unusual anatomy, this approach has wide indications. This technique may become an integral part of video- and robotic-assisted right upper lobectomies.