Objective: Prolonged air leak due to residual air space after lung resection is a main challenge. To date, few surgical options have been described to prevent this complication. The aim of this study is to investigate the safety and the efficacy of intraoperative phrenic nerve infiltration with long-acting anesthetics in producing transient hemidiaphragm paralysis in patients at high risk for prolonged air leak, thus improving pulmonary expansion after surgery and reducing air leaks, while controlling postoperative pain. Methods: Between January 2021 and 2023, 65 consecutive patients at risk for prolonged air leak (defined in accordance with "2019 Society of Thoracic Surgery score criteria of prolonged air leak") who underwent lung resection (lobectomy or anatomic segmentectomy) for malignancy were prospectively included in the study. They were randomly (1:2 ratio) assigned to receive (group A, 22 patients) intraoperative phrenic nerve infiltration with ropivacaine 10 mg/mL in the peri-neurotic fat on the pericardium or not to receive intraoperative phrenic nerve infiltration (group B, 43 patients). Five patients in group B were excluded because they did not undergo anatomic resection. Data on pulmonary reexpansion, prolonged air leaks, pain at 24 and 72 hours postsurgery, referred shoulder pain, length of hospital stay, and length of chest tube permanence were collected and compared. Results: Hemidiaphragm elevation (P =.006) and pulmonary expansion (P = .000) were significantly higher in group A. Patients in group A showed lower pain at 24 and 72 hours compared with group B (P = .004). Shoulder pain (0.001) and prolonged air leak (0.000) were higher in group B. Length of chest tube was longer in group B. No difference in hospital stay length was observed. Conclusions: This is the first study to investigate 2 combined effects of phrenic nerve anesthetic infiltration (hemidiaphragm elevation and pain control), with potential enhancement of a patient's recovery after surgery. Intraoperative phrenic nerve infiltration in patients with a risk for prolonged air leak appears to be a safe and effective clinical practice to improve pulmonary expansion in this set of patients, reducing postoperative air leak. This result is associated with an additional improvement in pain control, especially for shoulder pain. (JTCVS Open 2025;23:349-57)

Non-small-cell lung cancer (NSCLC) accounts for 80–85% of all lung cancers. Approximately 20% of patients with NSCLC are diagnosed with stage IIIA–IIIB disease, for which the optimal treatment remains unclear. Meta-analyses reveal that neoadjuvant/perioperative ICI–chemotherapy significantly improves pathological complete response (pCR), overall survival (OS), major pathological response (MPR), and R0 rate compared to standard neoadjuvant chemotherapy. Resectability is achieved when R0 resection can be performed after surgery. Radiographic downstaging often does not correspond to surgical downstaging. In fact, intra-operative fibrosis due to chemo-immunotherapy (synonymous with ICI–chemotherapy) can create adhesions and consequent difficult planes for dissection. Thus, pneumonectomy cannot be avoided. Even the suspicion of N2 after neoadjuvant treatment is considered a limitation of upfront surgery because of the risk of pneumonectomy. The aim of this review is to explore the literature on the technical strategies for surgical excision of NSCLC after chemo-immunotherapy, addressing even the most challenging scenarios.

OBJECTIVES:Idiopathic subglottic stenosis (ISS) is an airway stricture between larynx and trachea, within 1 cm from the vocal cords. Resection-reconstruction present technical issues because of the need to resect the anterior portion of the cricoid cartilage, but not the posterior plate beyond which the recurrent laryngeal nerves access the vocal cords. The main surgical challenge consists of the minute airway calibre short below the cords, ensuing after the resection. We propose drill posterior cricoid plate moulding to obtain antero-posterior and lateral amplification of the laryngo-tracheal anastomosis. METHODS:This is a retrospective study of patients who underwent laryngo-tracheal resection with drill enlargement between January 2023 and June 2024. Laryngo-tracheal resection was performed according to Pearson's technique. At this point, airway calibre is gauged by endotracheal tubes of increasing size. To enlarge the air space, the inner surface of the posterior plate was moulded by drill. Breathing, complications, voice and swallowing function were recorded. RESULTS:Our study includes 23 consecutive patients with ISS. No mortality was described. Fifteen patients (65.2%) described voice alteration and 7 (30.4%) experienced transient swallowing impairment. The mean operative time was 94.56 (±28.72) min. All patients breathed well at discharge. Overall early success rate was excellent (no sequelae) in 7 (30.4%) patients, and good (grade A: voice/breathing changes not influencing the quality of life; grade B: abnormal voice and shortness of breath, not hindering normal activities) in 15 (65.2%). At the mean follow-up of 10.5 ± 5.5 months, definitive success was achieved. CONCLUSIONS:This is the first study describing this technique. The results of our early experience with drill moulding of the posterior cricoid plate are promising. It is an innovative, simple, safe, and effective method for subglottic airway enlargement in ISS, resulting in low post-operative complications, and in good to excellent results.

ObjectiveThe large number of COVID-19 patients subjected to prolonged invasive mechanical ventilation has been expected to result in a significant increase of tracheal stenosis in the next years. The aim of the study was to evaluate and compare postoperative outcomes of survived COVID-19 critical illness patients who underwent tracheal resection for post-intubation/post-tracheostomy tracheal stenosis with those of non-COVID patients.MethodsIt is single-center retrospective study. All consecutive patients affected by post-intubation/post-tracheostomy tracheal stenosis who underwent tracheal resection from February 2020 to March 2022 were enrolled. A total of N=147 tracheal resections were performed: n=24 were Post-COVID patients and n=123 were Non-COVID patients. A 1:1 propensity score matching analysis was performed, considering age, gender, BMI (Body Mass Index), and length of stenosis. After matching, two groups of 24 patients each were identified: Post-COVID Group and Non-COVID Group.ResultsNo mortality after surgery was registered. Post-tracheostomy etiology of stenosis resulted more frequently in post-COVID patients (n=20 in Post-COVID Group vs n=11 in NON-COVID Group, p=0.03), as well as the ICU admission in the postoperative period (n=16 vs n=9 patients, p=0.04). Need for postoperative re-intubation for glottic edema and respiratory failure was higher in the Post-COVID Group (n=7 vs n=2 postoperative re-intubation procedures, p=0.04).Postoperative dysphonia was observed in n=11 (46%) patients of Post-COVID Group vs n=4 (16%) patients of NON-COVID Group (p=0.03).ConclusionsTracheal resection still continue to be safe and effective in COVID-19-related tracheal stenosis scenario. ICU admission rate and postoperative complications seem to be higher in post-COVID-19 patients who underwent tracheal resection compared to non-COVID-19 patients.

Objectives: The choice of the best Video-Assisted Thoracic Surgery (VATS) surgical approach is still debated. Surgeons are often faced with the choice between innovation and self-confidence. The present study reports the experience of a high-volume single institute, comparing data of uni-portal, bi-portal and tri-portal VATS, to find out the safest and most effective mini-invasive approach, leading surgeon’s choice. Methods: Between 2015 and 2022, a total of 210 matched patients underwent VATS lobectomy for early-stage cancer, using uni-portal (fifth intercostal space), bi-portal (seventh space for optic and the fifth), and tri-portal (seventh and the fifth/four) access. Patients were matched for age, BPCO, smoke, comorbidities, lesions (size and staging) to obtain three homogenous groups (A: uni-portal; B: bi-portal; C: tri-portal). The surgeons had comparable expertise. Data were retrospectively collected from institutional database and analyzed. Results: No differences were detected considering time of surgery, length of hospital stay, complications, conversion rate, specific survival, and days of chest tube length of stay. Better results on chest tube removal were described in group A (mean 1.1 days) compared to B (mean 2.6 days) and C (mean 4.7 days); nevertheless, they not statistically significant (p = 0.106). Conclusions: No significant differences among the groups were described, except for the reduction in chest tube permanence in group A. This allows to hypothesize an enhanced recovery after surgery in this group but the different approaches in this series seem to guarantee comparable safety and effectiveness. Considering no superiority of one method above the others, the best suggested approach should be the one for which the surgeon feels more confident.

Background: Early post-operative airway management after laryngo-tracheal surgery is crucial. Acute respiratory failure due to glottis’ edema may occur, requiring reintubation. This can prolong ventilatory assistance, jeopardizing anastomosis. To date, only judicious steroid administration and fluid management are available to avoid more invasive procedures. High-flow oxygen therapy (HFOT) is a noninvasive O2 support method providing humidification, warmed air, and Positive End-Expiratory Pressure (AIRVO2). No data about HFOT use to prevent early complications after laryngo-tracheal surgery are reported in the literature. Methods: Between September 2020 and September 2022, 107 consecutive patients who underwent laryngo-tracheal surgery received HFOT (Group A). Data and long-term results were compared with those of 80 patients operated between September 2018 and August 2020 (Group B), when HFOT was not available. All patients were operated in a single center. No pre- or post-operative settings changed, except for HFOT introduction. We analyzed and compared the risk for “delayed” reintubation (unexpected reintubation within the first 24–48 h after extubating/laryngeal mask removal) in the two groups. Results: No patients reported HFOT-related adverse events. The control group (B) presented “delayed” reintubation in 37% (p = 0.027), intensive care unit admission in 67% (p = 0.005) and longer hospital stay (p = 0.001) compared to the HFOT group (A). The minor complications’ rate was 3% in both group and overall mortality was 0%. Re-stenosis was described in 4.6% of the HFOT group, without a statistically significant difference (p = 0.7006). Conclusions: Our study is the first to investigate HFOT use in patients undergoing laryngo-tracheal surgery, potentially representing a consistent innovation in the peri-operative management of these patients. With the limitation of a retrospective series, we would suggest HFOT use for preventing post-operative reintubation rate, possibly reducing ICU admissions and hospital stays.

We are pleased to introduce the abstracts of the XXIII National Congress of the Italian Society of Thoracic Endoscopy (SIET), which will be held in Florence from 17 to 19 October 2024. The principal objectives of SIET are to (1) Promote research and innovation in the fields of thoracic surgery and endoscopy, facilitating the development and implementation of innovative techniques and technologies; (2) Provide education and training for surgeons, endoscopists, pulmonologists and other related specialties; and (3) Facilitate the exchange of knowledge with the aim of creating a cohesive and active scientific community. The Congress will address the integration of traditional surgical and endoscopic techniques with emerging technologies, with the goal of promoting innovation and education among professionals. The theme of integration will be explored throughout the programme, with a particular focus on the collaborative efforts of different medical specialties to improve patient outcomes. This event will host a multidisciplinary cohort comprising thoracic surgeons, endoscopists, pulmonologists, oncologists, pathologists, radiologists and anaesthetists, who will assume a pivotal role in the multidisciplinary sessions of the scientific programme. The Congress will include several core areas of expertise, including lung cancer, interventional endoscopy, pathology, and upper airway reconstruction. Emphasis will be placed on both the theoretical aspects of these subjects and their practical applications in patient care. The theme of integration will be explored throughout the programme, with particular attention on the impact of recent technological developments in the fields of thoracic surgery and endoscopy. Additionally, the Congress will examine the contributions of allied health professionals, including nurses, physiotherapists, and speech pathologists, to patient care.

Carinal resection is defined as the resection of tracheal-bronchial bifurcation with or without associated lung resection. It is usually indicated in case of primary tumors with limited involvement of the carina. The reported mortality ranges from 3% to 20% in high-volume centers. The surgical approach depends on the location of the lesion. Surgery for carinal pathology is technically difficult and the development of anastomotic complications such as devascularization, separation, and stenosis may be directly related to surgical technique.

This study aims to define the clinicopathological characteristics and prognosis of non-predominant lepidic invasive adenocarcinoma presenting as Ground Glass Opacity (GGO) nodules. The goal is to assess statistical relationships between histology, tumor size, location, and the incidence of relapse and lymph node dissemination. A retrospective multicenter study was conducted, including patients with GGO observed on CT scans between 2003 and 2021. Anamnestic, radiological, and histological data, as well as SUV values, lymphatic and vascular invasion, pathological stage, resection type, and adjuvant treatment, were analyzed. The primary endpoints were to evaluate prognostic factors for death and recurrence using Cox regression analysis. All 388 patients, including 277 with non-predominant lepidic invasive adenocarcinoma and 161 with lepidic adenocarcinoma, underwent curative anatomical resection. Non-predominant lepidic invasive adenocarcinoma demonstrated a worse prognosis than lepidic adenocarcinoma (p = 0.001). Independent prognostic factors for death and recurrence included lymph node involvement (p = 0.002) and vascular and lymphatic invasion (p < 0.001). In conclusion, non-predominant lepidic invasive adenocarcinoma and lymphatic and vascular invasion are prognostic factors for death and recurrence in GGO patients. Results suggest adjuvant treatment in the case of pN1-N2 disease, emphasizing the necessity of lymphadenectomy (sampling or systematic) for accurate staging and subsequent therapeutic procedures.

Objectives. During coronavirus disease (COVID-19) pandemic, preoperative screening before thoracic surgery is paramount in order to protect patients and staff from undetected infections. This study aimed to determine which preoperative COVID-19 screening tool was the most effective strategy before thoracic surgery. Methods. This retrospective cohort multicenter study was performed at 3 Italian thoracic surgery centers. All adult patients scheduled for thoracic surgery procedures from 4th March until 24th April, 2020, and submitted to COVID-19 preoperative screenings were included. The primary outcome was the yield of screening of the different strategies. Results. A total of 430 screenings were performed on 275 patients; 275 anamnestic questionnaires were administered. 77 patients were screened by an anamnestic questionnaire and reverse transcriptase polymerase chain reaction (RT-PCR). 78 patients were selected to combine screening with anamnestic questionnaire and chest computed tomography (CT). The positive yield of screening using a combination of anamnestic questionnaire and RT-PCR was 7.8% (95% CI: 2.6–14.3), while using a combination of anamnestic questionnaire and chest CT was 3.8% (95% CI: 0–9). Individual yields were 1.1% (95% CI: 0–2.5) for anamnestic questionnaire, 5.2% (95% CI: 1.3–11.7) for RT-PCR, and 3.8% (95% CI: 0–9). Conclusions. The association of anamnestic questionnaire and RT-PCR is able to detect around 8 positives in 100 asymptomatic patients. This combined strategy could be a valuable preoperative SARS-CoV-2 screening tool before thoracic surgery.

Cancer alters both local and distant tissue by influencing the microenvironment. In this regard, the interplay with the stromal fraction is considered critical as this latter can either foster or hamper the progression of the disease. Accordingly, the modality by which tumors may alter distant niches of stromal cells is still unclear, especially at early stages. In this short report, we attempt to better understand the biology of this cross-talk. In our “autologous stromal experimental setting,” we found that remote adipose tissue-derived mesenchymal stem cells (mediastinal AMSC) obtained from patients with lung adenocarcinoma sustain proliferation and clonogenic ability of A549 and human primary lung adenocarcinoma cells similarly to the autologous stromal lung counterpart (LMSC). This effect is not observed in lung benign diseases such as the hamartochondroma. This finding was validated by conditioning benign AMSC with supernatants from LAC for up to 21 days. The new reconditioned media of the stromal fraction so obtained, was able to increase cell proliferation of A549 cells at 14 and 21 days similar to that derived from AMSC of patients with lung adenocarcinoma. The secretome generated by remote AMSC revealed overlapping to the corresponding malignant microenvironment of the autologous local LMSC. Among the plethora of 80 soluble factors analyzed by arrays, a small pool of 5 upregulated molecules including IL1-β, IL-3, MCP-1, TNF-α, and EGF, was commonly shared by both malignant-like autologous A- and L-MSC derived microenvironments vs those benign. The bioinformatics analysis revealed that these proteins were strictly and functionally interconnected to lung fibrosis and proinflammation and that miR-126, 101, 486, and let-7-g were their main targets. Accordingly, we found that in lung cancer tissues and blood samples from the same set of patients here employed, miR-126 and miR-486 displayed the highest expression levels in tissue and blood, respectively. When the miR-126-3p was silenced in A549 treated with AMSC-derived conditioned media from patients with lung adenocarcinoma, cell proliferation decreased compared to control media.

The use of video-assisted thoracoscopic surgery has been exponentially increasing in the last few decades and >30% of lobectomy for lung cancer today are performed using minimally invasive techniques [1]. For this reason, nowadays, surgeons’ efforts should be guided towards improving surgical techniques, especially to reinforce the role of minimally invasive surgery, even in complicated thoracoscopic settings. In the literature, conversion rates for video-assisted thoracoscopic to open surgery range between 2% and 23%. Although oncological reasons are the most common causes of conversion, intraoperative complications frequently lead to conversion to thoracotomy. Bleeding is one of the most terrifying and challenging complications to deal with [2]. Bleeding from vascular injury, usually bleeding from branches of the pulmonary artery, can occur in thoracoscopic surgery. Clamping the pulmonary artery is necessary for arterial repair. Less frequently, clamping the pulmonary artery is intended for thoracoscopic arterial sleeve resection [3]. This study investigates different feasible clamping techniques in Thoracoscopic anatomical lung resection: the double-loop technique, DeBakey clamp, Fogarty clamp, endovascular clips and vessel loop technique. Chiba et al. [4] specifically focused on evaluating the efficacy and safety of the double-loop technique for pulmonary arterioplasty and/or injured artery repair. The study is divided into 2 main different parts: an experimental study in which a main pulmonary artery model has been used to evaluate the pressure resistance capacity and burst pressure of each clamping technique investigated, and a histological study aimed to evaluate the intimal damage of the human pulmonary artery associated with double loop technique and DeBakey clamp. According to the results of the experimental study, the double loop technique and DeBakey clamping at the third notch seem to be not significantly different in measured burst pressure and clamp pressure. Actually, investigating the intimal damage of clamping techniques in histological examination, the double-loop technique resulted in only intimal deformation in major part of the samples. Moreover, the double loop technique demonstrated advantages, such as an unbarred thoracoscopic view, compared to other techniques. Chiba et al. [4] demonstrated that the double loop technique is feasible and safe in video-assisted thoracoscopic arterioplasty and injured artery repair. This is the first study that evaluates the efficacy and safety of the available clamping technique in thoracoscopic anatomical lung resection using a main pulmonary artery model. The remarkable technology used during this study is, undoubtedly, one of its strengths. However, the use restricted to cadavers or human specimens undergoing pneumonectomy, lacking in potential histological different evidences showed for in vivo scenarios, could represent a bias. Histological changes due to formalin fixation in cadaver’s specimen should be considered. Moreover, it is clear that enrolling human cases undergoing pneumonectomy to obtain adequate specimens could be challenging due to the increasing of early-stage lung cancer diagnosis. The control of bleeding in thoracoscopic surgery can be obtained through different techniques, such as electrocautery, compression with gauze, local haemostatics or clamping the upstream principal vessel [5]. The latter often consists in localizing the site of bleeding, completing the pulmonary artery dissection and isolation, to control the haemorrhage. In an emergency context, especially for less experienced surgeons, the conversion to open approach remains the safest choice. In these cases, it is important to maintain the control of the surgical field and, at the same time, to act promptly [6]. For this reason, the double loop technique, despite its efficacy, could present a disadvantage in terms of time in emergency and instable situations. On the other hand, the double loop technique may offer its advantages in preventing bleedings when performed during arterioplasty and not in bleeding circumstances. In pulmonary artery thoracoscopic resections, in fact, especially in cases with a preoperative high risk of bleeding or vessels injuries, this technique may offer interesting results. Furthermore, in this setting, even the use of bulldogs or silk-suture or silicone catheter tourniquets may show the same advantages of easy application ensuring an optimal thoracoscopic view [7]. Certainly, histological and mechanistic results are interesting and propaedeutic to further clinical studies. It would be noteworthy to understand whether could sustain potential higher rates of TH O R A C IC O N C O LO G Y

BACKGROUND:Congenital Pulmonary Malformations (CPMs) are rare benign lesions potentially causing infective complications and/or malignant transformation, requiring surgery even when asymptomatic. CPMs are rare in adulthood but potentially detected at any age. There is not a consensus on the correct extent of resection in both adults and paediatrics. This retrospective multicentric study aims to identify the appropriate surgical resection to prevent the recurrence of the related respiratory symptoms.METHODS:Between 2010 and 2020, a total of 96 patients (adults and pediatrics) underwent surgery for CPMs in 4 centers. A 2:1 propensity score matching (considering sex and lesion side) was performed, identifying 2 groups: 50 patients underwent lobectomy (group A) and 25 sub-lobar resections (group B). Clinical and histopathological characteristics, early and late complications, and symptom recurrence were retrospectively analyzed and compared between the two groups by univariate and multivariate analysis.RESULTS:Patients who underwent lobectomy had a statistically significant lower rate of recurrence (4% vs. 24% of group B, p = 0.014) and a lower rate of intraoperative complications (p = 0.014). Logistic regression identified sub-lobar resection (p = 0.040), intra- and post-operative complications (p = 0.105 and 0.022),and associated developed neoplasm (p = 0.062) as possible risk factors for symptom recurrence after surgery.CONCLUSIONS:Pulmonary lobectomy seems to be the most effective surgical treatment for CPMs, guaranteeing the stable remission of symptoms and a lower rate of intra- and postoperative complications. To our knowledge, this is one of the largest studies comparing lobectomy and sub-lobar resections in patients affected by CPMs, considering the low incidence worldwide.

Reconstruction of the pulmonary artery (PA) associated with lobectomy for the radical resection of lung cancer has been progressively gaining diffusion in lung cancer surgery as a safe and effective therapeutic option that may allow radical resection when lobectomy is not technically feasible, avoiding pneumonectomy. There are some controversial aspects concerning the intraoperative and perioperative management of a sleeve resection with PA reconstruction that may influence the outcome. In the present article, the authors have analyzed some of the main technical and oncological aspects to take stock of what they have learned from their lung-sparing operations experience over time. PA reconstruction may require prosthetic materials including different options with variable cost. A main concern in vascular reconstructive procedures is avoiding tension on the anastomosis. When PA reconstruction is required, appropriate anticoagulation management is crucial. Results from the main literature data confirm the reliability of lobectomy associated with PA reconstruction in terms of perioperative morbidity and long-term survival. Sleeve lobectomy and PA reconstruction can be performed safely and effectively even after induction therapy.

OBJECTIVE:Pectus excavatum (PE) repair is burdened by severe postoperative pain. This retrospective study aimed to determine whether the analgesic effect of ultrasound-guided erector spinae plane block (ESPB) plus standard intravenous analgesia (SIVA) might be superior to SIVA alone in pain control after PE surgical repair via Ravitch or Nuss technique.DESIGN:A retrospective cohort study.SETTING:At a university hospital.PARTICIPANTS:All participants were scheduled for surgical repair of PE.INTERVENTIONS:From January 2017 to December 2019, all patients who received ESPB plus SIVA or SIVA alone were investigated retrospectively. A 2:1 propensity-score matching analysis considering preoperative variables was used to compare analgesia efficacy in 2 groups. All patients received a 24-hour continuous infusion of tramadol, 0.1 mg/kg/h, and ketorolac, 0.05 mg/kg/h, via elastomeric pump, and morphine, 2 mg, intravenously as a rescue drug. The ESPB group received preoperative bilateral ESPB block. Postoperative pain, reported using a numerical rating scale at 1, 12, 24, and 48 hours after surgery; the number of required rescue doses; total postoperative morphine milligram equivalents consumption; and the incidence of postoperative nausea and vomit were analyzed.MEASUREMENT AND MAIN RESULTS:A total of 105 patients were identified for analysis. Propensity-score matching resulted in 38 patients in the SIVA group and 19 patients in the ESPB group. Postoperative pain, the number of rescue doses, and postoperative nausea and vomit incidences were lower in the ESPB group (p < 0.005).CONCLUSIONS:Erector spinae plane block may be an effective option for pain management after surgical repair of PE as part of a multimodal approach. This study showed good perioperative analgesia, opioid sparing, and reduced opioid-related adverse effects.

Pectus excavatum (PE), a congenital deformity of the chest wall, can lead to cardiac compression and related symptoms. PE surgical repair can improve cardiac function. Intraoperative transesophageal echocardiography (TEE) has been successfully employed to assess intraoperative hemodynamic variations in patients undergoing PE repair. FloTrac/Vigileo™ system (Edwards Life-sciences Irvine, CA) (FT/V) is a minimally invasive cardiac output monitoring system. This retrospective study aimed to assess hemodynamic changes in surgical repair of PE using FT/V and concordance with parameters measured by TEE. N=19 patients submitted to PE repair via Ravitch or Nuss technique were enrolled. Intraoperative cardiac assessments simultaneously obtained via TEE and FT/V system were investigated. The agreement between TEE-derived cardiac output (CO-TEE) and FT/V system parameter (COAP) was evaluated. The relationship between COTEE and COAP was analyzed for all data using linear regression analysis. A significant correlation between COAP and COTEE values (R = 0.65, p < 0.001) was found. Bland-Altman analysis of COAP and COTEE showed a bias of 0.13 L/min and a limit of agreement of − 2.33 to 2.58 L/min, with a percentage error of 48%. Intraoperative measurements by TEE and FT/V both showed a significant increase in CO after surgical correction of PE (p < 0.005). FT/V system compared to TEE in hemodynamic monitoring during PE surgery yielded clinically unacceptable results due to a high percentage error. After surgical correction of PE, CO, measured by TEE and FT/V, significantly improved.

OBJECTIVES:The endotracheal tube (ETT) and the laryngeal mask airway (LMA) are possible strategies for airway management during tracheal resection and reconstruction for tracheal and laryngotracheal stenosis. The goal of the study was to analyse and compare outcomes in the LMA and ETT groups.METHODS:Between 2003 and 2020, a total of 184 patients affected by postintubation, post-tracheostomy and idiopathic stenosis who had tracheal or laryngotracheal resections and reconstructions via a cervicotomy were retrospectively enrolled in this single-centre study. In 29 patients, airway management was achieved through LMA during tracheal surgery, whereas in 155 patients, it was achieved through ETT. A case-control matching analysis was performed with a 1:1 ratio, according to age, gender, body mass index, aetiology and length of stenosis (1-4 cm), resulting in 22 patients managed through LMA (LMA group) matched with 22 patients managed through ETT (ETT group).RESULTS:No significant differences were found in the reintubation rate, 30-day mortality and postoperative length of stay. Operative time was shorter in patients with LMA (96.23 ± 34.72 min in the ETT group vs 76.14 ± 26.94 min in the LMA group; P = 0.043). Intensive care unit (ICU) admission rate and stay were lower in the LMA group [18 in the ETT group vs 8 in the LMA group, odds ratio = 10.17, confidence interval (CI) 95% 1.79-57.79; P = 0. 009; 22.77 ± 16.68 h in ETT group vs 9.23 ± 13.51 h in LMA group; P = 0.005]. Dysphonia was more frequent in the ETT group than in the LMA group (20 in the ETT group vs 11 in the LMA group, odds ratio = 13.79, CI 95% 1.86-102; P = 0.010).CONCLUSIONS:LMA is a feasible option for airway management in tracheal surgery, with lower operative time, ICU admission rate, ICU length of stay and postoperative dysphonia occurrence.

The anesthetic management of adult patient with Down syndrome (DS) can be challenging due to poor patient cooperation, age-related comorbidities, and a possible difficult airway. Thoracic anesthesia requires an advanced airway management; thus, treatment of DS patients can be particularly demanding. An accurate preoperative assessment is paramount in order to plan a well-designed perioperative strategy in advance. This report describes the anesthetic management of an adult patient affected by DS who underwent pleural decortication for pleural empyema.

This is the first report to our knowledge of a successful total tracheal replacement in a post-COVID-19 patient by cryopreserved aortic allograft. The graft was anastomosed to the cricoid and carina; a silicon stent was inserted to ensure patency. The patient was extubated on the operative table and was immediately able to breathe, speak, and swallow. No immunosuppression was administered. Three weeks after surgery, the patient was discharged from hospital in excellent health, and was able to resume his normal lifestyle, work, and activity as an amateur cyclist. Two months after surgery, the patient assumes aerosol with saline solution three times per day and no other therapy; routine bronchoscopy to clear secretions is no longer needed.