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Background: Data collection has gained a great importance in numerous areas in the last years and also in the medical field. Collecting data is the key to knowledge and consequently improving data quality is fundamental, as the results of the data analysis can have a large impact on the clinical practice. Methods: Collected data can be employed to assess the performance of surgeons or institutions and to implement hospital´s performance and productivity. The chest wall database is one of the satellites composing the European Society of Thoracic Surgery (ESTS) database and includes data on risk factors, surgical techniques, processes of care and outcomes related to chest wall pathologies. The participation to the registry is free and voluntary for the ESTS members. The ESTS chest wall database includes data on risk factors, surgical techniques, processes of care and outcomes related to chest wall pathologies. The collected data are designed for quality control and performance audit. Acquired data are anonymous, independently accessed and encrypted on a Dendrite platform, which provides data security and regular backups. The registry is managed by an external company (KData Clinicak Srl), which works together with the database committee in revising and updating periodically the database. Results: The ESTS chest wall database is structured in four main sections: preoperative, intraoperative, postoperative and follow up. For each procedure registered in the database are collected a number of different variables regarding the patients’ characteristics, the surgical technique, the postoperative course until the discharge and also follow up data. Correction of pectus excavatum is the most common procedures registered in 2017 (392 patients, 67% of all data), followed by pectus bar removal (159 patients, 27% of all procedures). Conclusions: The ESTS chest wall database is an ambitious European project, which aims to standardize all chest wall procedures in all their aspects.

Background: In the setting of solitary pulmonary nodules (SPNs), fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG-PET/CT) is considered a useful noninvasive diagnostic tool though false positive (FP) and false negative (FN) results affects accuracy due to different conditions, such as inflammatory diseases or low-uptake neoplasms. Aim of this study is to evaluate overall diagnostic performance of 18 F-FDG-PET/CT for malignant pulmonary nodules. Methods: A computerized research, including published articles from 2012 and 2017, was carried out. 18 F-FDG-PET/CT overall sensitivity (Se), specificity (Spe), positive likelihood ratio (PLR), negative likelihood ratio (NLR), positive predictive value (PPV), negative predictive value (NPV), diagnostic index and odds ratio were pooled. No selection-bias were found according to asymmetry test. Results: A total of twelve studies were included in the meta-analysis. The pooled Se, Spe, PLR, NLR, PPV, NPV and accuracy index (AI) with relative 95% confidence intervals (CI) were 0.819 (95% CI: 0.794– 0.843), 0.624 (95% CI: 0.582–0.665), 2.190 (95% CI: 1.950–2.440), 0.290 (95% CI: 0.250–0.330), 0.802 (95% CI: 0.783–0.819), 0.652 (95% CI: 0.618–0.684) and 0.649 (95% CI: 0.625–0.673), respectively. The diagnostic odds ratio (DOR) was 7.049 with a relative 95% CI between 5.550 and 8.944. Conclusions: The results suggest 18 F-FDG-PET/CT has good diagnostic accuracy in SPNs evaluation; but, it should not be considered as a discriminatory test rather than a method to be included in a clinical and diagnostic pathway.

Background: Video-assisted thoracoscopic surgery (VATS) lobectomy has recently been adopted as the gold standard surgical option for the treatment of early stage non-small cell lung cancer. Enhanced recovery after surgery (ERAS) is being progressively adopted in thoracic surgery to improve the postoperative outcomes. Even if the benefits of ERAS are universally accepted, to date a standardized and uniform approach has not been described in the medical literature. The Italian VATS group has recently proposed to include in the VATS lobectomy database a structured protocol for ERAS. Methods: The ERAS section of the Italian VATS group is proposing a comprehensive ERAS protocol within the VATS lobectomy database, allowing the prospective collection of a dedicated set of data. Separate sections of the protocol are dedicated to different topics of ERAS. This study is specifically dedicated to the section of physiokinesis therapy. The medical literature will be extensively reviewed and a physiotherapy (PT) protocol of ERAS will be presented and discussed. A seta of structured clinical pathways will also be suggested for adoption in the VATS Group database. Discussion: Pre- and post-operative adoption of an ERAS protocol in patients undergoing VATS lobectomy may promote an improved post-operative course, a shorter hospital stay and an overall more comfortable patients’ experience. The mainstays of a physiokinesis therapy ERAS protocol are patients’ education, constant physical and respiratory therapy sessions, and adoption of adequate devices. Although many studies have investigated the usefulness of physical and respiratory physiokinesis therapy, a comprehensive ERAS protocol for VATS lobectomy patients has not yet been described. The proposed ERAS platform, adopted by the VATS Group database, will contribute to a prospective data collection and allow a scientific analysis of the results.

Enhanced recovery after surgery (ERAS®) is a strategy that seeks to reduce patients’ perioperative stress response, thereby reducing potential complications, decreasing hospital length of stay and enabling patients to return more quickly to their baseline functional status. The concept was introduced in the late 1990s and was first adopted in patients undergoing open colorectal surgery. Since then, the concept of ERAS has been adopted by multiple surgical specialties. The diffusion of video-assisted thoracic surgery lobectomy (VATS-L) sets also the surgical treatment of lung cancer as a new area for ERAS development. In this paper, we present the Italian VATS Group (www.vatsgroup.org) surgical protocol as part of the ERAS clinical pathway belonging to the VATS-L national database.

Background Intraoperative alveolar air leak (IOAAL) is one of most common complications after video-assisted thoracoscopic surgery (VATS) lobectomy. The study aimed to evaluate if, in moderate IOAAL, intraoperative polymeric biodegradable sealant (ProgelTM) reduced postoperative air leak (PAL) and consequently was cost-effective. Methods Patients with moderate IOAAL were randomised in a multicentre trial to intraoperative use of a sealant (Sealant group) or standard management of air leaks (Control group). Primary endpoint was the postoperative duration of air leakage. Secondary outcomes included: time to drainage removal, length of hospital stay, postoperative complications within 2 months, and cost analysis. Results Between January 2015 and January 2017, 255 VATS lobectomies were performed in four centres. Fifty-five met inclusion criteria and were randomly assigned to Sealant group [28] and Control group [27]. The mean air leakage duration was statistically different between groups (Sealant group =1.60 days, Control group =5.04 days; P

may have already occurred, thus providing a rich environment for growth of P. aeruginosa. Nevertheless, the lack of improvement in lung function measures, despite aggressive treatment and apparent eradiation of P. aeruginosa, is concerning. This finding emphasizes the importance of employing preventative therapy before the development of airway inflammation and infection. Driven by detailed work performed in laboratories such as that described in this issue of the Journal, infant lung function testing has now entered a new stage and can be considered a clinical outcome measure, similar to spirometry in the older child. The raised-volume technique has been standardized (12), published reference values are available (14), procedural risks are acceptable, and studies have clearly demonstrated that this technique is suitable to discriminate lung disease from health (3–5). Results from a recently completed trial performed in infants with CF in the United States are encouraging as they demonstrate the feasibility of studying infant lung function in a multicenter setting when strict quality assurance and training is implemented (15). The tremendous progress in this area of measuring infant physiology will naturally lead to intervention studies using these parameters as outcome measures. Over the next decade, we expect that techniques such as infant and preschool lung function testing will not only improve our understanding of the once ‘‘silent’’ and mysterious young CF lung but will also help us to develop stronger evidence for potential early intervention strategies in this vulnerable age group (16).

I would like to thank Konge et al . (1) for the interest and comment about my article. I take this opportunity to voice our point of view on the need of the specific video-assisted thoracoscopic surgery (VATS) lobectomies training program, whose methods focused on the different opinions of surgeons. While in the past VATS approach represented only the smallest part of total lobectomies, today this is around 90% of total interventions in high-volume centers. The new generations of surgeons are faced with the necessity to quickly acquire the mastery of this technique, with the best planning which still arouses debate and controversy among experienced colleagues.

In the 1990s, a sequence of papers on fast-track programme in general surgery was published, showing a reduction of complications and the hospital length of stay (LOS).

Our society is gradually growing old worldwide and therefore the surgical demand of elderly patients is rising.

Mediastinal staging is a crucial moment in management of non-small cell lung cancer (NSCLC) patients. In integrated pathways, 18-fluorine fluorodeoxyglucose positron-emission tomography (18F-FDG-PET/CT) is an indispensable imaging resource with its peculiarities and its limitations. A critical review of work up protocols would certainly help to standardize procedures with important reflections also on the diagnostic value of this examination. In this regard, new semi-quantitative and semi-qualitative indexes have been proposed with the aim of increasing the accuracy of 18F-FDG-PET/CT in mediastinal lymph node staging. These latter, such as SUVn/t and SUV indexes, seem to overcome the problem of spatial resolution and discrimination of malignancy by endorsing a new predictive and prognostic role.

Pectus excavatum (PE) is also known as funnel or sunken chest. PE is the most common type of chest wall malformation, indeed occurs in about 1 of 300–400 births with a male predominance (M:F =3:1). It is featured of a depression of the body of the sternum and in association abnormalities of the costal cartilages. The aspect of the defect variant from mild to very severe. PE is frequently asymptomatic during childhood, but symptoms like easy tiredness and decreased hardiness often appear when patients become teenager or are involved in competitive sports. Surgical correction for PE has become rifer thanks to development of the mini-invasive repair (MIRPE), described for the first time by Nuss in 1989. MIRPE consists in a thoracoscopic fixing of at least one metal bar, which is maintained in the chest at least 2 years.

Background: Primary hyperhidrosis is characterized by excessive sweating in distinct parts of the body. Surgery appears to be the best strategy considering the limited invasiveness of modern techniques. In this work, we compared the excision of main sympathetic trunk with ganglia (sympathectomy) or the interruption of sympathetic chain (sympathicotomy) with the positioning of metal clips. Methods: A research via PubMed, including published articles between 2009 and 2019, was carried out. Meta-analysis was performed by combining the reported recurrence/failure and compensatory sweating outcomes of the individual studies using a random effect model. Results: Of the one hundred and twenty-five articles identified, only 9 are considered valid for meta-analysis with overall information on 2,206 patients treated for primary hyperhidrosis. For the compensatory hyperhidrosis, despite a considerable data heterogeneity, we found a stronger correlation with the endoscopic sympathectomy/sympathetic procedure compared to clipping (odds ratio of 0.62). For the recurrence/failure of treatment, although the same heterogeneity of the data, we highlighted a strong correlation with the clipping procedure compared to endoscopic sympathectomy/sympathicotomy (odds ratio of 2.35). Conclusions: Sympathectomy or sympathicotomy have instead proved to be a safe and effective technique, with a low rate of recurrences. Clipping showed a reduced percentage of compensatory sweating but the removal of device is never easy, exposing patients to higher risks of open approach.

Background: Malignant pleural mesothelioma (MPM) is a rare neoplasm with indolent course and worse prognosis. Notwithstanding improvements in histologic and cytologic characterization, a generalized lack of consensus about diagnostic criteria still claims debate, though several new immunohistochemical markers have been introduced. Aim of this study is to evaluate current role and accuracy of glucose transporter-1 (GLUT-1) assay in the evaluation of malignant mesothelial proliferations. Methods: A PubMed Embase, Google Scholar research was carried out by identifying eight eligible articles fulfilling inclusion criteria. Quality assessment was conducted according to QUADAS-2 test. Data were extracted to evaluate true positive (TP), false positive (FP), true negative (TN) and false negative (FN) rates. Results: Enrolling 728 patients (297 MPM vs. 431 reactive pleural diseases), TP, FP, TN and FN cases were 215, 33, 398 and 82, respectively. A proportion of 74.25% of MPM patients showed immunoreactivity for GLUT-1. The pooled sensitivity (Se), specificity (Spe), positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy (DA) and disease prevalence (DP) were 0.74 [95% confidence interval (CI): 0.57–0.85], 0.91 (95% CI: 0.79–0.96), 0.87 (95% CI: 0.82–0.90), 0.83 (95% CI: 0.80–0.85), 0.84 (95% CI: 0.81–0.97) and 0.41 (95% CI: 0.37–0.44). Conclusions: In conclusions, GLUT-1 immunohistochemistry for MPM is characterized both by high Se and Spe rates. However, according to DP rates, its properties should be considered in the setting of a panel of markers rather than alone.

Approximately two decades ago, thoracic surgery witnessed the leap from thoracotomy to the first video-assisted thoracic surgery (VATS) lobectomy. VATS lobectomy is now widely established as a safe and oncological sound technology that is the standard of care for early-stage lung cancer. Reduction of trauma, bleeding, pain, hospitalisation time and recovery for the patient, these, in short, the main advantages of minimally invasive surgery that for several years is now increasingly replacing the traditional thoracotomy in many pulmonary surgical indications.

Background: In surgically fit non-small cell lung cancer (NSCLC) patients, pulmonary lobectomy still represents the standard of care. In recent years, the development of minimally invasive video-assisted techniques has reduced perioperative surgical stress, including patients previously thought to be unfit for surgery. Methods: We carried out a review of literature in order to evaluate the role of the preoperative parameters in functionally compromised patients and the effectiveness of video-assisted thoracoscopic surgery (VATS) compared to the “muscle sparing” axillary mini-thoracotomy in major lung resections. Results: Of 99 analyzed papers, we considered the 24 most significant, according to the preoperative functional status evaluation and, especially cardiac and respiratory reserve. Conclusions: In patients with a reduced cardio-respiratory function undergoing pulmonary resection, VATS guarantees results superimposable to mini-thoracotomy and represents a valid alternative to be taken into consideration.

Video-assisted thoracoscopic surgery (VATS) lobectomy represents, nowadays, the gold standard for the treatment of early-stage non-small cell lung cancer (NSCLC). This approach provides a viable alternative to open lobectomy, in terms of radical oncological surgery and of low incidence of complications, as a consequence of sustained innovations and improvements, due to the new available technology devices. Aim of the study was to evaluate the benefits and feasibility of such minimally invasive approaches throughout a careful review of the literature.

Lung cancer is one of the most frequent neoplastic diseases. To date, most lung cancer is diagnosed at an advanced stage, making it difficult to choose the diagnostic and therapeutic strategy. Surgical resection represents the best therapeutic solution. However, the best results are obtained only in the early stages of the disease. Lymph node involvement conditions the treatment (surgical or non-surgical approach). Mediastinoscopy is an effective and widely used method for mediastinal staging but does not allow us to reach many mediastinal lymph nodes. Endobronchial ultrasound/transbronchial needle aspiration (EBUS-TBNA) allows us to reach more lymph nodes and is referred to as a first-choice exam for mediastinal staging.

In the setting of a stage IV non-small cell lung cancer (NSCLC), oligometastatic patients represent a heterogeneous group whose incidence is increasing as far as with the adoption of new therapeutic regimens, the improvement of the molecular characterization assays and the increasing number of long-survivor patients. The oligometastatic state undergone a major revision with the introduction of the new TNM lung cancer staging system, being characterized by a different prognosis compared to multi-metastatic patients. Furthermore, the presence of a limited number of metastases imposes a local control especially when clonal selections occur during adjuvant therapy. In this regard, the review seeks to clarify the indications for surgical treatment by organ according to recent guidelines, by analyzing prognostic factors and outcome of patients. Although accurate patient stratification is mandatory, aggressive local control strategies represent a valid therapeutic approach in patients with oligometastatic NSCLC. At the same time, persevering with ablative strategies raises both medical and ethical issues about limits and reiteration, which certainly requires a deep reflection, being, on the other hand, in front of a metastatic disease.

Uniportal video-assisted thoracoscopic surgery (VATS) is the most advanced evolution of the minimally invasive technique, which allows often the possibility to include patients in enhanced recovery programs in order to optimize the therapeutic pathway, shorten the length of stay and reduce hospital costs. Non-intubated VATS procedures allow the performance of surgeries with minimal sedation without general anesthesia, maintaining throughout the operation spontaneous breathing. The principle is to create an iatrogenic spontaneous pneumothorax, which can provide a good lung isolation without the need of a double lumen tube. A survey between the members of the European Society of Thoracic Surgery (ESTS) showed that non-intubated VATS procedures are already performed by a large number of ESTS members for minor procedures. With the publication of new data and the spreading of uniportal VATS in many centers worldwide in the last decades, the application of the non-intubated technique in major procedure like anatomic resections is expected to grow. This technique can potentially be beneficial for high-risk patients but also could be used for the routine procedures as well, but more data are needed to establish the real benefit for these groups of patients.

We standardised a Ventilation Mechanical Test (VMT) after video-assisted thoracoscopic surgery (VATS) lobectomy that classifies intraoperative alveolar air leaks (IOAALs) in mild, moderate and severe. We assumed that mild IOAALs (400 mL/min) must be treated. An IOAAL between 100 and 400 mL/min was defined moderate and constituted the study population of a prospective multicentre randomised trial on the use of a polymeric biodegradable sealant (ProgelTM Pleural Air Leak Sealant, Bard Davol, USA) in case of moderate IOAAL compared with no treatment. We assumed that the standardised VMT allows to accurately selected patients needing treatment, thus limiting unnecessary sealant use. We analysed data of the randomised trial to assess the cost-effectiveness of Progel treatment in VMT selected patients. This is a multicenter randomised controlled trial. Patients with moderate IOAAL were randomised to Progel (group A) or “no treatment” (group B).The primary efficacy endpoint of the study was the postoperative duration of air leakage. The secondary outcome measures included: mean time to chest drain removal, mean length of hospitalisation, the percentage of postoperative complications occurring within two months, and cost of treatment. Between January 2015 and January 2017, 255 VATS lobectomies were performed in 4 centres, 55 met the inclusion criteria, and they were randomly assigned to 2 different groups (28 in the Progel and 27 in the control group). The mean air leakage duration was statistically different between the two groups: in the group A was 1.60 vs. 5.04 days in group B (P

Video-assisted thoracoscopic (VAT) procedures are emerging for treatment of both benign and malignant thoracic diseases and substituting classical approaches, such as thoracotomies, thanks to several advantages concerning postoperative morbidity rates and overall patients’ outcome (i.e., postoperative pain, chronic pain and quality of life). However, a VAT approach needs an established learning curve making procedures as safe as in open surgery. With regard of trainee surgeons, notwithstanding an increasing number of learning tools and strategies, such as simulation programs (i.e., black-boxes, wet labs, cadaver or animal labs, 3D virtual reality simulators) and direct observation both of live surgery and videos with a supportive evidence base from benchtop studies, there remains inconsistent adoption in surgical educations.

Pleural empyema represents a frequent disease, characterized sometimes by blurred and unspecific signs or symptoms but requiring timely diagnosis in order to plan the most appropriate therapeutic regimen. Several classifications have proposed and the most widely used is the American Thoracic Society (ATS) one, according to increasing severity depending of the extent of disease. Different therapeutic strategies such as conservative regimens (antibiotic therapy and chest tube placement) and surgical one (empyemectomy with pleural decortication) were applied. To this date, minimally invasive surgery is assuming an important role in the management of empyema and represents the gold standard in stage II disease and a valid alternative to the classical approach in stage III in absence of a complete obliteration of the pleural space. Aim of the work is to define, through a comprehensive review of literature, the role of video-assisted thoracoscopic surgery according to limits and advantages compared to conservative methods and the most invasive surgical approaches.

Professor Crisci and I have the great pleasure to introduce you to this special issue. It has been authored by prominent surgeons and it summarise all the topics discussed during the 4th International VATS Symposium in London.

Traumatic pathology of the chest wall, which is increasing in the new millennium, poses the need to question both pathophysiological and therapeutic aspects, linked to the topography of the bone structure involved and the morphology of the lesion. The different types of treatments (conservative or surgical) cannot ignore the correlation between anatomical and functional damages. This study analyses the various reconstructive methods regarding the flail chest, isolated sternal fracture and manubriosternal dislocation, considering literature and the personal clinical experience. The invasive approach, carried out exclusively on hemodynamically stable patients, has the aim to restore the normal intrathoracic balance pressure and the regular mechanical ventilation, avoiding cardiorespiratory complications. The comparison between the established methodologies and the latest technological innovations also responds to the need of achieving excellent aesthetic results, psychologically and socially indispensable to the patient.