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Background: Multislice computed tomography (MSCT) increased detection of solitary pulmonary nodules (SPNs), changing the management based on radiological and clinical factors. When 18-fluorine fluorodeoxyglucose positron emission tomography combined with computed tomography ( 18 F-FDG-PET/CT) was considered for the evaluation of nodules, the maximum standardized uptake value (SUVmax) more than 2.5 is used frequently as a cut off for malignancy. The purpose of this study is to evaluate SUVmax PET/CT and pulmonary attenuation patterns at MSCT in patients with SPN according to morphological and pathological characteristics of the lesion. Methods: A retrospective study on 1,592 SPN patients was carried out following approval by the Italian Registry of VATS Lobectomies. Results: All patients underwent VATS lobectomy. On histologic examination, 98.1% had primary or second metachronous primary lung cancers. In addition, 10.7% presented occult lymph node metastases (pN1 or pN2) on histological examination. Nodule attenuation on CT was associated with the histology of the lesion (p= 0.030); in particular, pure ground glass opacities (pGGOs) and partially solid nodules were related to adenocarcinomatous histotypes. Conversely, a significant relationship between SUVmax and age, nodule size, pathological node status (pN) was found (P=0.007, P=0.000 and P=0.002 respectively). Conclusions: Nodule attenuation can predict the histology of the lesion whereas SUVmax may relate to the propensity to lymph node metastases.

Background Since the first years of the 1980s, some authors described the use of mechanical stapler for the creation of anastomosis in biliary surgery. However, the use of these devices has not spread during the following decades, and nowadays most centers usually craft hand-sewn anastomosis. Methods We retrospectively collected data from medical records, surgical registries and computerized databases about the use of mechanical circular staplers for the creation of hepaticojejunostomy at our institution. Results From 2012 to 2020, 11 stapled hepaticojejunostomy for both neoplastic and non-neoplastic diseases were performed at our institution. The mean age of the patient was 74, with a sex distribution of 5 men and 6 women. The mean preoperative common bile duct diameter was 19 mm. Preoperative blood samples showed mean total bilirubin of 6.95 mg/dL. No intraoperative complications were reported. Two patients (18%) had minor postoperative complications (1 wound dehiscence and 1 episode of melena that required blood transfusions), while no major complications occurred. No patients developed biliary fistula or anastomotic dehiscence. No one dies within 30 days from surgery. The mean postoperative length of stay was 13 days. Conclusions According to our limited experience, stapled hepaticojejunostomy seems to be a safe and effective technique in selected patients.

Amaç: Anal fistül iyi tanımlanmış bir hastalıktır ancak kesin bir cerrahi teknik geliştirilmemiştir. Hastanemizde 2012-2018 yılları arasında perianal fistül nedeniyle cerrahi tedavi uygulanan hastaları değerlendirmek için tek merkezli, retrospektif bir kohort çalışması yürüttük. Çalışmanın amacı, farklı cerrahi tekniklerin (Fistülotomi / fistülektomi ve seton, Video Destekli Anal Fistül Tedavisi (VAAFT), Mikro-parçalanmış yağ dokusu enjeksiyonu, Lipogems®) sonuçlarını karşılaştırmaktı.Yöntemler: Elektif cerrahi için uygun olan anal fistüllü 103 hastadan oluşan bir kohort, 2012 ve 2018 yılları arasında Ferrara'daki Sant’Anna Hastanesi’nde opere edildi. Tüm hastalara fistül traktını ve iç açıklığı belirlemek için ameliyat öncesi rektal tuşe ve manyetik rezonans görüntüleme (MRI) uygulandı. Hastalar, geçirdikleri her ameliyat için birer tane olmak üzere 4 gruba ayrıldı: Fistülotomi / fistülektomi ve seton, Video Destekli Anal Fistül Tedavisi (VAAFT), Mikro parçalı yağ dokusu enjeksiyonu, Lipogems®). Ameliyattan bir hafta sonra öznel ağrıyı değerlendirmek için sayısal derecelendirme ölçeği (NRS) kullanıldı ve sonuçlar kaydedildi. Puanlar, 0, hiç ağrı yok, ile 10, karşılaşılan en şiddetli ağrı, arasında değişmekteydi. Birincil sonlanım noktası, 1 yıllık takipte fistül rekürrensiydi. İkincil sonlanım noktası, ameliyat sonrası ağrının değerlendirilmesiydi.Bulgular: Ortanca yaşı 50 olan (aralık 21-89 yaş) 71 erkek ve 32 kadın çalışmaya dahil edildi. Bunlardan 79 hastaya yeni teşhis konulmuş, diğer 24 hasta daha önce ameliyat olmuş ve nüksetmişti. Anal fistül için toplam 118 cerrahi operasyon yapıldı. Takip süresince VAAFT sonrası 13 hastada, Mikro parçalı yağ dokusu enjeksiyonu sonrası 3 hastada, fistülotomi sonrası 4 hastada, fistülotomi sonrası 12 hastada, seton yerleştirme sonrasında 10 hastada ve Lipogems® tekniğinden sonra 8 hastada anal fistül rekürrensi gözlendi. Ameliyattan bir hafta sonra ağrı tüm hastalar tarafından 0 ile 10 arasında bir ölçekte değerlendirildi. VAAFT, mikro parçalı yağ dokusu enjeksiyonu, fistülotomi, fistülektomi, seton yerleştirme ve Lipogems® tekniği uygulanan hastaların ortalama skorları sırasıyla 1 (0- 5), 1.5 (0-8), 5 (3-8), 6.8 (5-9), 4.2 (2-6) ve 0’dı (0-2).Sonuç: Bu çalışma anal fistül yönetimindeki zorlukları ve çeşitli cerrahi seçenekleri sunmaktadır. VAAFT ve Mikro-parçalanmış yağ dokusu enjeksiyonu, anal fistül yönetiminde güvenli ve uygulanabilir seçenekler gibi görünmektedir ve kısa süreli iyileşme oranları, kontinans üzerinde kalıcı bir etki olmaksızın kabul edilebilirdir. Bununla birlikte, uzun vadeli sonuçları olan güvenilir veri yetersizliği olduğundan, bu teknikler, bu nedenle memnuniyetle karşılanmaktadır. Lipogems ® tekniği güvenli ve tekrarlanabilir bir işlemdir, ancak ne yazık ki deneyimlerimize göre, tekrarlayan sfinkterik anal fistülü olan hastalarda fistül iyileşmesini desteklememektedir. Bu tekniğin birinci basamak tedavi olarak kullanılmasını önermiyoruz., Aim: Fistula-in-ano is a well described disease but no definitive surgical technique has been developed. We conducted a retrospective cohort study in a single center to evaluate patients who underwent surgical treatment of a perianal fistula from 2012 to 2018 in our hospital. The aim of the study was to compare the outcome of different surgical techniques (Fistulotomy/fistulectomy and seton, Video-Assisted Anal Fistula Treatment (VAAFT), Micro-fragmented adipose tissue injection, Lipogems®).Methods: A cohort of 103 patients with anal fistula who qualified for elective surgery between 2012 and 2018 were recruited at Sant’Anna Hospital in Ferrara. All patients underwent a digital rectal examination and preoperative magnetic resonance imaging (MRI) to identify the fistula tract and internal opening. Patients were divided into 4 groups, one for each type of surgery they underwent: Fistulotomy/fistulectomy and seton, Video-Assisted Anal Fistula Treatment (VAAFT), Micro-fragmented adipose tissue injection, Lipogems®). Numerical rating scale (NRS) was used to assess subjective pain one week after surgery and documented. The scale ranged from 0 to 10, where 0 stands for no pain and 10 stands for worst pain ever faced. Primary end point was fistula recurrence at 1 year of follow-up. Secondary end point was evaluation of post-operative pain. Results: There were 71 males and 32 females, with a median age of 50 years (range 21-89 years). Among them, 79 patients were newly diagnosed, the other 24 patients had undergone previous surgery and had recurrence. In total, 118 surgical operation were performed for anal fistula. During the follow-up period, anal fistula recurrence was observed in 13 patients after VAAFT, 3 patients after Micro-fragmented adipose tissue injection, 4 after fistulotomy, 12 after fistulectomy, 10 after seton placement and 8 after Lipogems® technique. One week after surgery, pain was evaluated by all patients on a scale from 0 to 10. The mean scores of patients who underwent VAAFT, micro-fragmented adipose tissue injection, fistulotomy, fistulectomy, seton placement and Lipogems® technique were 1 (0-5), 1.5 (0-8), 5 (3-8), 6.8 (5-9), 4.2 (2-6) and 0 (0-2), respectively. Conclusion: This study presents the difficulties in managing anal fistulas and the variety of surgical options. VAAFT and Micro-fragmented adipose tissue injection appear to be safe and feasible options in the management of anal fistula, and short-term healing rates are acceptable with no sustained effect on continence. There is, however, a paucity of robust data with long-term outcomes. These techniques are thus welcome additions. Lipogems ® technique is a safe and reproducible procedure, unfortunately according to our experience, it does not promote fistula healing in patients with recurrent inter-sphincteric anal fistula. We do not suggest the use of this technique as a first-line treatment.

OBJECTIVES The Italian VATS Group database was accessed to evaluate whether preoperative and intraoperative factors may affect the safety of lymphadenectomy (LA) during video-assisted thoracic surgery lobectomy. METHODS All video-assisted thoracic surgery lobectomy procedures performed between 1 January 2014 and 30 March 2017 for non-small-cell lung cancer with cN0 or cN1 disease were identified in the database. LA safety was evaluated based on intraoperative (operative time, bleeding and conversion rate) and postoperative (30-day morbidity and mortality, chest drain duration and length of stay) outcomes and was correlated with the number of resected lymph nodes and the rates of nodal upstaging. Continuous variables were presented as mean ± standard deviation and compared using the unpaired t-test; the X2 test was used for categorical variables. Univariable analysis was performed on selected variables. Significant variables (P < 0.30) were entered into a Cox multivariable logistic regression model, using the overall and specific occurrence of complications as dependent variables. The Spearman's rank correlation coefficient was applied as needed. RESULTS A total of 3181 cases (2077 men, 65.3%; mean age of 69 years) met the enrolment criteria. Final pathology was consistent with adenocarcinoma (n = 2262, 67.5%), squamous cell (n = 520, 15.5%), typical (n = 184, 5.5%) and atypical carcinoid (n = 48, 1.4%) and other (n = 335, 10%). The mean number of resected lymph nodes was 13.42 ± 8.24; nodal upstaging occurred in 308 of 3181 (9.68%) cases. Six hundred and fifty-five complications were recorded in 404 (12.7%) patients; in this series, no mortality was observed. Univariable and multivariable analyses did not show any association between the extension of LA and intraoperative or postoperative outcomes. The number of resected lymph nodes and nodal upstagings showed a minimal correlation with intraoperative outcomes and a moderate correlation with postoperative air leak (p = 0.35 and p = 0.48, respectively), arrhythmia (p = 0.29 and p = 0.35, respectively), chest drain duration (p = 0.35 and p = 0.51, respectively) and length of stay (p = 0.35). CONCLUSIONS Based on the VATS Group data, video-assisted thoracic surgery LA proved to be safe and displayed good outcomes even when performed with an extended approach.

Background: VATS lobectomy is an established option for the treatment of early-stage NSCLC. Complete lymph node dissection (CD), systematic sampling (SS) or resecting a specific number of lymph nodes (LNs) and stations are possible intra-operative LN management strategies. Methods: All VATS lobectomies from the “Italian VATS Group” prospective database were retrospectively reviewed. The type of surgical approach (CD or SS), number of LN resected (RN), the positive/resected LN ratio (LNR) and the number and types of positive LN stations were recorded. The rates of nodal upstaging were assessed based on different LN management strategies. Results: CD was the most frequent approach (72.3%). Nodal upstaging rates were 6.03% (N0-to-N1), 5.45% (N0-to-N2), and 0.58% (N1-to-N2). There was no difference in N1 or N2 upstaging rates between CD and SS. The number of resected nodes was correlated with both N1 (OR =1.02; CI, 1.01–1.04; P=0.03) and N2 (OR =1.02; CI, 1.01–1.05; P=0.001) upstaging. Resecting 12 nodes had the best ability to predict upstaging (6 N1 LN or 7 N2 LN). The finding of two positive LN stations best predicted N2 upstaging [area under the curve (AUC) of receiver operating characteristic (ROC) =0.98]. Conclusions: Nodal upstaging (and, indirectly, the effectiveness of intra-operative nodal management) cannot be predicted based on the surgical technique (CD or SS). A quantitative assessment of intra-operative LN management may be a more appropriate and measurable approach to justify the extension of LN resection during VATS lobectomy.

We report here a case of primary pulmonary epithelioid hemangioendothelioma diagnosed in a 67-year-old Caucasian man, presenting with exertion dyspnoea, dry cough, and multiple bilateral pulmonary nodules revealed by computed tomography. At the 18F-fluorodeoxyglucose positron emission tomography, these nodules were negative. The histopathological diagnosis was made on a pulmonary wedge resection (performed during video-thoracoscopic surgery).

Objectives Vascular injuries are among the most severe causes of unplanned conversion during VATS lobectomies. The study aimed to analyse the incidence of vascular injuries and their risk factors during VATS lobectomy. Methods The Italian VATS lobectomy Registry was used to collect data from 66 Thoracic Surgery Units. From 2013 to October 2016 (out of more than 3,700 patients enrolled) only information from Units with an enrollment >100 VATS lobectomies were retrospectively analysed. Logistic regression analysis was performed on selected variables of the univariate analysis. Results Ten institutions contributed a total of 1,679 patients. Vascular injuries leading to conversion occurred in 44 (2.6%) patients. Years of experiences were inversely related to the risk of vascular injuries. Univariate analysis showed age, gender, surgical activity, Charlson Index Score and number of resected lymph nodes like significantly associated variables. Multivariate analysis revealed that number of resected lymph nodes, VATS experience ratio (number of VATS lobectomies/total lobectomies performed in the same year at same centre), and surgical activity of the centre were significantly associated with the risk of conversion. Unplanned thoracotomy was correlated with postoperative morbidity. Conclusion Vascular injuries in VATS lobectomies represented a rare complication which could directly affect the postoperative outcomes. The predictive factors for conversion were multifactorial and depended on characteristics of centres and surgeons’ seniority. Minimally invasive VATS lobectomy approaches did not influence the risk of vascular damages.

The hypothesis to use microRNAs (miRNAs) circulating in the blood as cancer biomarkers was formulated some years ago based on promising initial results. After some exciting discoveries, however, it became evident that the accurate quantification of cell-free miRNAs was more challenging than expected. Difficulties were linked to the strong impact that many, if not all, pre- and post- analytical variables have on the final results. In this study, we used currently available high-throughput technologies to identify miRNAs present in plasma and serum of patients with breast, colorectal, lung, thyroid and melanoma tumors, and healthy controls. Then, we assessed the absolute level of nine different miRNAs (miR-320a, miR-21-5p, miR-378a-3p, miR-181a-5p, miR-3156-5p, miR-2110, miR-125a-5p, miR-425-5p, miR-766-3p) in 207 samples from healthy controls and cancer patients using droplet digital PCR (ddPCR) technology. We identified miRNAs specifically modulated in one or more cancer types, according to tissue source. The significant reduction of miR-181a-5p levels in breast cancer patients serum was further validated using two independent cohorts, one from Italy (n = 70) and one from US (n = 90), with AUC 0.66 and 0.73 respectively. This study finally powers the use of cell-free miRNAs as cancer biomarkers and propose miR-181a-5p as a diagnostic breast cancer biomarker. The hypothesis to use microRNAs (miRNAs) circulating in the blood as cancer biomarkers was formulated some years ago based on promising initial results. After some exciting discoveries, however, it became evident that the accurate quantification of cell-free miRNAs was more challenging than expected. Difficulties were linked to the strong impact that many, if not all, pre- and post-analytical variables have on the final results. In this study, we used currently available high-throughput technologies to identify miRNAs present in plasma and serum of patients with breast, colorectal, lung, thyroid and melanoma tumors, and healthy controls. Then, we assessed the absolute level of nine different miRNAs (miR-320a, miR-21-5p, miR-378a-3p, miR-181a-5p, miR-3156-5p, miR-2110, miR-125a-5p, miR-425-5p, miR-766-3p) in 207 samples from healthy controls and cancer patients using droplet digital PCR (ddPCR) technology. We identified miRNAs specifically modulated in one or more cancer types, according to tissue source. The significant reduction of miR-181a-5p levels in breast cancer patients serum was further validated using two independent cohorts, one from Italy (n = 70) and one from US (n = 90), with AUC 0.66 and 0.73 respectively. This study finally powers the use of cell-free miRNAs as cancer biomarkers and propose miR-181a-5p as a diagnostic breast cancer biomarker.