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OBJECTIVES Digital chest drainage systems allow real-time and continuous monitoring and recording of air leak flow rate and intrapleural pressure (IPP) from the immediate postoperative period to the chest drainage removal. A multicentre retrospective observational analysis of consecutive patients undergoing pulmonary lobectomy for lung cancer was performed to evaluate the association between the airflow and IPP digitally recorded during the immediate postoperative period after video-assisted thoracic surgery (VATS) lobectomy for lung cancer. Here, we present a work in progress report. METHODS All patients treated with VATS lobectomies for lung cancer were included. Multiple airflow measurements and minimum and maximum IPP through the chest tubes were digitally monitored and recorded using microelectronic mechanical sensor technology. The PALs were defined as an air leak lasting >5 days from the conclusion of the surgical procedure. The cessation of air leaks was defined as an airflow RESULTS This analysis comprised 76 patients who underwent VATS lobectomy for lung cancer. Nineteen patients (25%) showed prolonged air leaks (PAL) (≥5 days). The operative time was higher in the PAL group (mean difference = 44 min) without a statistically significant difference. Before the 7th postoperative hours, there were no statistically significant differences in IPPs. CONCLUSIONS Patients with PAL showed less negative IPP in the first 24 postoperative hours. Therefore, the 7th—24th postoperative hours were critical in PAL prediction since the mechanism for PAL seems to develop after the 7th postoperative hour.

Backgrounds Oligometastatic Non-Small Cell Lung Cancer (NSCLC) patients represent a category without a standard therapeutic approach. However, in selected oligometastatic NSCLC, radical surgery seems to offer a good prognosis. This retrospective study aimed to analyse the long-term outcomes of synchronous oligometastatic patients treated with curative intent and identify the factors associated with better results and the proposal of a risk stratification system for classifying the synchronous oligometastatic NSCLC. Methods The medical records of patients from 18 centres with pathologically diagnosed synchronous oligometastatic NSCLC were retrospectively reviewed. The inclusion criteria were synchronous oligometastatic NSCLC, radical surgical treatment of the primary tumour with or without neoadjuvant/adjuvant therapy and radical treatment of all metastatic sites. The Kaplan – Meier method estimated survivals. A stratified backward stepwise Cox regression model was assessed for multivariable survival analyses. Results 281 patients were included. The most common site of metastasis was the brain, in 50.89 % patients. Median overall survival was 40 months (95 % CI: 29–53). Age ≤65 years (HR = 1.02, 95 % CI: 1.00–1.05; p = 0.019), single metastasis (HR = 0.71, 95 % CI: 0.45–1.13; p = 0.15) and presence of contralateral lung metastases (HR = 0.30, 95 % CI: 0.15 – 0.62; p = 0.001) were associated with a good prognosis. The presence of pathological N2 metastases negatively affected survival (HR = 2.00, 95 % CI: 1.21–3.32; p = 0.0065). These prognostic factors were used to build a simple risk classification scheme. Conclusions Treatment of selected synchronous oligometastatic NSCLC with curative purpose could be conducted safely and at acceptable 5-year survival levels, especially in younger patients with pN0 disease.

OBJECTIVES This study reports the results of an international expert consensus process evaluating the assessment of intraoperative air leaks (IAL) and treatment of postoperative prolonged air leaks (PAL) utilizing a Delphi process, with the aim of helping standardization and improving practice. METHODS A panel of 45 questions was developed and submitted to an international working group of experts in minimally invasive lung cancer surgery. Modified Delphi methodology was used to review responses, including 3 rounds of voting. The consensus was defined a priori as >50% agreement among the experts. Clinical practice standards were graded as recommended or highly recommended if 50–74% or >75% of the experts reached an agreement, respectively. RESULTS A total of 32 experts from 18 countries completed the questionnaires in all 3 rounds. Respondents agreed that PAL are defined as >5 days and that current risk models are rarely used. The consensus was reached in 33/45 issues (73.3%). IAL were classified as mild (400 ml/min; 74%). If mild IAL are detected, 68% do not treat; if moderate, consensus was not; if severe, 90% favoured treatment. CONCLUSIONS This expert consensus working group reached an agreement on the majority of issues regarding the detection and management of IAL and PAL. In the absence of prospective, randomized evidence supporting most of these clinical decisions, this document may serve as a guideline to reduce practice variation.

Purposes We compared two different surgical methods evaluating the effectiveness of procedures and the quality of life (QoL) of patients. Methods From January 2010 to November 2017 we carried out 476 biportal video-assisted thoracoscopic surgery (VATS) approaches of sympathetic chain in 238 patients. One hundred and twenty-nine (54%) patients underwent conventional sympathectomy (CS) while 109 (46%) patients underwent sympathicotomy associated with the division of the rami communicantes (MWT). Quality of Life (QoL) was classified as follows: from 20 to 35 excellent; from 36 to 51 very good; from 52 to 68 good; from 69 to 84 poor; and > 84 very poor. Results We noticed statistical significant reduction of complications comparing CS with MWT approaches (chest pain from 36.4 to 4.5%; paresthesias from 8.5 to 3.6%; bradycardia from 28.6 to 10%, respectively). The preoperative and postoperative QoL index evaluation revealed a statistically significant improvement after surgery (CS: 86 ± 2 versus 35 ± 1, p = 0.00001; MWT: 85 ± 1 versus 33 ± 2, p = 0.00001), with general satisfaction of the two techniques. Conclusion Modified Wittmoser method seems to be a valid alternative to conventional sympathectomy, minimizing the percentage rate of complications and showing significant effectiveness in the quality of life improvement.

Background Non-Intubated Thoracic Surgery (NITS) is becoming increasingly adopted all over the world. Although it is mainly used for pleural operations,, non-intubated parenchymal lung surgery has been less frequently reported. Recently, NITS utilization seems to be increased also in Italy, albeit there are no multi-center studies confirming this finding. The objective of this survey is to assess quantitatively and qualitatively the performance of NITS in Italy. Methods In 2018 a web-based national survey on Non-Intubated management including both thoracic surgeons and anesthesiologists was carried out. Reference centers have been asked to answer 32 questions. Replies were collected from June 26 to November 31, 2019. Results We raised feedbacks from 95% (55/58) of Italian centers. Seventy-eight percent of the respondents perform NITS but only 38% of them used this strategy for parenchymal surgery. These procedures are more frequently carried out in patients with severe comorbidities and/or with poor lung function. Several issues as obesity, previous non-invasive ventilation and/or oxygen therapy are considered contraindications to NITS. The regional anesthesia technique most used to provide intra- and postoperative analgesia was the paravertebral block (37%). Conversion to general anesthesia is not anecdotal (31% of answerers). More than half of the centers believed that NITS may reduce postoperative intensive care unit admissions. Approximately a quarter of the centers are conducting trials on NITS and, three quarters of the respondent suppose that the number of these procedures will increase in the future. Conclusions There is a growing interest in Italy for NITS and this survey provides a clear view of the national management framework of these procedures.

Thoracoscopic lobectomy (VATS-L) for non-small-cell lung cancer (NSCLC) is a well-established option for early stage NSCLC, but the evidences are limited for octogenarians.The objectives of this multi-institutional study were to evaluate the post-operative outcomes of VATS-L in octogenarians and to estimate the post-operative quality of life (QoL) using a validated questionnaire (EuroQoL5D).Data from patients underwent VATS-L between 2014 and 2019 were analysed and divided into two groups: Group A (younger patients) and Group B (octogenarians). To define predictors for complications, univariate and multivariable logistic regression analysis were performed.7023 patients underwent VATS-L and 329 (4.6%) were octogenarians. 30-day and 90-day post-operative mortality were similar (0.95% vs 0.91%, p = 0.84 and 1.3% vs 1.2%, p = 0.58), whereas the percentage of patients who suffered from any complication (25.5% vs 31.9%, p = 0.012) and the complication rate (31.6% vs 45.2%, p=0.01) were higher for octogenarians. At discharge, the values of EuroQoL5D were worse in group B, but after one month these levels became similar. Age80 years had a significant influence on morbidity on both univariate and multivariable analyses (p = 0.025).VATS-L for NSCLC can be performed in selected octogenarians without increased risk of post-operative death, acceptable not-life-threatening complications and a moderate impact on QoL.

Notwithstanding advances in medical and surgical management of flail chest, its morbidity and mortality rates are still high. Aim of this study is to compare three approaches for parietal thoracic stabilization by analyzing both early and long-term patient outcomes.A retrospective study from January 2006 to January 2018 involving sixty-five surgical flail chest (25 plates,11 struts and 29 wires fixations) was conducted. A mean Abbreviated Injury Scale (AIS) was 2.38±0.82 and a mean Injury Severity Score (ISS) was 32.02±8.21.Struts and plates stabilizations compared with wires fixation showed an immediate restoring of the partial pressure of oxygen (90.56 mmHg vs 91.90 mmHg vs 89.23 mmHg, p = 0.021), the carbon-dioxide levels (36.00 mmHg vs 35.03 mmHg vs 38.98 mmHg, p = 0.000) and the oxygen-blood saturation (97.71% vs 98.21% vs 92.12%, p = 0.000) in the early postoperative period. Furthermore, struts and plates ensured a better recovery of daily activities up to the 3rdmonth (QoL=1.0: p0.001 in lateral flail chest and p0.02 in anterior and antero-lateral flail chest). At the 12thmonth no difference in QoL was found between the different approaches.Plate and strut fixation revealed a lower rate of postoperative morbidity and mortality. Wires stabilization was characterized for a reduction of operative time.

Primary spontaneous pneumothorax (PSP) is a commonly known condition due to the accumulation of air in the pleural space in otherwise healthy people, without apparent underlying lung disease. To date, the exact pathogenesis of PSP is unclear, but it still represents a public health issue. We performed a review of the literature concerning the epidemiology of PSP, examining age of onset and presentation symptoms, in order to assess the possible correlation between these characteristics and its occurrence. Data concerning age, signs, and symptoms were collected. For description purposes, information regarding aetiological and anthropomorphic data was also gathered. In total, 265 papers were evaluated. Regarding age of onset, PSP is a disease that can occur in a broad age group with a double cluster (15-30 and 40-45 yr). Regarding symptoms, pain and dyspnoea (in its various forms) are the most described in PSP. Pain was recorded in 69.25% (range, 9-100%) of the population studied, whereas dyspnoea was present in an average of 54.55% (range, 27-77.1%). Tobacco exposure seems to play an important role in the early onset of PSP. Concerning age at presentation, this review highlights that PSP can occur over a broad age range. The literature appears to be consistent in reporting PSP occurrence mostly below 45 years of age. Asymptomatic PSP is an almost unseen entity. Finally, of pollutants, cigarette smoking should be considered as the most significant exogenous risk factor in the development of PSP.

OBJECTIVESThe objective of this retrospective multi-institutional study was to evaluate the postoperative outcomes of video-assisted thoracoscopic surgery (VATS)-lobectomy (VATS-L) for non-small-cell lung cancer (NSCLC) in patients with impaired lung function. The second end point was to illustrate the effective role of forced expiratory volume in 1 s (FEV1%) and the diffusing capacity of the lung for carbon monoxide (DLCO%) in predicting complications in this population.METHODSData from patients who underwent VATS-L at participating centres were analysed and divided into 2 groups: group A comprised patients with FEV1% and/or DLCO% >60% and group B included patients with impaired lung function defined as FEV1% and/or DLCO% ≤60%. To define clinical predictors of death and complications, we performed univariate and multivariable regression analyses.RESULTSA total of 5562 patients underwent VATS-L, 809 (14.5%) of whom had impaired lung function. The postoperative mortality rate did not differ between the 2 groups (2.3% vs 3.2%; P = 0.77). The percentage of patients who had any complication (21.4% vs 34.2%; P ≤ 0.001), the complication rate (28% vs 49.8%; P ≤ 0.001) and the length of hospital stay (P ≤ 0.001) were higher for patients with limited pulmonary function. Impaired lung function was a strong predictor of overall and pulmonary complications at multivariable analysis.CONCLUSIONSVATS-L for NSCLC can be performed in patients with impaired lung function without increased risk of postoperative death and with an acceptable incidence of overall and respiratory complications. Our analysis suggested that FEV1% and DLCO% play a substantial role in estimating the risk of complications after VATS-L, but their role was less reliable for estimating the mortality.

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., The global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resulting coronavirus disease 2019 (COVID-19) quickly escalated into a critical situation for healthcare systems worldwide [1].

Validation of predictive risk models for prolonged air leak (PAL) is essential to understand if they can help to reduce its incidence and complications. This study aimed to evaluate both the clinical and statistical performances of 4 existing models. We selected 4 predictive PAL risk models based on their scientific relevance. We referred to these models as Chicago, Bordeaux, Leeds and Pittsburgh model, respectively, according to the affiliation place of the first author. These predicting risk models were retrospectively applied to patients recorded on the second edition of the Italian Video-Assisted Thoracoscopic Surgery Group registry. Predictions for each patient were calculated based on the logistic regression coefficient values provided in the original manuscripts. All models were tested for their overall performance, discrimination, and calibration. We recalibrated the original models with the re-estimation of the model intercept and slope. We used curve decision analysis to describe and compare the clinical effects of the studied risk models. Better statistical metrics characterize the models developed on larger populations (Chicago and Bordeaux models). However, no model has a valid benefit for threshold probability greater than 0.30. The Net benefit of the most performing model (Bordeaux model) at the threshold probability of 0.11 is 23 of 1000 patients, burdened by 333 false positive cases. One of 1000 is the Net benefit at the threshold probability of 0.3. The use of PAL scores based on preoperative predictive factors cannot be currently used in a clinical setting because of a high false positive rate and low positive predictive value.

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.

Objective: The objective of the study is to analyse the causes and impact of conversion from VATS to thoracotomy identifying any possible pre-operative risk factors and related consequences. Methods: Data from patient who underwent VATS lobectomy (VATS-L) for NSCLC at VATS Group participating centres were retrospectively analysed and divided in two groups: patients treated with VATS-L and patients who suffered from conversion. Predictors of conversion were assessed with univariate and multivariable exact logistic regression. Complications were evaluated as dependent variables of conversion in a Cox multivariable logistic regression model. Results: A total of 4629 patients underwent planned VATS-L for NSCLC and of these, 432 (9.3%) required conversion; the most frequent causes were bleeding (30.4%) and fibro-calcified hilar lymph nodes (23.9%). The independent risk factors at multivariable analysis model were sex male (OR 1.458, p < 0.01), age older than 70years (OR 1.248, p = 0.036) and the clinically node-positive disease (OR 2.258, p < 0.01). The mortality rate was similar, but the percentage of patients who suffered from any complication (41.7% vs 24.4%, p < 0.01), the complication rate (65% vs 32.2%, p < 0.01), chest tube duration (p < 0.01) and the hospitalisation rate (p < 0.01) were higher for patients converted. Atrial fibrillation (OR 1.471, p = 0.019), prolonged air leak (OR 1.403, p = 0.043), blood transfusions (OR 4.820, p < 0.01), sputum retention (OR 1.80, p = 0.027) and acute kidney failure (OR 2.758, p = 0.03) were significantly associated with conversion at multivariable analysis. Conclusions: Conversion is associated with increased surgical morbidity, blood loss and hospital stay. Sex male, old age and the clinical involvement of lymph nodes were the strongest predictors of conversion.

This report highlights the results of the Italian video-assisted thoracoscopic surgery (VATS) Group, launched in mid 2013, which now has a website and an established database with over 4000 VATS lobectomy cases recruited from 67 thoracic surgery units across Italy. The year 2016 has been crucial for the following steps: inclusion of a dedicated biostatistician and a ‘Survey Analysis & Data Quality Check’; the First Consensus Meeting with statements consequently adopted as Recommendations for the Italian Thoracic Surgery Society and published in a peer-reviewed journal; two papers published under the logo Italian VATS Group and seven abstracts accepted at annual international meetings (European Society of Thoracic Surgeons, European Association of Cardio-Thoracic Surgeons, European Lung Cancer Conference and European Respiratory Society); the institution of a Master Course on VATS lobectomy; the partnership with AME Publishing Company.

Background Several gray areas and controversies exist concerning the management of pulmonary ground-glass opacities (GGOs), and there is a lack of consensus among clinicians on this topic. One of the main aims of the Italian Society of Thoracic Surgery is to promote education and research, so we decided to perform a survey on this topic to estimate current trends in practice in a large sample of thoracic surgeons. Methods A total of 160 thoracic surgeons responded, namely, completed our questionnaire (response rate, 53%; 160 of 302). The survey was composed of 36 questions divided into six subsections: (1) demographic characteristics of the respondents; (2) terminology and taxonomy; (3) radiologic and radiometabolic evaluation; (4) diagnostic approach and indications for surgery; (5) surgical management; and (6) radiologic surveillance. Results We observed some divergence of opinion regarding the definition of mixed GGOs, the role of 18F fluorodeoxyglucose positron emission tomography and computed tomography scans, indications for nonsurgical biopsy, intraoperative techniques for localizing GGOs, indications for surgery, extension of lung resection and lymph node dissection according to the radiologic scenario, use of intraoperative frozen section analysis, and radiologic surveillance of pure GGOs. Conclusions This topic warrants more investigation in the future. An upcoming consensus conference of Italian Society of Thoracic Surgery experts (also open to experts in other specialties) could provide updated indications for GGO management based on the literature, expert opinions, and the results of the present survey.

Primitive malignant sternal tumours are extremely rare and represent less than 1% of all chest wall tumours. A combination of radical surgery and accurate reconstruction is mandatory to ensure adequate stability and to reduce paradoxical movement. To date, this is one of the few reports on a successful sternal reconstruction using a rigid titanium mesh to restore the skeletal integrity, which was then covered by bilateral muscular flaps.

Solitary pulmonary nodules are common radiologic findings and their detection has increased due to the introduction and improvement of diagnostics. Since a nodule can be an expression of early lung cancers, a proper classification and management are required because its treatment might lead to decreased morbidity and mortality. In this regard, prominent guidelines are available although they are characterized sometimes by discordant and misleading evidences. Furthermore, the same results of studies in the literature appear conflicting. Aim of this work is to evaluate the role of imaging through an extensive literature review but focusing on 18-fluorine fluorodeoxyglucose positron emission tomography combined with computed tomography (18F-FDG-PET/CT) in order to assess the limits and future perspectives of solitary pulmonary nodule characterization in early detection of lung cancer. Key messages Detection of solitary pulmonary nodules has increased. Management of solitary pulmonary nodules is still debated. Future perspectives of early solitary pulmonary nodule characterization.

This study compares the uniportal with the 3-portal video-assisted thoracic surgery (VATS) by examining the data collected in the Italian VATS Group Database. The primary end point was early postoperative pain; secondary end points were intraoperative and postoperative complications, surgical time, number of dissected lymph nodes and length of stay.This was an observational, retrospective, cohort, multicentre study on data collected by 49 Italian thoracic units. Inclusion criteria were clinical stage I-II non-small-cell lung cancer, uniportal or 3-portal VATS lobectomy and R0 resection. Exclusion criteria were cT3 disease, previous thoracic malignancy, induction therapy, significant comorbidities and conversion to other techniques. The pain parameter was dichotomized: the numeric rating scale ≤3 described mild pain, whereas the numeric rating scale score3 described moderate/severe pain. The propensity score-adjusted generalized estimating equation was used to compare the uniportal with 3-portal lobectomy.Among 4338 patients enrolled from January 2014 to July 2017, 1980 met the inclusion criteria; 1808 patients underwent 3-portal lobectomy and 172 uniportal surgery. The adjusted generalized estimating equation regression model using the propensity score showed that over time pain decreased in both groups (P 0.001). There was a statistical difference on the second and third postoperative days; odds ratio (OR) 2.28 [95% confidence interval (CI) 1.62-3.21; P 0.001] and OR 2.58 (95% CI 1.74-3.83; P 0.001), respectively. The uniportal-VATS group had higher operative time (P 0.001), shorter chest drain permanence (P 0.001) and shorter length of stay (P 0.001).Data from the Italian VATS Group Database showed that in clinical practice uniportal lobectomy seems to entail a higher risk of moderate/severe pain on second and third postoperative days.

Video-assisted thoracic surgery (VATS) was considered the gold standard approach in recurrent spontaneous pneumothorax, with unanimous consensus of opinions. The cost-effectiveness analysis in the surgical treatment of recurrence of primary spontaneous pneumothorax (PSP) was carried out comparing VATS with muscle-sparing axillary minithoracotomy (MSAM). Between July 2006 and October 2012 we treated 56 patients with a second episode of PSP by VATS or open approach. Time of intervention, prolonged air leaks, duration of pleural drainage, length of hospitalization, and long-term morbidity were evaluated, establishing the relationship between costs and quality-adjusted life for each technique. The assessment of pain and threshold of tenderness was more favorable in VATS in respect to MSAM during the 5 years of follow-up (p = 0.004 and

As part of the third Mediterranean Symposium in Thoracic Surgical Oncology, we introduce the Italian VATS Group ( http://vatsgroup.org/sito/index.php ). This national collaborative initiative was established in 2013 and started to recruit patients in January 2014; as of July 2016, 3680 patients have been enrolled in the database. Three different video-assisted thoracic surgery approaches have been predominantly used by Italian thoracic surgery centers, 71% of them preferentially adopting a multi-portal approach, with a 20% recorded morbidity. The majority of the cases were stage I adenocarcinomas of the lung. Conversion to open surgery occurred in 9% of the cases. The study suggests video-assisted thoracic surgery lobectomy as a ‘gold standard’ for the surgical treatment of early-stage lung cancer in Italy.

Background Primary malignant tracheal tumors account for only 0.2 % of all malignancies of the respiratory tract. Tracheal chondrosarcoma is a rare condition and only 17 cases have been described in the literature from 1965 to date. Herein we report the very unusual case of a patient with a tracheal chondrosarcoma, electively treated by curative surgery despite the virtually complete obstruction of the airway. Case presentation We present the case of a 79-year old Caucasian man with long-lasting wheezing misdiagnosed as asthma and affected by a tracheal chondrosarcoma almost completely obstructing the airway. Videobronchoscopy and imaging investigations revealed a well-circumscribed mass arising from the cartilaginous rings of the cervical trachea with a posterior residual respiratory space of about 1 mm. Because of the mobility and flaccidity of the uninvolved pars membranacea, the tiny respiratory space slightly expanded during inspiration and expiration allowing the patient to be treated without an essential emergency procedure. Standard tracheal intubation was impossible. Rigid bronchoscopy enabled placement of a small tracheal tube distally to the tumor. Successful cervical tracheal resection and reconstruction was then performed, achieving complete tumor excision. Histologically, the mass was characterized as a low-grade tracheal chondrosarcoma. Videobronchoscopy performed 9 months after surgery showed a wide, well healed tracheal anastomosis. Ten months after surgery, the patient is alive and disease free. Conclusion Complete surgical resection is the treatment of choice for tracheal chondrosarcoma. Rigid bronchoscopy is an essential tool for diagnostic and therapeutic purposes. It allows the palliative maneuvers for obstruction relief but also, in resectable patients, the intraoperative safe and straightforward management of the obstructed airway. Electronic supplementary material The online version of this article (doi:10.1186/s13019-016-0498-8) contains supplementary material, which is available to authorized users.

We present a case of spontaneous rupture of the diaphragm, characterized by nonspecific symptoms. The rapid diagnosis and appropriate surgical approach led to a positive resolution of the pathology.

To compare the operative technique and complications of the Fantoni tracheostomy (TLT) with those of the Ciaglia Blue Rhino tracheostomy (CBR). We also compared the costs of mini-invasive tracheostomy with those of surgical tracheostomy (ST).Between January 1998 and January 2006, 530 patients needed emergency intubation and protracted assisted ventilation in our department. We performed 470 mini-invasive tracheostomies: as TLT in 350 and as CBR in 120. The time between intubation and tracheostomy was 4 +/- 1 days. Interventions were carried out in our intensive care unit (ICU).One hundred and nine patients died within 20 +/- 5 days of intervention, but 361 are still alive after 100 +/- 3 months. TLT and CBR complications were independent of the operative technique (P = 0.74, r = 0.285 vs P = 0.61, r = 0.271) or procedure time (P = 0.95, r = 0.297 vs P = 0.92, r = 0.295). Ciaglia Blue Rhino tracheostomy was noted to have a cost-benefit advantage over TLT and ST (P = 0.0002, P = 0.009, P = 0.22, respectively). The average time until decannulation was 20 +/- 1 days.Mini-invasive tracheostomies are easy, safe, and fast. Ciaglia Blue Rhino tracheostomy took less time to perform and had fewer complications than TLT, because the technique was simpler.

Our study shows the different therapeutic procedures in 64 patients with pleural effusion due to MRSA pneumonia. The thoracostomy tube associated with pleural washing was decisive in 10 simple effusion patients. Video-assisted thoracic surgery allowed a complete resolution of the disease in 22 complex parapneumonic effusion patients. In 20 of 32 patients with frank pus in the pleural cavity, the videothoracoscopic insufflation of carbon dioxide (CO2) before thoracotomy facilitated the dissection of the lung tissue. In 12 patients, this approach was not applied because of cardiac insufficiency. Videothoracoscopy and decortication after thoracotomy ensured the recovery of functions.

We present three patients with bronchial carcinoids, in which a more probed study emphasized the presence of three multiple endocrine neoplasia (MEN). Assessment included a total-body computerized tomography, a total-body single-photon emission computerized tomography by111In-DTPA-D-Phe1octreotide, and genetic map. Two patients presented an atypical MEN 1 and one patient showed an atypical MEN 1 with a familial medullary thyroid carcinoma. All patients were operated upon: two are still alive and one died 50 months after the first intervention. Precocious diagnosis of MEN permits a good long-term outcome.

Objective The aim of the study was to evaluate the sympathectomy procedures for primary hyperhidrosis in terms of complications and effectiveness. Methods From January 2010 to September 2012 we performed 130 sympathectomies in 65 patients, 27 males (42%) and 38 females (58%). Electrocoagulation was used in 20 procedures (15%), ultrasonic scalpel in 54 (42%), and radiofrequency dissector in 56 (43%). Seven patients (11%) underwent bilateral sympathectomy in the same surgical session, while in 58 (89%) the right surgical approach was delayed 30 days from the first procedure. Results We noticed 12 complications (9%): (a) chest pain in 6 patients (4 with electrocoagulation, 1 with ultrasonic scalpel, and 1 with radiofrequency dissector), which disappeared in 20 ± 1 day; (b) paresthesias in 3 electrocoagulation patients, was solved in 23 ± 5 days; (c) bradycardia in 1 ultrasonic patient, normalized in 4th postoperative hour; (d) unilateral relapse in 2 electrocoagulation patients after the second side approach, positively treated in 1 patient by resurgery in video-assisted thoracoscopy (VAT). The quality-adjusted life year and the quality of life evaluation revealed a statistically significant improvement (p = 0.02) in excessive sweating and general satisfaction after surgery, with Ultracision and LigaSure showing better findings than electrocoagulation. Conclusion The latest generation devices offered greater efficacy in the treatment of hyperhidrosis, minimizing complications and facilitating the resumption of normal work and social activity of patients.

AIM: To report our experience with bronchial carcinoids. METHODS: From January 1990 to March 2003 we treated 42 such patients, 30 females and 12 males. All patients underwent preoperative total body computed tomography (CT), total body In-111 octreotide scintigraphy, and SPECT of the thorax, with evaluation of serum levels of CEA, CgA, NSE, and urinary 5-HIAA. Diagnosis was obtained in 28 patients with fibre-optic bronchoscopy and in 14 patients with CT-guided trans-thoracic needle biopsy. RESULTS: There were 26 typical and 16 atypical carcinoids. 30 lobectomies, 5 bilobectomies, 6 wedge resections, and 1 pneumonectomy were carried out. The 3-year and the 5-year survival rates in the typical and atypical carcinoid groups were 100 % and 96 % vs. 81 % and 68 %, respectively (p < 0.001). CONCLUSIONS: Long-term survival is based on histological completeness of surgical treatment. Octreotide scintigraphy and SPECT document N (1) and N (2) precisely.

Objective: Advances in video-assisted thoracic surgical (VATS) technique led the authors to reconsider the treatment and thoracoscopic management of patients with giant bullous emphysema (GBE). Methods: From January 1993 to December 2001 we treated 40 patients with unilateral GBE: 24 males and 16 females, mean age 51 ^ 1 years. Thirty patients presented respiratory insufficiency, seven patients a spontaneous pneumothorax and three patients a bullae infection. Excision was performed by using Nd:YAG laser in five patients (12.5%) and stapling device in 35 patients (87.5%). Among the last 35, in 20 patients a partial pleurectomy stripping up to the 5th intercostal space was associated. In 15 patients this technique was modified through the systematic application of polytetrafluoroethylene (PTFE) to reinforce stitches. Results: We experienced one conversion to open thoracotomy owing to haemorrhaging, in one patient who underwent a partial pleurectomy stripping. In the stapler resection patients, with PTFE application, the mean duration of air leaks, for type 1 bullae of Wakabayashi was 2.2 ^ 1.8 days and, for type 4, 5.9 ^ 1.4 days; the mean length of hospital stay was 6.1 ^ 0.5 days. Conclusions: The resection in VATS of giant bullous emphysema by stapling device associated to reinforcement in PTFE reduces duration of air leaks and hospitalisation and improves pulmonary function. q 2002 Elsevier Science B.V. All rights reserved.

Background The aim of the study was to analyze the cost-effectiveness outcomes of video-assisted thoracic surgery (VATS) in the treatment of primary spontaneous pneumothorax (PSP), comparing the minimally invasive procedure with pleural drainage (PD). Methods Between July 2006 and October 2012, we treated 122 patients with a first episode of PSP by VATS (61 patients) or pleural drainage (61 patients). We established the relationship between costs and quality-adjusted life (QAL) for both techniques. Results The total cost per patient of minimally invasive procedure was more advantageous than that of chest tube (€2,422.96 vs €4,855.12). The QAL expectancy of VATS was longer than that of PD (57.00 vs 40.80 at 60 months). The QAL year of VATS (.32 at 1st year and .25 at 5th year) was better than that of PD. Incremental cost-effectiveness ratio of VATS versus PD was between €7,600.00 (1st year) and €10,045.00 (5th year), remaining well below the threshold of acceptability. Conclusion VATS as the first-line treatment for PSP allowed low morbidity, short hospitalization, and excellent quality of life.

The aim of this study was to evaluate the surgical procedures of osteosynthesis and the respective costs in isolated sternal fractures and manubriosternal dislocations.Between January 2006 and July 2011, we treated 47 patients with an isolated fracture and 18 patients with a dislocation of the sternum surgically. In case of sternal fracture, the titanium plate was used in 30 (64%), steel plate in 12 (25%), and steel wire in 5 patients (11%). The stabilization after traumatic luxation was obtained with steel wire in 4 patients (22%) and titanium plate associated with demineralized bone matrix in 14 patients (78%). The quality adjusted life years (QALYs) was analyzed, as well as the incremental cost-effectiveness ratio based on QALYs.In the sternal fractures, titanium plate showed a decreased time of intervention (30 [2] minutes), length of stay (3 [1] days), and total cost (OV0556;2,277.10) compared with steel plate (OV0556;2,667.70) and steel wire (OV0556;2,801.60) procedures, displaying an excellent difference in QALYs (0.825 and 1.615, respectively). In the sternal dislocation, steel wire technique highlighted a poor QALYs, although this approach was less expensive than titanium plate with demineralized bone matrix (OV0556;3,553.60 vs.OV0556;6,047.80). Incremental cost-effectiveness ratio revealed that the titanium plate costs wereOV0556;623.55 more than the steel wire per QALYs gained.The rigid titanium plate application ensured a safe and easy management of traumatic sternal lesions with a good prognosis of patients, justified by the improved QALYs compared with other methods.Therapeutic study, level IV; economic analysis, level IV.

OBJECTIVES: Impaired cardiopulmonary reserve is the main cause of inoperability in non-small-cell lung cancer (NSCLC). This study aims to evaluate the role of a preoperative pulmonary rehabilitation (PPR) programme in the improvement of functional parameters, which can enable an increase in the number of patients eligible for surgery. METHODS: From January 2008 to June 2011, we observed a uniform group of 27 patients with NSCLC and chronic obstructive pulmonary disease (COPD). It showed: (i) a body mass index of 21.5 ± 2 kg/m²; (ii) forced expiratory volume in 1 s (FEV1) of 1.14 ± 0.7 l; (iii) maximal peak of oxygen consumption (VO2max) of 12.9 ± 1.8 ml/kg/min; (iv) carbon monoxide diffusing capacity (DLCO) of 72 ± 3% predicted; (v) stage IB of lung cancer. All patients underwent a 4-week PPR programme, 6 days a week and were re-evaluated before inclusion for surgery. RESULTS: The rehabilitation programme was completed by all patients and extended by 2 weeks in nine patients, in order to obtain a further functional improvement. A statistically significant increase has been in the values of PaO2 (60 ± 10 vs. 82 ± 12 mmHg), of VO2max (12.9 ± 1.8 vs. 19.2 ± 2.1 ml/kg/min, P = 0.00001) and of FEV1 (1.14 ± 0.7 vs. 1.65 ± 0.8 l, P = 0.02). All patients underwent a lobectomy, with a postoperative morbidity of 15%. CONCLUSIONS: A 4 to 6-week PPR programme prepares the NSCLC and COPD patients properly for the surgical approach, reducing the functional limitations of inoperability.

Background Solitary pulmonary micronodules (SPMN) characteristically have a diameter of 0.1–0.5 cm. Objective The aim of this prospective study is to evaluate the surgical approach to SPMN in order to establish the most appropriate treatment. Methods Between January 2007 and June 2011, 146 SPMN patients (94 males and 52 females) were prospectively evaluated. Patients were divided into two groups based on history of malignancy (Group A, 59 patients) and generic risk factors for lung cancer (Group B, 87 patients). After gathering patient information, we proposed surgery or thin-section computed tomography (TSCT) follow-up to both Groups. Results Preference for surgery versus TSCT follow-up was 90% versus 10% in Group A and 78% versus 22% in Group B, respectively. In Group A, we discovered 46 metastases from previous cancer (78%), 8 primary lung cancers (14%) and 5 benign lesions (8%). In Group B, we found 5 metastases (6%), 13 non-small-cell lung cancer (15%) and 69 benign lesions (79%). Statistical analysis revealed a high positive predictive value (PPV=0.9) between total surgical patients versus TSCT follow-up patients. Conclusions The indication for surgery in solitary pulmonary micronodules is aimed at establishing early diagnosis and curing malignant disease. Our study indicates that in patients with previous cancer, surgery is essential. In patients with generic risk for lung cancer, surgical indications should be contemplated more carefully, even though the pulmonary malignancy rate of 21% in Group B seems to indicate the advisability of surgery.

OBJECTIVE: Aim of the study was to establish a noninvasive method for the preoperative characterisation of a pulmonary nodule when biopsy of the small mass is impossible. METHODS: From 1 January 2006 to 31 December 2008, we observed 124 asymptomatic patients with a noncalcified single lung nodule highlighted by computerised tomography (CT) of the thorax. Patients were divided into 2 groups: Group A consisted of 57 patients with lesion diameters between 0.5 cm and 0.99 cm; Group B consisted of 67 patients with lesion diameters between 1.0 cm and 1.5 cm. Fibreoptic bronchoscopy was negative for endobronchial neoformation in all patients. The topographic distribution of the lesions advised against CT-guided transthoracic needle biopsy or video-assisted thoracoscopy. All patients had preoperative 18-fluorine fluorodeoxyglucose ( 18 F-FDG) positron emission tomography (PET) associated with CT of the thorax, which was compared with CT for evaluation of the mass. RESULTS: Postoperative histological diagnosis revealed 54 primary lung cancers, 47 lung metastases and 23 benign lesions. In Group A the sensitivity of 18 F-FDG PET/CT and CT was 95 % and 73 % and the specificity was 72 % and 64 %, respectively ( P = 0.000001 for 18 F-FDG PET/CT; P = 0.000177 for CT). In Group B the sensitivity of 18 F-FDG PET/CT and CT was 95 % and 97 %, and the specificity was 80 % and 87 %, respectively ( P = 0.000001). CONCLUSIONS: Our study shows that 18 F-FDG PET/CT improves the identification and characterisation of potentially malignant pulmonary nodules with a diameter < 1 cm. This technique could be a valid alternative to a surgical approach, currently the main method to investigate indeterminate lung nodules.

I would like to congratulate Dr Cardillo and Dr Rena [1,2] for the valuable debate on the indications for video-assisted thoracoscopic surgery (VATS) in pleural space infection. In accordance with the authors, preoperative pulmonary function and blood gas analysis do not permit a clear evaluation of patient capacity to sustain monolateral ventilation because of the general septic condition. Thus, the possibility of carrying out a thoracoscopy is often decided in progress. We think that VATS is the main treatment in class 5 (complex complicated stage) of empyema, according to Light [3], by the debridement of the multiloculated pleural cavity. The process at class 6—7 (a simple and a complex empyema stage) required an open surgery approach as the mini-invasive procedure does not permit reaching the pleural symphysis and the cavity obliteration. Stressing VATS in the same conditions determines wide pulmonary lesions, prolonged operative time, and a high incidence of openthoracotomy wedge resections. Conversion rates of 16.4% by Cardillo et al. [1] and of 11.4% by Tong et al. [4] are not referable to an advanced state of empyema. In such cases, the use of a device may decrease the need for open thoracotomy. In selected patients with no complete fibrosis in the pleural cavity, we used carbon dioxide (CO2) insufflation during thoracoscopy [5]. This is a technique derived from laparoscopic pneumoperitoneum to facilitate the detection of a cleavage plan, which ensures pleurectomy and decortication. The eventual conversion of lateral thoracotomy was characterized by better pleural and parenchymal exposition and the easy dissection. The contraindications for such an approach are the hemodynamic instability of the patient and the wide parenchymal laceration, which increases the risk of a gas embolism. We opine that the ideal indication of videothoracoscopy is in class 1—5 for empyema. In class 6—7, VAT CO2 insufflation is effective in reducing the entity of thoracotomy conversion, postoperative air leaks, and time of hospitalization.

The aim of the study was to evaluate the double modality working of a new autofluorescence videobronchoscope SAFE-3000 for the detection and localization of precancerous and malignant lesions. From April to May 2009, 168 patients underwent SAFE-3000 bronchoscopy using 'Twin Mode' and 'Multiple Image Xposition (MIX)' technologies. The study considers only 97 patients with morphological alterations (visual score 2 or 3) of mucosa; four bronchial biopsies (two for every modality) have been performed on every patient. Histological diagnosis of the 388 biopsies revealed normal mucosa in 11 patients, four benign lesions, 27 precancerous lesions and 55 malignant lesions. The sensitivity of the 'Twin Mode' and 'MIX' techniques in the characterization of premalignant and malignant lesions was 96% vs. 100%. The specificity was 60% in both of these technologies. SAFE-3000 autofluorescence bronchoscopy allows an early diagnosis of preneoplastic or neoplastic lesions according to the careful analysis of the bronchial mucosa, due to the complementarity of two modalities 'Twin Mode' and 'MIX'. Based on the relationship between the bronchoscopic goal and the histological results the MIX method contributes more of the new endoscopic technique findings.

This study examines the role of chemoradiotherapy, surgical reconstructive techniques of the esophagus and lymphadenectomy in relation to morbidity and mortality. METHODS. From January 2005 to January 2008 we observed 18 patients with esophagus cancer. Eleven patients manifested a lesion of the middle third, 4 patients had a lesion of the upper third and 3 patients had a lesion of the lower third. Preoperative histological evaluation revealed 3 adenocarcinomas and 15 squamous carcinomas. Four patients with a lesion of the upper third received neoadjuvant chemotherapyIn 13 patients reconstruction used stomach and 5 patients underwent reconstruction with the colon. Complications ensued in 3 of the latter: dehiscence of the anastomosis, anastomotic stenosis and chylothorax. Three patients highlighted a moderate malabsorption syndrome. A T3N1M0 patient received postoperative cisplatin/5-fluorouracil and radiation therapy.The use of the stomach represents the therapeutic gold standard for minimized incidence of complications. Lymphadenectomy allows to establish a precise stage of cancer. Chemoradiotherapy is recommended in case of risk of relapse.

Traumatic sternal segments dislocation is a rare pathology that is on the increase because of road accidents. Ideal treatment is controversial as it is a benign non-life-threatening lesion. The few cases reported in the literature do not shed light on any preferred procedure. In the present study, three patients were treated by surgical steel monofilament and eight by titanium screws and plates and demineralized bone matrix. The reduced hospitalization, rapid functional recovery, and excellent aesthetic results of the titanium patients make use of the surgical approach inevitable.

Objective To examine the diagnostic and therapeutic role of fiber-optic and rigid bronchoscopy in pediatric patients with foreign body inhalations. Methods From January 1986 to December 2004, we observed 128 young patients with suspicion of foreign body aspiration. Patients were divided into 3 groups: group I, patients with negative chest X-ray; group II, patients with radiological direct signs; group III, patients with radiological indirect signs. Results Removal of the foreign body was effected in 105 patients by rigid bronchoscopy and in 13 patients by fiber-optic bronchoscopy. In 3 group II patients a thoracotomy with a bronchotomy was necessary. Conclusions Fiber-optic bronchoscopy showed a diagnostic accuracy rate of 100 % but played a poor therapeutic role with a case resolution of 10.7 %. Rigid bronchoscopy was the main technique, permitting the removal of the tracheobronchial foreign body in 97.2 % of patients.

The aim of our study is to evaluate the relationship between diet and cancer development. It has been estimated that 30-40% of all kinds of cancer can be prevented with a healthy lifestyle and dietary measures. A low use of fibres, the intake of red meat and an imbalance of Omega-3 and Omega-6 fats may contribute to increase the risk of cancer. On the other hand, the assumption of lots of fruit and vegetables may lower the risk of cancer. Protective elements in a cancer-preventive diet include selenium, folic acid, vitamin B12, vitamin D, chlorophyll and antioxidants such as carotenoids (alpha-carotene, beta-carotene, lycopene, lutein, cryptoxanthin). Ascorbic acid has limited benefits if taken orally, but it effective through intravenous injection. A supplementary use of oral digestive enzymes and probiotics is also an anticancer dietary measure. A diet drawn up according to the proposed guidelines could decrease the incidence of breast, colon-rectal, prostate and bronchogenic cancer.

Objective The diagnostic procedures, role of surgery and multimodal treatment for osteosarcoma pulmonary metastases are examined. Methods From January 2000 to June 2005, we observed 35 patients with osteogenic repetitions. Patients were studied by total-body computerised tomography (CT) and by thoracic single-photon emission computerised tomography (SPECT). Preoperative histological diagnosis was obtained by CT-guided transthoracic needle biopsy (23 cases) and fibre-optic bronchoscopy (12 cases). Results Four lower, 6 upper and 2 middle lobectomies were carried out using a thoracotomy approach. Video-assisted thoracoscopy was used in the other 23 patients who underwent 36 wedge resections. CT showed a sensitivity of 86 % and a specificity of 66 %; SPECT had a sensitivity of 80 % and a specificity of 100 %. Twenty-five patients are still living 25 +/- 11 months after the intervention. Conclusions SPECT was demonstrated to offer a better result in the individualisation of secondary pulmonary nodules after primary osteosarcoma. The excision of all resectable lung metastases, integrated in a multidisciplinary strategy, offers good results in terms of survival.

The aim of this study was to evaluate the diagnostic role and therapeutic effectiveness of videothoracoscopy in chest trauma. Between 1st January 1993 and 30th September 2003, 112 traumatized patients underwent a videothoracoscopy. The origin of trauma was different: 60 road accidents, 42 accidental falls, 7 knife wounds and 3 firearm wounds. Seventy-six patients presented hemothorax, 21 hemopneumothorax, 10 suspected diaphragmatic injury and 5 pericardium effusion. All patients were hemodynamically stable and conscious. In suspected diaphragmatic rupture patients, videothoracoscopy confirmed the presence of 4 lesions with diameter from 7 to 10cm. The etiopathogenetic causes in the other clinical patterns were: 20 lung lacerations, 17 apical adhesion lacerations, 11 diaphragmatic lesions, 16 wall bleedings and 38 vessel lesions. Ninety patients (80.3%) were treated with video assisted thoracic surgery. The remaining procedures were : 17 drainage tube insertions, 4 thoracotomies and 1 laparotomy. Videothoracoscopy made the use of the primary intention drainage tube obsolete in stable traumatized patients with hemothorax or hemopneumothorax. It is a safe technique that allows the diagnostic and surgical management of the lesions.

The authors present a case of a patient with double metastatic abdominal and thoracic localization coming from breast cancer. Peculiarity of this case concerns both the considerable size of metastatic abdominal mass (11 centimetres of the major axis for a weight of almost half a kilogram) and the swift development of the relapses at distance, even in the presence of an original tumour at first stage. Both abdominal surgical operation of the removal of the mass and diagnostic video assisted thoracoscopy (VAT) are described.

Objective: The fundamental role of video-assisted thoracic surgery (VATS) in the treatment of spontaneous pneumothorax is generally acknowledged today. This study intends to evaluate whether VATS is justified at the onset of a first spontaneous pneumothorax through analysis of parameters tested on two group of patients treated respectively with pleural drainage and VATS. Patients/methods: The study includes 70 patients affected by first spontaneous pneumothorax divided into two groups of 35 patients for the purpose of therapeutic treatment. The first group underwent pleural drainage while the second underwent VATS. Parameters analyzed were as follows: (1) prolonged air leaks (more than 6 days); (2) time required for pleural drainage; (3) time of hospital stay; (4) management costs; (5) recurrences (follow-up at 12 months). Results: Prolonged air leaks occurred in four patients (11.4%) in the first group and two patients (5.7%) in the second; recurrences occurred in eight patients in the first group (22.8%), and only one in the second group (2.8%). Mean time for drainage and hospitalization was, respectively, 9 and 12 days in patients with pleural drainage against 3.9 and 6 days of those using VATS. Average management costs per patients including hospitalization was calculated at $2,750.00 per patient for the first group compared with $1,925.00 for the second group. Conclusions: The use of VATS at first spontaneous pneumothorax is justified in the interest of both patients and health administrations as demonstrated by the number of recurrences in patients in the first group and economy savings resulting from use of VATS. q 2001 Elsevier Science B.V. All rights reserved.

We report 5 cases of Boerhaave's syndrome with necrotizing mediastinitis and pleural empyema. We chose a surgical treatment characterized by manual suture and heterologous tissue to repair esophagus rupture. This option allows a better result in terms of morbidity and mortality.

Objecti6e: In several previous studies, including one of our own, CT and MRI provided similar information on N2 detection in the staging of lung cancer. Both imaging techniques can be considered effective in detecting enlarged mediastinal lymph nodes but the results are often inaccurate when confronted with pathological findings. The purpose of this study was to assess the diagnostic accuracy of gadolinium‐DTPA enhanced MRI in the detection of mediastinal lymph nodes in lung cancer. Methods: A prospective study to compare standard unenhanced MRI and Gd‐DTPA enhanced MRI was carried out in patients with diagnosed lung cancer. The study focused on the status of mediastinal lymph nodes. Gd‐DTPA was administered at a dosage of 0.2 mmol:kg before T1 weighted sequences. Qualitative visual analyses of both standard and contrast enhanced MRI images were performed on each patient by 2 independent radiologists. The imaging results were then compared to pathological findings obtained after surgical operation. Results: In the identification of mediastinal lymph node metastases standard MRI was 62% sensitive, 100% specific and 74% accurate whereas Gd‐DTPA enhanced MRI was 100% sensitive, 91% specific and 97% accurate. Conclusions: Gd‐DTPA enhanced MRI was more accurate than standard MRI in the detection of metastatic lymph nodes in patients with lung cancer. These initial results can be considered encouraging especially with regards to the reduction of false negative findings although further confirmation is, understandably, required. © 1997 Elsevier Science B.V.

OBJECTIVE: Video-assisted thoracoscopic surgery (VATS) represents at present the most suitable treatment of recurrent spontaneous pneumothorax. After three years we consider this interesting to draw up a trial balance of our VATS experience in comparison with the cases treated before 1991 with the classic thoracotomic approach. METHODS: We have considered retrospectively the results obtained in a series of 30 consecutive patients with recurrent spontaneous pneumothorax treated with VATS between November 1991 and August 1994 in comparison with those obtained in a group of 30 patients previously treated with a traditional thoracotomy. The groups have been selected in such a way that surgical indications, sex ratio, age and number of episodes were homogeneous. The parameters we have compared were the postoperative complications, the duration of chest drainage and hospitalization, the operating times and the relapses. Besides these technical parameters we considered the economic data too. RESULTS: On average drains removal occurred one day before in VATS-Group: the time spent in the Hospital was significantly shorter in VATS-Group, being on average 1 week. Short term complications may be considered similar in the two Groups. Prolonged air leaks occurred in 13% and 16% respectively. Emothorax requesting reoperation occurred in 1 case for each Group. One death occurred in thoracotomy-Group in an old patient presenting a severe chronic respiratory insufficience with exacerbation in postoperative time. We have registered 2 relapses after VATS and none after thoracotomy. CONCLUSIONS: The study has demonstrated the therapeutic efficacy of VATS and in the same time that in VATS the total economic cost is lower (22.7%) in comparison with traditional thoracotomy.