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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.

Surgery in COVID‐19 disease complicated by APF represents the last life‐saving treatment option. The choice of the therapeutic period to indicate this approach is fundamental. In fact, the clinical stability of patient is necessary in order to allow single‐lung ventilation and to minimize postoperative sequelae.

Background The usefulness of digital chest drain is still debated. We are carrying out a study to determine if the use of a digital system compared with a traditional system reduces the duration of chest drainage. To evaluate safety, benefit, or futility of this trial we planned the current interim analysis. Methods An interim analysis on preliminary data from ongoing investigator-initiated, multicenter, interventional, prospective randomized trial. Original protocol number: (NCT03536130). The interim main endpoint was overall complications; secondary endpoints were the concordance between the two primary endpoints of the RCT (chest tube duration and length of hospital stay). We planned the interim analysis when half of the patients have been randomised and completed the study. Data were described using mean and standard deviation or absolute frequencies and percentage. T-test for unpaired samples, Chi-square test, Poisson regression and absolute standardized mean difference (ASMD) were used. P-value Results From April 2017 to November 2018, out of 317 patients enrolled by 3 centers, 231 fulfilled inclusion criteria and were randomized. Twenty-two of them dropped out after randomization. Finally, 209 patients were analyzed: among them 94 used the digital device and 115 the traditional one. The overall postoperative complications were 35 (16.8%) including prolonged air leak (1.9%). Mean chest tube duration was 3.6 days (SD = 1.8), with no differences between two groups (p = 0.203). The overall difference between hospital stay and chest tube duration was 1.4 days (SD = 1.4). Air leak at first postoperative day detected by digital and traditional devices predicted increasing in tube duration of 1.6 day (CI 95% 0.8–2.5, p p Conclusions This interim analysis supported the authors’ will to continue with the enrollment and to analyze data once the estimated sample size will be reached. Trial registration Trial registration number NCT03536130, Registered 24 May 2018 - Retrospectively registered.

Background The usefulness of digital chest drain is still discussed. We are carrying out a study to determine if the use of a digital system compared with a traditional system reduces the duration of chest drainage. To evaluate safety, benefit, or futility of this trial we planned the current interim analysis. Methods An interim analysis on preliminary data from ongoing investigator-initiated, multicenter, interventional, prospective randomized trial. Original protocol number: (NCT03536130). The interim main endpoint was overall complications; secondary endpoints were the concordance between the two primary endpoints of the RCT (chest tube duration and length of hospital stay). We planned the interim analysis when half of the patients have been randomised and completed the study. Data were described using mean and standard deviation or absolute frequencies and percentage. T-test for unpaired samples, Chi-square test, Poisson regression and absolute standardized mean difference (ASMD) were used. P-value

Background: In patients submitted to major pulmonary resection, post-operative length of stay is mainly influenced by duration of air leaks and chest tube removal. The measurement of air leaks largely relies on traditional chest drainage systems which are prone to subjective interpretation. Difficulty in differentiating between active air leaks and bubbles due to a pleural space effect may also lead to tentative drain clamping and prolonged time for chest drain removal. New digital systems allow continuous monitoring of air leaks, identifying subtle leakage that may be not visible during daily patient evaluation. Moreover, an objective assessment of air leaks may lead to a reduced interobserver variability and to an optimized timing of chest tube removal. Methods: This study is a prospective randomized, interventional, multicenter trial designed to compare the electronic chest drainage system (Drentech™ Palm Evo) with the traditional one (Drentech™ Compact) in a cohort of patients undergoing pulmonary lobectomy through a standard 3-ports VATS approach both for benign or malignant disease. It will enroll 382 patients in 3 Italian centers. Duration of chest drainage and length of hospital stay will be evaluated in the two groups. Moreover, it will be evaluated if the use of a digital chest system compared with a traditional system reduces theinterobserver variability. Finally, it will be evaluated if the digital drain system may help in distinguishing an active air leak from a pleural space effect, by the digital assessment of intrapleural differential pressure, and in identifying potential predictors of prolonged air leaks. Discussion : To date, few studies have been performed to evaluate clinical impact of digital drainage systems. The proposed prospective randomized trial will provide new knowledge to this research area by investigating and comparing the difference between digital and traditional chest drain systems. In particular, the objectives of this project are to evaluate the feasibility and usefulness of digital chest drainages and to provide new tools to identify patients at higher risk of developing prolonged air leaks.

In 2012, open procedures represented 63% of the total number of lobectomies performed in our unit; in 2015, video-assisted thoracoscopic surgery (VATS) lobectomy numbers increased up to 66% of the total number of lobectomies performed. When carrying out the procedures, we followed the guidelines presented by the International VATS Lobectomy Consensus Group regarding indications, contraindications, preoperative investigations and conversions. In view of 280 VATS major lung resections from May 2012 to May 2016, we describe some tips and tricks that can be useful in this surgical technique, from general principles to single operative procedures.

Thoracoscopic surgical techniques have numerous advantages compared to open techniques such as decreasing hospital stay, analgesic requirements and postoperative pain. Since the first video-assisted thoracoscopic surgery (VATS) lobectomy performed 20 years ago this procedure, associated with mediastinal lymph node dissection, has been widely accepted as a standard surgical treatment for early stage non-small cell lung cancer. Traditionally the videoscopic approach is based on the three- or four-port approach but more than 50% of the patients developed post-operative chest wall paraesthesia due to nerve injury. In order to avoid this postoperative complication traditional VATS approach has been modified by using few and smaller working ports developing the so called two-portal VATS. The purpose of this study is to establish the advantages of biportal VATS reviewing a series of 400 consecutive cases of VATS lobectomy performed from May 2012 to December 2017, using progressively less ports (4-3-2 ports), at our Institution. There were 42 patients in four-port, 56 patients in three-port and 302 patients in two-port group. A propensity-score analysis showed that, as compared with two- and three-port group, patients in the four-port group had increased duration of chest tube (respectively difference and 95% CI are 1.493, 0.965; 2.053 and 1.246, 0.472; 2.002), increased postoperative length of stay (respectively difference and 95% CI are 2.564, 1.336; 3.952 and 2.205, 0.672; 3.740), increased postoperative pain only in comparison with two-ports (difference and 95% CI in VAS score 1.482, 0.909; 2.055). There were no significant differences in terms of demographic characteristics, histology, type of intervention, number of complications, operative time, number of lymph nodes retrieved and pStage between the three groups.

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.

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.

Extrapleural solitary fibrous tumors are very rare and occasionally they appear in extraserosal soft tissues or parenchymatous organs. In such cases the right preoperative diagnosis is often difficult and challenging, because both radiological and cytological examinations are not exhaustive. For these reasons, surgical excision is frequently the only way to reach the correct diagnosis and to achieve definitive treatment. A few cases of solitary fibrous tumors have been also described in the breast. Although rare, this lesion opens difficulties in preoperative diagnosis entering in differential diagnosis with other benign lesions as well as with breast cancer. In this article we describe a case of a solitary fibrous tumor of the breast in a 49-year-old man. Problems related to differential diagnosis and the possible pitfalls that can be encountered in the diagnostic iter of such rare tumor are discussed.