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The aim of the study is to evaluate clinical applications, safety, and effectiveness of a porcine-derived acellular cross-linked dermal matrix biological mesh in chest wall reconstruction.We retrospectively analyzed a prospective multicenter database of chest wall reconstructions using a biological mesh in adult patients undergoing operation between October 2013 and December 2020. We evaluated preoperative data, type of resection and reconstruction, hospitalization, 30-day morbidity and mortality, and overall survival.A total of 105 patients (36 women [34.2%]; mean age, 57.0 ± 16.1 years; range, 18-90 years) were included, they have admitted for: primary chest wall tumor (n = 52; 49.5%), secondary chest wall tumor (n = 29; 27.6%), lung hernia (n = 12; 11.4%), trauma (n = 10; 9.6%), and infections (n = 2; 1.9%). The surgical sites were preoperatively defined as at high risk of infection in 28 patients (26.7%) or as infected in 16 (15.2%) patients. Thirty-days morbidity was 30.5% (n = 32 patients); 14 patients (13.3%) had postoperative complications directly related to chest wall surgical resection and/or reconstruction. We experienced no 30-day mortality; 1-year and 2-year mortality was 8.4% and 16.8%, respectively.Biological mesh represents a valuable option in chest wall reconstruction even when surgical sites are infected or at high-risk of infections. This mesh shows low early and late postoperative complication rates and excellent long-term stability.

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Stage Ia presents an optimal survival rate after surgical resection, but the type of lymphadenectomy to use in these patients is still debated. The aim of this study is evaluate if one type of lymphadenectomy adopted influences survival in patients who underwent VATS lobectomy for stage Ia NSCLC.Clinical and pathological data from pIa patients in the prospective VATS Italian nationwide registry were reviewed and analysed. Patients and tumour characteristics,type of lymphadenectomy (sampling or radical nodal dissection,MRLD), were collected and correlated to Overall Survival(OS) and Disease free Survival(DFS). The Kaplan-Meier product-limit method was used to estimate OS and DFS and the log-rank test was adopted to evaluate the differences between groups. A propensity match was performed to reduce bias due to the retrospective study design.The final analysis was conducted on 2039 patients, 179 died during follow-up,recurrence rate was 13%. MRLD was performed in 1287(63.1%)patients. The univariable analysis identified as favourable prognostic factors for OS the female sex(p = 0.023), low ECOG-score(0.008),low SUVmax(p 0.001), GGO appearance(p 0.001), pT 2 cm(p = 0.002) and low tumour grading(p = 0.002). The multivariable analysis confirmed as independent prognostic factors low ECOG-score(p = 0.012), low SUVmax(p 0.001) and low tumour grading(p 0.001). Analysing survival in patients with solid/sub-solid nodules and after propensity score matching for pTdimension and number of N2 resected lymphnodes, no OS differences were present comparing sampling vs MRLD.Survival in pIa patients seems to be determined by patient and tumour characteristics such as performance status,grading and SUVmax. Type of lymphadnectomy did not seem to be correlated with OS in these patients.

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.

The aim of this study was to assess the impact of BMI on perioperative outcomes in patients undergoing VATS lobectomy or segmentectomy. Data from 5088 patients undergoing VATS lobectomy or segmentectomy, included in the VATS Group Italian Registry, were collected. BMI (kg/m

OBJECTIVES: Although unexpected conversion during Video-Assisted Thoracic Surgery (VATS) lobectomy is up to 23%, the effects on postoperative outcomes remain debatable. This retrospective study aimed: (i) to identify potential preoperative risk factors of VATS conversion to standard thoracotomy; (ii) to assess the impact of surgical experience in VATS lobectomy on conversion rate and patient health-related quality of life. METHODS: We extracted detailed information on VATS lobectomy procedures performed consecutively (2014-2019). Predictors of conversion were assessed with univariable and multivariable logistic regressions. To assess the impact of VATS lobectomy experience, observations were divided according to surgeons' experiences with VATS lobectomy. The impact of VATS lobectomy experience on conversion and occurrence of postoperative complications was evaluated using logistic regressions. The impact of VATS lobectomy experience on EuroQoL-5D (EQ-5D) scores at discharge was assessed using Tobit regressions. RESULTS: A total of 11,772 patients underwent planned VATS for non-small-cell lung cancer (NSCLC), with 1074 (9.1%) requiring conversion to thoracotomy. The independent predictors at multivariable analysis were: FEV1% (OR = 0.99; 95% CI: 0.98-0.99, p = 0.007), clinical nodal involvement (OR = 1.43; 95% CI: 1.08-1.90, p = 0.014). Experienced surgeons performed 4079 (34.7%) interventions. Experience in VATS lobectomy did not show a relevant impact on the risk of open surgery conversion (p = 0.13) and postoperative complications (p = 0.10), whereas it showed a significant positive impact (p = 0.012) on EQ-5D scores at discharge. CONCLUSIONS: Clinical nodal involvement was confirmed as the most critical predictor of conversion. Greater experience in VATS lobectomy did not decrease conversion rate and postoperative complications but was positively associated with postoperative patient quality of life. ispartof: CANCERS vol:15 issue:2 ispartof: location:Switzerland status: published

Objective. There are limited data for estimating the risk of early discharge following thoracoscopic lobectomy. The objective was to identify the factors associated with a short length of stay and verify the influence of these variables in uncomplicated patients. Methods. We reviewed all lobectomies reported to the Italian VATS Group between January 2014 and January 2020. Patients and perioperative characteristics were divided into two subgroups based on whether or not they met the target duration of stay (≤ or >4 days). The association between preoperative and intraoperative variables and postoperative length of stay (LOS) ≤4 days was assessed using a stepwise multivariable logistic regression analysis to identify factors independently associated with LOS and factors related to LOS in uncomplicated cases. Results. Among 10,240 cases who underwent thoracoscopic lobectomy, 37.6% had a hospital stay ≤4 days. Variables associated with LOS included age, hospital surgical volume, Diffusion Lung CO % (81 [69–94] vs. 85 [73–98]), Forced Expiratory Volume (FEV1) % (92 [79–106] vs. 96 [82–109]), operative time (180 [141–230] vs. 160 [125–195]), uniportal approach (571 [9%] vs. 713 [18.5%]), bioenergy sealer use, and pain control through intercostal block or opioids (p < 0.001). Except for FEV1 and blood loss, all other factors emerged significantly associated with LOS when the analysis was limited to uncomplicated patients. Conclusions. Demographic, clinical, and surgical variables are associated with early discharge after thoracoscopic lobectomy. This study indicates that these characteristics are associated with early discharge. This result can be used in association with clinical judgment to identify appropriate patients for fast-track protocols.

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.

Sternal resection and anterior chest wall reconstruction techniques for malignant processes are not always standardized. We report an innovative method of sternal osteosynthesis in two patients, 65-year-old and 41-year-old women, with Ewing's sarcoma, and infiltrating thymoma, respectively. The first case manifested itself as a voluminous palpable mass while the second case was characterized for a paramediastinal mass widely extended to the anterior chest wall. Reconstruction with titanium mesh allowed the quick restoration of parietal stability, facilitating respiratory dynamic and recovery of patients.

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.

Background: In previous multicentre studies, the longest survival was observed in synchronous lung oligometastatic patients without pN2 disease. This paper aimed to identify preoperative favourable prognostic factors and propose a preoperative classification for categorising the synchronous oligometastatic non-small cell lung cancer (NSCLC). Methods: A retrospective review of prospectively collected patients was performed. The inclusion criteria were: synchronous oligometastatic NSCLC (≤5 extrapulmonary metastases), radical surgical treatment of the primary tumour and all metastatic sites (2005–2018). Exclusion criteria were: palliative surgery, recurrent lung cancer, low-performance status, follow-up information unavailable. The reverse Kaplan – Meier method estimated median overall survival (OS) and progression-free survival. A stratified backward stepwise Cox regression model was employed for multivariable survival analyses. A prognostic grouping considering all the relevant prognostic factors simultaneously was constructed, and a Receiver Operating Characteristic (ROC) curve was generated. Hosmer-Lemeshow χ statistics was used for measuring OS calibration within groups. Findings: 281 patients were included. Data from the Cox regression model were used to construct a prognostic risk classification. Four parameters (age ≤65 years, site of metastasis, clinical nodal status, and induction treatment) were used to build a risk classification. Group A: no risk factors (age ≤65 years, lung/brain metastasis, cN0, induction treatment); Group B: one risk factor (age >65 years or no lung/brain metastasis or cN1–2 or no induction treatment); Group C: two risk factors; Group D: ≥3 risk factors. The Area Under the Curve (AUC) was 0.56 (95% CI: 0.49–0.62), Hosmer-Lemeshow χ statistics was 21.3 (3 degrees of freedom, p=0.0042). Interpretations: Patient selection is critical in identifying the proper subsets of oligometastatic NSCLC. After clinical validation, this preoperative risk classification might support decision-making during the multidisciplinary team assessment and patient selection for enrolment in future randomised trials. Funding: This work was partially supported by the Italian Ministry of Health with Ricerca Corrente and 5 x 1000 funds. Declaration of Interest: All authors have no conflict of interest to declare. Ethical Approval: This research was carried out following the Helsinki Declaration 10. The Ethical Committee authorised the study (785/19).

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.

Surgery is the gold standard treatment of lung cancer. The minimally invasive technique does not only concern access to the chest but also the limits of parenchymal resection. The study debates on the safety and oncological adequacy of sublobar resections in bronchogenic carcinoma patients. A systematic analysis of the data in the literature was carried out, comparing the outcomes of patients with resectable non-small lung cancer (NSCLC) who underwent lobectomy or sublobar resection. These last interventions include both segmentectomies and wedge resections taking into consideration the following parameters: complications, relapse rate and overall survival. The complication rate is higher in patients underwent lobectomy compared to sublobar resection, especially in presence of high comorbidity index or octogenarian patients (overall values respectively between 0 and 48% and 0 and 46.6%). Contrarily, the relapse rate (6.2% to 32% vs. 3.6% to 53.4%) and overall survival (50.2% to 93.8% vs. 38.6% to 100%) are more favorable in patients undergoing lobectomy. Sublobar resections are particularly indicated in elderly patients and in patients with high comorbidity index or reduced respiratory functional reserve. However, pulmonary lobectomy still remains the safest and oncologically correct method in patients with good performance status or higher risk of recurrence.

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].

Parenchymal-sparing resections for the treatment of Non-Small Cell Lung Cancer (NSCLC) still arise both technical and oncological issues. However, from some historical landmarking reports several evidences have moved towards their safety and feasibility for high-selected early stage NSCLC patients. In this view, the concept of compromise strategies has been overcome by intentional purposes. Anyway, results are sometimes conflicting or affected by not negligible bias with subsequent low evidences though interest has grown towards non anatomic resections as a consequence of the definitive downset of the “pneumonectomy” era.

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.

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.

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 for use with patients undergoing open colorectal surgery. Since that time, the concept of ERAS has spread to multiple surgical specialties. This article explores the key elements for patient care using an ERAS protocol applied to minimally invasive thoracic surgery.

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