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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.

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Background: We analyzed our experience in sternal resections (SRs) for primary or secondary neoplasm focusing on technical aspects of reconstruction, post-operative outcomes and long term survival. Methods: From January 2005 to December 2015, 36 patients (24 males, 67%) underwent surgical excision of primary (chondrosarcoma n=18 patients, 50%; osteosarcoma n=2, 6%; Ewing sarcoma n=1, 3%; other n=2, 6%) or secondary (breast cancer n=7, 19%; kidney carcinoma n=2, 6%) sternal tumour. We performed n=30 partial sternectomy and n=6 total sternectomy with en-bloc resection of the sternocostal cartilages in all patient and extended resection in 7 patients. Stability was obtained with prosthetic material, rigid and non-rigid and a muscular flap: rigid material [Strasbourg Thoracic Osteosynthesis System (STRATOS), MedXpert GmbH] and muscle flap n=11 (30.6%); polytetrafluoroethylene patch and muscle flap n=6 (16.7%); muscle flap alone n=19 (52.8%). Results:The 30-day mortality rate was 0, overall complication rate was 19%. The median ICU stay was 1.5 days and mean hospital stay was 10.6±5.9 days. We obtained a complete (R0) resection in all patients. Overall survival (OS) at 5 and 10 years were 59% and 40%; in the group of primary neoplasm OS rate at 5 and 10 years was 79% and 54%. Disease free survival (DFS) rate at 5 years was 61%. Higher grading was identified as negative prognostic factor.Conclusions: Wide radical resections of anterior chest wall are basilar in a multimodality treatment for primary or metastatic neoplasm of the sternum. Stabilization with titanium bars and clips provides rigidity of chest wall with good functional results.

Uniportal thoracoscopic decortication for pleural empyema is a safe and effective approach for selected patients based on a combination of clinical and imaging staging. US patterns well corresponded with intraoperative pleural findings and showed a prognostic value.

BackgroundThe development of a video assisted thoracic surgery lobectomy (VATS-L) program provides a dedicated surgical team with a recognized learning curve (LC) of 50 procedures. We analyse the results of our program, comparing the LC with subsequent cases.MethodsFrom June 2012 to March 2015, we performed n = 146 VATS major pulmonary resections: n = 50 (Group A: LC); n = 96 (Group B). Pre-operative mediastinal staging followed the National Comprehensive Cancer Network guidelines. All procedures were performed using a standard anterior approach to the hilum; lymphadenectomy followed the NCCN recommendations. During the LC, VATS-L indication was reserved to clinical stages I, therefore evaluated case by case.ResultsMean operative time was 191 min (120-290) in Group A and 162 min (85-360) in Group B (p <0,01). Pathological T status was similar between two Groups. Lymphadenectomy included a mean of 5.8 stations in Group A and 6.6 in Group B resulting in: pN0 disease: Group A n = 44 (88 %), Group B n = 80 (83.4 %); pN1: Group A n = 3 (6 %), Group B n = 8 (8.3 %); pN2: Group A n = 3 (6 %), Group B n = 8 (8.3 %). Conversion rate was: 8 % in group A (n = 4 vascular injuries); 1.1 % in Group B (n = 1 hilar lymph node disease). We registered n = 6 (12 %) complications in Group A, n = 10 (10.6 %) in Group B. One case (1.1 %) of late post-operative mortality (90 days) was registered in Group B for liver failure. Mean hospital stay was 6.5 days in Group A and 5.9 days in Group B.ConclusionsWe confirm the effectiveness of a VATS-L program with a learning curve of 50 cases performed by a dedicated surgical team. Besides the LC, conversion rate falls down, lymphadenectomy become more efficient, indications can be extended to upper stages.

Patients affected by an invasive ADC with at least another GGO nodule enjoy good OS and DFS with a surgical reiterative approach. Part-solid GGO is associated with GGO progression requiring treatment, but OS is not influenced by the new onset or evolution of GGOs. DFS is affected by the stage of the MC which dictates the treatment strategy.

Backgrounds:The aim of this study was to report our Institutional experience with extended sleeve lobectomy (ESL) in centrally located non-small cell lung cancer (NSCLC), focusing on technical details, post-operative results, recurrence and survival, to determine whether ESL can be accepted as a favorable alternative procedure to pneumonectomy (PN). Methods: Twenty-two consecutive patients undergoing ESL for centrally located tumors from January 2014 to June 2019 were prospectively enrolled. Results: Six (27.3%) patients had been preoperatively considered unfit for PN. Neo-adjuvant chemotherapy was administered in 7 (31.8%) out of the 10 patients that showed a cN2 disease. According to Okada classification, 8 cases of type A ESL (resection of right upper plus middle lobe ± segment 6), one case of type B (resection of left upper lobe + segment 6) and 13 cases of type C (resection of left lower lobe + lingulectomy) ESL were performed. Concomitant pulmonary angioplasty was done in 7 (31.8%) patients. Complete resection was achieved in all patients. There was no postoperative mortality. Major postoperative complications developed in 2 (9.1%) patients (one small anastomotic dehiscence healed in few weeks, one pulmonary embolism). Complete long-term patency of the reconstructed airway was documented in all patients by fiberoptic bronchoscopy. At the median follow-up of 21 months (4-57 months), the recurrence rate was 54.5%, with 4 (18.2%) patients developing a loco-regional recurrence but no endobronchial or perianastomotic recurrence occurred. The overall 3-year survival rate was 45% with a median survival of 33 months. Conclusions: ESL is a safe and effective procedure that should be considered a favorable alternative to PN whenever it may guarantee a complete resection.