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post-operative day 9. Pathological study confirmed the diagnosis of adenocarcinoma (T2N1M0-Stage IIB) and he underwent adjuvant chemotherapy. At the time of present paper, patient is alive and well without signs of recurrence or metastasis. Our minimally approach compared to standard open procedure would help reduce post-operative pain and favours early return to normal activity. However, future experiences with a control group are required before our strategy can be widely used.

Objective: There are several airway devices available for difficult tracheal intubation (DTI) management, but the failure rate remains high. The use of laryngoscopy to facilitate the fibreoptic-bronchoscope intubation (CLBI) has been increasingly reported in DTI situations, but it has not been formally studied yet. Methods:We designed a single-centre simulation study on DTI (neck rigidity and tongue oedema) comparing three techniques: direct laryngoscopy (DL), video-laryngoscopy (VLS) and CLBI. Eighteen anaesthesiologists naïve to VLS/CLBI approaches, participated in the study. The primary outcome was the intubation rate at the first attempt. Secondary outcomes were an overall time-to-intubate (TTI) and time-to-ventilate (TTV), success at the second and third attempt and ease of intubation as evaluated by a subjective 5-point Likert scale. Results:The CLBI technique had a higher success rate at the first attempt than DL (66% vs 22%, p=0.007), while VLS did not (44%, p=0.16). A trend towards higher success at the third attempt was found for both VLS and CLBI vs DL (p=0.07 and p=0.06, respectively). The VLS had a shorter overall TTV than DL (88±60 vs 121±59 sec, respectively, p=0.04) and a trend towards a shorter TTI (81±61 vs 116±64 sec, respectively, p=0.06). The CLBI approach showed a non-significantly lower TTI/TTV as compared to DL (p=0.10 and p=0.16, respectively). Anaesthesiologists judged that the intubation with VLS (3.7±1.0) and CLBI (3.8±1.0) was easier than with DL (1.7±0.8, both p<0.001). Conclusion:In a simulated DTI scenario, CLBI had a higher success rate at the first attempt than DL, while VLS did not. By the third attempt, both rescue techniques had a trend towards a higher success rate than DL. The CLBI technique seems a promising alternative for the management of DTI.

by incising the scar tissue. Meanwhile, considering the circumstantial possibility of block of the upper end of the MT, the anaesthesia circuit (circle system) was connected to the anterior limb of MT using an appropriate size TT connecter. This enabled us to ventilate the child without any leak from the upper end of the MT. The pulse oximeter saturation picked up (on 100% oxygen) and a visible chest rise could be appreciated (although the chest compliance seemed poor on bag ventilation). After ventilation for a few minutes, the haemodynamics became stable and ventilation was continued from the external limb without any detectable oral leak. An endoscopic assessment of the upper airway revealed mucosal overgrowth completely obstructing the top lumen of the MT (Fig. 1). The MT was removed and replaced with the flexometallic TT inserted through the orifice initially accommodating the external limb of the MT. An intraoperative fluoroscopic chest assessment to evaluate the possible cause of decreased compliance showed bilateral lung lower zone loculated pneumothorax.The airway was finally secured using a tracheostomy tube and on consultation with a chest physician, a computed tomography (CT)-guided chest tube/pigtail catheter insertion was planned subsequently.The present case illustrates that an apparently normal functioning MT after operation could lead to a potentially lifethreatening hazard. The child had no predictors suggestive of difficult mask ventilation and had no respiratory obstruction after operation. The possibility of occlusion of the upper end of the MT could only be considered when bag-mask ventilation completely failed. Such a complication with an MT has not previously been reported. As a remedy to prevent such accidents, we suggest that during preoperative evaluation, the anterior limb of the MT should be occluded and ensured that the child continues to breathe normally without developing signs of respiratory distress/airway obstruction. In situations like the present case where tissue overgrows the upper end of the MT, occlusion of the anterior limb shall block the only patent airway path, thus presenting with signs of distress. Moreover, this will not only detect complete occlusion but can also predict a partial occlusion significant enough to cause intraoperative ventilatory difficulties.

Open surgery remains the standard strategy for management of esophageal diverticulum in symptomatic patients. However, in the last years an increasing number of minimally invasive approaches have been proposed for this issue in order to reduce the surgical trauma and favor a fast return to daily activity. Herein, we describe a novel technique as uniportal video-assisted thoracoscopic surgery (VATS) for performing resection of esophageal diverticulum. This procedure was successfully carried out in three consecutive patients with giant mid-esophageal diverticulum (mean size: 6.5±0.5 cm). The mean post-operative time was 121±10 minutes. The chest drain was removed 48 hours later in all cases and the mean length of hospital stay was 9±1 days. No intraoperative neither postoperative complications were found in all patients but one. He had a small fistula 15 days later that was successfully treated with stent insertion. No recurrence of diverticulum was seen in all cases. Uniportal VATS is a feasible procedure that in theory could reduce the surgical trauma compared to standard open approach. However, future prospective studies should corroborate our impression before it can be recommended as acceptable therapy.

Standard video-assisted thoracoscopic surgery has been reported as a minimally invasive approach alternative to sternotomy for management of myasthenia gravis (MG) associated with thymoma or thymic hyperplasia. Uniportal video-thoracoscopy is an evolution of standard multi-portal video-thoracoscopy for management of several thoracic diseases but its role for resecting mediastinal tumor remains under-evaluated.Herein, we describe our experience with bilateral uniportal thoracoscopic sequential extended thymectomy with case and video illustrations.

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