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.

Background: In the treatment of malignant pleural mesothelioma the Hyperthermic Intra THOracic Chemotherapy (HITHOC) can improve the efficacy of pleurectomy and decortication with a local cytotoxic effect. However its biological impact in patient's hemodynamic and microcirculatory changes were rarely investigated. Aim of this study is to describe our experience with HITHOC after pleurectomy and decortication evaluating the role of sublingual video-microscopy in assessing the microcirculatory changes in the perioperative period. Methods: This is a prospective and observational study concerning 10 consecutive patients undergoing extended P/D followed by HITHOC. These patients underwent sublingual microcirculatory monitoring, which was adopted as a routine procedure since 2012. Haemodynamic parameters were collected at eight consecutive times: the day before surgery (T1), induction of anaesthesia (T2), surgical phase before HITHOC beginning (T3), 5 and 30 minutes after HITHOC start (T4 and T5, respectively), 5 minutes from HITHOC end (T6), after the admission in ICU (T7), at discharge from the ICU (T8). Cardiac output (CO) was calculated with MostCare. Systemic vascular resistance (SVR), oxygen delivery (DO 2 ), and oxygen extraction rate (O 2 ER) were calculated using standard formulas. Arterial blood pressure and central venous pressure (CVP) were obtained with standard arterial and venous catheters. At the same times we assessed the sublingual microcirculation with Sidestream Dark Field technique. Results: Hemodynamic and microcirculatory data were collected in 10 patients, 8 male and 2 females (mean age 68.6±9.0, and body surface area of 1.9±0.1 m 2 ). All patients had arterial hypertension, and one patient had diabetes. The mean arterial pressure significantly decreased at T2, with respect to T1 (P=0.05). CO, CVP, DO2 , O 2 ER, and ScvO 2 , did not change significantly over the time. All patients needed infusion of noradrenalin from T4 to T6. TVD significantly decreased from T1 to T3, T5, and T8. Similarly, PVD significantly decreased from T1 to T3 and T8, and MFI from T1 to T6 and T8. PPV and HI did not change over the study period. No correlation was found between hemodynamic parameters (MAP, CO, CVP, DO 2 , O 2 ER, ScvO 2 ) and microcirculatory data (TVD, PVD, PPV, MFI, HI), at any time of the study. Conclusions: In patients who receive HITHOC the fluid load can reduce the microvascular impairment restoring the normal tissue perfusion. This process takes days but is most evident in the first 72 h. The use of colloid and blood transfusion is much more effective in restoring microcirculation and reducing tissue damaging.

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Robot-assisted thymectomy and total transaxillary thyroidectomy represent two excellent therapeutic options for functional and oncological diseases of these two organs. We report the first case in literature of combined robot-assisted resection. The patient was positioned in supine position with the left arm raised cranially 90°-120° to expose the axillary area. After completing the thymectomy we rotated 30° counter-clockwise the robot for the second surgical time. This led to an optimization of disposable instruments and a gain in terms of hospitalization and postoperative recovery for the patient. To perform these two procedures it was enough to rotate 30° the robot.

Video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) are two different types of surgical approach for the treatment of early stage lung cancer. Technological innovations brought on the beginning of a new era in thoracic surgery in the last 20-30 years. A need for training led many thoracic surgery centers to study how the learning of these new techniques took place among their surgeons: the so-called learning curve (LC). This review aimed not only to evaluate the recent literature about the LC of these two minimally invasive techniques but also to point out what are the similarities and differences between the two techniques. We chose a total of 50 reports from papers published between 2008 and 2019: 30 about the LC of VATS lobectomy and 20 studies about the LC of RATS lobectomy. We observed a substantial overlap between the training of both techniques even though the LC of RATS appears to be shorter than VATS. There are common cornerstones in the two LCs like reduction of operating times, reduction of blood loss, more complete lymphadenectomy, conversion rate reduction; a minimum number of at least 50 cases for VATS and 20 cases for RATS are needed to overcome the initial phase of the LC. We noticed that the need for accessory thoracoscopic access is particularly reduced with experience in the LC of the single-port VATS while the evaluation of the docking time is uniquely taken into account for RATS as for the need of specific training for basic robotic skills.

The last 10 years showed a wild diffusion of mini-invasive thoracic procedures for lung and mediastinum diseases. Mediastinal goiters, ectopic thyroids and forgotten goiters represent rare thoracic diseases, treated in the past by sternotomy, thoracotomy or combined cervicosternotomy. The evolution of robotic assisted thoracic surgery seems to offer a valid therapeutic option also in patients with thoracic and cervicothoracic thyroid correlate diseases. However some contraindications and technical aspects must be taken in account to achieve the best surgical results and patients satisfaction.

Background Penetrating neck and chest trauma is a very common entity in emergency medicine that usually requires surgical treatment. Our case report illustrates the case of a 27-year-old Arabian man with hemopneumothorax associated with pneumomediastinum due to an unusual occupational injury. Case presentation A metal sliver, coming from an axe using for wood chopping, penetrated the neck of a 27-year-old Arabian man in the left supraclavicular region mimicking a gun bullet; the entrance hole was at the left pleural dome where the sliver had just penetrated the apex of the lung passing through the upper lobe of his left lung creating an exit wound in the dorsal segment of the same lobe arriving in the posterior thoracic wall. Biportal video-assisted thoracic surgery was performed to remove blood clots and the unusual foreign body. Conclusion In the literature, there are several case series about this topic, with some of them reporting unusual foreign bodies that lead to penetrating trauma. However, to the best of our knowledge, no cases like the one we have reported are described in the current literature.

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