Thoracoscopic Management of Chylothorax by Application of a Fibrin Sealant Patch.

Thoracic duct ligation is a demanding procedure when the chyle leak and/or the duct itself are not identified. This report describes a new procedure using thoracoscopic closure of the chyle leak by application of a fibrin sealant patch. This strategy was successfully applied for closing (i) a small fistula due to a postoperative lesion of the lymphatic tributary vessels in one case, and (ii) a large fistula due to idiopathic rupture of the thoracic duct in another case.

The Prediction of Fissure Integrity by Quantitative Computed Tomography Analysis.

BACKGROUND: Incomplete interlobar fissure may increase the difficulty of thoracoscopic lobectomy. Herein, we compared the accuracy of visual versus quantitative analysis to predict fissure integrity in lung cancer patients undergoing thoracoscopic lobectomy and evaluated the effects of fissure integrity on surgical outcome. METHODS: This was a single-center retrospective study including consecutive patients undergoing VATS (video-assisted thoracoscopic surgery) lobectomy for lung cancer. The target interlobar fissures were classified as complete or incomplete by visual and quantitative analysis. Using the intraoperative finding as the reference method, the diagnostic accuracy of the two methods to define fissure completeness (dependent variable) was calculated and statistically compared. Yet, we evaluated differences in postoperative outcomes between patients with complete and incomplete fissure integrity. RESULTS: A total of 93 patients were included in the study; 33/93 (36%) presented complete fissure. Visual and quantitative analyses correctly identified complete fissure in 19/33 (57%) and 29/33 (88%) patients, respectively, and incomplete fissure in 56/60 (93%) and 58/60 (96%) patients, respectively. Quantitative analysis had better diagnostic accuracy than visual analysis (81 vs. 93%; p = 0.01). Patients with incomplete fissure compared with those with complete fissure had a higher conversion rate (6 vs. 13%; p = 0.43), higher persistent air leak rate (0/33 vs. 14/60; p = 0.03), and longer hospitalization (12.6 ± 3.8 vs. 7.1 ± 2.4 days; p = 0.01). CONCLUSION: Quantitative analysis accurately predicted the fissures' integrity; it may be useful for selecting suitable cases for thoracoscopic lobectomy especially for surgeons with limited minimally invasive experience.

Solitary Fibrous Tumor of the Pleura: Surgical Treatment and Recurrence.

BACKGROUND: Solitary fibrous tumors of the pleura (SFTPs) are primary pleural tumors originating from the mesenchymal tissue. Surgical treatment was the first choice for management of SFTPs. There were no defined guidelines for the follow-up of these tumors and the postoperative therapy due to the rarity of these tumors. METHODS: We conducted a retrospective, multicenter study from two high-volume centers in Italy. Data of patients diagnosed with pleural solitary fibrous tumors between January 2003 and October 2022 were prospectively recorded and retrospectively analyzed. The aim of this study was to identify predictive prognostic factors and the correlation between tumor characteristics and recurrence. RESULTS: In all, 107 patients undergoing R0 surgical resection of pleural solitary fibrous tumor were included in the study. Patients were divided in two groups: benign and malignant. All the patients were treated with surgery with the aim to obtain R0 resection. Lung resection was necessary when the tumor adhered strongly to the lung parenchyma or infiltrated it. Twenty of the 107 patients had tumor recurrence. At a multivariate analysis, histological characteristics (high mitotic index) and maximum standardized uptake values (maxSUV) were related to recurrence. The mean disease-free survival (DFS) was 143.3 ± 6.1 months. CONCLUSION: In our experience, histological features of malignancy and maxSUV are significantly related to recurrence, which can occur even years after the first diagnosis. Surgical excision with negative surgical margins results in good long-term outcomes. After surgery, a long-term and strict follow-up should be done, in order to detect recurrence early. R0 of the recurrence is associated with long-term survival.

Endobronchial Ultrasound for Benign Tracheal Stenosis.

We reported the role of endobronchial ultrasound as complement to standard diagnostic exams to better define the benign tracheal stenosis (i.e., thickness and tracheal cartilage integrity) and to plan the treatment with flexible instead of rigid bronchoscope. Under sedation and spontaneous ventilation, the flexible bronchoscope was inserted through the laryngeal mask airway that assured the ventilation. The stenosis was first resected with cold scissors and then dilated with balloon catheter. This strategy was successfully applied in five consecutive patients. Inclusion criteria for the procedure were stenosis < 1 cm in length, without tracheomalacia and with integrity of airway cartilage.

Is a vessel-sealing system useful for resection of anterior mediastinal mass?

OBJECTIVE: To valuate if the LigaSure (Valleylab, Boulder, Colorado, United States) vessel-sealing system could reduce operative time, intraoperative blood loss, drainage duration, and hospital stay in patients with anterior mediastinal mass undergoing open resection. METHODS: Forty consecutive patients having resection of anterior mediastinal mass were randomized into two groups according to whether LigaSure was used (n = 20) or not (n = 20). Tumor size, operative time, intraoperative blood loss, chest tube output and duration, length of hospital stay, morbidity, and mortality were prospectively recorded, then intergroup differences were statistically analyzed. RESULTS: Both groups were well matched for age, tumor size, pathologic diagnosis, and incidence of complications. LigaSure significantly reduced operative duration (p < 0.0001) compared with the traditional technique but without leading to any significant reduction in intraoperative blood loss (p = 0.2), chest tube output (p = 0.2) and duration (p = 0.2), and length of hospital stay (p = 0.5). CONCLUSIONS: The reduced operative time using LigaSure translates into less exposure to general anesthesia, which is particularly important for patients with myasthenia and potentially reducing cost.

The Feasibility of LigaSure to Create Intestinal Anastomosis: Results of Ex Vivo Study.

OBJECTIVE: To evaluate the feasibility and the effectiveness of LigaSure Forced Triad to create intestinal anastomosis in an ex vivo porcino model. METHODS: Colon samples (n = 100) were prospectively randomized into 2 groups: LigaSure group (n = 90) and Stapler group (n = 10). The LigaSure group was divided into 9 subgroups, each of 10 samples, according to the different power levels of the LigaSure system (Bar 1, Bars 2, and Bars 3) and radiofrequency application (1 application, 2 applications, and 3 applications) used. All anastomoses were tested for early burst pressure. The LigaSure subgroup having the highest burst pressure was compared with the Stapler group. Finally, the specimen was reviewed by the same pathologist. RESULTS: The burst pressures of the 9 subgroups of LigaSure segments were the following: 29.7 ± 4.5 (Subgroup a); 27.4 ± 3.1 (Subgroup b); 25.3 ± 4 (Subgroup c); 32.9 ± 2.3 (Subgroup d); 30.7 ± 3.8 (Subgroup e); 25.7 ± 4.8 (Subgroup f); 42 ± 4.7 (Subgroup g); 31.8 ± 3.8 (Subgroup h); and 28.5 ± 3 (Subgroup j). Subgroup g (3 bars-power levels/1 frequency application) had the highest burst pressure (P < .001; ANOVA test). No significant difference was found between burst pressure of Subgroup g and Stapler group (42 ± 4.7 vs 42 ± 4.3, respectively, P = .9). On histological view, the LigaSure anastomosis was formed by collagen sealed without cavitation defects. CONCLUSIONS: Our study seems to confirm the feasibility of creating intestinal anastomosis using LigaSure. However, further researches in in vivo models are mandatory before recommending its clinical usage in such settings.

The influence of body mass index and weight loss on outcome of elderly patients undergoing lung cancer resection.

BACKGROUND: The aim of the study was to evaluate the influence of nutritional status on outcome of elderly patients resected for lung cancer. MATERIALS AND METHODS: A total of 117 consecutive patients aged ≥ 70 years undergoing lung cancer resection were enrolled. In addition to routine preoperative evaluations, other variables such as body mass index, weight loss, serum albumin, lymphocytes, and transferrin were counted. According to the body mass index value, patients were divided into Group A (≤ 18.5, underweight) and Group B (> 18.5) and risk factors for morbidity and mortality were analyzed. RESULTS: Group A and Group B counted 21 and 96 patients, respectively. The mean age was 74.9 ± 2.6; body mass index of Group A was significantly lower than that of Group B (16.7 ± 1.3 vs. 23.5 ± 1.7, respectively, p < 0.0001). On multivariate analysis, significant risk factors for complications were pneumonectomy (p = 0.001), stage (p = 0.006), predictive postoperative flow expiratory volume in 1 second (ppoFEV1%) (p = 0.003), and coronary disease (p = 0.04) and significant risk factors for early mortality were pneumonectomy (p = 0.0002), ppoFEV1% (p < 0.0001), BMI (0.02), and weight loss (0.007). The median survival time of Group A and Group B was 41 versus 54 months, respectively (p = 0.1). However, body mass index of less than 18.5 (p = 0.01) and weight loss of > 5% before operation (p = 0.01) were independent risk factors for 1 year mortality. CONCLUSIONS: In elderly patients, malnutrition was a significant additional risk factor for early death. Nutritional assessment should be included in the routine preoperative selection. In malnourished patients, nutritional support before and after operation and a careful postdischarge care might be beneficial, but it should be corroborated by further prospective studies.

Lung Resection for Non-Small Cell Lung Cancer following Bronchoscopic Lung Volume Reduction for Heterogenous Emphysema.

Bronchoscopic lung volume reduction (BLVR) is a minimally invasive treatment for emphysema. Lung cancer may be associated with emphysema due to common risk factors. Thus, a growing number of patients undergoing BLVR may develop lung cancer. Herein, we evaluated the effects of lung resection for non-small cell lung cancer in patients undergoing BLVR. The clinical data of patients undergoing BLVR followed by lung resection for NSCLC were retrospectively reviewed. For each patient, surgical and oncological outcomes were recorded to define the effects of this strategy. Eight patients were included in our series. In all cases but one, emphysema was localized within upper lobes; the tumor was detected during routine follow-up following BLVR and it did not involve the treated lobe. The comparison of pre- and post-BLVR data showed a significant improvement in FEV1 (29.7 ± 4.9 vs. 33.7 ± 6.7, p = 0.01); in FVC (28.5 ± 6.6 vs. 32.4 ± 6.1, p = 0.01); in DLCO (31.5 ± 4.9 vs. 38.7 ± 5.7, p = 0.02); in 6MWT (237 ± 14 m vs. 271 ± 15 m, p = 0.01); and a reduction in RV (198 ± 11 vs. 143 ± 9.8, p = 0.01). Surgical resection of lung cancer included wedge resection (n = 6); lobectomy (n = 1); and segmentectomy (n = 1). No major complications were observed and the comparison of pre- and post-operative data showed no significant reduction in FEV1% (33.7 ± 6.7 vs. 31.5 ± 5.3; p = 0.15) and in DLCO (38.7 ± 5.7 vs. 36.1 ± 5.4; p = 0.15). Median survival was 35 months and no cancer relapses were observed. The improved lung function obtained with BLVR allowed nonsurgical candidates to undergo lung resection for lung cancer.

Modified blade: an interventional option in rigid bronchoscopy for non-resectable benign tracheal stenosis.

INTRODUCTION: Benign tracheobronchial stenosis is a abnormal tracheal lumen narrowing that may incur progressive dyspnea and life-threatening hypoxemia. There is no consensus on which patients should be treated with endoscopic or surgical method. This study investigates the outcomes of bronchoscopic dilatation in the treatment of benign tracheal stenosis using a device equipped with a blade to cut the stenotic lesions with dense fibrosis. MATERIALS AND METHODS: The procedure was carried out in an operating room under general anesthesia. All patients were intubated with a Rigid Bronchoscope (RB) placed just above the stenosis. Through Rigid Bronchoscopy combined modalities were used as needed: radial incisions of the mucosal stenosis with blade at the levels of 4, 8 and 12 o'clock, with back and forth movements, then the stenotic area was dilated more easily with a rigid bronchoscope. Dilatation was performed by passing the RB of increasing diameter through stenotic areas and then Balloon dilatation of increasing diameter. There were no complications during the procedure. RESULT: We conducted an observational, retrospective, single-centre study in the Thoracic Surgery Unit of the University of 'Luigi Vanvitelli' of Naples from November 2011 to September 2021. We included all consecutive patients with benign tracheal stenosis inoperable. During the study period, 113 patients were referred to our department with benign tracheal stenosis inoperable. 61 patients were treated with the blade. During the follow-up, a recurrence of the stenosis was observed in 8 patients in the first month and in 4 patients in the third month. Instead in the patients treated with the use of laser (52 patients), during the follow-up a recurrence was observed in 16 patients in the first month and in 6 patients in the third month; no patient relapsed after 6 months and after 1 year. Long term successful bronchoscopic management with blade was attained by 99% in simple and 93% in mixed stenosis and in complex type stenosis. CONCLUSION: Our study underlines the importance of the use of the blade in bronchoscopic treatment as a valid conservative approach in the management of patients with inoperable benign tracheal stenosis as an alternative to the use of the laser, reducing the abnormal inflammatory reaction in order to limit recurrences.

Multidisciplinary Management of Descending Necrotizing Mediastinitis: Is Thoracoscopic Treatment Feasible?

Background: Descending necrotizing mediastinitis (DNM) is a life-threatening condition, generally caused by downward dissemination of oropharyngeal infections through cervical fascial planes. Mediastinal drainage is conventionally achieved by thoracotomy, but a Video-Assisted Thoracoscopic Surgery (VATS) approach is gaining interest due to the reduced invasiveness of procedure. We aimed to evaluate the effectiveness of VATS treatment in patients with DNM. Methods: We conducted a retrospective multicenter study including patients with descending mediastinitis that underwent mediastinal drainage through VATS (VATS group) or thoracotomy (thoracotomy group), both in association with cervical drainage. Patients with mediastinitis secondary to cardiac, pulmonary, or esophageal surgery were excluded. The intergroup differences regarding surgical outcome and postoperative morbidity and mortality were compared. Results: A total of 21 patients were treated for descending mediastinitis during the study period. Cervicotomy and thoracotomy were performed in 15 patients (71%), while cervicotomy and VATS were performed in 6 patients (29%). There were no significant differences in surgical outcome, postoperative morbidity, and mortality between groups. VATS treatment was not associated with a higher complication rate. Patients in the VATS group had a shorter operative time (p = 0.016) and shorter ICU stay (p = 0.026). Conclusions: VATS treatment of DNM is safe and effective. The comparison with thoracotomy showed no significant differences in postoperative morbidity and mortality. The VATS approach is associated with a shorter operative time and ICU stay than thoracotomy.

Use of the LigaSure device and the Stapler for closure of the small bowel: a comparative ex vivo study.

PURPOSE: To evaluate the feasibility and effectiveness of the LigaSure device in closing divisions of the small bowel in an ex vivo porcine model. METHODS: Two types of closure were performed: stumps created by "muco-mucosa" fusion and stumps created by "sero-serosa" fusion. For each type of closure, different power levels of the LigaSure system were tested in combination with different numbers of applications and then compared with the Stapler group. RESULTS: With both types of intestinal closure, the highest value of burst pressure was obtained with the application of a power level of three bars and one frequency application. The high burst pressure of the muco-mucosa stump group was significantly lower than that of the Stapler group (41.8 ± 5.9 vs. 75.8 ± 5.9, respectively, p < 0.01). No differences were found between the high burst pressure of the sero-serosa stump group and the Stapler group (74.1 ± 5.5 vs. 75.8 ± 5.9, respectively, p = 0.2). CONCLUSIONS: Our preliminary results showed that the LigaSure is an efficient tool for closing the intestines when sero-serosa stumps are created. The second step of our work will be to evaluate the feasibility of this tool in creating intestinal anastomoses.

One-way endobronchial valves in the management of complex persistent air leaks in a soft tissue sarcoma patient.

Complex persistent air leak (PAL) is a clinical condition which is difficult to treat. Herein, we report the clinical case of an 18-year-old woman with lung and bone metastases due an ultrarare sarcoma: "round cell sarcoma non-Ewing". She developed persistent air leaks due to an alveolopleural fistula which developed following two cycles of chemotherapy with doxorubicin. Chest drainage with suction failed to resolve the air leaks, while surgical treatment was unfeasible due to the poor clinical condition of the patient. Thus, she was reviewed for endoscopic treatment with one-way endobronchial valves. A small valve was sequentially inserted within each segment of the right upper bronchus to occlude the entire upper lobe. Two days after the procedure, resolution of the air leaks were obtained. Chest drainage was removed 5 days later and the patient was discharged. Chemotherapy was resumed. The patient died 7 months later because of disease progression.

Endoscopic treatment of solitary fibrous tumor of the trachea: a case report.

Background: Solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm, generally arising in the visceral pleura. It rarely originates from other sites such as trachea, orbital cavities, nasal cavities, peritoneum, paranasal sinuses, meninges, salivary glands, thyroid gland, diaphragm, liver, pancreas, lung kidney, adrenal gland, mediastinum, spermatid cord, pericardium, urinary bladder, prostate, uterine cervix, testis, spinal cord, periosteum, skin, soft tissue and bone. Case Description: We present a surgical case of a rare primary tracheal tumor. High resolution computed tomography (HRCT) scan of the chest showed a 5 mm hypodense lesion, located on the right lateral wall of the proximal third of trachea; however the tracheal lumen was normal. We performed a rigid bronchoscopy in order to remove the endotracheal tumor with palliative purposes only. For this reason, we did not perform a prior histologic examination. The lesion was easily removed with common biopsy forceps and with standard aspirator. The debulking of the tumor was achieved with the use of laser Nd-YAP, electrocautery was used also for hemostasis to prevent bleeding during the operation. Without complications during the endoscopic treatment, the procedure was well tolerated by the patient. The pathological diagnosis was SFT. Conclusions: SFT located in the trachea can be endoscopically resceted. Endoscolical treatment is indicated for patients with poor clinical conditions (heart disease, respiratory failure) that are not elegible for surgical resection.

Outcomes of Thoracoscopic Lobectomy after Recent COVID-19 Infection.

BACKGROUND: The COVID-19 outbreak had a massive impact on lung cancer patients with the rise in the incidence and mortality of lung cancer. METHODS: We evaluated whether a recent COVID-19 infection affected the outcome of patients undergoing thoracoscopic lobectomy for lung cancer using a retrospective observational mono-centric study conducted between January 2020 and August 2022. Postoperative complications and 90-day mortality were reported. We compared lung cancer patients with a recent history of COVID-19 infection prior to thoracoscopic lobectomy to those without recent COVID-19 infection. Univariable and multivariable analyses were performed. RESULTS: One hundred and fifty-three consecutive lung cancer patients were enrolled. Of these 30 (19%), had a history of recent COVID-19 infection prior to surgery. COVID-19 was not associated with a higher complication rate or 90-day mortality. Patients with recent COVID-19 infection had more frequent pleural adhesions (p = 0.006). There were no differences between groups regarding postoperative complications, conversion, drain removal time, total drainage output, and length of hospital stay. CONCLUSIONS: COVID-19 infection did not affect the outcomes of thoracoscopic lobectomy for lung cancer. The treatment of these patients should not be delayed in case of recent COVID-19 infection and should not differ from that of the general population.

Risk Factors for Pneumocystis jirovecii Pneumonia in Non-HIV Patients Hospitalized for COVID-19: A Case-Control Study.

BACKGROUND: Very few cases of Pneumocystis jirovecii pneumonia (PJP) have been reported in COVID-19 so far, and mostly in patients with concomitant HIV infection or in solid-organ transplant recipients. Despite COVID-19 being associated with lymphopenia and the use of steroids, there are no studies specifically aimed at investigating the risk factors for PJP in COVID-19. METHODS: A retrospective case-control study was performed. We matched PJP cases with controls with a 1:2 ratio, based on age ± 10 years, solid-organ transplantation (SOT), hematological malignancies, and in the setting of PJP development (ICU vs. non-ICU). A direct immunofluorescence assay on bronchoalveolar lavage fluid was used to diagnose PJP. RESULTS: We enrolled 54 patients. Among 18 cases of PJP, 16 were diagnosed as "proven". Seven of the eighteen cases were immunocompromised, while the other patients had no previous immunological impairment. Patients with PJP had significantly lower median lymphocyte values (p = 0.033), longer COVID-19 duration (p = 0.014), a higher dose of steroid received (p = 0.026), higher CRP values (p = 0.005), and a lower SARS-CoV-2 vaccination rate than the controls (p = 0.029). Cumulative steroid dose is the independent risk factor for PJP development (OR = 1.004, 95%CI = 1-1.008, p = 0.042). CONCLUSIONS: PJP develops in COVID-19 patients regardless of immunosuppressive conditions and the severity of disease, and it is correlated to the corticosteroid dose received.

Intrathoracic neurogenic tumors (ITNs): Management of solid and cystic lesions.

BACKGROUND: Intrathoracic neurogenic tumors (INTs) are derived from nerve tissue and grow within the chest. Preoperative diagnosis can be challenging and only complete surgical exeresis enables confirmation of the suspected diagnosis. Here, we analyzed our experience on management of paravertebral lesions with solid and cystic patterns. METHODS: A monocentric retrospective study was conducted, which included 25 consecutive cases of ITNs in the period from 2010 to 2022. These cases had been surgically treated by thoracoscopic resection alone, or in combination with neurosurgery in the case of dumbbell tumors. The demographic and operative data along with complications were recorded and analyzed. RESULTS: Twenty-five patients were diagnosed with a paravertebral lesion of which 19 (76%) had solid features and six (24%) had cystic features. The most common diagnosis was schwannoma (72%), followed by neurofibroma (20%) and malignant schwannoma (8%). In four cases (12%) the tumor showed an intraspinal extension. None of the patients had recurrence until 6 months of follow-up. Comparison between the VATS and thoracotomy procedures showed that outcome of discharge on the postoperative day, on average, was 2.61 ± 0.5 versus 3.51 ± 0.53, respectively (p-value <0.001). CONCLUSION: The treatment of choice for INTs is complete resection which is tailored to tumor size, location, and extension. In our study, paravertebral tumors with cystic characteristics were not associated with an intraspinal extension and did not show a different behavior from solid tumors.

Three-dimensional lung reconstructions for the localization of lung nodules to be resected during surgery.

BACKGROUND: The localization of lung nodules is challenging during thoracoscopy. In this study, we evaluated the use of three-dimensional (3D) lung reconstruction for use in the operating room to guide the identification of lung nodules during thoracoscopy. METHODS: This was a single-center retrospective study. All consecutive patients undergoing thoracoscopic resection of lung nodules were included in the study. Patients were retrospectively divided into two groups based upon whether the thoracoscopic resection was performed with the assistance (3D group) or not (standard group) of 3D lung reconstruction. The operative time (minutes) to detect lung nodules was statistically compared between the two study groups in relation to the characteristics of lung nodules as size, localization, and distance from the visceral pleura. RESULTS: Our study population consisted of 170 patients: 85 in the 3D group and 85 in the standard group. No intergroup difference differences were found regarding the characteristics and histological diagnosis of lesions. The standard group compared to the 3D group was associated with a significantly longer operative time for the detection of lesions <10 mm (13.87 ± 2.59 vs. 5.52 ± 1.01, p < 0.001), lesions between 10 and 20 mm (5.05 ± 0.84 vs. 3.89 ± 0.92; p = 0.03), lesions localized in complex segments (7.49 ± 4.25 vs. 5.11 ± 0.97; p < 0.001), and deep lesions (9.58 ± 4.82 vs. 5.4 ± 1.01, p < 0.001). CONCLUSIONS: Our 3D lung reconstruction model for use in the operating room may be an additional tool for thoracic surgeons to guide the detection of small and deep nodules during thoracoscopy. It is a noninvasive and cost saving procedure and may be widely used.

Advances in Endoscopic Management of Endobronchial Carcinoid.

INTRODUCTION: Bronchial carcinoid (BC) tumors represent between 1% and 5% of all lung cancers and about 20-30% of carcinoid tumors; they are classified into two groups: typical and atypical bronchial carcinoids. The aim of the present study was to review the results of endoscopic treatments as an alternative to surgical treatment in selected patients. MATERIALS AND METHODS: The present study was a retrospective and multicentric study, in which all data were reviewed for patients with BC in the central airways, referred to the Thoracic Surgery Units of Luigi Vanvitelli University of Naples and Sant'Andrea Hospital in Rome between October 2012 and December 2022 Overall, 35 patients, 13 of whom were female, were included in the study (median age, 53 years; range, 29-75 years). All patients underwent rigid bronchoscopy combined with flexible bronchoscopy. Tumor clearance was mostly performed by use of Argon Plasma Coagulation or Thulep Laser, mechanical debridement and excision with the use of forceps and aspirator through the working channel of the 8.5 mm-sized rigid bronchoscope. There were no complications during the treatment. RESULTS: Endobronchial treatment provided complete tumor eradication in all patients; two patients had controlled bleeding complications; however, bleeding was well controlled without patient desaturation, and only one patient died of renal failure during the follow-up period. We found two recurrences in the left and right main bronchus, in patients with atypical carcinoma during fiberoptic bronchoscopy follow-up. Only one patient died of renal failure. At the first analysis, there were no significant differences between the patients receiving endobronchial treatment and patients receiving surgical treatment in the present study (p-value > 0.05-it means statistically insignificant). CONCLUSIONS: Endobronchial treatment is a valid and effective alternative for patients with BC unsuitable for surgery.

Intraoperative lung ultrasound improves subcentimetric pulmonary nodule localization during VATS: Results of a retrospective analysis.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) resection of deep-seated lung nodules smaller than 1 cm is extremely challenging. Several methods have been proposed to overcome this limitation but with not neglectable complications. Intraoperative lung ultrasound (ILU) is the latest minimally invasive proposed technique. The aim of the current study was to analyze the accuracy and efficacy of ILU associated with VATS to visualize solitary and deep-seated pulmonary nodules smaller than 1 cm. METHODS: Patients with subcentimetric solitary and deep-seated pulmonary nodules were included in this retrospective study from November 2020 to December 2022. Patients who received VATS aided with ILU were considered as group A and patients who received conventional VATS as group B (control group). The rate of nodule identification and the time for localization with VATS alone and with VATS aided with ILU in each group were analyzed. RESULTS: A total of 43 patients received VATS aided with ILU (group A) and 31 patients received conventional VATS (group B). Mean operative time was lower in group A (p < 0.05). In group A all the nodules were correctly identified, while in group B in one case the localization failed. The time to identify the lesion was lower in group A (7.1 ± 2.2 vs. 13.8 ± 4.6; p < 0.05). During hospitalization three patients (6.5%; p < 0.05) in group B presented air leaks that were conservatively managed. CONCLUSION: Intracavitary VATS-US is a reliable, feasible, real-time and effective method of localization of parenchymal lung nodules during selected wedge resection procedures.