Microenvironmental acidification by pneumococcal sugar consumption fosters barrier disruption and immune suppression in the human alveolus.

Streptococcus pneumoniae (S.p.) is the most common causative agent of community-acquired pneumonia worldwide. A key pathogenic mechanism that exacerbates severity of disease is the disruption of the alveolar-capillary barrier. However, the specific virulence mechanisms responsible for this in the human lung are not yet fully understood.In this study, we infected living human lung tissue with S.p. and observed a significant degradation of the central junctional proteins occludin and VE-cadherin, indicating barrier disruption. Surprisingly, neither pneumolysin, bacterial hydrogen peroxide nor pro-inflammatory activation were sufficient to cause this junctional degradation. Instead, pneumococcal infection led to a significant decrease of pH (approximately 6), resulting in acidification of the alveolar microenvironment, which was linked to junctional degradation. Stabilising the pH at physiological levels during infection reversed this effect, even in a therapeutic-like approach.Further analysis of bacterial metabolites and RNA sequencing revealed sugar consumption and subsequent lactate production were the major factors contributing to bacterially induced alveolar acidification, which also hindered the release of critical immune factors.Our findings highlight bacterial metabolite-induced acidification as an independent virulence mechanism for barrier disruption and inflammatory dysregulation in pneumonia. Thus, our data suggest that strictly monitoring and buffering alveolar pH during infections caused by fermentative bacteria could serve as an adjunctive therapeutic strategy for sustaining barrier integrity and immune response.

Localization and pneumococcal alteration of junction proteins in the human alveolar-capillary compartment.

Loss of alveolar barrier function with subsequent respiratory failure is a hallmark of severe pneumonia. Although junctions between endo- and epithelial cells regulate paracellular fluid flux, little is known about their composition and regulation in the human alveolar compartment. High autofluorescence of human lung tissue in particular complicates the determination of subcellular protein localization. By comparing conventional channel mode confocal imaging with spectral imaging and linear unmixing, we demonstrate that background fluorescent spectra and fluorophore signals could be rigorously separated resulting in complete recovery of the specific signal at a high signal-to-noise ratio. Using this technique and Western blotting, we show the expression patterns of tight junction proteins occludin, ZO-1 as well as claudin-3, -4, -5 and -18 and adherence junction protein VE-cadherin in naive or Streptococcus pneumoniae-infected human lung tissue. In uninfected tissues, occludin and ZO-1 formed band-like structures in alveolar epithelial cells type I (AEC I), alveolar epithelial cells type II (AEC II) and lung capillaries, whereas claudin-3, -4 and -18 were visualised in AEC II. Claudin-5 was detected in the endothelium only. Claudin-3, -5, -18 displayed continuous band-like structures, while claudin-4 showed a dot-like expression. Pneumococcal infection reduced alveolar occludin, ZO-1, claudin-5 and VE-cadherin but did not change the presence of claudin-3, -4 and -18. Spectral confocal microscopy allows for the subcellular structural analysis of proteins in highly autofluorescent human lung tissue. The thereby observed deterioration of lung alveolar junctional organisation gives a structural explanation for alveolar barrier disruption in severe pneumococcal pneumonia.

Robotic-assisted thymectomy: surgical procedure and results.

BACKGROUND: Thymectomy is an essential component in the treatment of myasthenia gravis (MG) and the best treatment for localized thymoma. Minimally invasive thymectomy has advanced to include robotic-assisted techniques. The acceptance of this approach is growing rapidly, while the debate on the adequate technique for thymectomy remains open. METHODS: We describe the technique of robotic-assisted thymectomy and its modifications. The worldwide registries and the literature are reviewed. The experience from the largest single-center database is analyzed. RESULTS: The unilateral three-trocar approach for robotic thymectomy from either left or right side has been standardized. More than 100 centers worldwide perform robotic thymectomy. The annual number of this procedure increased steadily and reached 1,000 in 2012, while the largest single-center experiences comprise almost 500 cases. The end points improvement of MG and recurrence of thymoma are comparable to open procedures. There are special advantages of robotic assistance for complete mediastinal dissection. The perioperative complication rate is below 2%. CONCLUSION: Robotic thymectomy combines minimal incisional discomfort with extensive mediastinal dissection. As its use expands, robotic thymectomy may become the standard for all indications of thymectomy.

Chest wall resections for non-small cell lung cancer: a literature review.

Background and Objective: The development of early screening for lung cancer has led to improved overall survival in patients with non-small cell lung cancer (NSCLC). However, the management of NSCLC patients with resectable and potentially resectable chest wall invasion (CWI) requires attention. The purpose of this review is to summarize the role of surgery (chest wall resections) in NSCLC patients with CWI. Methods: A literature search and review from three databases (PubMed, Embase, and ScienceDirect) comprised the last 39 years. This review was focused on the treatment of NSCLC patients with CWI, mainly including the preoperative evaluation, principles of treatment and strategic decision-making, surgical complications, and prognostic factors. Key Content and Findings: Through the collection of relevant literature on NSCLC that invades the chest wall, this narrative review describes the actual role in clinical practice and future developments of chest wall resections. Preoperative treatment requires the multidisciplinary team (MDT) team to conduct accurate clinical staging of the patient and pay attention to the patient's lymph node status and rib invasion status. The successful implementation of chest wall resection and possible chest wall reconstruction requires refined individualized treatment based on the patient's clinical characteristics, supplemented by possible postoperative systemic treatment. Conclusions: Surgery plays an important role in treating NSCLC patients with CWI, and a collaborative, experienced MDT is an essential component of the successful treatment of CWI with lung cancer. In the future, more high-quality clinical research is needed to focus on CWI patients so that patients can receive more effective treatment options and better clinical prognosis.

Robotic-assisted extended thymectomy for large resectable thymoma: 21 years' experience.

OBJECTIVE: This study aims to evaluate the perioperative and midterm oncological outcomes of robotic-assisted thoracic surgery extended thymectomy for patients with large resectable thymomas compared with small thymomas. METHODS: This retrospective single-center study included 204 patients with thymomas who underwent robotic-assisted thoracic surgery extended thymectomy between January 2003 and February 2024. Patients were divided into 2 groups based on the thymoma size (5-cm threshold). RESULTS: The study comprised 114 patients (55.9%) in the small thymoma group and 90 patients (44.1%) in the large thymoma group. No significant differences were found between the groups regarding gender, age, proportion of elderly patients, or pathologic high-risk classifications. Apart from a longer operative time (P = .009) in the large thymoma group, no differences were observed between the 2 groups regarding surgical parameters and postoperative outcomes. No deaths occurred within 30 days in either group. During a median follow-up of 61.0 months (95% CI, 48.96-73.04), 4 patients experienced recurrence (1.96%). No significant differences in the 5-year overall survival (P = .25) or recurrence-free survival (P = .43) were observed between groups. CONCLUSIONS: Robotic-assisted thoracic surgery extended thymectomy is technically feasible, safe, and effective for treating large resectable thymomas. Moreover, midterm outcomes for patients with completely resected large thymomas were comparable to those with small thymomas during a median follow-up period of up to 5 years.

Do skip-N2 metastases significantly impact overall survival and disease-free interval in N2 non-small-cell lung cancer patients? A multicentre analysis.

OBJECTIVES: Skip-N2 metastasis (N0N2), thus N2 metastasis in the absence of N1 metastasis, occurs in ∼20-30% of non-small-cell lung cancer patients. N0N2 patients have a better prognosis than continuous-N2 metastasis (N1N2) patients following surgery. However, this effect remains controversial. Therefore, we conducted a multicentre study to compare the long-term survival and disease-free interval (DFI) of N1N2- and N0N2 patients. METHODS: One- and 3-year survival rates were measured. Kaplan-Meier curves and a Cox proportional hazards model assessed survival and were used to identify prognostic factors for overall survival. In addition, we performed propensity score matching (PSM) to rule out confounding factors. All patients received adjuvant chemoradiation therapy according to European guidelines. RESULTS: Between January 2010 and December 2020, 218 stage IIIA/B N2 patients were included in our analysis. The Cox regression analysis revealed that N1N2 significantly influenced the overall survival rate. Before PSM, N1N2 patients showed significantly more metastatic lymph nodes (P < 0.001) and significantly larger tumours (P = 0.05). After PSM, baseline characteristics did not differ between groups. Before and after PSM, N0N2 patients showed significantly better 1- (P = 0.01; P = 0.009) and 3-year (P < 0.001) survival rates than N1N2 patients. Furthermore, N0N2 patients showed significantly longer DFI than N1N2 patients before and after PSM (P < 000.1). CONCLUSIONS: Prior and after PSM analysis, N0N2 patients were confirmed to have better survival and DFI than N1N2 patients. Our results demonstrate that stage IIIA/B N2 patients are heterogeneous and would benefit from a more precise subdivision and differential treatment.

Streptococcus pneumoniae-induced regulation of cyclooxygenase-2 in human lung tissue.

The majority of cases of community-acquired pneumonia are caused by Streptococcus pneumoniae and most studies on pneumococcal host interaction are based on cell culture or animal experiments. Thus, little is known about infections in human lung tissue. Cyclooxygenase-2 and its metabolites play an important regulatory role in lung inflammation. Therefore, we established a pneumococcal infection model on human lung tissue demonstrating mitogen-activated protein kinase (MAPK)-dependent induction of cyclooxygenase-2 and its related metabolites. In addition to alveolar macrophages and the vascular endothelium, cyclooxygenase-2 was upregulated in alveolar type II but not type I epithelial cells, which was confirmed in lungs of patients suffering from acute pneumonia. Moreover, we demonstrated the expression profile of all four E prostanoid receptors at the mRNA level and showed functionality of the E prostanoid(4) receptor by cyclic adenosine monophosphate production. Additionally, in comparison to previous studies, cyclooxygenase-2/prostaglandin E(2) related pro- and anti-inflammatory mediator regulation was partly confirmed in human lung tissue after pneumococcal infection. Overall, cell type-specific and MAPK-dependent cyclooxygenase-2 expression and prostaglandin E(2) formation in human lung tissue may play an important role in the early phase of pneumococcal infections.

Outcomes of Juvenile Myasthenia Gravis: A Comparison of Robotic Thymectomy With Medication Treatment.

BACKGROUND: The study aimed to compare the clinical outcomes of patients with juvenile myasthenia gravis (MG) who underwent robotic thymectomy with that of those who only received medication therapy. METHODS: We retrospectively reviewed patients who visited our institution for the diagnosis or treatment of MG with an age at onset younger than 18 years. Patients who underwent thymectomy comprised the surgical group and those who received only medication therapy comprised the nonsurgical group. The clinical outcomes were assessed according to the Myasthenia Gravis Foundation of America Post-Intervention Status. RESULTS: Forty-seven patients (35 female, 12 male) were included as the surgical group and 20 patients (15 female, 5 male) comprised the nonsurgical group. Significant differences were observed between the surgical and nonsurgical groups in antibody against acetylcholinesterase receptor (91.5% vs 65%; P = .012), disease duration (median 16 [interquartile range, 7-25] months vs 96 [interquartile range, 42-480] months; P < .001), and corticosteroids requirement (53.2% vs 15%; P = .004) at baseline. Kaplan-Meier analysis showed a higher cumulative probability of complete stable remission in the surgical group (P = .002) compared with the nonsurgical group. Moreover, thymectomy (hazard ratio, 3.842; 95% confidence interval, 1.116-13.230; P = .033) and age at onset (hazard ratio, 0.89; 95% confidence interval, 0.80-0.99; P = .037) were still associated with the achievement of complete stable remission in the multivariable analysis. Furthermore, a significant steroid-sparing effect was observed in the surgical group but not in the nonsurgical group. CONCLUSIONS: Robotic thymectomy seems to be more effective than medication therapy on juvenile MG in terms of inducing remission and reducing the use of corticosteroids.

Prediction of the generalization of myasthenia gravis with purely ocular symptoms at onset: a multivariable model development and validation.

Background: About half of myasthenia gravis (MG) patients with purely ocular symptoms at onset progress to generalized myasthenia gravis (gMG). Objectives: To develop and validate a model to predict the generalization of MG at 6 months after disease onset in patients with ocular-onset myasthenia gravis (OoMG). Methods: Data of patients with OoMG were retrospectively collected from two tertiary hospitals in Germany and China. An accelerated failure time model was developed using the backward elimination method based on the German cohort to predict the generalization of OoMG. The model was then externally validated in the Chinese cohort, and its performance was assessed using Harrell's C-index and calibration plots. Results: Four hundred and seventy-seven patients (275 from Germany and 202 from China) were eligible for inclusion. One hundred and three (37.5%) patients in the German cohort progressed from OoMG to gMG with a median follow-up time of 69 (32-116) months. The median time to generalization was 29 (16-71) months. The estimated cumulative probability of generalization was 30.5% [95% CI (confidence interval), 24.3-36.2%) at 5 years after disease onset. The final model, which was represented as a nomogram, included five clinical variables: sex, titer of anti-AChR antibody, status of anti-MuSK antibody, age at disease onset and the presence of other autoimmune disease. External validation of the model using the bootstrap showed a C-index of 0.670 (95% CI, 0.602-0.738). Calibration curves revealed moderate agreement of predicted and observed outcomes. Conclusion: The nomogram is a good predictor for generalization in patients with OoMG that can be used to inform of the individual generalization risk, which might improve the clinical decision-making.

Robotic-Extended Rethymectomy for Refractory Myasthenia Gravis: A Case Series.

To assess the safety and efficacy of robotic-extended rethymectomy in selected refractory myasthenia gravis (MG) patients with suspected residual thymic tissue. Robotic-extended rethymectomy was performed in 6 MG patients with seropositive acetylcholine receptors (AChR) antibody who had undergone a previous thymectomy (1 cervicotomy, 2 video-assisted thoracoscopic surgeries, and 3 sternotomies). The median observation time before robotic rethymectomy was 108 (24-171) months. The main outcomes were perioperative morbidity, mortality, conversion to open surgery, and clinical outcomes according to the Myasthenia Gravis Foundation of America Post-Intervention Status (MGFA-PIS). Before rethymectomy, all patients required immunosuppressants and 5 patients (83.3%) required intravenous immune globulin and/or plasma exchange to control the symptoms. The median specimen weight was 24.5 (14-144) g after rethymectomy, and residual thymic tissue was found in 5 patients (83.3%). No conversion to open surgery or perioperative morbidity and mortality was observed. With a median follow-up time of 46.5 (13-155) months, 3 patients (50%) achieved "improved" and 3 (50%) were "unchanged" according to the MGFA-PIS. Compared with preoperative use, the median daily dose of corticosteroids statistically decreased (25 [7.5-60] vs 0 [0-5] mg, P = 0.002) without significant change in azathioprine use (100 [0-200] vs 50 [0-150] mg, P = 0.360). AChR antibody positive MG patients with a treatment refractory long-term course after thymectomy might have remaining thymic tissue with the 2 commonly associated thymus pathologies, thymoma, and follicular hyperplasia. Robotic-extended rethymectomy might be considered as a safe and beneficial treatment option in these patients.

Surgical Techniques for Myasthenia Gravis: Robotic-Assisted Thoracoscopic Surgery.

Robotic-assisted thoracoscopic surgery (RATS) creates an extended approach for thymectomy in terms of locating contralateral phrenic nerve and upper poles of the thymus. RATS thymectomy is indicated in all non-thymomatous myasthenia gravis (MG) patients and thymomatous MG patients with resectable thymoma, typically Masaoka-Koga I and II. Left-sided RATS thymectomy is superior for anatomic reasons and in the special care patients with MG. Up to now, left-sided three-trocar RATS thymectomy is the perfect combination of radical resection and minimal invasiveness among various approaches for thymectomy.

Results of Robotic Thymectomy Performed in Myasthenia Gravis Patients Older Than 60 Years at Onset.

BACKGROUND: Data are limited on the safety and efficacy of robotic thymectomy in patients with myasthenia gravis (MG) older than 60 years at onset. METHODS: Patients older than 60 years at MG onset who underwent robotic thymectomy in Charite Universitaetsmedizin Berlin between 2003 and 2017 were potentially eligible for inclusion. The main outcomes were perioperative complications and clinical outcome according to the Myasthenia Gravis Foundation of America Post-Intervention Status. RESULTS: Sixty-eight (25 women, 43 men) of 580 patients with MG who underwent robotic thymectomy were eligible for perioperative analyses (median age at MG onset 67 years, range: 61 to 85 years). The perioperative morbidity rate was 13.2%, and the only perioperative death was due to aortic dissection. Fifty-one patients were available for further analysis with a median follow-up time of 60 months (range: 12 to 263 months). The complete stable remission rate was 7.8%, the improvement rate was 68.6%, and the overall mortality rate was 11.8%. Compared with preoperative use, the mean daily dose of corticosteroid agents was significantly reduced at the last follow-up (17.6 ± 23.6 mg versus 2.6 ± 6.1 mg, p = 0.0001) without increased use of azathioprine (35.9 ± 61.9 mg versus 42.7 ± 59 mg, p = 0.427). After excluding 2 patients seronegative for the anti-acetylcholine receptor antibody, 10 of 49 seropositive patients achieved "good outcome" (including four complete stable remissions, three pharmacologic remissions, and three minimal manifestations 0) which was predicted by being free of concomitant disease (odds ratio 7.307, 95% confidence interval: 1.188 to 44.937, p = 0.032) and Myasthenia Gravis Foundation of America classification I before thymectomy (odds ratio 6.696, 95% confidence interval: 1.259 to 35.620, p = 0.026). CONCLUSIONS: Robotic thymectomy seems to be safe and effective in patients with MG older than 60 years at onset with a statistically significant steroid-sparing effect.

Robotic-assisted laparoscopic and thoracoscopic surgery with the da Vinci system: a 4-year experience in a single institution.

PURPOSE: We set up a pilot study to evaluate the efficacy of telerobotic surgery using the da Vinci system for several procedures for which traditional laparoscopy (or thoracoscopy) is a standard approach in a single institution. METHODS: We performed fundoplications (hiatal hernia repair and antireflux surgery, n=112), upside-down stomach (14), cholecystectomy (16), gastric banding (3), colectomy (5), esophagectomy (4), sub/total gastrectomy (2), gastrojejunostomy (2), along with thymectomy (100), thoracic symatectomy (11), lobectomy (5), mediastinal parathyroidectomy (5), and left pancreatic resection (1). RESULTS: The median set up time for all procedures was reduced from 25.0 to 10.4 minutes. Conversion to traditional laparoscopy or thoracoscopy occurred in 12 cases and in open surgery in 11 cases. There was no morbidity related to the telerobotic system. CONCLUSIONS: Robotically assisted laparoscopic and thoracoscopic surgery is feasible and safe for a variety of procedures in general, visceral, and thoracic surgery.

Do statins improve outcomes for patients with non-small cell lung cancer? A systematic review and meta-analysis protocol.

INTRODUCTION: Lung cancer is the most common neoplasm and the leading cause of cancer-related death worldwide. Non-small cell lung cancer (NSCLC), accounting for 85% of all lung cancer cases, is frequently diagnosed at an advanced and metastatic stage. In addition, survival of patients with NSCLC has not improved significantly over the recent decades. Statins are used as a cholesterol-lowering agent, but recently preclinical and clinical studies have revealed their anticancer effects. Thus, this systematic review and meta-analysis aims to clarify whether statins improve the prognosis of patients with NSCLC. METHODS AND ANALYSIS: We will search MEDLINE (PubMed), EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov with no restriction on language. Both randomised controlled trials (RCTs) and observational cohort studies evaluating the prognostic role of statins in patients with NSCLC will be included. The primary outcome will be overall survival, and the secondary outcomes will include cancer-specific survival, disease-free survival and cancer recurrence. Two assessors will assess the RCTs using the Cochrane Collaboration's risk of bias tool and the observational cohort studies according to ROBINS-I. Publication bias will be assessed by funnel plot using the STATA software v.13.1. ETHICS AND DISSEMINATION: No ethical issues are predicted. This systematic review and meta-analysis aims to describe the prognostic effects of statins in patients with NSCLC, which would help clinicians to optimise treatment for patients with NSCLC. These findings will be published in a peer-reviewed journal and presented at national and international conferences. PROSPERO REGISTRATION NUMBER: CRD42016047524.

Lymph node upstaging for non-small cell lung cancer after uniportal video-assisted thoracoscopy.

BACKGROUND: Radical lymph node dissection (LND) plays a major role in the treatment of non-small cell lung cancer (NSCLC). This study presents the analysis of the results after uniportal video-assisted thoracoscopy (VATS) lymphadenectomy during anatomical lung resections for NSCLC, focusing on pathological nodal upstaging. Any possible risk factor affecting nodal upstaging was also investigated. METHODS: The prospectively collected clinical data of 136 patients undergone uniportal VATS anatomical lung resections, from June 2012 to September 2017, were reviewed. In particular, all details inherent the clinical and pathological node stage and any possible risk factor affecting nodal upstaging were analyzed. RESULTS: The patient population consisted of 90 males and 46 females; their mean age was 67.42±10.64 years. The mean number of lymph nodes retrieved during uniportal VATS lymphadenectomy was 20.14±10.73 (7.27±5.90 and 12.60±7.96 in N1 and N2 stations, respectively). The incidence of nodal upstaging was 13.3% (18 cases). In particular there was a N0-1 upstaging in 10 cases (7.4%), a N1-2 upstaging in 3 (2.2%) and a N0-2 in 4 (3%). The ROC analysis showed that the resection of 18 lymph nodes was the best predictor of a general upstaging with an AUC-ROC of 0.595, while the resection of 7 hilar lymph nodes was the best predictor of N1 upstaging (AUC-ROC: 0.554) and 11 mediastinal nodes was the best predictor of N2 upstaging (AUC-ROC: 0.671). The number of positive lymph nodes of stations 5-6 (OR: 2.035, 95% CI: 1.082-3.826, P=0.027) and stations 2-3-4 (OR: 6.198, 95% CI: 1.580-24.321, P=0.009) were confirmed to be the only independent risk factors for N2 upstaging by multivariate analysis. CONCLUSIONS: According to our experience, uniportal VATS allows a safe and effective radical lymphadenectomy, with a satisfactory pathological nodal upstaging, comparable to other minimally invasive techniques.

Uniportal video-assisted thoracoscopy major lung resections after neoadjuvant chemotherapy.

BACKGROUND: The combination of neoadjuvant chemotherapy and surgery in lung cancer therapy is well established. The role of uniportal video assisted thoracoscopy (VATS) is still not described in literature. This study presents the preliminary short-term results of uniportal VATS after neoadjuvant therapy in our series. METHODS: The prospectively collected data of 154 patients after uniportal VATS anatomical lung resection (18 patients after neoadjuvant chemotherapy and 136 surgeries alone) were retrospectively reviewed. The perioperative results and follow-up of patients after neoadjuvant therapy were analyzed and compared to those after surgery alone. RESULTS: The mean age of population was 67.51±10.63 years. The mean operative time was overlapping in both groups: 248.97±118.17 min in surgery group and 287.17±94.13 min in chemotherapy + surgery group (P=0.190), with no difference in terms of types of anatomical lung resections performed and number of lymph nodes retrieved. The intraoperative mortality was null in both groups. The incidence of all complications was the same in both groups and no correlations was found with any possible risk factor evaluated (age, gender, comorbidities, type of resection, histology, etc.). Among minor complications, the incidence of parenchymal fistula was significantly higher in the 18 patients underwent chemotherapy (22.2% vs. 5.1% respectively, P=0.013). The overall survival of the series was 93% at 1 year follow-up and 88% at 5-year. The 1- and 2-year survival in only surgery group was 94% and 89% respectively vs. 85% and 85% in Chemotherapy + surgery, without any significant difference (P=0.324). CONCLUSIONS: According to our experience, uniportal VATS after neoadjuvant therapy is feasible and quite safe. The oncological results and postoperative complications are comparable to those of other techniques. Uniportal VATS can be performed even for complicated cases in experienced centers.

Uniportal vs. triportal video-assisted thoracic surgery in the treatment of primary pneumothorax-a propensity matched bicentric study.

BACKGROUND: The role of triportal video-assisted thoracoscopic surgery (VATS) is widely recognized for the treatment of primary spontaneous pneumothorax (PSP). The aim of this study was to assess the effectiveness and the potential advantages of uniportal VATS (U-VATS) for the treatment of PSP compared with triportal VATS. METHODS: A total of 104 triportal (n=39) and uniportal (n=65) VATS procedures where performed for the treatment of PSP in two University hospitals. The prospectively collected data of postoperative outcomes were retrospectively reviewed and a 1:1 propensity score matching analysis was performed to compare the two VATS approaches. RESULTS: No major adverse events occurred after operation. Compared with triportal-VATS, Uniportal-VATS showed the same effectiveness in terms of risk of recurrence (null in both groups), post-operative complications (P=1.000) and operating time (66.04±16.92 vs. 74.57±21.38 min, P=0.141). However, there was a statistically significant difference in favor of uniportal-VATS in terms of necessity of further access [0 vs. 7 (30.4%), P=0.004], chest tube duration (4.39±1.41 vs. 6.32±0.94 days, P<<0.001), postoperative hospital stay (4.78±1.31 vs. 6.61±1.67 days, P<<0.001), visual analogue pain score (VAS) at 24 hours (3.45±1.41 vs. 6.44±2.45, P<<0.001), number of patients who had pain after chest drain removal [1 (4.3%) vs. 16 (69.6%), P<<0.001], VAS after drainage removal (0.11±0.47 vs. 2.74±2.25, P<<0.001), postoperative pain duration (2.50±1.20 vs. 14.82±37.41 days, P<<0.001), pain killers intake (0.75±1.06 vs. 7.53±3.96 days, P=0.001), chronic paresthesia (level scale: 0 to 2; 0 vs. 0.52±0.66, P<<0.001), chronic neuralgia (0 vs. 0.43±0.59, P<<0.001) and cosmetic results (level scale: 0 to 3; 2.91±0.28 vs. 2.00±0.77, P<<0.001). CONCLUSIONS: U-VATS is feasible and safe and may be a less invasive alternative to triportal VATS for the treatment of PSP because of its effectiveness in reducing postoperative pain, paresthesia, hospital stay and in improving cosmetic results.

Uniportal video-assisted thoracic surgery in the treatment of pleural empyema.

BACKGROUND: The efficacy of video-assisted thoracic surgery (VATS) in the treatment of pleural empyema has recently been proven. Till today, very few works evaluated the role of uniportal-VATS (U-VATS) approach in the treatment of pleural empyema even if it currently represents the most innovative and less invasive thoracoscopic approach. We report our experience with U-VATS in the treatment of pleural empyema. METHODS: A retrospective bicentric analysis of 35 consecutive patients who underwent surgical treatment of stage II and stage III pleural empyema was performed, from January 2015 to May 2017. RESULTS: The mean age of patients was 57.26±18.29 years and 54.3% of them were males. In 85.7% of the cases, empyema was related to a complicated parapneumonic effusion; in only 5 cases it was a post-surgical consequence. All patients were treated with broad-spectrum antibiotics and subsequent target therapy for 14.62±21.76 days prior to operation and 23 patients needed the placement of a chest tube. Twenty patients (57.1%) presented with stage III, 11 patients (31.4%) stage II and 4 patients (11.4%) stage I empyema. Complete debridement and decortication were obtained in all patients through U-VATS approach and no conversion or further access was needed for any reason. No major complication was recorded. Only 2 cases of trapped lung were not responsive to surgical treatment. At a mean follow-up of 247.42±306.29 days, 33 patients (94.3%) were alive with no recurrence, 2 patients died for causes unrelated to the operation. CONCLUSIONS: According to our experience, we consider U-VATS as an adequate procedure in the treatment of "stages II and III" empyemas when the necessary surgical expertise has been achieved. Indeed, U-VATS permits an easier performance and complete debridement and decortication, with a very low risk for conversion and excellent postoperative outcomes in terms of less pain, fast recovery and cosmetic results.