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.

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.

Background: To evaluate the effect of first-time and eventual reiterative surgery on overall survival (OS) and disease-free survival (DFS) in Caucasian patients affected by an invasive adenocarcinoma (ADC) with at least another ground-glass opacity (GGO). Methods: We analysed 47 patients operated on for lung ADC, identified as main cancer (MC), with at least one synchronous GGO, from January 2003 to March 2017. Characteristics associated with the evolution of GGOs were investigated with logistic regression and overall and DFS were evaluated with Kaplan-Meier method. Results: Forty-two (89%) patients received an anatomic resection of the MC, 5 patients were treated by a single or multiple wedge resections. In total, 9 (19.1%) patients had all the lesions resected undergoing simultaneous resection of ipsilateral GGOs at first surgery while the remaining 38 (80.9%) patients still had at least one GGO that was followed up by serial CT scan. At the median follow-up of 41 months, GGO evolved in 16 (42.1%) patients. The presence of solid component at the initial CT scan was the only risk factor for evolution of the GGO. Thirteen patients underwent surgical resection showing an invasive ADC in 9 patients, MIA in 3 and AIS in 1. New GGOs developed in 7 (14.9%) patients, in which three underwent surgery showing the presence of solid ADC, MIA and AAH. OS rate at 5 years was 97.4%. DFS at 3 years was 82% and was significantly influenced by the stage of MC. Conclusions: 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.

The 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. From 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. Mean 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. We 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.