Background: Video-assisted thoracoscopic surgery (VATS) lobectomy has recently been adopted as the gold standard surgical option for the treatment of early stage non-small cell lung cancer. Enhanced recovery after surgery (ERAS) is being progressively adopted in thoracic surgery to improve the postoperative outcomes. Even if the benefits of ERAS are universally accepted, to date a standardized and uniform approach has not been described in the medical literature. The Italian VATS group has recently proposed to include in the VATS lobectomy database a structured protocol for ERAS. Methods:The ERAS section of the Italian VATS group is proposing a comprehensive ERAS protocol within the VATS lobectomy database, allowing the prospective collection of a dedicated set of data. Separate sections of the protocol are dedicated to different topics of ERAS. This study is specifically dedicated to the section of physiokinesis therapy. The medical literature will be extensively reviewed and a physiotherapy (PT) protocol of ERAS will be presented and discussed. A seta of structured clinical pathways will also be suggested for adoption in the VATS Group database.Discussion: Pre-and post-operative adoption of an ERAS protocol in patients undergoing VATS lobectomy may promote an improved post-operative course, a shorter hospital stay and an overall more comfortable patients' experience. The mainstays of a physiokinesis therapy ERAS protocol are patients' education, constant physical and respiratory therapy sessions, and adoption of adequate devices. Although many studies have investigated the usefulness of physical and respiratory physiokinesis therapy, a comprehensive ERAS protocol for VATS lobectomy patients has not yet been described. The proposed ERAS platform, adopted by the VATS Group database, will contribute to a prospective data collection and allow a scientific analysis of the results.

Awake single access video-assisted thoracic surgery with local anesthesia improves procedure tolerance, reduces postoperative stay and costs. Materials & methods: Local anesthesia was made with lidocaine and ropivacaine. We realize one 20 mm incision for the 'single-access', and two incisions for the '2-trocars technique'. Results: Mortality rate was 0% in both groups. Postoperative stay: 3dd ± 4 versus 4dd ± 5, mean operative time: 39 min versus 37 min (p < 0.05). Chest tube duration: 2dd ± 5 versus 3dd ± 6. Complications: 11/95 versus 10/79. Conclusion: Awake technique reduce postoperative hospital stay and chest drainage duration, similar complications and recurrence rate. The authors can say that 'awake single-access VATS' is an optimal diagnostic and therapeutic tool for the management of pleural effusions, but above extends surgical indication to high-risk patients. KEYWORDS• awake VATS • pleural effusion • single port • VATSThe history of video-assisted thoracic surgery (VATS) utilizing the local anesthesia and sedation is almost one century old with Jacobeus and Bethune [1].The authors started an 'awake single port VATS' program because they hypothesized that the use of just one access associated with local anesthesia might be feasible and could result in a better procedure acceptance, in a more rapid recovery, in a reduced procedure-related cost and in a more less invasive procedure.A single access associated with local anesthesia aims to improve procedure tolerance, shorten recovery and reduce costs. Materials & methodsThe authors retrospectively analyzed 174 patients with pleural effusion treated by awake technique or general anaesthesia. At admission, patients underwent complete laboratory assay, blood gases, chest roentgenograms, ectrocardiogram and eventually chest computed tomography (CT) scan and cardiological evaluation. An informed consent was obtained from all patients, including possibility of endotracheal intubation and thoracotomy. Premedication consisted in atropine 0.01 mg/kg and ondansetron 8 mg. Pain control and sedation were obtained by remifentanile (0.05-0.1 μg/kg/min) and midazolam (0.02-0.04 mg/kg). In the operating room, the patient was turned to a full lateral decubitus position and the table was flexed to widen the rib spaces on the operation side. A small antidecubitus mattress was placed below the dependent hemitorax to obtain a slight splitting of intercostal spaces without patient's discomforts. The position of the lonely trocar was usually defined with the help of utrasound (US). The using of US to choose the site of access was a rapid and safe method that helped to visualize the pleural effusion and that guided the operator to define the site of access, keeping away from some 'hazardous areas.' A line which included the plan of incision was drawn and the standard antiseptic procedure was performed. Local anesthesia was obtained with For reprint orders, please contact: reprints@futuremedicine.com

Purpose: Pleural nodular histiocytic/mesothelial hyperplasia is a nodular histiocytic/ mesothelial proliferation, often delimiting cystic cavities, due to irritation by a pulmonary noxa. Case report results: The patient had right pleural parietal and diaphragmatic thickness, with pleural effusion, without lung alterations. He previously underwent left hemicolectomy and liver resection, due to a diverticulitis and a liver histiocytes-rich abscess. Video-assisted thoracoscopy biopsy showed a double population of reactive mesothelial cells and histiocytes. Conclusion: Nodular histiocytic/mesothelial hyperplasia represents a potential pitfall for pathologists. Immunohistochemistry is crucial for the differential diagnosis with some malignancies. We suggest that in our patient, a chronic mesothelium inflammation happened by transdiaphragmatic involvement as a consequence of the liver abscess. Some pathogenetic mechanisms are hypothesized. KEYWORDS• mesothelial hyperplasia • pleural effusion • VATS Nodular histiocytic/mesothelial hyperplasia (NHMH) is a benign localized alteration, first described in 1975 by Rosai in the hernia sac [1]. Few pulmonary cases have been reported in literature [2][3][4][5][6]. Sometimes it has been reported in the pericardium [7,8] or presenting as an inguinal mass [9]. The 'mesothelial/monocytic incidental cardiac excrescence', first described by Weinot et al. in 1994 [10] is now considered a similar lesion to NHMH [11].It consists of a reactive proliferation of histiocytes and mesothelium secondary to chronic irritation and it has been observed in pleura-damaging processes, such as pneumothorax [5], or as consequence of cardiac catheterization, inflammation, mechanical or tumor stimulation [11].The rarity of NHMH and the moderate cytological atypia often present, make this lesion difficult to diagnose. It can be easily confused with primary mesothelial lesions and neoplasms such as adenocarcinomas, granulosa cell tumors or Langerhans' histiocytosis.We report a case of pleural NHMH in a patient with a subphrenic abscess, in which no pulmonary pathogenic noxa was evident. We hypothesize a transdiaphragmatic chronic irritation as a pathogenetic mechanism underlying NHMH. Case reportA 57-year-old man presented to our department in June 2014, due to the presence of a right pleural effusion with undefined diagnosis. At admission he had no fever, infections or history of exposure to asbestos and other dust. Shortness of breath after moderate exertion was noted, blood pressure was 130/85 mmHg and heart rate 77 bpm with normal sinus rhythm. Physical examination showed abolition of breath sounds and fremitus on all fields on the right side and dullness plexus. The patients drug history was negative. Due to the onset of pleural effusion and dyspnea, the patient For reprint orders, please contact: reprints@futuremedicine.com

3D CT scan should be performed before surgery if possible.

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