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Simple Summary: Completion lobectomy (CL) entails the resection of the remaining pulmonary lobe subsequent to wedge resection or segmentectomy. Indications for CL include reoperations for multiple or relapsed lung cancers and metastatic lung tumors, and the prognostic advantage of these procedures has been widely reported. However, ipsilateral surgical treatments, particularly within the same lobe, present challenges due to the development of intrapleural adhesions, rendering reoperation more difficult and time-consuming. VATS has emerged as the gold standard in the surgical treatment of early-stage NSCLC, offering superior postoperative outcomes when compared to thoracotomy. Its efficacy has been well established, even during complex procedures. However, its application in ipsilateral reoperations remains anecdotal, and to the best of our knowledge, no studies have analyzed the safety and efficacy of uniportal-VATS in this setting. This paper aims to evaluate the role of iniportal-VATS in CL long after wedge resection or anatomical segmentectomy in the same lobe. Background: Completion lobectomy (CL) following a prior resection in the same lobe may be complicated by severe pleural or hilar adhesions. The role of uniportal video-assisted thoracoscopic surgery (U-VATS) has never been evaluated in this setting. Methods: Data were collected from two Italian centers. Between 2015 and 2022, 122 patients (60 men and 62 women, median age 67.7 ± 8.913) underwent U-VATS CL at least 4 weeks after previous lung surgery. Results: Twenty-eight (22.9%) patients were affected by chronic obstructive pulmonary disease (COPD) and twenty-five (20.4%) were active smokers. Among the cohort, the initial surgery was performed using U-VATS in 103 (84.4%) patients, triportal-VATS in 8 (6.6%), and thoracotomy in 11 (9.0%). Anatomical segmentectomy was the initial surgery in 46 (37.7%) patients, while hilar lymphadenectomy was performed in 16 (13.1%) cases. CL was performed on 110 (90.2%) patients, segmentectomy on 10 (8.2%), and completion pneumonectomy on 2 (1.6%). Upon reoperation, moderate pleural adhesions were observed in 38 (31.1%) patients, with 2 (1.6%) exhibiting strong adhesions. Moderate hilar adhesions were found in 18 (14.8%) patients and strong adhesions in 11 (9.0%). The median operative time was 203.93 ± 74.4 min. In four (3.3%) patients, PA taping was performed. One patient experienced intraoperative bleeding that did not require conversion to thoracotomy. Conversion to thoracotomy was necessary in three (2.5%) patients. The median postoperative drainage stay and postoperative hospital stay were 5.67 ± 4.44 and 5.52 ± 2.66 days, respectively. Postoperative complications occurred in 34 (27.9%) patients. Thirty-day mortality was null. Histology was the only factor found to negatively influence intraoperative outcomes (p = 0.000). Factors identified as negatively impacting postoperative outcomes at univariate analyses were male sex (p = 0.003), age > 60 years (p = 0.003), COPD (p = 0.014), previous thoracotomy (p = 0.000), previous S2 segmentectomy (p = 0.001), previous S8 segmentectomy (p = 0.008), and interval between operations > 5 weeks (p= 0.005). In multivariate analysis, only COPD confirmed its role as an independent risk factor for postoperative complications (HR: 5.12, 95% CI (1.07–24.50), p = 0.04). Conclusions: U-VATS CL seems feasible and safe after wedge resection and anatomical segmentectomy. [ABSTRACT FROM AUTHOR]

OBJECTIVES The most recent evolution of patient management after thoracic surgery implies the concept of fast-tracking. Since 2008, our unit has implemented a programme based on clinical protocols and standardized pathways of care aimed to reduce the postoperative stay after major lung resection. The objective of this study was to verify the safety of this policy by monitoring the patient readmission rate. METHODS This is a prospective observational study on 914 consecutive pulmonary lobectomies performed at our institution from January 2000 to October 2010. Since we started the fast-tracking program in January 2008, we divided the patients into two groups: early period (678 patients, 2000–2007) and recent period (236 patients, 2008–October 2010). Several baseline and operative factors were used to build a propensity score that was applied to match the recent group patients with their early group counterparts. These two matched groups were then compared in terms of early outcomes and readmission rate. Readmission was defined as a re-hospitalization for any cause related to the operation within 30 days after discharge. We excluded from the analysis those patients with in-hospital mortality. RESULTS Propensity score yielded 232 well-matched pairs operated on in the early (non-fast-tracked patients) and most recent period (fast-tracked patients). The fast-tracking management resulted in a postoperative stay reduction of 2.8 days (P < 0.0001), with a 3-fold higher proportion of patients discharged before the sixth postoperative day (P < 0.0001). Nevertheless, we did not observe any differences in terms of readmission rate between the two periods. CONCLUSIONS In our experience, the implementation of a fast-tracking program after pulmonary lobectomy was very effective and safe. It led to a postoperative reduction of hospital stay without an increase in the readmission rate. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim of the present study was to evaluate the usefulness of the Thoracic Morbidity and Mortality (TMM) scoring system in auditing the quality of care of our unit. METHODS We analysed the performance of our unit comparing the incidence of complications and mortality occuring after anatomic lung resections during two different periods: early period (January 2000 to December 2009: 830 lobectomy, 134 pneumonectomy and 78 segmentectomy) and recent period (January 2010 to August 2012: 191 lobectomy, 8 pneumonectomy and 19 segmentectomy). The cardiopulmonary complications as traditionally defined in the European Society of Thoracic Surgeons (ESTS) database were also classified according to the TMM system: this method grades the postoperative adverse events from 1 to 5 reflecting an increasing severity of management regardless the type of complication. Complications graded higher than 2 are regarded as major complications. To account for confounders, several baseline and surgical factors were used to build a propensity score that was applied to match the patients of the most recent group with their early-group counterparts. These two matched groups were compared in terms of cardiopulmonary morbidity (codified by ESTS definitions) and mortality rates and incidence of major complications according to the TMM system. RESULTS The propensity score analysis yielded 209 well-matched pairs of patients operated on in the two periods. The two groups had similar rates of ESTS-defined cardiopulmonary complications (recent: 38 patients vs early: 37 patients, P = 0.9). The use of the TMM system revealed a higher incidence of major (grade > 2) complications rate in the recent period (recent: 29 patients vs early: 14 patients, P = 0.02). CONCLUSIONS The TMM scoring system for classifying the postoperative complications revealed a decline of quality of care of our unit otherwise undetected by applying traditional outcome measures. This tool can be used as an additional graded outcome endpoint to refine internal audit of performance. [ABSTRACT FROM AUTHOR]

OBJECTIVES The measurement of maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax) generated at the mouth is an accepted non-invasive clinical method for evaluating the strength of respiratory muscles. The aim of our study was to verify whether PImax and PEmax measured before and after a symptom-limited stair-climbing test are associated with complications in patients submitted to major lung resections. METHODS In a prospective cohort study of 283 consecutive patients submitted to lobectomy (231) or pneumonectomy (52) with a preoperative symptom-limited stair-climbing test, PImax and PEmax were measured before and immediately after the exercise. PImax and PEmax values were expressed as percentages of predicted values. ΔPImax and ΔPEmax were defined as the percentage difference between the pre- and postexercise values. Logistic regression analysis and the bootstrap resampling technique were performed to identify predictors of cardiopulmonary complications. RESULTS On average, PImax dropped by 3.6% and PEmax increased by 0.8% after the exercise. In total, 173 patients (61%) experienced a reduction in their PImax after exercise, while 150 (53%) had their PEmax reduced. Postoperative cardiopulmonary complications occurred in 74 patients (26%). Complicated patients had a greater reduction in their PImax compared with non-complicated patients (8.7% vs 2.1%, P = 0.03), whereas ΔPEmax was similar in complicated and non-complicated patients (0.7% vs 1.3%, P = 0.5). Receiver operating characteristic analysis indicated that the best cut-off for predicting complications was a ΔPImax of 10%. Stepwise logistic regression analysis and bootstrap confirmed that ΔPImax of >10 was associated with cardiopulmonary complications after adjusting for baseline and surgical factors (ΔPImax regression coefficient −0.02, P = 0.09, bootstrap frequency 51%). A progressive increase in complications was observed in patients with greater reduction in ΔPImax after exercise, particularly for values >10% reduction. CONCLUSION The measurement of PImax at the mouth during exercise represents an additional parameter that can be used to refine risk stratification of lung resection candidates and to identify patients who may benefit from inspiratory muscle training. [ABSTRACT FROM AUTHOR]

OBJECTIVE The aim of this study was to assess the immediate influence of chest tube removal on chest pain and forced expiratory volume in 1 s (FEV1) after pulmonary resection. METHODS Prospective longitudinal investigation on 104 consecutive patients (53 wedge/segmentectomies and 51 lobectomies; 69 muscle and nerve-sparing lateral thoracotomy and 35 video-assisted thoracoscopic surgery (VATS)). Post-operative chest pain was controlled in all patients by a standardized combination of oral and intravenous non-opioid analgesics. All patients had one chest tube (24 French). Static and dynamic (after forced expiratory effort) pain and FEV1 were assessed before and 1 h after the chest tube removal by the same operator. No additional analgesics were administered before or after the chest tube removal. The pain level was assessed by the numeric pain scale [range: 0 (no pain)–10 (excruciating pain)]. FEV1 was assessed by a portable spirometer. Bronchodilators were not used in these patients. Pre- and post-removal measurements were compared by the Wilcoxon signed rank test. RESULTS The average pre-removal static and dynamic pain scores were 2.6 and 4.1, respectively. The static and dynamic pain scores decreased by 42 and 41%, respectively, after the tube removal (P < 0.0001). The average FEV1 before the chest tube removal was 1.5 l or 53% of the predicted value and increased by 13% after the tube removal (P = 0.0004). In total, 56 and 78% of patients reported static and dynamic pain scores improvement and 67% showed an FEV1 improvement after the chest tube removal. Similar results were observed in patients operated on through VATS or thoracotomy. Compared with patients whose chest tube was removed later, those who had their chest tube removed before post operative day 3 (POD3), showed a greater reduction in the static pain score (41 vs. 31%, P = 0.05) and greater improvement in FEV1 (18 vs. 0.01%, P = 0.02). CONCLUSIONS The removal of a chest tube reduces pain and improves ventilatory function, independent of surgical access and particularly in the early post-operative phase. A fast track chest tube removal policy may favour patients' recovery. [ABSTRACT FROM AUTHOR]

Abstract: Background: The objective of this investigation was to assess the quality of life (QoL) before and after pulmonary lobectomy in patients with chronic obstructive pulmonary disease (COPD) and to compare these values with a case-matched population of patients with normal respiratory function. Methods: This is an observational analysis performed on a prospective dataset of 220 consecutive patients submitted to pulmonary lobectomy for lung cancer (2006–2008). Patients submitted to extended procedures (chest wall resection and superior sulcus) were excluded from the analysis. Pre- and postoperative (3 months) QoL were assessed in all patients through the administration of the Short Form 36v2 (SF36v2) health survey, a generic QoL instrument assessing eight health physical and mental concepts. Propensity score was used to match COPD patients (according to the NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria: forced expiratory volume in 1s/forced expiratory vital capacity (FEV1/FVC) ratio <0.7 and FEV1 <80%) with counterparts without COPD. QoL scales were compared between the two matched groups by means of the Mann–Whitney test. Results: Propensity score yielded 50 well-matched pairs of patients with and without COPD. Compared with non-COPD patients, those with COPD had a threefold higher rate of cardiopulmonary morbidity (14 cases vs 5 cases, 28% vs 10%, p =0.04), lower reduction in FEV1 (6% vs 13%, p =0.0002), but lower residual postoperative FEV1 values (62% vs 74%, p <0.0001). Postoperative carbon monoxide lung diffusion capacity (DLCO) (69% vs 65%, p =0.1) and VO2max (15.3mlkg−1 min−1 vs 14.3mlkg−1 min−1 p =0.4) values were similar between the groups. Although most of the preoperative and postoperative QoL domains in both groups were reduced compared with normal population (<50), we were not able to find differences between the groups in any of the preoperative and postoperative physical and mental QoL scales. Conclusions: The evidence of an acceptable QoL in COPD patients may help both patients and physicians in the surgical decision-making process in the face of high rates of complications. [Copyright &y& Elsevier]

OBJECTIVES The aim of the present study was to verify whether the implementation of an electronic health record (EHR) in our thoracic surgery unit allows creation of a high-quality clinical database saving time and costs. METHODS Before August 2011, multiple individuals compiled the on-paper documents/records and a single data manager inputted selected data into the database (traditional database, tDB). Since the adoption of an EHR in August 2011, multiple individuals have been responsible for compiling the EHR, which automatically generates a real-time database (EHR-based database, eDB), without the need for a data manager. During the initial period of implementation of the EHR, periodic meetings were held with all physicians involved in the use of the EHR in order to monitor and standardize the data registration process. Data quality of the first 100 anatomical lung resections recorded in the eDB was assessed by measuring the total number of missing values (MVs: existing non-reported value) and inaccurate values (wrong data) occurring in 95 core variables. The average MV of the eDB was compared with the one occurring in the same variables of the last 100 records registered in the tDB. RESULTS The tDB and eDB had similar MVs (0.74 vs 1, P = 0.13). The learning curve showed an initial phase including about 35 records, where MV in the eDB was higher than that in the tDB (1.9 vs 0.74, P = 0.03), and a subsequent phase, where the MV was similar in the two databases (0.7 vs 0.74, P = 0.6). The inaccuracy rate of these two phases in the eDB was stable (0.5 vs 0.3, P = 0.3). Using EHR saved an average of 9 min per patient, totalling 15 h saved for obtaining a dataset of 100 patients with respect to the tDB. CONCLUSION The implementation of EHR allowed streamlining the process of clinical data recording. It saved time and human resource costs, without compromising the quality of data. [ABSTRACT FROM AUTHOR]