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Background: Diabetes is considered a general surgical risk factor, but with few data from enhanced recovery (ERAS) otherwise known to improve outcome. Therefore, this study aimed to investigate postoperative outcomes of patients with diabetes who underwent video-assisted thoracoscopic surgery (VATS) lobectomy in an established ERAS setting. Methods: We retrospectively analysed outcome data (hospital stay (LOS), readmissions, and mortality) from a prospective database with consecutive unselected ERAS VATS lobectomies from 2012 to 2022. Complete follow-up was secured by the registration system in East Denmark. Results: We included 3164 patients of which 323 had diabetes, including 186 treated with insulin and antidiabetic medicine, 35 with insulin only and 102 with antidiabetic medicine only. The median LOS was 3 days, stable over the study period. There were no differences in terms of LOS, postoperative complications, readmissions or 30 days alive and out of hospital. Patients with diabetes had significantly higher 30- and 90-day mortality rates compared to those without diabetes (p <.001), but also had higher preoperative comorbidity. Preoperative HbA1c levels did not correlate with postoperative outcomes. Conclusion: In an ERAS setting, diabetes may not increase the risk for prolonged LOS, complications, and readmissions after VATS lobectomy, however with higher 30- and 90-day mortality probably related to more preoperative comorbidities. [ABSTRACT FROM AUTHOR]

Background: Despite the implementation of Enhanced Recovery After Surgery (ERAS) programs, surgical stress continues to influence postoperative rehabilitation, including the period after discharge. However, there is a lack of data available beyond the point of discharge following video-assisted thoracoscopic surgery (VATS) wedge resection. Therefore, the objective of this study is to investigate incidence and risk factors for readmissions after ERAS VATS wedge resection. Methods: A retrospective analysis was performed on data from prospectively collected consecutive VATS wedge resections from June 2019 to June 2022. We evaluated main reasons related to wedge resection leading to 90-day readmission, early (occurring within 0–30 days postoperatively) and late readmission (occurring within 31–90 days postoperatively). To identify predictors for these readmissions, we utilized a logistic regression model for both univariable and multivariable analyses. Results: A total of 850 patients (non-small cell lung cancer 21.5%, metastasis 44.7%, benign 31.9%, and other lung cancers 1.9%) were included for the final analysis. Median length of stay was 1 day (IQR 1–2). During the postoperative 90 days, 86 patients (10.1%) were readmitted mostly due to pneumonia and pneumothorax. Among the cohort, 66 patients (7.8%) had early readmissions primarily due to pneumothorax and pneumonia, while 27 patients (3.2%) experienced late readmissions mainly due to pneumonia, with 7 (0.8%) patients experiencing both early and late readmissions. Multivariable analysis demonstrated that male gender, pulmonary complications, and neurological complications were associated with readmission. Conclusions: Readmission after VATS wedge resection remains significant despite an optimal ERAS program, with pneumonia and pneumothorax as the dominant reasons. Early readmission was primarily associated with pneumothorax and pneumonia, while late readmission correlated mainly with pneumonia. [ABSTRACT FROM AUTHOR]

Objectives: Lung volume reduction surgery (LVRS) has proven an effective treatment for emphysema, by decreasing hyperinflation and improving lung function, activity level and reducing dyspnoea. However, postoperative air leak is an important complication, often leading to reoperation. Our aim was to analyse reoperations after LVRS and identify potential predictors. Methods: Consecutive single-centre unilateral VATS LVRS performed from 2017 to 2022 were included. Typically, 3–5 minor resections were made using vascular magazines without buttressing. Data were obtained from an institutional database and analysed. Multivariable logistic regression was used to identify predictors of reoperation. Number and location of injuries were registered. Results: In total, 191 patients were included, 25 were reoperated (13%). In 21 patients, the indication for reoperation was substantial air leak, 3 patients bleeding and 1 patient empyema. Length of stay (LOS) was 21 (11–33) vs. 5 days (3–11), respectively. Only 3 injuries were in the stapler line, 13 within < 2cm and 15 injuries were in another site. Multivariable logistic regression analysis showed that decreasing DLCO increased risk of reoperation, OR 1.1 (1.03, 1.18, P = 0.005). Resections in only one lobe, compared to resections in multiple lobes, were also a risk factor OR 3.10 (1.17, 9.32, P = 0.03). Patients undergoing reoperation had significantly increased 30-day mortality, OR 5.52 (1.03, 26.69, P = 0.02). Conclusions: Our incidence of reoperation after LVRS was 13% leading to prolonged LOS and increased 30-day mortality. Low DLCO and resections in a single lobe were significant predictors of reoperation. The air leak was usually not localized in the stapler line. Key question: What characterizes reoperations after lung volume reduction surgeries? Key findings: Lung injuries were predominantly located away from the original surgical site. Take home message: Lung injuries remote from the stapler line is frequent during reoperation after lung volume reduction surgery. Location of lung injuries found during reoperation after lung volume reduction surgery [ABSTRACT FROM AUTHOR]

Simple Summary: Atypical carcinoid is a rare type of lung cancer, which exhibits a varying malignant potential. In this study, we aimed to identify the prognostic thresholds of the mitotic count and Ki-67 labeling index for recurrence and survival in atypical carcinoids. Our findings show that more patients recurred and died from this disease if their mitotic count exceeded three and four mitoses per 2 mm2, respectively, or if their Ki-67 labeling index exceeded 14% and 11%, respectively. These thresholds may serve as a valuable tool for clinicians and researchers in making treatment plans and predicting outcomes for patients with atypical carcinoids. Atypical carcinoid (AC) is a rare neuroendocrine neoplasm of the lung, which exhibits a varying malignant potential. In this study, we aimed to identify the prognostic thresholds of the mitotic count and Ki-67 labeling index for recurrence and survival in AC. We retrospectively reviewed 78 patients who had been radically resected for AC and calculated said thresholds using time-dependent receiver operating characteristic curves and the Youden index. We then dichotomized the patients into groups of above or below these thresholds and estimated the cumulative incidences of the groups using the Aalen–Johansen estimator. We compared the groups using univariable and multivariable Fine–Gray subdistribution hazard models. Our findings show that more patients recurred and died from this disease if their mitotic count exceeded three and four mitoses per 2 mm2, respectively, or if their Ki-67 labeling index exceeded 14% and 11%, respectively. Both thresholds independently predicted survival (p < 0.001 and p = 0.015, respectively). These thresholds may serve as a valuable tool for clinicians and researchers in making treatment plans and predicting outcomes for patients with AC. [ABSTRACT FROM AUTHOR]

Google Scholar OpenURL Placeholder Text WorldCat 119 Tao G, Jingying Y, Tan G, Xiaotao D, Min C. A novel CT-guided technique using medical adhesive for localization of small pulmonary ground-glass nodules and mixed ground-glass nodules (<=20 mm) before video-assisted thoracoscopic surgery. ABBREVIATIONS AND ACRONYMS 2 ABSTRACT 3 PREAMBLE 3 1 INTRODUCTION 4 1.1 Definition of GGO and nodule classification 4 1.2 Characteristics of subsolid nodules 4 2 METHODOLOGY 4 3 BACKGROUND 5 3.1 Definition of a ground-glass opacity 6 3.2 Assessment of the malignant risk of a subsolid nodule 8 4 MANAGEMENT OF SINGLE PURE GROUND-GLASS OPACITIES (NON-SOLID NODULES) 12 4.1 The role of a non-surgical biopsy 12 4.2 Surgery in pure GGO 12 4.3 Lymph node strategy 12 5 MANAGEMENT OF THE PART-SOLID NODULE 13 5.1 The role of a non-surgical biopsy 13 5.2 Mutational status 14 5.3 Lymph node strategy 14 6 MANAGEMENT OF MULTIPLE GROUND-GLASS NODULES 15 7 HOW TO IDENTIFY A NON-PALPABLE GROUND-GLASS OPACITY 15 7.1 Preoperative techniques for localization and marking 15 7.2 Injectable agents 16 7.3 Intraoperative techniques for localization and marking 17 8 MINIMALLY INVASIVE SURGERY APPROACH 17 9 SUBLOBAR VERSUS LOBAR RESECTION 17 9.1 Pulmonary function 18 9.2 Oncological outcomes 18 10 FUTURE DIRECTIONS AND GAPS IN KNOWLEDGE 19 11 KEY MESSAGES 19 SUPPLEMENTARY MATERIAL 19 CONFLICTS OF INTEREST 19 ACKNOWLEDGEMENTS 20 FUNDING 20 AUTHOR CONTRIBUTIONS 20 Reviewer information 20 REFERENCES 20 Graph: Central illustration. 1): Pure ground-glass opacity (non-solid nodules): CTR = 0; Part-solid nodule: 0 < CTR < 1; Solid nodule: CTR = 1. 1.2 Characteristics of subsolid nodules Previous articles have stated that lung adenocarcinomas with a CTR <= 0.5 could be non-invasive [[5], [7]]. Subsolid nodules are staged pure GGOs (non-solid nodules) and part-solid nodules [[2]]. [Extracted from the article]

Heart rate variability (HRV) is a measure of cardiac autonomic modulation and is potentially related to hypotension, postoperative atrial fibrillation, and orthostatic intolerance. However, there is a lack of knowledge on which specific time points and indices to measure. To improve future study design, there is a need for procedure-specific studies in an enhanced recovery after surgery (ERAS) video-assisted thoracic surgery (VATS) lobectomy setting, and for continuous measurement of perioperative HRV. HRV was measured continuously from 2 days before until 9 days after VATS lobectomy in 28 patients. After VATS lobectomy, with median length of stay = 4 days, the standard deviation between normal-to-normal beats and the total power of HRV were reduced for 8 days during the night and day times, while low-to-high frequency variation and detrended fluctuation analysis were stable. This is the first detailed study to show that HRV measures of total variability were reduced following ERAS VATS lobectomy, while other measures were more stable. Further, preoperative HRV measures showed circadian variation. The patch was well tolerated among participants, but actions should be taken to ensure proper mounting of the measuring device. These results demonstrate a valid design platform for future HRV studies in relation to postoperative outcomes. [ABSTRACT FROM AUTHOR]

Aims and Objectives: To gain insight into nursing in an enhanced recovery after surgery program for lung cancer, we explored its meaning for nurses in a thoracic surgery unit. Background: Since nurses play a key role in overcoming implementation barriers in enhanced recovery after surgery programs, successful implementation depends on their care approach during the surgery pathway. Design: Qualitative focus group study. Methods: A hermeneutic approach inspired by Gadamer guided the research. Sixteen thoracic surgery nurses participated in focus group interviews. Benner and Wrubel's primacy of caring theory enhanced understanding of the findings. COREQ guidelines were followed. Results: The thoracic surgery nurses compared the streamlined trajectory in the program to working in a factory. Shifting focus away from a dialogue‐based, situated care practice compromised their professional nursing identity. The program made combining scientific evidence with patients' lifeworld perspectives challenging. Although the nurses recognised that the physiological processes and positive outcomes promoted recovery, they felt each patient's life situation was not sufficiently considered. To meet the program's professional nursing responsibilities and provide comprehensive care, specialised thoracic nursing should continue after discharge to allow professional care while meaningfully engaging with the patient's situatedness and lifeworld. Conclusions: Primacy of caring risks being compromised if accelerated treatment is implemented uncritically. If care is based on the dominant rational justifications underpinning surgical nursing, living conditions and patient values might be overlooked, affecting how disease, illness and health are managed. Relevance to Clinical Practice: Our findings focus on obvious unintended consequences of enhanced recovery after surgery programs. To avoid dehumanising patients, surgical lung cancer programs must adopt a humanistic attitude in a caring practice guided by the moral art and ethics of care and responsibility. Public Contribution: To reminding us of what matters and helping us think differently, we discussed the results of the study with organisational stakeholders. [ABSTRACT FROM AUTHOR]

Simple Summary: Lung neuroendocrine neoplasms comprise a diverse group of cancers that arise from pulmonary neuroendocrine cells. They account for about 20% of all primary lung cancers and classify into four subtypes: typical carcinoid, atypical carcinoid, large cell neuroendocrine carcinoma, and small cell lung carcinoma. These subtypes share some morphological and protein expression immunohistochemistry features but differ greatly in their biological behaviors. Typical and atypical carcinoids are well differentiated low- and intermediate-grade tumors, respectively, whereas large cell neuroendocrine carcinoma and small cell lung carcinoma are poorly differentiated high-grade tumors. The common thread in all lung neuroendocrine neoplasms is that patients with localized disease primarily undergo surgery, while patients with locally advanced or metastatic disease receive tailored oncological therapies. This review summarizes key recent developments relevant to the surgical management of lung neuroendocrine neoplasms (L-NENs), including typical and atypical carcinoids, large cell neuroendocrine carcinoma, and small cell lung carcinoma. This review includes recent insights into the classification, clinical presentation, diagnostic workup, treatment options, and follow-up. Highlighted topics include general principles of surgery in localized or locally advanced or metastatic L-NENs, lung-sparing surgery for small, peripheral typical carcinoids, adjuvant and systemic therapies for typical and atypical carcinoids, and surgery and adjuvant therapies for large cell neuroendocrine carcinoma and small cell lung carcinoma. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Aim The aim of this study is to develop a reliable composite score based on simulator metrics to assess competency in virtual reality video-assisted thoracoscopic surgery lobectomy and explore the benefits of combining it with expert rater assessments. METHODS Standardized objective assessments (time, bleeding, economy of movement) and subjective expert rater assessments from 2 previous studies were combined. A linear mixed model including experience level, lobe and the number of previous simulated procedures was applied for the repeated measurements. Reliability for each of the 4 assessments was calculated using Cronbach's alpha. The Nelder–Mead numerical optimization algorithm was used for optimal weighting of scores. A pass–fail standard for the composite score was determined using the contrasting groups' method. RESULTS In total, 123 virtual reality video-assisted thoracoscopic surgery lobectomies were included. Across the 4 different assessments, there were significant effects (P  < 0.01) of experience, lobe, and simulator experience, but not for simulator attempts on bleeding (P  = 0.98). The left upper lobe was significantly more difficult compared to other lobes (P = 0.02). A maximum reliability of 0.92 could be achieved by combining the standardized simulator metrics with standardized expert rater scores. The pass/fail level for the composite score when including 1 expert rater was 0.33. CONCLUSIONS Combining simulator metrics with 1 or 2 raters increases reliability and can serve as a more objective method for assessing surgical trainees. The composite score may be used to implement a standardized and feasible simulation-based mastery training program in video-assisted thoracoscopic surgery lobectomy. [ABSTRACT FROM AUTHOR]

Objectives: To determine the number of procedures and expert raters necessary to provide a reliable assessment of competence in Video-Assisted Thoracoscopic Surgery (VATS) lobectomy. Methods: Three randomly selected VATS lobectomies were performed on a virtual reality simulator by participants with varying experience in VATS. Video recordings of the procedures were independently rated by three blinded VATS experts using a modified VATS lobectomy assessment tool (VATSAT). The unitary framework of validity was used to describe validity evidence, and generalizability theory was used to explore the reliability of different assessment options. Results: Forty-one participants (22 novices, 10 intermediates, and 9 experienced) performed a total of 123 lobectomies. Internal consistency reliability, inter-rater reliability, and test–retest reliability were 0.94, 0.85, and 0.90, respectively. Generalizability theory found that a minimum of two procedures and four raters or three procedures and three raters were needed to ensure the overall reliability of 0.8. ANOVA showed significant differences in test scores between the three groups (P < 0.001). A pass/fail level of 19 out of 25 points was established using the contrasting groups' standard setting method, leaving one false positive (one novice passed) and zero false negatives (all experienced passed). Conclusion: We demonstrated validity evidence for a VR simulator test with different lung lobes, and a credible pass/fail level was identified. Our results can be used to implement a standardized mastery learning training program for trainees in VATS lobectomies that ensures that everyone reaches basic competency before performing supervised operations on patients. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The purpose of this study was to describe the incidence of and reasons for early (0–30 days) and late (31–90 days) readmissions after enhanced recovery video-assisted thoracoscopic surgery lobectomy. METHODS We performed a retrospective analysis of prospectively collected consecutive VATS lobectomy data in an institutional database from January 2019 through December 2020. All reasons for readmission with complete follow-up were individually evaluated. Univariable and multivariable analyses were used to assess predictors. RESULTS In total, 508 patients were included; the median length of stay after the operation was 3 days. There were 77 (15%) early and 54 (11%) late readmissions, respectively. There were 33 (7%) multiple readmissions during postoperative days 0–90 ; pneumonia (19.8%) and pneumothorax (18.3%) were the dominant reasons for early readmissions, and the side effects of adjuvant chemotherapy (22.0%), for late readmissions. In multivariable analyses, current smoking (P = 0.001), alcohol abuse (P = 0.024) and chronic obstructive pulmonary disease (P = 0.019) were predictors of early readmissions, whereas Clavien-Dindo I-II grade gastrointestinal complications predicted late readmissions (P = 0.006) and multiple readmissions (P = 0.007). Early discharge (< 3 days) was not a predictor of readmissions. Early readmission did not increase late readmission. CONCLUSIONS Early and late readmissions after video-assisted thoracoscopic lobectomy are frequent even when enhanced recovery programmes are followed. Pulmonary complications and adjuvant chemotherapy are the most predominant reasons for early and late readmissions. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Days alive and out of hospital (DAOH) integrates overall information of hospitalization, readmissions, and mortality that have been applied as a new outcome measure. However, DAOH after video-assisted thoracoscopic surgery (VATS) in an established enhanced recovery after surgery (ERAS) programme has not been reported. METHODS Patients aged ≥18 years with non-small-cell lung cancer undergoing VATS lobectomy in an established ERAS programme were eligible. The primary and secondary outcomes were DAOH during the first postoperative 365 days and reasons for reduced DAOH. RESULTS A total of 316 consecutive patients with well-defined inclusion criteria and complete follow-up were assessed retrospectively. The median length of stay was 3 days (IQR 2–6). The medians (IQR) of postoperative 30, 60, 90, 180 and 365 DAOH were 27 (22–28), 57 (51–58), 86 (80–88), 176 (169–178) and 359 (349–363) days, respectively. Air leak was the dominant factor for reduced DAOH from postoperative day (POD) 0–30 (47.2%) and 0–365 (38.3%). Side effects of adjuvant chemotherapy were dominant from POD 31–60 and 61–90 (23.5% and 47.1%) and recurrence/metastases from POD 91–180 and 181–365 (25.6% and 50.0%). A low diffusing capacity for carbon monoxide (odds ratios 1.28, 95% confidence interval 1.07–1.53; P =0.007) and prior surgical history (odds ratios 1.80, 95% confidence interval 1.08–2.99; P =0.023) were predictors for low DAOH. CONCLUSIONS DAOH after 1 year with an established VATS lobectomy ERAS programme was only reduced with a median of 6 days. The main factors reducing DAOH were air leak, adjuvant chemotherapy and recurrence. DAOH may be an important patient-centred outcome to define future improvement strategies. [ABSTRACT FROM AUTHOR]

The potential complications related to unplanned conversion to thoracotomy remains a major concern in thoracoscopic lobectomy and may limit the wide adoption of this strategy. We reviewed the literature from 1990 until February 2022, analyzing all papers comparing successful thoracoscopic lobectomy versus converted thoracoscopic lobectomy and/or upfront thoracotomy lobectomy to establish whether unplanned conversion negatively affected outcomes. Thirteen studies provided the most applicable evidence to evaluate this issue. Conversion to thoracotomy was reported to occur in up to 23% of cases (range, 5%–16%). Vascular injury, calcified lymph nodes, and dense adhesions were the most common reasons for conversion. Converted thoracoscopic lobectomy compared to successful thoracoscopic lobectomy was associated with longer operative time and hospital stay in all studies, with higher postoperative complication rates in seven studies, and with higher perioperative mortality rates in four studies. No significant differences were found between converted thoracoscopic lobectomy and upfront thoracotomy lobectomy. Five studies evaluated long‐term survival, and in all papers conversion did not prejudice survival. Surgeons should not fear unplanned conversion during thoracoscopic lobectomy, but to avoid unexpected conversion that may negatively impact surgical outcome, a careful selection of patients is recommended–especially for frail patients. [ABSTRACT FROM AUTHOR]

Background Despite implementation of enhanced recovery after surgery (ERAS) in lung surgery, potential barriers for improvements should be identified. The aim of this single-centre, prospective ERAS cohort study was to explore reasons for delayed patient discharge after video-assisted thoracoscopic surgery (VATS) lobectomy with a median length of hospital stay (LOS) of 2 days. Methods Consecutive patients referred for VATS lobectomy were consulted twice daily by an investigator for the primary reasons for continued hospitalization. The secondary outcomes were risk factors for delayed recovery using univariate and multivariate regression analyses. Results A total of 147 patients were included (69 with LOS more than 2 days and 78 with LOS of 2 days or less) from April 2020 to December 2020. Air leak (27.7 per cent), pneumonia (20.2 per cent), pain (15.3 per cent), urinary/renal factors (11.0 per cent), atrial fibrillation (7.0 per cent), respiratory failure (4.5 per cent), cognitive factors/delirium (4.3 per cent), gastrointestinal factors (3.8 per cent), oxygen dependency (2.7 per cent), social factors (2.0 per cent), and pleural effusion (1.4 per cent) were important factors for discharge more than 2 days after surgery. The 30-day readmission rate after discharge was 21 per cent for LOS of 2 days or less and 22 per cent for LOS more than 2 days (P  = 0.856). On a multivariate regression model, age (per 5-year increase, odds ratio (OR) 1.29, 95 per cent c.i. 1.01 to 1.66, P  = 0.043) and forced expiratory volume in 1 s (FEV1) per cent (per 5 per cent increase, OR 0.89, 95 per cent c.i. 0.81 to 0.98, P  = 0.021) were significantly related to discharge after more than 2 days. Conclusion Despite a short median LOS of 2 days, air leak, pneumonia, and pain remain the most important challenges for further improvement of the ERAS programme. Age and FEV1 per cent were statistically significant risk factors for LOS longer than 2 days. [ABSTRACT FROM AUTHOR]

Background: Video-Assisted Thoracoscopic Surgery (VATS) lobectomy is an advanced procedure and to maximize patient safety it is important to ensure the competency of thoracic surgeons before performing the procedure. The objective of this study was to investigate validity evidence for a virtual reality simulator-based test including multiple lobes of the lungs. Method: VATS experts from the department of Cardiothoracic Surgery at Rigshospitalet, Copenhagen, Denmark, worked with Surgical Science (Gothenburg, Sweden) to develop VATS lobectomy modules for the LapSim® virtual reality simulator covering all five lobes of the lungs. Participants with varying experience in VATS were recruited and classified as either novice, intermediate, or experienced surgeons. Each participant performed VATS lobectomy on the simulator for three different randomly chosen lobes. Nine predefined simulator metrics were automatically recorded on the simulator. Results: Twenty-two novice, ten intermediate, and nine experienced surgeons performed the test resulting in a total of 123 lobectomies. Analysis of Variances (ANOVA) found significant differences between the three groups for parameters: blood loss (p < 0.001), procedure time (p < 0.001), and total instrument path length (p = 0.03). These three metrics demonstrated high internal consistency and significant test–retest reliability was found between each of them. Relevant pass/fail levels were established for each of the three metrics, 541 ml, 30 min, and 71 m, respectively. Conclusion: This study provides validity evidence for a simulator-based test of VATS lobectomy competence including multiple lobes of the lungs. The test can be used to ensure basic competence at the end of a simulation-based training program for thoracic surgery trainees. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive surgery combined with enhanced recovery programmes has improved outcomes after lung cancer surgery and where early mobilisation may be an important factor. However, little is known about pulmonary function and oxygenation during mobilisation after video-assisted pulmonary lobectomy. The aim of this prospective pilot cohort study was to explore the effect of postural changes (from supine to sitting to standing) on pulmonary function and oxygen saturation in a well-defined enhanced recovery programmes setting after video-assisted thoracoscopic surgery lobectomy. Methods: A total of 24 patients were evaluated daily for postoperative pain score, pulmonary function (forced expiratory volume 1 s) and oxygen saturation in supine, sitting and standing position from 6 h after surgery to 6 h after chest drain removal. Results: Mobilisation from supine to standing position showed a significant 7.9% increase (p = 0.04) in forced expiratory volume in 1 s percentage and oxygen saturation about 1.8% (p< 0.001) without increasing pain (p = 0.809). Conclusions: Early mobilisation should be encouraged to enhance recovery after video-assisted thoracoscopic surgery lobectomy by increasing lung function and oxygen delivery. Trial registration: • Name of the registry: clinicaltrials.gov • Trial registration number: NCT04508270 • Date of registration: August 11, 2020 [ABSTRACT FROM AUTHOR]

Thoracoscopic lobectomy has become the preferred approach for surgical management of early stage lung cancer, but the potential higher operative costs limit its widespread use. Theoretically, higher direct costs may be significantly counterbalanced by lower indirect costs, resulting in lower overall costs for thoracoscopic than for open lobectomy. To support this hypothesis, we reviewed the literature until May 2020, analyzing all papers comparing the cost of thoracoscopic versus open lobectomy.A total of 20 studies provided the most applicable evidence to evaluate this issue. In all the studies apart from one, thoracoscopic lobectomy was associated with higher operative costs due to the increased use of disposable instruments, and prolonged operative time. By contrast, in 17 studies the increased operative costs were significantly offset by indirect costs which were lower in thoracoscopic than in open lobectomy due to fewer postoperative complications, faster recovery, and lower readmission rates. It translated into lower overall costs for thoracoscopic than for open lobectomy in 10 studies, similar costs in seven, and higher in three, despite the lower hospitalization costs. The low bed fees and high prices of disposable instruments in these three studies may explain the discordance. The careful use of disposable instruments, and the minimizing hospitalization costs can reduce the total costs of thoracoscopic lobectomy to levels similar or to below those of open lobectomy. The worry that video‐assisted thoracoscopic surgery lobectomy (VATSL) might be associated with an increased overal cost is thus not warranted, and should not be used as an excuse against the use of VATS in surgery for early stage lung cancers. [ABSTRACT FROM AUTHOR]

Background: Models for predicting the survival outcomes of stage I non-small-cell lung cancer (NSCLC) defined by the newly released 8th edition TNM staging system are scarce. This study aimed to develop a nomogram for predicting the cancer-specific survival (CSS) of these patients and identifying individuals with a higher risk for CSS. Methods: A total of 30,475 NSCLC cases were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. We identified and integrated the risk factors to build a nomogram. The model was subjected to bootstrap internal validation with the SEER database, and external validation with a multicenter cohort of 1133 patients from China. The difference in the impact of adjuvant chemotherapy on model-defined high- and low-risk patients was examined using the National Cancer Database (NCDB). Results: Eight independent prognostic factors were identified and integrated into the model. The calibration curves showed good agreement. The concordance index (C-index) of the nomogram was higher than that of the staging system (IA1, IA2, IA3, and IB) (internal validation set 0.63 vs. 0.56; external validation set 0.66 vs. 0.55; both p < 0.01). Specifically, 21.7% of stage IB patients (7.5% of all stage I) were categorized into the high-risk group (score > 30). There was a significant interaction effect between the adjuvant chemotherapy and risk groups in the NCDB cohort (p = 0.003). Conclusions: We established a practical nomogram to predict CSS for 8th edition stage I NSCLC. A prospective study is warranted to determine its role in identifying adjuvant chemotherapy candidates. [ABSTRACT FROM AUTHOR]

Background: Competency-based training has gained ground in surgical training and with it assessment tools to ensure that training objectives are met. Very few assessment tools are available for evaluating performance in thoracoscopic procedures. Video recordings would provide the possibility of blinded assessment and limited rater bias. This study aimed to provide validity evidence for a newly developed and dedicated tool for assessing competency in Video-Assisted Thoracoscopic Surgery (VATS) lobectomy.Methods: Participants with varying experience with VATS lobectomy were included from different countries. Video recordings from participants' performance of a VATS right upper lobe lobectomy on a virtual reality simulator were rated by three raters using a modified version of a newly developed VATS lobectomy assessment tool (the VATSAT) and analyzed in relation to the unitary framework (content, response process, internal structure, relation to other variables, and consequences of testing).Results: Fifty-three participants performed two consecutive simulated VATS lobectomies on the virtual reality simulator, leaving a total of 106 videos. Content established in previously published studies. Response process Standardized data collection was ensured by using an instructional element, uniform data collection, a special rating program, and automatic generation of the results to a database. Raters were carefully instructed in using the VATSAT, and tryout ratings were carried out. Internal structure Inter-rater reliability was calculated as intra-class correlation coefficients, to 0.91 for average measures (p < 0.001). Test/re-test reliability was calculated as Pearson's r of 0.70 (p < 0.001). G-coefficient was calculated to be 0.79 with two procedures and three raters. By performing D-theory was found that either three procedures rated by two raters or five procedures rated by one rater were enough to reach an acceptable G-coefficient of ≥ 0.8. Relation to other variables Significant differences between groups were found (p < 0.001). The participants' VATS lobectomy experience correlated significantly to their VATSAT score (p = 0.016). Consequences of testing The pass/fail score was found to be 14.9 points by the contrasting groups' method, leaving five false positive (29%) and six false negatives (43%).Conclusion: Validity evidence was provided for the VATSAT according to the unitary framework. The VATSAT provides supervisors and assessors with a procedure-specific assessment tool for evaluating VATS lobectomy performance and aids with the decision of when the trainee is ready for unsupervised performance. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES The optimal level of suction on digital chest drainage devices after lobectomy using video-assisted thoracoscopic surgery (VATS) is unknown and varies between thoracic centres. In this randomized controlled trial, we assessed the potential benefits of low suction of –2 cmH2O compared to –10 cmH2O, using a digital drainage device. METHODS Two hundred and twenty-eight patients were randomized into 2 groups after VATS lobectomy for suspected or confirmed lung cancer. Primary outcome was time to chest drain removal. Drain data were obtained from the digital drainage devices, and patient data were obtained from medical records during admission, with a follow-up until postoperative day 30. RESULTS For the –2 cmH2O and –10 cmH2O groups, median (interquartile range) drainage duration was 27.4 h (23.3–71.2) and 47.5 h (24.5–117.8) (P  = 0.047), and the incidence of prolonged air leak >5 days was 14.4% and 24.3% (P  = 0.089), respectively. Median total fluid production was 566 h (329–1155) ml and 795 h (454–1605) ml (P  = 0.007). Median time to consistent air leak cessation (<20 ml/min) was 5.2 h (0.3–34.2) and 23.7 h (0.8–90.8) (P  < 0.001). There were no differences in the proportion or the size of the pneumothorax or subcutaneous emphysema after drain removal, and no differences were observed in postoperative morbidity. Median length of in-hospital stay was 2.0 days (2.0–5.8) and 3.0 days (2.0–9.0) (P  = 0.18). CONCLUSIONS A low suction level significantly shortened drainage duration, time to air leak cessation and total fluid production, without increasing morbidity. Clinical trial registration number NCT02911259. [ABSTRACT FROM AUTHOR]

Background: Specific assessment tools can accelerate trainees' learning through structured feedback and ensure that trainees attain the knowledge and skills required to practice as competent, independent surgeons (competency-based surgical education). The objective was to develop an assessment tool for video-assisted thoracoscopic surgery (VATS) lobectomy by achieving consensus within an international group of VATS experts.Method: The Delphi method was used as a structured process for collecting and distilling knowledge from a group of internationally recognized VATS experts. Opinions were obtained in an iterative process involving answering repeated rounds of questionnaires. Responses to one round were summarized and integrated into the next round of questionnaires until consensus was reached.Results: Thirty-one VATS experts were included and four Delphi rounds were conducted. The response rate for each round were 68.9% (31/45), 100% (31/31), 96.8% (30/31), and 93.3% (28/30) for the final round where consensus was reached. The first Delphi round contained 44 items and the final VATS lobectomy Assessment Tool (VATSAT) comprised eight items with rating anchors: (1) localization of tumor and other pathological tissue, (2) dissection of the hilum and veins, (3) dissection of the arteries, (4) dissection of the bronchus, (5) dissection of lymph nodes, (6) retrieval of lobe in bag, (7) respect for tissue and structures, and (8) technical skills in general.Conclusion: A novel and dedicated assessment tool for VATS lobectomy was developed based on VATS experts' consensus. The VATSAT can support the learning of VATS lobectomy by providing structured feedback and help supervisors make the important decision of when trainees have acquired VATS lobectomy competencies for independent performance. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Large retrospective series have indicated lower rates of cN0 to pN1 nodal upstaging after video-assisted thoracic surgery (VATS) compared with open resections for Stage I non-small-cell lung cancer (NSCLC). The objective of our multicentre study was to investigate whether the presumed lower rate of N1 upstaging after VATS disappears after correction for central tumour location in a multivariable analysis. METHODS: Consecutive patients operated for PET-CT based clinical Stage I NSCLC were selected from prospectively managed surgical databases in 11 European centres. Central tumour location was defined as contact with bronchovascular structures on computer tomography and/or visibility on standard bronchoscopy. RESULTS: Eight hundred and ninety-five patients underwent pulmonary resection by VATS (n = 699, 9% conversions) or an open technique (n = 196) in 2014. Incidence of nodal pN1 and pN2 upstaging was 8% and 7% after VATS and 15% and 6% after open surgery, respectively. pN1 was found in 27% of patients with central tumours. Less central tumours were operated on by VATS compared with the open technique (12% vs 28%, P < 0.001). Logistic regression analysis showed that only tumour location had a significant impact on N1 upstaging (OR 6.2, confidence interval 3.6-10.8; P < 0.001) and that the effect of surgical technique (VATS versus open surgery) was no longer significant when accounting for tumour location. CONCLUSIONS: A quarter of patients with central clinical Stage I NSCLC was upstaged to pN1 at resection. Central tumour location was the only independent factor associated with N1 upstaging, undermining the evidence for lower N1 upstaging after VATS resections. Studies investigating N1 upstaging after VATS compared with open surgery should be interpreted with caution due to possible selection bias, i.e. relatively more central tumours in the open group with a higher chance of N1 upstaging. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The optimal postoperative analgesic strategy after video-assisted thoracoscopic surgery lobectomy remains undetermined. We hypothesized that high-dose preoperative methylprednisolone (MP) would improve analgesia compared to placebo. METHODS: A total of 120 adult patients were randomized equally to 125 mg MP or placebo before the start of their elective video-assisted thoracoscopic surgery lobectomy. Group allocation was blinded to patients, investigators and caregivers, and all patients received standardized multimodal, opioid-sparing analgesia. Our primary outcome was area under the curve on a numeric rating scale from 0 to 10, for pain scores on the day of surgery and on postoperative days 1 and 2. Clinical follow-up was 2–3 weeks, and telephone follow-up was 12 weeks after surgery. RESULTS: Ninety-six patients were included in the primary analysis. Methylprednisolone significantly decreased median pain scores on the day of surgery: at rest (numeric rating scale 1.6 vs 2.0, P = 0.019) and after mobilization to a sitting position (numeric rating scale 1.7 vs 2.5, P = 0.004) but not during arm abduction and coughing (P = 0.052 and P = 0.083, respectively). Nausea and fatigue were reduced on the day of surgery (P = 0.04 and 0.03), whereas no outcome was improved on postoperative Days 1 and 2. Methylprednisolone did not increase the risk of complications but increased blood glucose levels on the day of surgery (P < 0.0001). CONCLUSIONS: High-dose preoperative MP significantly reduced pain at rest and after mobilization to a sitting position on the day of surgery, without later analgesic effects. Nausea and fatigue were improved without side effects, except transient higher postoperative blood glucose levels. [ABSTRACT FROM AUTHOR]

Background: The societies of thoracic surgery are working to incorporate simulation and competency-based assessment into specialty training. One challenge is the development of a simulation-based test, which can be used as an assessment tool. The study objective was to establish validity evidence for a virtual reality simulator test of a video-assisted thoracoscopic surgery (VATS) lobectomy of a right upper lobe.Methods: Participants with varying experience in VATS lobectomy were included. They were familiarized with a virtual reality simulator (LapSim®) and introduced to the steps of the procedure for a VATS right upper lobe lobectomy. The participants performed two VATS lobectomies on the simulator with a 5-min break between attempts. Nineteen pre-defined simulator metrics were recorded.Results: Fifty-three participants from nine different countries were included. High internal consistency was found for the metrics with Cronbach's alpha coefficient for standardized items of 0.91. Significant test-retest reliability was found for 15 of the metrics (p-values <0.05). Significant correlations between the metrics and the participants VATS lobectomy experience were identified for seven metrics (p-values <0.001), and 10 metrics showed significant differences between novices (0 VATS lobectomies performed) and experienced surgeons (>50 VATS lobectomies performed). A pass/fail level defined as approximately one standard deviation from the mean metric scores for experienced surgeons passed none of the novices (0 % false positives) and failed four of the experienced surgeons (29 % false negatives).Conclusion: This study is the first to establish validity evidence for a VATS right upper lobe lobectomy virtual reality simulator test. Several simulator metrics demonstrated significant differences between novices and experienced surgeons and pass/fail criteria for the test were set with acceptable consequences. This test can be used as a first step in assessing thoracic surgery trainees' VATS lobectomy competency. [ABSTRACT FROM AUTHOR]

I Dear Editor i We would like to thank Shen I et al. i for their interest in our study[1] and their comments on our results. Reasons for staying in hospital after video-assisted thoracoscopic surgery lobectomy. Although reduction of length of hospital stay is one of the goals of enhanced recovery after surgery (ERAS), focus should be on faster achievement of accepted discharge criteria rather than the length itself. [Extracted from the article]

OBJECTIVES: Lung cancer is the most common cause of cancer-related deaths worldwide. Survival is highly dependent on surgery. Videoassisted thoracoscopic surgery (VATS) is increasingly chosen over open thoracotomy (OT) because of the possible benefits of the minimally invasive approach. Consequently, our aim was to compare the 30-day morbidity and mortality for lung cancer patients operated by VATS lobectomy or lobectomy by OT. METHOD: Data were obtained from prospective national and regional databases, including patients who underwent lobectomy for lung cancer in the eastern part of Denmark from 1 January 2005 to 31 December 2011. All patients operated before 2009 were re-staged according to the latest International Association for the Study of Lung Cancer lung cancer classification. Patient characteristics, comorbidities, pathology and operative data were assessed using an independent samples t-test, Pearson's ?2, Fisher's exact test and Mann-Whitney test. Morbidity was assessed using multinomial logistic regression adjusted for gender, age, cancer stage, forced expiratory volume in 1 s (FEV1), year of surgery and Charlson comorbidity score. RESULTS: In total, 1379 patients underwent lobectomy, 785 patients via VATS and 594 patients via thoracotomy. The two groups were similar in gender and FEV1. The patients operated by VATS were older (P < 0.001), and had a lower Charlson comorbidity score (P = 0.034), higher frequency of adenocarcinomas (P < 0.001) and lower cancer stage (P < 0.001). Among the VATS patients, 285 (36.3%) and among the thoracotomy patients, 288 (48.5%) had minor complications (P < 0.001); and 157 (20.0%) VATS patients and 212 (35.7%) thoracotomy patients had major complications (P < 0.001). The 30-day mortality rate was 1% in the VATS group and 1.5% in the thoracotomy group (P = 0.47). Multinomial logistic regression analysis showed that the prevalence of both minor [odds ratio (OR) = 1.51; 95% confidence interval (Cl) = 1.18-1.96] and major complications (OR = 1.91, 95% Cl = 1.44-2.53) was significantly higher for patients who underwent lobectomy via thoracotomy compared with VATS. CONCLUSION: Patients undergoing lobectomy via VATS were less likely to have at least one minor complication within the first 30 postoperative days and less likely to have at least one major complication, compared with patients operated by thoracotomy. These findings remained after adjusting for gender, age, FEV1, cancer stage, year of surgery and Charlson comorbidity score. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Video-assisted thoracoscopic anatomical resections are increasingly used in Europe to manage primary lung cancer. The purpose of this study was to compare the outcome following thoracoscopic versus open lobectomy in case-matched groups of patients from the European Society of Thoracic Surgeon (ESTS) database. METHODS: All patients having lobectomy as the primary procedure via thoracoscopy [video-assisted thoracoscopic surgery (VATS)-L)] or thoracotomy (TH-L) were identified in the ESTS database ( January 2007 to December 2013). A propensity score was constructed using several patients’ baseline characteristics. The matching using the propensity score was responsible for the minimization of selection bias. A propensity score-matched analysis was performed to compare the incidence of postoperative major complications (according to the ESTS database definitions) and mortality at hospital discharge between the matched groups. After exclusions, 28 771 patients were identified: 26 050 having thoracotomy and 2721 having thoracoscopy. Propensity score yielded two well-matched groups of 2721 patients. Numeric variables were compared by Student’s t-tests and categorical variables were compared by McNemar’s tests. RESULTS: Compared with TH-L, VATS-L was associated with a lower incidence of total complications [n = 792 (29.1%) vs 863 (31.7%), P = 0.0357], major cardiopulmonary complications [n = 316 (15.9%) vs 435 (19.6%), P = 0.0094], atelectasis requiring bronchoscopy [n = 65 (2.4%) vs 150 (5.5%), P < 0.0001], initial ventilation >48 h [n = 18 (0.7%) vs 38 (1.4%), P = 0.0075] and wound infection [n = 6 (0.2%) vs 17 (0.6%), P = 0.0218]. There was no difference in the incidence of postoperative atrial fibrillation between the two groups (P = 0.14). Postoperative hospital stay was 2 days shorter in the VATS-L patients (mean: 7.8 vs 9.8 days; P = 0.0003). In terms of outcome at hospital discharge, there were 27 deaths in the VATS-L group (1%) versus 50 in the TH-L group (1.9%, P = 0.0201). CONCLUSIONS: Data from the ESTS database confirmed that lobectomy performed through VATS is associated with a lower incidence of complications compared with thoracotomy. [ABSTRACT FROM AUTHOR]

Bronchopulmonary neuroendocrine tumours (BP-NET) are a heterogeneous population of neoplasms with different pathology, clinical behaviour and prognosis compared to the more common lung cancers. The management of BP-NET patients is largely based on studies with a low level of evidence and extrapolation of data obtained from more common types of neuroendocrine tumours. This review reflects our view of the current state of the art of diagnosis and treatment of patients with BP-NET. [ABSTRACT FROM PUBLISHER]

Background: Video-assisted thoracic surgery is gradually replacing conventional open thoracotomy as the method of choice for the treatment of early-stage non-small cell lung cancers, and thoracic surgical trainees must learn and master this technique. Simulation-based training could help trainees overcome the first part of the learning curve, but no virtual-reality simulators for thoracoscopy are commercially available. This study aimed to investigate whether training on a laparoscopic simulator enables trainees to perform a thoracoscopic lobectomy.Methods: Twenty-eight surgical residents were randomized to either virtual-reality training on a nephrectomy module or traditional black-box simulator training. After a retention period they performed a thoracoscopic lobectomy on a porcine model and their performance was scored using a previously validated assessment tool.Results: The groups did not differ in age or gender. All participants were able to complete the lobectomy. The performance of the black-box group was significantly faster during the test scenario than the virtual-reality group: 26.6 min (SD 6.7 min) versus 32.7 min (SD 7.5 min). No difference existed between the two groups when comparing bleeding and anatomical and non-anatomical errors.Conclusion: Simulation-based training and targeted instructions enabled the trainees to perform a simulated thoracoscopic lobectomy. Traditional black-box training was more effective than virtual-reality laparoscopy training. Thus, a dedicated simulator for thoracoscopy should be available before establishing systematic virtual-reality training programs for trainees in thoracic surgery. [ABSTRACT FROM AUTHOR]

Video-assisted thoracic surgery (VATS) is emerging as the standard surgical procedure for both minor and major oncological lung surgery. Thoracic epidural analgesia (TEA) and paravertebral block (PVB) are established analgesic golden standards for open surgery such as thoracotomy; however, there is no gold standard for regional analgesia for VATS. This systematic review aimed to assess different regional techniques with regard to effect on acute postoperative pain following VATS, with emphasis on VATS lobectomy. The systematic review of PubMed, The Cochrane Library and Embase databases yielded 1542 unique abstracts; 17 articles were included for qualitative assessment, of which three were studies on VATS lobectomy. The analgesic techniques included TEA, multilevel and single PVB, paravertebral catheter, intercostal catheter, interpleural infusion and long thoracic nerve block. Overall, the studies were heterogeneous with small numbers of participants. In comparative studies, TEA and especially PVB showed some effect on pain scores, but were often compared with an inferior analgesic treatment. Other techniques showed no unequivocal results. No clear gold standard for regional analgesia for VATS could be demonstrated, but a guide of factors to include in future studies on regional analgesia for VATS is presented. [ABSTRACT FROM AUTHOR]

ERAS, Lung surgery, VATS lobectomy, Fast track. [Extracted from the article]

Background: Lobectomy using video-assisted thoracoscopic surgery (VATS) still is a controversial operation despite its many observed benefits. The controversy may be due to difficulties performing the procedure. This study addresses a standardized anterior approach facilitating the operation. Methods: This report describes 156 VATS lobectomies performed with a uniform anterior three-port technique. The surgeon and the assistant stand on the abdominal side of the patient, and the setup is independent of the lobe to be resected. Results: From 2005 to 2007, 156 VATS lobectomies and 13 conversions (7.7%) were performed with an anterior three-port technique. No mortality occurred among the VATS lobectomies during a 30-day period. The major comorbidity rate was 78%. The comorbidities included former thoracic surgery (9%) or a history of another cancer (22%), indicating potentially difficult surgery and a nonselected population. The majority (92%) of the patients had lung cancer. The major postoperative problem was air leakage, which usually prolongs the tube time and the in-hospital stay, but a 'no-touch fissure' technique significantly reduced the median tube time to 4 days and the postoperative hospital stay to 5 days. Conclusions: This study shows that VATS lobectomies can be performed using a standardized anterior approach with low rates of conversion and morbidity. A 'no-touch fissure' technique lowers the postoperative tube time, the in-hospital stay, and the number of patients with prolonged air leakage. A uniform anterior approach facilitates VATS lobectomy and makes this advanced procedure more easily adaptable by many surgeons familiar with an open anterior approach. The findings show that VATS lobectomy can be performed safely for a large proportion of lung cancer patients. [ABSTRACT FROM AUTHOR]

Letter to the editor are presented in response to article "Major intraoperative complications during video-assisted thoracoscopic anatomical lung resections: an intention-to-treat analysis" by H. Decaluwe and colleagues in the previous issue along with response from the authors.