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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., (© 2024. The Author(s).)

Background: This study aimed to identify the impact of margin distance on locoregional recurrence (LRR) and survival outcomes after thoracoscopic segmentectomy for non-small cell lung cancer., Methods: We retrospectively analyzed data from prospectively collected consecutive thoracoscopic segmentectomies in a single center from January 2008 to February 2023. The restricted cubic spline of the adjusted Cox regression model for LRR displayed the breakpoint of margin distance. The Kaplan-Meier estimator with log-rank test evaluated the overall survival between the 2 groups stratified by the breakpoint, and the Aalen-Johansen estimator with the Gray test assessed the LRR-free survival and lung cancer-specific survival in the competing model., Results: The study included 155 patients. LRR was observed in 22 patients (14.2%), with a median time to LRR of 17.1 months (interquartile range, 6.3-26.3 months). Margin distance was found to be a predictor for LRR (hazard ratio, 0.92; P = .033). The identified breakpoint for margin distance in this cohort was 19.8 mm. Compared with this cutoff, a margin distance of 15 mm increased the risk of LRR by 65%, whereas 25 mm decreased the risk to LRR with 31%. A segmentectomy with a margin distance ≥20 mm resulted in significant improvements in overall survival (P = .020), lung cancer-specific survival (P = .010), and LRR-free survival (P < .001) compared with cases with a margin distance of <20 mm., Conclusions: Margin distance ≥20 mm decreased LRR and improved survival outcomes for thoracoscopic segmentectomy in this study., Competing Interests: Disclosures René Horsleben Petersen reports a relationship with Medtronic Inc that includes: speaking and lecture fees; with Medela Inc that includes: speaking and lecture fees; with AstraZeneca that includes: consulting or advisory and speaking and lecture fees; with Ambu Inc that includes: speaking and lecture fees; with MSD Denmark that includes: consulting or advisory; with Bristol-Myers Squibb Co that includes: consulting or advisory; and with Roche that includes: consulting or advisory. Lin Huang has no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to identify the impact of number of dissected lymph nodes during thoracoscopic segmentectomy on recurrence and survival of clinical stage I non-small cell lung cancer (NSCLC)., Patients and Methods: We retrospectively analysed data from prospectively collected consecutive thoracoscopic segmentectomies conducted between June 2008 and September 2023 at a single institution. Kaplan-Meier analysis with log-rank test assessed OS. Fine-Gray's test assessed specific death in a competing risk model. The logistic regression model was utilized to predict recurrence, while the Cox regression model was employed to analyse overall survival (OS). Subgroup and sensitivity analyses were performed., Results: A total of 227 patients were included in the final analyses. The mean follow-up was 38.4 months (standard deviation 35.8). Among all patients, 37 patients (16.3 %) experienced recurrence and 51 (22.5 %) deceased during the follow-up period. The median number of dissected lymph nodes was 9 (interquartile range (IQR) 6-12). No statistical difference in recurrence rate and 5-year OS was observed between cases with dissected lymph nodes > 9 and ≤ 9 (14.6 % vs. 17.6 %, p = 0.549; 75.5 % vs. 69.5 %, p = 0.760). On multivariable analysis, body mass index (odds ratio [OR] 1.15, p = 0.002), Charlson Comorbidity index (OR 1.28, p = 0.002), synchronous pulmonary cancer (OR 3.05, p = 0.019), and tumour size (OR 1.04, p = 0.044) increased of the recurrence rate, while percentage of predicted forced expiratory volume in 1 s (hazard ratio (HR) 1.09, p = 0.048), history of smoking (HR 1.02, p = 0.009), and solid nodule (HR 1.56, p = 0.010) was related to poorer survival., Conclusions: In this study, number of dissected lymph nodes did not impact recurrence rate or overall survival after thoracoscopic segmentectomy for clinical stage I NSCLC., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [RHP reports speaker fee from Medtronic, Medela, AstraZeneca and AMBU, advisory board member for AstraZeneca, MSD, BMS and Roche. The other authors have no conflict of interest to report]., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Sleeve lobectomy is a challenging procedure with a high risk of postoperative complications. To facilitate surgical decision-making and optimize perioperative treatment, we developed risk stratification models to quantify the probability of postoperative complications after sleeve lobectomy., Methods: We retrospectively analyzed the clinical features of 691 non-small cell lung cancer (NSCLC) patients who underwent sleeve lobectomy between July 2016 and December 2019. Logistic regression models were trained and validated in the cohort to predict overall complications, major complications, and specific minor complications. The impact of specific complications in prognostic stratification was explored via the Kaplan-Meier method., Results: Of 691 included patients, 232 (33.5%) developed complications, including 35 (5.1%) and 197 (28.5%) patients with major and minor complications, respectively. The models showed robust discrimination, yielding an area under the receiver operating characteristic (ROC) curve (AUC) of 0.853 [95% confidence interval (CI): 0.705-0.885] for predicting overall postoperative complication risk and 0.751 (95% CI: 0.727-0.762) specifically for major complication risks. Models predicting minor complications also achieved good performance, with AUCs ranging from 0.78 to 0.89. Survival analyses revealed a significant association between postoperative complications and poor prognosis., Conclusions: Risk stratification models could accurately predict the probability and severity of complications in NSCLC patients following sleeve lobectomy, which may inform clinical decision-making for future patients., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-24-325/coif). C.C. serves as an unpaid Associate Editor-in-Chief of Translational Lung Cancer Research from August 2023 to July 2024. M.B.A. received consulting fees for Astra Zeneca, Merck, Bristol Myers Squibb, Ethicon. R.H.P. reports speaker fees from Medtronic, Medela, AstraZeneca, and AMBU; advisory board memberships for AstraZeneca, MSD, BMS, and Roche. The other authors have no conflicts of interest to declare., (2024 Translational Lung Cancer Research. All rights reserved.)

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., (© 2024. The Author(s).)

Objectives: The study objectives were to describe the compounded complication rate of minimally invasive repair of pectus excavatum, identify predisposing risk factors, and evaluate the optimal timing of correction. Minimally invasive repair of pectus excavatum is the standard treatment for pectus excavatum and consists of 2 invasive procedures, for example, correction with bar insertion followed by bar removal after 2 to 3 years., Methods: A retrospective cohort study identifying children, adolescents, and adults of both genders corrected for pectus excavatum with minimally invasive repair of pectus excavatum between 2001 and 2022. Information on complications related to bar insertion and removal procedures for each individual patient was compiled into a compounded complication rate. Complication severities were categorized according to the Clavien-Dindo classification., Results: A total of 2013 patients were corrected by minimally invasive repair of pectus excavatum with a median age (interquartile range) for correction of 16.6 (5) years. Overall compounded complication rate occurred at a frequency of 16.4%, of which 9.3% required invasive reinterventions (Clavien-Dindo classification ≥IIIa). The complication rate related to bar insertion was 2.6-fold higher compared with bar removal (11.8% vs 4.5%, respectively). Multivariable analysis revealed age (adjusted odds ratio, 1.05; P < .001), precorrection Haller Index (adjusted odds ratio, 1.10; P < .033), and early-phase institutional experience (adjusted odds ratio, 1.59; P < .002) as independent predisposing risk factors. The optimal age of correction was 12 years, and the compounded complication rate correlated exponentially with age with a doubling time of 7.2 years. Complications increased 2.2-fold when the Haller index increased to 5 or more units., Conclusions: Minimally invasive repair of pectus excavatum is associated with a high compounded complication rate that increases exponentially with age and high Haller Index. Consequently, we recommend repair during late childhood and early adolescence, and emphasize the importance of informing patients and relatives about the significant risks of adult correction as well as the need of 2 consecutive procedures taking the complication profile into account before planning surgery., Competing Interests: Conflict of Interest Statement Dr Petersen: Speaker for Medtronic, AMBU, Medelea, and AstraZeneca; Advisory Board: AstraZeneca, MSD, BMS, and Roche. Dr Christensen: Payment or honoraria from AstraZeneca, Bristol Myers, and Novartis. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

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., (© 2023. The Author(s).)

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 mm 2 , 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.

Enhanced recovery after surgery programs with median postoperative hospitalization of 2 days improve outcomes after lung cancer surgery. This article explores nursing care practices for patients with lung cancer who remain hospitalized despite having recovered somatically. Qualitative focus group interviews were conducted with 16 nurses. Ricoeur's phenomenological hermeneutics underpins the methodology applied in this study, and we relied on Benner and Wrubel's theory. The nurses emphasized that the thoughts of patients with a recent lung cancer diagnosis revolve around more than the surgery. Nursing comprises not only practicalities but also attending to patients' stress and their coping with being struck with lung cancer and having undergone surgery. A counterculture emerged to counteract the logic of productivity, indicating that caring as a worthy end in itself may be underestimated in protocol-driven care. Prolonging hospitalization largely depends on clinical judgment. The nurses' aim is not to keep patients in the hospital but to avoid any needless suffering, allowing them to reclaim the primacy of caring., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background and Objective: Pleural infection is associated with significant mortality and morbidity worldwide, with a steadily increasing incidence. We sought to investigate whether video-assisted thoracic surgery (VATS) or thoracotomy provides the best outcomes in the treatment of stage II and III pleural infection as indications remain controversial., Methods: Systematic review of relevant articles from the PubMed database., Key Content and Findings: Nine non-randomized retrospective studies published between 1996 and 2020 with a total of 2,121 patients were included. Results varied between studies, but overall shorter operative and recovery times and greater patient satisfaction were demonstrated using VATS compared with thoracotomy., Conclusions: Although VATS and thoracotomy are viable treatment options for stage II and III pleural infection, VATS has potential advantages in terms of decreased operation time, fewer days with tube drainage, shorter postoperative hospital stay, reduced postoperative pain, increased patient satisfaction with the procedure, and wound appearance. VATS has limitations in the treatment of patients with stage III pleural infection, where delayed surgical referral has been shown to increase the risk of intraoperative conversion to thoracotomy. The data to date implies that debridement by VATS should be proposed as soon as possible in stage II pleural infection and considered in cases of stage III pleural infection., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-928/coif). R.H.P. serves as an unpaid editorial board member of Journal of Thoracic Disease from October 2022 to September 2024. R.H.P. has received a speaker’s fee from Medtronic, AstraZeneca, Ambu and Medela and on the advisory board for AstraZeneca, Bristol-Myers Squibb, Roche and Merck Sharp & Dohme (MSD). T.D.C. has been on the speaker bureaus for AstraZeneca, Bristol-Myers and Novartis and has been in an Advisory Board for AstraZeneca and Sanofi. NMR has received consulting fee from Rocket Medical UK and Cook Medical USA. C.B.L. has received payment for lectures at educational events/symposia/courses organised by AstraZeneca and royalties as author of book chapters/book editor from Munksgaard (publisher). Unpaid, he is ERS TUS training program committee member, ERS Monograph Deputy Chief Editor and a Board Member, Organization of Danish Medical Societies. The other authors have no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Background: Days alive and out of hospital is proposed as a valid and patient-centred quality measure for perioperative care. However, no procedure-specific data exist after pulmonary wedge resection. The aim of this study was to assess the first 90 days alive and out of hospital after video-assisted thoracoscopic surgery wedge resection in an optimized enhanced recovery programme., Methods: A retrospective analysis of prospectively collected data of consecutive patients undergoing enhanced recovery thoracoscopic wedge resections from January 2021 to June 2022 in a high-volume centre was carried out. All factors leading to hospitalization, readmission, and death were evaluated individually. A logistic regression model was used to evaluate predictors. Additionally, a sensitivity analysis was performed., Results: A total of 433 patients were included (21.7% (n = 94) with non-small cell lung cancer, 47.6% (n = 206) with metastasis, 26.8% (n = 116) with benign nodules, and 3.9% (n = 17) with other lung cancers). The median duration of hospital stay was 1 day. The median of postoperative 30 and 90 days alive and out of hospital was 28 and 88 days respectively. Air leak (112 patients) and pain (96 patients) were the most frequent reasons for reduced days alive and out of hospital from postoperative day 1 to 30, whereas treatment of the original cancer or metastasis (36 patients) was the most frequent reason for reduced days alive and out of hospital from postoperative day 31 to 90. Male sex, reduced lung function, longer dimension of resection margin, pleural adhesions, and non-small cell lung cancer were independent risks, confirmed by a sensitivity analysis., Conclusion: Days alive and out of hospital within 90 days after enhanced recovery thoracoscopic wedge resection was only reduced by a median of 2 days, mainly due to air leak and pain., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.)

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., (© 2023. The Author(s).)

Background: There is growing evidence that misdiagnosis contributes to the high mortality rate in lung cancer patients complicated with pulmonary embolism (PE). This current study analyzed predictors of PE in lung cancer patients with lower extremity deep venous thrombosis (DVT) with the aim of personalizing the treatment and management of patients with PE., Methods: This retrospective case-control study included lung cancer patients with DVT at the emergency department of Shanghai Chest Hospital from January 2018 to December 2019. Patients were classified as having DVT with or without PE. The following characteristics were examined, including age, gender, smoking, hypertension, surgical trauma, hyperlipidemia, long-term bedridden status, calf swelling, coronary heart disease, chronic pulmonary disease, DVT location, DVT type, prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen, and D-dimer, and univariate and multivariate analyses were performed., Results: A total of 90 patients with lung cancer and DVT were analyzed, of whom 60% (54/90) had PE. Those variables independently associated to PE were hypertension [odds ratio (OR): 7.883, 95% confidence interval (CI): 2.038-30.495, P=0.003], long-term bedridden status (OR: 4.166, 95% CI: 1.236-14.044, P=0.021), and D-dimer levels (OR: 2.123, 95% CI: 1.476-3.053, P=0.000) were identified as independent risk factors for PE. The cut-off value of the receiver operating characteristic (ROC) curve for predicting PE by presented scoring system according to the risk factors was 1.5 and the area under the curve (AUC) was 0.84 (P<0.001)., Conclusions: Hypertension, being bedridden for an extended period, and elevated serum D-dimer levels were independent risk factors of PE in lung cancer patients with lower extremity DVT. Novel strategies for patient management should be developed to decrease the risk of PE., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-23-346/coif). RHP received speaker fee from Medtronic, AMBU, AstraZeneca, Medela, and serves on the Advisory Board of AstraZeneca, BMS, Roche and MSD. The other authors have no conflicts of interest to declare., (2023 Translational Lung Cancer Research. All rights reserved.)

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., (© 2022 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Objectives: To identify and prioritize technical procedures for simulation-based training to be integrated into the thoracic surgical curriculum., Methods: A 3-round Delphi survey was conducted from February 2022 to June 2022 among 34 key opinion leaders in thoracic surgery from 14 countries worldwide. The 1st round was a brainstorming phase to identify technical procedures that a newly qualified thoracic surgeon should be able to perform. All the suggested procedures were categorized, qualitatively analysed and sent to the 2nd round. The second round investigated: the frequency of the identified procedure at each institution, the number of thoracic surgeons that should be able to perform these procedures, the degree of risk to the patient if the procedure is performed by a non-competent thoracic surgeon and the feasibility of simulation-based education. In the 3rd round, elimination and re-ranking of the procedures from the 2nd round were performed., Results: Response rates in the 3 iterative rounds were 80% (28 out of 34), 89% (25 out of 28) and 100% (25 out of 25) in the 1st, 2nd and 3rd round, respectively. Seventeen technical procedures were included for simulation-based training in the final prioritized list. The top 5 procedures were Video-Assisted Thoracoscopic Surgery (VATS) lobectomy, VATS segmentectomy, VATS mediastinal lymph node dissection, diagnostic flexible bronchoscopy and robotic-assisted thoracic surgery port placement, robotic-assisted thoracic surgery docking and undocking., Conclusions: The prioritized list of procedures represents a consensus of key thoracic surgeons worldwide. These procedures are suitable for simulation-based training and should be integrated in the thoracic surgical curriculum., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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.

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 &lt; 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., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

This report presents the case of a woman successfully treated with thoracoscopic detorsion of the right lung after she was diagnosed with a 180-degree torsion, 6 months after a video-assisted thoracoscopic right upper lobectomy for a stage 1 adenocarcinoma., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

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., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: This study reports the results of an international expert consensus process evaluating the assessment of intraoperative air leaks (IAL) and treatment of postoperative prolonged air leaks (PAL) utilizing a Delphi process, with the aim of helping standardization and improving practice., Methods: A panel of 45 questions was developed and submitted to an international working group of experts in minimally invasive lung cancer surgery. Modified Delphi methodology was used to review responses, including 3 rounds of voting. The consensus was defined a priori as >50% agreement among the experts. Clinical practice standards were graded as recommended or highly recommended if 50-74% or >75% of the experts reached an agreement, respectively., Results: A total of 32 experts from 18 countries completed the questionnaires in all 3 rounds. Respondents agreed that PAL are defined as >5 days and that current risk models are rarely used. The consensus was reached in 33/45 issues (73.3%). IAL were classified as mild (<100 ml/min; 81%), moderate (100-400 ml/min; 71%) and severe (>400 ml/min; 74%). If mild IAL are detected, 68% do not treat; if moderate, consensus was not; if severe, 90% favoured treatment., Conclusions: This expert consensus working group reached an agreement on the majority of issues regarding the detection and management of IAL and PAL. In the absence of prospective, randomized evidence supporting most of these clinical decisions, this document may serve as a guideline to reduce practice variation., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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., (© 2022 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

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., (© The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd.)

Background: Pulmonary large-cell neuroendocrine carcinoma (LCNEC) is a rare subtype of lung cancer with dismal prognosis. Long-term outcomes after primarily video-assisted thoracoscopic surgery (VATS) have not yet been described in LCNEC. This study aims to determine overall survival and recurrence-free survival after VATS as well as to identify prognostic factors for survival and recurrence., Methods: Data were obtained from a prospective institutional database. Kaplan-Meier estimates of overall survival and recurrence-free survival were determined and compared across prognostic factors using log-rank analysis and the Cox proportional hazards model., Results: Data from 82 consecutive patients undergoing surgical resection from 2009 to 2020 were included. All patients underwent surgical resection with curative intent, of whom 96.3% were by a VATS approach. Morbidity was low without any conversions or 30-day mortality. Lobectomy was performed in 87.8% of patients, followed by wedge resection in 4.9% and segmentectomy in 3.7%. No pneumonectomies were performed. Radical resection (R0) was achieved in 97.6%. Thirty-four patients (41.5%) had adjuvant platinum-based chemotherapy and high proportion completed at least four series (76.7%). The mean follow-up was 5.1 years. The 1-year, 3-year, and 5-year overall survival rates were 86%, 54%, and 45%, while the corresponding recurrence-free survival rates were 67%, 45%, and 35%. Advanced age was an independent predictor of poor overall survival (HR 2.08; 95% CI 1.04-4.17; p = 0.038)., Conclusion: A 96.3% VATS rate was feasible in LCNEC and associated with a low morbidity rate and a high compliance with adjuvant chemotherapy. Overall survival and recurrence-free survival was comparable to previous series using thoracotomy., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Use of neoadjuvant immunotherapy agent in advanced stage NSCLC is controversial. Herein, we aim to report on a case series of successful conversion from initial unresectable stage cIIIB NSCLC to radical minimally invasive surgery through immunochemotherapy; with particular attention given to surgical outcomes and survival benefit of surgery., Methods: Fifty-one patients with initial stage cIIIB NSCLC who received PD-1 agents plus platinum-based chemotherapy between May, 2018 to August, 2020 were retrospectively identified. Surgical and oncological outcomes of enrolled patients were collected., Results: Of 31 patients who underwent subsequent resection, 23 (74.2%) patients underwent lobectomy, 1 (3.2%) underwent pneumonectomy, 5 (16.1%) underwent sleeve lobectomy, and 2 (6.5%) with bilobectomy. The median surgical time was 205 minutes (range, 100-520). The average blood loss was 185 (range: 10-1100) ml. Dense adhesions or fibrosis was noted in 15 cases. The median postoperative hospital stay was 6 (range: 3-13) days. No surgical-related mortality was recorded, only 5 patients (16.1%) experienced any postoperative morbidity (no grade 3 complications). Ten patients (32.3%) had major pathological response, with mediastinal down-staging been observed in 22/31 (71.0%) patients. With a median after up of 15.4 months, thirty-one patients that had surgery had relatively longer median DFS/PFS compared to that of either non-responders or responders that without surgery (27.5 vs. 4.7 vs. 16.7 months, respectively)., Conclusions: Radical surgery after chemoimmunotherapy in initial unresectable stage IIIB NSCLC seems to be safe with low surgical-related mortality and morbidity, and was favorably associated with longer DFS/PFS compared to those without surgery., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

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., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

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., (© 2021. The Author(s).)

Background: The reporting of surgical techniques is of mixed quality, with most at a very minimal level. Reporting guidelines that could be applied to guide surgical technique reporting vary in methodology for development, discipline coverage, dimension coverage and detail requested. However, a scoping review that could indicate the gaps and efforts needed in surgical technique reporting guidelines is lacking and warranted. This study aims to design a methodological rigour protocol to guide the development of a scoping review of surgical technique reporting guidelines., Methods: This protocol is designed following the 2020 manual proposed by the Joanna Briggs Institute. To further ensure the soundness of the protocol, we also included multidisciplinary professionals (including methodologists, clinicians, and journal editors) to refine the protocol., Discussion: Seven key steps for developing the scoping review are identified and presented in detail, including (I) identifying the research questions; (II) inclusion criteria; (III) search strategy; (IV) source of evidence selection; (V) data extraction; (VI) analysis of the evidence; and (VII) presentation of the results. Guided by this protocol, the subsequent scoping review will inform us the overview of surgical technique reporting guidelines and precisely guide our direction and next steps in improving surgical technique reporting guidelines., Trial Registration: This protocol is not registered as the PROSPERO database only accepts registration of systematic review protocols while does not accept registration of scoping review protocols., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/gs-21-311). AF declares a pending patent (PCT/IT2018/00000S) related to the project. ADLS receives Speaker’s honoraria from Medtronic and is the consultancy of Medela. FD declares a licensed patent (Italian patent application “TO2013A000038”) related to the project. RHP receives Speaker fee from Medtronic and Advisory Board member AstraZeneca. KZ, GSL, XT and SDW are staff of AME publishing company (the publisher of Gland Surgery). The other authors have no conflicts of interest to declare., (2021 Gland Surgery. All rights reserved.)

Objective: The aim of this study was to determine overall survival and recurrence-free survival after resection of bronchopulmonary carcinoids by means of predominantly minimally invasive surgery and lung-sparing resections. In addition, we aimed to identify prognostic factors for overall survival., Materials and Methods: Retrospective review of consecutive patients operated for bronchopulmonary carcinoids between January 2009 and October 2020 identified from a prospectively collected database., Results: A total of 236 patients representing 240 cases of bronchopulmonary carcinoids were included. Of these, 212 (88.3 %) were typical carcinoids, while 28 (11.7 %) were atypical carcinoids. A Video-Assisted Thoracoscopic Surgery (VATS) approach was used in 75 % of cases. There was no 30-day mortality. The median follow-up was 5.6 years for overall survival and 4.7 years for recurrence-free survival. 5- and 10-year overall survival rates were 89 % and 71 %, while 5- and 10-year recurrence-free survival rates were 84 % and 71 %. Patients with atypical carcinoids had significantly reduced overall survival and recurrence-free survival rates (HR 3.4; 95 % CI 1.5-7.6; p = 0.003 and HR 5.4; 95 % CI 2.6-11.4; p < 0.001). Independent predictors of overall survival included atypical carcinoid (HR 2.7; 95 % CI 1.2-6.0; p = 0.018) and age > 60 years (HR 2.9; 95 % CI 1.2-7.3; p = 0.021)., Conclusion: Surgery for bronchopulmonary carcinoids by means of predominantly VATS and lung-sparing resections provides favorable long-term survival. Atypical carcinoids and age > 60 years are independent predictors of poor overall survival., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: what is the optimal level of suction on digital chest drainage devices following pulmonary lobectomy? Altogether 367 papers were found using the reported search, of which 4 randomized controlled trials using digital chest drainage devices represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The new digital drainage systems enhance early mobilization as recommended in the enhanced recovery after surgery programme. There is, however, no consensus on the optimal level of suction to apply after pulmonary lobectomy. This is especially the case for digital drainage devices. Surgeon preference will likely continue to guide practice, until the evidence gives clear-cut recommendations. According to the current data, a low suction reduces total fluid drainage and perhaps air leak duration compared to higher suction levels in both video-assisted thoracoscopic surgery and open pulmonary lobectomies using digital drainage devices, although the evidence is not overwhelming., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: A specific risk-stratification tool is needed to facilitate safe and cost-effective approaches to the prophylaxis of acute pulmonary thromboembolism (PTE) in lung cancer surgery patients. This study aimed to develop and validate a simple nomogram model for the prediction of PTE after lung cancer surgery using readily obtainable clinical characteristics., Methods: A total of 14,427 consecutive adult patients who underwent lung cancer surgery between January 2015 and July 2018 in our institution were retrospectively reviewed. Included in the cohort were 136 patients who developed PTE and 544 non-PTE patients. The patients were randomly divided into the derivation group (70%, 95 PTE patients and 380 non-PTE patients) and the validation group (30%, 41 PTE patients and 164 non-PTE patients). A nomogram model was developed based on the results of multivariate logistic analysis in the derivation group. The cut-off values were defined using Youden's index. The prognostic accuracy was measured by area under the curve (AUC) values., Results: In the derivation group, multivariate logistic analysis was carried out to evaluate the risk score. The risk assessment model contained five variables: age [95% confidence interval (CI): 1.008-1.083, P=0.016], body mass index (95% CI: 1.077-1.319, P=0.001), operation time (95% CI: 1.002-1.014, P=0.008), the serum level of cancer antigen 15-3 (CA15-3) before surgery (95% CI: 1.019-1.111, P=0.005), and the abnormal results of compression venous ultrasonography before surgery (95% CI: 2.819-18.838, P<0.001). All of them were independent risk factors of PTE. To simplify the risk assessment model, a nomogram model was established, which showed a good predictive performance in the derivation group (AUC 0.792, 95% CI: 0.734-0.853) and in the validation group (AUC 0.813, 95% CI: 0.737-0.890)., Conclusions: A high-performance nomogram was established on the risk factors for PTE in patients undergoing lung cancer surgery. The nomogram could be used to provide an individual risk assessment and guide prophylaxis decisions for patients. Further external validation of the model is needed in lung cancer surgery patients in other clinical centers., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tlcr-21-109). RHP receive speaker fee from Medtronic and Advisory Board AstraZeneca. The authors have no other conflicts of interest to declare., (2021 Translational Lung Cancer Research. All rights reserved.)

Within the last decade, the number of technical procedures in respiratory medicine and thoracic surgery has grown and created a higher demand for effective and evidence-based education. Today, trainees are often allowed to perform procedures unsupervised on patients after obtaining a course certificate from a theoretic course and having performed a fixed number of supervised procedures. However, these methods do not ensure adequate competence. Well-structured and effective educational programmes including validated tests are needed to reduce economic expenses, optimize time spend, and ensure patient safety. The aim of this article is to summarize current state of educational strategies for technical procedures within respiratory medicine and thoracic surgery. Thus, to discuss future recommendations for curriculum development and assessment of competences based on Kern's framework. The approach by Kern consists of six topics, which needs to be considered and evaluated and in order to educate physicians and surgeons most effective and evidence-based. We present a practical guide contributing to future educators' considerations on (I) problem identification and general needs assessment, (II) targeted needs assessment, (III) goals and objectives, (IV) educational strategies, (V) implementation, and finally (VI) evaluation and feedback., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd.2019.02.39). The series “Training in Pulmonary Medicine and Surgery” was commissioned by the editorial office without any funding or sponsorship. RH Petersen serves as an unpaid editorial board member of Journal of Thoracic Disease from Sep 2018 - Aug 2022. CB Laursen reports personal fees from GE, outside the submitted work. The authors have no other conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

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., (© 2020 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Background: The aim of this systematic review and meta-analysis was to determine the efficacy and safety of omitting chest drains compared to routine chest drain placement after video-assisted thoracoscopic surgery (VATS)., Methods: Five bibliographic databases, ClinicalTrials.gov and PROSPERO were comprehensively searched from inception to July 29, 2020 (no language restrictions). Postoperative outcomes were extracted and synthesized complying with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Risk of bias (RoB) including non-reporting bias, heterogeneity, and sensitivity were assessed. Subgroup analyses were performed based on study design., Results: Of 7,166 identified studies, 10 studies [four randomized controlled trials (RCTs) and six non-RCTs] with 1,079 patients were included. There were 561 patients in the no chest drain group (NCD) and 518 patients in the standard chest drain group (CD). In pairwise analysis the NCD group had significant shorter length of stay (LOS) [weighted mean difference (WMD) -1.53 days, P<0.001], less postoperative pain scores (WMD -1.09, P=0.002), but higher risk of drain insertion or thoracocentesis [risk radio (RR) 3.02, P=0.040]. There were no significant differences on the incidence of minor pneumothorax (RR 1.77, P=0.128), minor pleural effusion (RR 1.88, P=0.219), minor subcutaneous emphysema (RR 1.37, P=0.427) or pneumonia (RR 0.53, P=0.549). No mortality was observed in either group during the observation period (in-hospital or 30-day mortality)., Conclusions: Omitting chest drains in selected patients after VATS seems effective leading to enhanced recovery with shorter length of postoperative stay and less pain but with a higher risk of drain insertion or thoracocentesis. However, a major part of the evidence comes from observational studies with high RoB. Further RCTs are needed to improve the current evidence., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-20-3130). RH Petersen reports personal fees from Medtronic, personal fees from Astra Zeneca, outside the submitted work. RHP serves as an unpaid editorial board member of Journal of Thoracic Disease from Sep 2020 to Aug 2022. BLH reports a speaker’s fee from Medela Healthcare, outside the submitted work. The other authors have no conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

Background: Lung cancer has changed significantly during the past 2 decades in its epidemiology and treatment. This retrospective analysis used data from 7 major areas of China over 10 years to evaluate clinicopathologic and surgical treatment trends of lung cancer in China during the past decade., Methods: Data from 7184 patients with primary lung cancer who were treated between 2005 and 2014 in 8 provinces of China were retrospectively collected. Their clinicopathologic features and surgical treatment information were recorded. Simple linear regression models and the Cochrane-Armitage trend test were used to assess temporal trends., Results: The proportion of female patients (from 57.4% to 59.6%; P < .001) and nonsmoking patients (from 37.1% to 48.9%; P < .001) and of patients with a family history of malignant tumors (from 7.0% to 11.5%; P < .001) increased significantly. The percentage of adenocarcinomas increased significantly (from 36.4% to 53.5%; P < .001), with a decrease in squamous cell carcinomas (from 45.4% to 34.4%; P < .001). After 2008, the application of minimally invasive surgery significantly increased in China (from 2.4% in 2008 to 34.4% in 2014; P < .001), with a decline in the rate of conversion to open operation (from 14.3% in 2008 to 4.8% in 2014; P = .146) and an increase in the proportion of systematic mediastinal lymph node dissection (from 50.0% in 2008 to 84.1% in 2014; P = .001)., Conclusions: This study investigated recent 10-year trends in the clinicopathologic features and surgical treatment of lung cancer in China and found significant important changes. These findings provide valuable information and evidence for the future control of the disease in China., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

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.

Background: The optimal treatment for stage IIIA-N2 non-small cell lung cancer (NSCLC) is controversial. We aimed to address this important issue through a Bayesian network meta-analysis., Methods: We performed a search of electronic databases for randomized controlled trials comparing the following treatments: surgery, radiotherapy, chemotherapy, and their multiple combinations before March 25, 2018. Pooled data on overall survival and treatment-related deaths were analyzed within the Bayesian framework., Results: Eighteen eligible trials reporting 13 treatments were included. In terms of overall survival, neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy or radiotherapy, which tended to be consistent (hazard ratio [HR] 1.14, 95% credible interval [CrI] 0.21 to 5.93), ranked superior to other treatments. Notably, neoadjuvant chemotherapy followed by surgery and adjuvant radiotherapy was significantly more effective in prolonging survival than surgery alone (HR 0.38, 95% CrI 0.18 to 0.81), surgery plus adjuvant radiotherapy (HR 0.51, 95% CrI 0.29 to 0.92) and potentially surgery plus adjuvant chemotherapy (HR 0.49, 95% CrI 0.23 to 1.05). Overall, with 29% as the highest possibility of causing the fewest treatment-related deaths, neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy or radiotherapy was the safest treatment option., Conclusions: Neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy or radiotherapy has the greatest possibility to be the optimal treatment with the best overall survival and fewest treatment-related deaths for stage IIIA-N2 NSCLC., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

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.

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., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)