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Background: Ischemia-reperfusion associated with prolonged warm ischemia during donation after circulatory death (DCD) induces acute lung injury. The objective of this study was to combine ex vivo lung perfusion (EVLP) and a heat shock protein-90 inhibitor (HSP90i) to recondition DCD organs and prevent primary graft dysfunction., Methods: Pigs (55 to 65 kg) were anesthetized, ventilated, and hemodynamically monitored. Cardiac arrest was induced with potassium chloride, and animals were left nonventilated for 2 hours. Lungs were procured and perfused in an EVLP platform for 4 hours by using a cellular perfusate. In the study group, the perfusate contained HSP90i and its transport vehicle (n = 4). In the control group, the perfusate contained only the transport vehicle (n = 4). Gas exchange, airway pressures, and compliance were measured. Pulmonary edema was assessed by bronchoscopy and weight measurement. Lung biopsy samples were obtained for histologic analyses and protein expression measurements., Results: The use of HSP90i reduced lung weight gain to 8.4 ± 3.4% vs 26.6 ± 6.2% in the control group (P < .05). There was reduced edema formation. The ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen at the end of EVLP was 423 ± 65 in the study group vs 339 ± 25 mm Hg in the control group, but this difference was not statistically significant. Lactate metabolism, pulmonary vascular resistance, and pulmonary arterial pressure improved during EVLP with the use of the HSP90i., Conclusions: The use of HSP90i with EVLP improves the lung reconditioning process. Further research is required to confirm whether these findings translate to benefit once transplanted and observed in vivo. Successful pharmacologic inhibitors may expand the donor pool in the context of DCD donors., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: To meet the need for competency assessment in thoracic surgery education, we developed and tested an instrument to assess trainees' ability to perform anatomic lung resection for cancer., Methods: The Thoracic Competency Assessment Tool-Anatomic Resection for Lung Cancer (TCAT-ARC) was developed through a multistep process involving logical analysis, expert review, and simulation-based and clinical pilot testing. Validity evidence was gathered during a 6-month clinical study of trainees performing anatomic lung resections and assessments of practicing surgeons. Feedback was gathered via post-encounter questionnaires., Results: A 35-item instrument was developed and was tested in the clinical validation study. Seven trainees in 4 North American institutions participated and completed 64 anatomic lung resections. Reliability was high (α = 0.93). Interobserver reliability (k = 0.73) and correlation with an existing global competency scale (k = 0.68) were moderately high. Item analysis revealed the most difficult and discriminatory items, which matched well with a conceptual understanding of lung resection. Both trainees and assessors viewed the instrument as highly educationally effective and user-friendly. Practicing surgeons outperformed trainees., Conclusions: The TCAT-ARC demonstrated early evidence of validity and reliability in assessing performance of anatomic lung resection. The instrument may be most useful early in training and as a means for providing fine-grained formative feedback about which steps have been mastered and which still require improvement. The TCAT-ARC may be used in training programs to aid in the development of trainees' competency and as a part of an aggregate assessment of trainees' overall mastery of the procedure and readiness for independent practice., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: To develop and evaluate a surgical trainee competency assessment instrument for invasive mediastinal staging, including cervical mediastinoscopy and endobronchial ultrasound (EBUS), a comprehensive instrument was developed, the Thoracic Competency Assessment Tool-Invasive Staging (TCAT-IS), using expert review and simulated and clinical pilot-testing., Methods: Validity and reliability evidence were collected, and item analysis was performed. Initially, a 27-item instrument was developed, which underwent expert review with members of the Canadian Association of Thoracic Surgeons (n = 86) in 2014 to 2015 (response rate, 57%). TCAT-IS was refined to 29 items in 4 competency areas: preoperative, general operative, mediastinoscopy, and EBUS. Further refinements were made based on simulated use. The final version was then used to assess competency of 5 thoracic trainees performing invasive mediastinal staging in live patients., Results: Participants were assessed during 20 mediastinoscopy and 8 EBUS procedures, with 47 total assessments completed. Reliability (Cronbach's alpha = 0.94), interrater reliability (κ = 0.80), and correlation with an established global competency scale (κ = 0.75) were high. The most difficult items were "set up and adjust EBUS equipment" and "identify vascular anatomy (EBUS)." Feedback questionnaires from trainees (response rate, 80%) and surgeons (response rate, 100%) were consistently positive regarding user friendliness, utility as an assessment tool, and educational benefit. Participants believed the tool "facilitated communicating feedback to the trainee with specific areas to work on.", Conclusions: TCAT-IS is an effective tool for assessing competence in invasive staging and may enhance instruction. This initial test establishes early validity and reliability evidence, supporting the use of TCAT-IS in providing structured, specific, formative assessments of competency., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Assessment of mediastinal lymph nodes is integral in staging patients with non-small cell lung cancer (NSCLC). This study delineated the lymph node staging practices of Canadian thoracic surgeons in patients with potentially resectable NSCLC., Methods: A questionnaire was distributed to Canadian Association of Thoracic Surgeons members (n = 86). Items addressed the use of imaging, thresholds/methods for preoperative invasive staging, and intraoperative node staging. Comparison was made against Canadian, American, and European guidelines., Results: Forty-seven surgeons (55%) responded. Although most stated they derived practices from published guidelines, a significant proportion did not reflect those recommendations. Most respondents ordered a positron emission tomography scan for every patient (87.2%), and the same proportion (87.2%) performed invasive staging selectively, with a wide range of indications. The most common thresholds were suspicious nodes on imaging (80.5%), tumor within the central third of the lung (67.5%), and tumor exceeding 3 cm (34.2%). Endobronchial ultrasound, alone or with endoscopic ultrasound, was selected as the initial staging procedure of choice by 47.9%, and 43.5% selected mediastinoscopy first. Of surgeons selecting mediastinoscopy, 61.9% reported some barriers to performing endobronchial ultrasound. There was variability, between surgeons and between lobes, in which nodes respondents harvested intraoperatively for given lobectomies. A sizeable minority (13%) did not routinely harvest lymph nodes intraoperatively., Conclusions: Determining the appropriate treatment and prognosis of NSCLC patients relies on proper staging. Significant variability exists in node staging practices in Canada as well as divergence from guidelines. This may result in understaging or overstaging patients and inappropriate care., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Neoplastic involvement of the mediastinum can contribute to both airway and esophageal pathology. That can manifest as combined esophageal and airway stenosis, or tracheobronchoesophageal fistula. Conventional palliative treatment of these problems consists of endoluminal stent insertion. The double stenting approach consists of insertion of a tracheobronchial and an esophageal stent in parallel and allows concomitant symptomatic relief of both the airway and esophageal pathology., Methods: The study consists of a retrospective case series of patients who underwent a double stenting procedure for concomitant airway and esophageal disease between August 2009 and September 2014. The type of airway stent chosen was determined based on the pathology and the level of the lesion (simple tubular in the mid trachea or mainstem bronchus, Y-stent for carina)., Results: Thirty-nine patients were treated using the double stenting approach during a combined procedure over 5 years: 15 patients with tracheobronchoesophageal fistula and 24 with stenosis. Immediate relief of symptoms, defined as resuming oral intake and breathing without an external tracheal device, was observed in 25 patients (64%). Thirty-two patients (82%) were discharged from hospital, and 7 patients died in hospital (18%). Of these 7 deaths, 6 patients died of pulmonary complications. Inhospital complications occurred in 11 patients (28%). Of the patients discharged from the hospital, 14 died during a mean follow-up period of 54 days. Mean and median survival were 49 and 24 days, respectively (range, 1 to 448), and median hospital stay was 3 days (range, 1 to 46)., Conclusions: Treatment of combined airway and esophageal pathology using a double stenting approach is safe, feasible, provides reasonable immediate palliation of symptoms, and is associated with acceptable morbidity. It is a palliative procedure that allows for early hospital discharge of patients who are diagnosed with an incurable malignancy., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Patient selection for surgery after neoadjuvant therapy for locally advanced non-small cell lung cancer depends on accurate restaging of mediastinal (N2) lymph nodes. Our objective is to assess the accuracy of endobronchial ultrasound (EBUS) for restaging N2 lymph nodes after neoadjuvant therapy., Methods: This is a retrospective review of patients with non-small cell lung cancer who underwent staging with repeat computed tomography and positron emission tomography and had restaging EBUS for sampling of N2 lymph nodes. Endobronchial ultrasound was performed for suspicious nodes in stations 2R, 2L, 4R, 4L, and 7. Selected patients who were N2-negative underwent thoracotomy with complete thoracic lymphadenectomy., Results: There were 32 patients with N2 disease who underwent preoperative chemotherapy or radiotherapy, or both, and subsequently had restaging EBUS. There were 3 patients who had recalcitrant N2 nodal disease detected by EBUS. There were 5 patients with pulmonary function or comorbidities that were prohibitive for surgery. Of the remaining 24 patients with negative EBUS, 3 underwent mediastinoscopy and 2 had recalcitrant N2 disease. The remaining 22 patients underwent thoracotomy. Recalcitrant N2 disease was noted in 1 patient at thoracotomy in the EBUS-assessable nodal stations. Thus EBUS was falsely negative in 3 patients. The sensitivity and negative predictive value of restaging EBUS were 50% and 88%, respectively., Conclusions: Restaging EBUS is relatively accurate at predicting the absence of metastatic disease in N2 mediastinal lymph node in patients who underwent neoadjuvant therapy for non-small cell lung cancer., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The primary objective of this study was to evaluate our experience using a completely portal (no access incision) robotic pulmonary lobectomy or segmentectomy., Methods: This was a retrospective review of a consecutive series of patients., Results: From February 2010 until October 2013, 862 robotic operations were performed by 1 surgeon. Of these, 394 were for a planned anatomic pulmonary resection, comprising robotic lobectomy in 282, robotic segmentectomy in 71, and conversions to open in 41 (10 for bleeding, 1 patient required transfusion; and no conversions for bleeding in the last 100 patients). Indications were malignancy in 88%. A median of 17 lymph nodes were removed. Median hospital stay was 2 days. Approximate financial data yielded: median hospital charges, $32,000 per patient (total, $12.6 million); collections, 23.7%; direct costs, $13,800 per patient; and $4,750 profit per patient (total, $1.6 million). Major morbidity occurred in 9.6%. The 30-day operative mortality was 0.25%, and 90-day mortality was 0.5%. Patients reported a median pain score of 2/10 at their 3-week postoperative clinic visit., Conclusions: Robotic lobectomy for cancer offers outstanding results, with excellent lymph node removal and minimal morbidity, mortality, and pain. Despite its costs, it is profitable for the hospital system. Disadvantages include capital costs, the learning curve for the team, and the lack of lung palpation. Robotic surgery is an important tool in the armamentarium for the thoracic surgeon, but its precise role is still evolving., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)