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Objectives: To determine safety and survival outcomes associated with lobectomy, segmentectomy and wedge resection for early-stage lung cancer by quiring the French population-based registry EPIdemiology in THORacic surgery (EPITHOR)., Methods: Retrospective analysis of 19 452 patients with stage c IA lung carcinoma who underwent lobectomy, segmentectomy or wedge resection between 2016 and 2022 with curative-intent. Main outcome measures were 90-day mortality and 5-year overall survival estimates. Proportional hazards regression and propensity score matching were used to adjust outcomes for key patient, tumour and practice environment factors., Results: The treatment distribution was 72.2% for lobectomy, 21.5% for segmentectomy and 6.3% for wedge. Unadjusted 90-day mortality rates were 1.6%, 1.2% and 1.1%, respectively (P = 0.10). Unadjusted 5-year overall survival estimates were 80%, 78% and 70%, with significant inter-group survival curves differences (P < 0.0001). Multivariable proportional hazards regression showed that wedge was associated with worse overall survival [adjusted hazard ratio (AHR), 1.23 (95% confidence interval 1.03-1.47); P = 0.021] compared with lobectomy, while no significant difference was disclosed when comparing segmentectomy to lobectomy (1.08 [0.97-1.20]; P = 0.162). The three-way propensity score analyses confirmed similar 90-day mortality rate for wedge resection and segmentectomy compared with lobectomy (hazard ratio: 0.43; 95% confidence interval 0.16-1.11; P = 0.081 and 0.99; 0.48-2.10; P = 0.998, respectively), but poorer overall survival (1.45; 1.13-1.86; P = 0.003 and 1.31; 1-1.71; P = 0.048, respectively)., Conclusions: Wedge resection was associated with comparable 90-day mortality but lower overall survival when compared to lobectomy. Overall, all types of sublobar resections may not offer equivalent oncologic effectiveness in real-world settings., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: There is a lack of evidence on whether perioperative outcomes differ in obese patients after video-assisted thoracic surgery (VATS) or open lobectomy. We queried the European Society of Thoracic Surgeons database to assess morbidity and postoperative length of hospital stay in obese patients submitted to VATS and open pulmonary lobectomy for non-small-cell lung cancer., Methods: We collected all consecutive patients from 2007 to 2021 submitted to lobectomy through VATS or thoracotomy with a body mass index greater than or equal to 30. An intention-to-treat analysis was carried out. Primary outcomes were morbidity rate, mortality and postoperative length of stay (LOS). Differences in outcomes were assessed through univariable, multivariable-adjusted and propensity score-matched analysis., Results: Out of a total of 78 018 patients submitted to lung lobectomy, 13 999 cases (17.9%) were considered in the analysis, including 5562 VATS lobectomies and 8437 thoracotomy lobectomies. The VATS group showed a lower complication rate (23.2% vs 30.2%, P < 0.001), mortality (0.8% vs 1.5%, P < 0.001) and postoperative LOS (median 5 vs 7 days, P < 0.001). After propensity score matching, the VATS approach confirmed a lower complication rate (24.7% vs 29.7%, P = 0.002) and postoperative LOS (median 5 vs 7 days, P < 0.001). Moreover, these results were consistently observed when analyzing the severe obese subgroup (body mass index 35-39.9) and morbid obese subgroup (body mass index ≥40)., Conclusions: In obese patients with non-small cell lung cancer, VATS lobectomy was found to be associated with improved postoperative outcomes than open lobectomy. Consequently, it should be considered the approach of choice for the Obese population., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The General Data Protection Regulation (GDPR), enacted in the European Union in 2018, has significantly transformed the landscape of personal data management and protection. This article provides an overview of GDPR's impact, focusing on its applicability, fundamental principles and influence on data management practices, particularly within the European Society of Thoracic Surgeons (ESTS) database. GDPR's reach extends to all entities collecting and processing personal data of European Union residents, regardless of their location. It encompasses various data types, emphasizing meticulous handling and protection of identifiable information. Special categories of data, such as health and sensitive attributes, require even more stringent protection. The regulation sets legal, fair and transparent data processing principles, emphasizing accuracy, purpose limitation and data minimization. It also stresses accountability, leading to the appointment of Data Protection Officers and significant penalties for non-compliance. The ESTS database, designed to enhance thoracic surgical research and care, collects data on European procedures. It follows GDPR principles by pseudonymizing data, ensuring secure data transmission and providing clear instructions for data submission. The database contributes to research, policymaking and practice improvement in thoracic surgery by offering a comprehensive dataset for analysis. Here, we aim to shed light on the complexities of GDPR implementation and emphasize the need for comprehensive data management strategies to ensure compliance and enhance privacy protection with the contribution to the ESTS database. GDPR compliance comes with challenges, including potential human dignity and privacy rights violations. Data breaches can result in unauthorized disclosures, and non-compliance can lead to substantial fines and reputational damage. The implementation of GDPR encourages organizations to prioritize ethical data practices, security measures and transparent data handling. In conclusion, GDPR has revolutionized personal data protection by emphasizing accountability, transparency and individual rights. It has impacted organizations globally, promoting responsible data management practices. Adhering to GDPR ensures privacy protection, trust-building and overall enhancement of data management in today's data-driven environment., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The clinical profile and outcomes of patients with Coronavirus Disease 2019 (COVID-19) who require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or veno-arterial-venous extracorporeal membrane oxygenation (VAV-ECMO) are poorly understood. We aimed to describe the characteristics and outcomes of these patients and to identify predictors of both favourable and unfavourable outcomes., Methods: ECMOSARS is a multicentre, prospective, nationwide French registry enrolling patients who require veno-venous extracorporeal membrane oxygenation (ECMO)/VA-ECMO in the context of COVID-19 infection (652 patients at 41 centres). We focused on 47 patients supported with VA- or VAV-ECMO for refractory cardiogenic shock., Results: The median age was 49. Fourteen percent of patients had a prior diagnosis of heart failure. The most common aetiologies of cardiogenic shock were acute pulmonary embolism (30%), myocarditis (28%) and acute coronary syndrome (4%). Extracorporeal cardiopulmonary resuscitation (E-CPR) occurred in 38%. In-hospital survival was 28% in the whole cohort, and 43% when E-CPR patients were excluded. ECMO cannulation was associated with significant improvements in pH and FiO2 on day 1, but non-survivors showed significantly more severe acidosis and higher FiO2 than survivors at this point (P = 0.030 and P = 0.006). Other factors associated with death were greater age (P = 0.02), higher body mass index (P = 0.03), E-CPR (P = 0.001), non-myocarditis aetiology (P = 0.02), higher serum lactates (P = 0.004), epinephrine (but not noradrenaline) use before initiation of ECMO (P = 0.003), haemorrhagic complications (P = 0.001), greater transfusion requirements (P = 0.001) and more severe Survival after Veno-Arterial ECMO (SAVE) and Sonographic Assessment of Intravascular Fluid Estimate (SAFE) scores (P = 0.01 and P = 0.03)., Conclusions: We report the largest focused analysis of VA- and VAV-ECMO recipients in COVID-19. Although relatively rare, the need for temporary mechanical circulatory support in these patients is associated with poor prognosis. However, VA-ECMO remains a viable solution to rescue carefully selected patients. We identified factors associated with poor prognosis and suggest that E-CPR is not a reasonable indication for VA-ECMO in this population., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: For centrally located lung tumours, sleeve lobectomy is preferred over pneumectomy. We report on the surgical practices and perioperative outcomes of sleeve resections based on data from the European Society of Thoracic Surgeons database., Methods: We retrieved data of patients undergoing sleeve lobectomy or bilobectomy from 2007 to 2021. We evaluated baseline characteristics, surgical approach, neoadjuvant treatments, morbidity and postoperative outcomes of open and video-assisted thoracoscopic surgery (VATS) procedures., Results: In total, 1652 patients (median age: 63 years; females/males: 446/1206) underwent sleeve lobectomy (n = 1536) or bilobectomy (n = 116) by open thoracotomy (n = 1491; 90.2%) or VATS (n = 161; 9.8%) with a thoracotomy conversion rate of 21.1% (n = 34); 398 (24.1%) patients received neoadjuvant treatment. Overall morbidity and 30-day mortality were 40.6% and 2.2%, respectively. Bronchial anastomotic complications occurred in 29 patients (1.8%) with conservative treatment in 6 cases (20.7%) and operative management in 23 (79.3%). On multivariable analysis, factors related to the elevated risk of cardiopulmonary complications were body mass index &lt; 20 [odds ratio (OR): 2.26; P &lt; 0.001] and bilobectomy (OR : 2.28, P &lt; 0.001). Age &lt;60 years (OR: 0.71, P = 0.013), female sex (OR: 0.54, P &lt; 0.001) and VATS (0.64, P &lt; 0.001) were associated with decreased risk. Neoadjuvant treatment was not associated with increased risks of cardiopulmonary complications (OR: 1.05; P = 0.664). Compared to open thoracotomy, VATS was associated with significantly decreased overall morbidity (30.4% vs 41.7%, P = 0.006) and length of stay (median: 5 days vs 8 days; P &lt; 0.001)., Conclusions: Sleeve lobectomies can be safely performed after neoadjuvant treatment. The VATS approach fosters shorter length of stay and decreased morbidity., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of this study was to analyse the outcomes of an international cohort of patients affected by Masaoka stage III thymic epithelial tumours with vascular involvement and treated by surgery., Methods: Study design was the observational multicentre retrospective cohort study. Data were extracted from the European Society of Thoracic Surgeons thymic database; additional variables were collected. Inclusion criteria were as follows: stage III (Masaoka-Koga) thymic epithelial tumours; surgery with radical intention; clinical or pathological great vessels involvement; and radiologically suspected or diagnosed intraoperatively. Outcome items were analysed., Results: Sixty-five patients submitted to surgery from 2001 to 2017 fulfilled inclusion criteria. Thymoma and thymic carcinoma patients did not differ for demographics and clinical characteristics. The majority of great vessel treated were superior vena cava or innominate veins (72.3%). Eleven patients (16.9%) had postoperative cardiopulmonary complications; vascular stenosis was observed in 3 patients (4.6%). The multivariable Cox analysis for disease-free survival showed an increased hazard of recurrence for thymic carcinoma (hazard ratio = 3.59; 95% confidence interval: 1.66-7.78, P = 0.001). The 1-, 3-, 5- and 10-year overall survival rates were 0.86, 0.84, 0.81, and 0.53, respectively. There was no significant difference in overall survival according to resection status or between thymoma and thimic carcinoma. The univariable Cox regression model did not show an increased hazard of death for myasthenic patients considering all resection status and for patients who received neoadjuvant therapy., Conclusions: We observed that clinical outcomes of patients treated for stage III thymic epithelial tumours with vascular involvement are satisfactory suggesting to increase the confidence in dealing with these complex surgeries. Complete resection should be achieved, even though extensive vascular reconstructions are required., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Intraoperative conversion from video-assisted thoracic surgery (VATS) to thoracotomy may occur during anatomical lung resection. The objectives of the present study were to identify risk factors for intraoperative conversion and to develop a predictive score., Methods: We performed a multicentre retrospective analysis of French thoracic surgery departments that contributed data on anatomical lung resections to the Epithor database over a 10-year period (from January-2010 to December-2019). Using univariate and multivariate logistic regression analyses, we determined risk factors for intraoperative conversion and elaborated the Epithor conversion score (ECS). The ECS was then validated in a cohort of patients operated on between January- and June-2020., Results: From January-2010 to December-2019, 210,037 patients had been registered in the Epithor database. Of these, 55,030 had undergone anatomical lung resection. We excluded patients who had upfront a thoracotomy or robotic-assisted thoracoscopic surgery (n = 40,293) and those with missing data (6,794). Hence, 7943 patients with intent-to-treat VATS were assessed: 7100 with a full VATS procedure and 843 patients with intraoperative conversion to thoracotomy (conversion rate: 10.6%). Thirteen potential risk factors were identified among patients' preoperative characteristics and planned surgical procedures and were weighted accordingly to give the ECS. The score showed acceptable discriminatory power (area under the curve: 0.62 in the development cohort and 0.64 in the validation cohort) and good calibration (P = 0.23 in the development cohort and 0.30 in the validation cohort)., Conclusions: Thirteen potential preoperative risk factors were identified, enabling us to develop and validate the ECS-an easy-to-use, reproducible tool for estimating the risk of intraoperative conversion during VATS., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Resection of thymic tumours including the removal of both the tumour and the thymus gland (thymothymectomy; TT) is the procedure of choice and is recommended in most relevant articles in the literature. Nevertheless, in recent years, some authors have suggested that resection of the tumour (simple thymomectomy; ST) may suffice from an oncological standpoint in patients with early-stage thymoma who do not have myasthenia gravis (MG) (non-MG). The goal of our study was to compare the short- and long-term outcomes of ST versus TT in non-MG early-stage thymomas using the European Society of Thoracic Surgeons thymic database., Methods: A total of 498 non-MG patients with pathological stage I thymoma were included in the study. TT was performed in 466 (93.6%) of 498 patients who had surgery with curative intent; ST was done in 32 (6.4%). The completeness of resection, the rate of complications, the 30-day mortality, the overall recurrence and the freedom from recurrence were compared. We performed crude and propensity score-adjusted comparisons by surgical approach (ST vs TT)., Results: TT showed the same rate of postoperative complications, 30-day mortality and postoperative length of stay as ST. The 5-year overall survival rate was 89% in the TT group and 55% in the ST group. The 5-year freedom from recurrence was 96% in the TT group and 79% in the ST group., Conclusion: Patients with early-stage thymoma without MG who have a TT show significantly better freedom from recurrence than those who have an ST, without an increase in postoperative morbidity rate., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The American College of Chest Physicians functional guidelines classify patients with predicted postoperative forced expiratory volume in 1 s or predicted postoperative carbon monoxide lung diffusion capacity <60% and with maximal oxygen consumption (VO2max) between 10 and 20 ml/kg/min in a heterogeneous category broadly defined as 'moderate risk' with variable morbidity and mortality. Data to support this statement are lacking. Using the European Society of Thoracic Surgeons database, our goal was to test this definition by evaluating the morbidity and mortality of those patients falling into this class., Methods: All patients who had anatomical lung resection for lung cancer (2007-2019) and were deemed of moderate risk were identified in the European Society of Thoracic Surgeons database. Cardiopulmonary morbidity and 30-day mortality of these patients were assessed by the type of operation., Results: A total 2016 patients were identified. The incidence of cardiopulmonary complications in this group was 21% after lobectomy (294/1435), 29% after bilobectomy (33/112), 22% after pneumonectomy (72/333) and 16% after segmentectomy (22/136) (analysis of variance P = 0.07). The 30-day mortality was 3.4% after lobectomy (49/1435), 8.9% after bilobectomy (10/112), 7.8% after pneumonectomy (26/333) and 3.7% after segmentectomy (5/136) (analysis of variance P = 0.0005). The 30-day mortality rate was 1.6-fold higher in patients with a VO2max between 10 and 15 ml/kg/min compared to those with a higher VO2max [49/861 (5.7%) vs 41/1155 (3.5%); P = 0.022]. For operations that were less extensive than a pneumonectomy and were performed by minimally invasive surgery, there was no difference in mortality between patients with a VO2max between 10 and 15 ml/kg/min and those with a higher VO2max [7/181 (3.8%) vs 11/272 (4.0%); P = 0.92]. On the other hand, after open surgery, the mortality of patients with a lower VO2max (10-15 ml/kg/min) was higher than that of those with a higher VO2max [26/501 (5.1%) vs 20/721 (2.8%); P = 0.034]. Linear regression adjusting for the extent and access of the operation confirmed that within the moderate-risk group a VO2max <15 ml/kg/min was associated with higher mortality (P = 0.028; odds ratio 1.61; 95% confidence interval 1.1-2.5)., Conclusions: Morbidity and mortality rates found in this study are not negligible and reinforce the recommendation to ensure careful patient discussion and informed decision-making prior to lung cancer resection surgery., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The use of sealants is one of the methods available to reduce the occurrence of intraoperative air leaks. The objective of this modified Delphi survey among ESTS members is to understand the attitudes of clinicians to the optimal use of sealants in air leak management., Methods: To understand the attitudes of a wider sample of clinicians, a questionnaire was developed highlighting key issues through 37 statements. Respondents were invited to score their level of agreement with each. A modified Delphi methodology was used to review responses with a threshold of agreement for consensus of 75%., Results: A total of 258 responses were received (response rate 17%). Respondents agreed that prolonged air leaks are a common complication in thoracic surgery presenting a burden to the patient and increasing the costs of care. There is clear support for the use of sealants to reduce costs and improve the efficiency of healthcare provision and duration of chest tube use in selected high-risk patients with intraoperative air leak at the end of the lung surgery. Respondents also agreed that, due to often complex nature of thoracic surgery, sealants should be developed specifically for this application., Conclusion: There is a clear role for sealants in the management of air leaks and certain surgical procedures demand their use (i.e. lung volume reduction surgery, decortication). This opinion-based consensus review helps to raise the debate about the burden of air leaks in thoracic surgery in order that this issue is recognized in practice and informs the optimal use of sealants in lung surgery., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: We report an overview of surgical practices and outcomes in patients undergoing pulmonary metastasectomy based on data from the European Society of Thoracic Surgeons database., Methods: We retrieved data on resections performed for pulmonary metastases between July 2007 and July 2019. We evaluated baseline characteristics, surgical management and postoperative outcomes. Open and video-assisted thoracic surgery (VATS) procedures were compared in terms of surgical management, morbidity and mortality., Results: We selected 8868 patients [male/female 5031/3837; median age: 64 years (interquartile range 55-71)] who underwent pulmonary metastasectomy. Surgical approach consisted of open thoracotomy in 63.5% of cases (n = 5627) and VATS in 36.5% (n = 3241), with a conversion rate of 2.1% (n = 69). Surgical resection was managed by wedge or local excision in 61% (n = 5425) of cases and anatomical resection in 39% (n = 3443); lobectomy: 26% (n = 2307); segmentectomy: 11% (n = 949); bilobectomy: 1% (n = 95); pneumonectomy: 1% (n = 92)). Lymph node assessment was realized in 58% (n = 5097) [sampling: 21% (n = 1832); complete dissection: 37% (n = 3265)]. Overall morbidity and mortality rates were 15% (n = 1308) and 0.8% (n = 69), respectively. Median duration of stay was 6 days (interquartile range 4-8). The rate of VATS procedures increased from 15% in 2007 to 58% in 2018. When comparing VATS and Open surgery, there were significantly (P < 0.001) fewer anatomical resections by VATS (24% vs 49%), lymph node assessments (36% vs 70%), less morbidity (9% vs 18%) and shorter durations of stay (median: 4 vs 7 days)., Conclusions: We report a good overview of current surgical practices in terms of resection extent and postoperative outcomes with a gradual acceptance of VATS., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: We queried the European Society of Thoracic Surgeons (ESTS) database with the aim to assess cardiopulmonary morbidity and 30-day mortality of segmentectomies and lobectomies in patients with a Eurolung-predicted mortality above the upper interquartile and classified as high risk., Methods: A total of 61 492 patients registered in the ESTS database (2007-2018) and submitted to lobectomy (55 353) or segmentectomy (6139) were divided into high risk or low risk according to a Eurolung-predicted mortality cut-off of 2.5% (corresponding in our population to the upper interquartile). Predicted versus observed mortalities were compared within each type of operation by using binomial test of proportion. Observed morbidity and mortality rates were compared between the 2 procedures using the χ2 test., Results: A total of 14 007 lobectomies and 1251 segmentectomies were classified as high risk. In the high-risk group, the cardiopulmonary morbidity and 30-day mortality rates observed in segmentectomies were lower than in lobectomies (morbidity: 12% vs 17%, P < 0.0001; mortality: 2.4% vs 3.7%, P = 0.018). In segmentectomy patients, the observed mortality rate was lower than the Eurolung-predicted one (2.4% vs 3.8%, P = 0.009), while in the lobectomy patients, there was no difference between observed and predicted mortality (3.7% vs 3.8%, P = 0.9). In the low-risk group, the cardiopulmonary morbidity and 30-day mortality rates observed in segmentectomies were lower than in lobectomies (morbidity: 4.5% vs 7.8%, P < 0.0001; mortality: 0.6% vs 1.0%, P = 0.01). In segmentectomy patients, the observed mortality rate was lower than the Eurolung-predicted one (0.6% vs 1.0%, P = 0.0003), while in the lobectomy patients, there was no difference between observed and predicted mortality (1.0% vs 1.1%, P = 0.06)., Conclusions: Segmentectomy was found associated with a 0.65 relative risk of mortality rate compared to lobectomy in patients deemed at higher surgical risk., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The performance of prediction models tends to deteriorate over time. The purpose of this study was to update the Thoracoscore risk prediction model with recent data from the Epithor nationwide thoracic surgery database., Methods: From January 2016 to December 2017, a total of 56 279 patients were operated on for mediastinal, pleural, chest wall or lung disease. We used 3 recommended methods to update the Thoracoscore prediction model and then proceeded to develop a new risk model. Thirty-day hospital mortality included patients who died within the first 30 days of the operation and those who died later during the same hospital stay., Results: We compared the baseline patient characteristics in the original data used to develop the Thoracoscore prediction model and the validation data. The age distribution was different, with specifically more patients older than 65 years in the validation group. Video-assisted thoracoscopy accounted for 47% of surgeries in the validation group compared but only 18% in the original data. The calibration curve used to update the Thoracoscore confirmed the overfitting of the 3 methods. The Hosmer-Lemeshow goodness-of-fit test was significant for the 3 updated models. Some coefficients were overfitted (American Society of Anesthesiologists score, performance status and procedure class) in the validation data. The new risk model has a correct calibration as indicated by the Hosmer-Lemeshow goodness-of-fit test, which was non-significant. The C-index was strong for the new risk model (0.84), confirming the ability of the new risk model to differentiate patients with and without the outcome. Internal validation shows no overfitting for the new model., Conclusions: The new Thoracoscore risk model has improved performance and good calibration, making it appropriate for use in current clinical practice., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Venous thromboembolic events can be successfully prevented with chemical and/or mechanical prophylaxis measures, but evidence-based guidelines in thoracic surgery are limited, particularly regarding extended post-discharge prophylaxis. This study attempts to gather an international consensus on best practices to inform the development of such guidelines., Methods: A series of 3 surveys was distributed to the ESTS/AATS/ISTH (European Society of Thoracic Surgeons, American Association of Thoracic Surgeons, International Society for Thrombosis and Haemostasis) venous thromboembolic events prophylaxis working group starting January 2017. This iterative Delphi consensus process sought to gather a consensus on (i) risk factors; (ii) preferred agents; (iii) duration; and (iv) perceived barriers to an extended thromboprophylaxis approach. Participant responses were expressed on a 10-point scale, and the results were summarized and circulated to all respondents in subsequent rounds. A coefficient of variance of ≤0.3 was identified pre hoc to identify agreement., Results: A total of 21 Working Group members completed the surveys, composed of 19% non-surgeon thrombosis experts, and 48% from North America. Respondents largely saw agreement regarding risk factors that indicate a need for extended thromboprophylaxis. The group agreed that low-molecular-weight heparin is a suitable agent for use post-discharge, but there was a wide variety in response regarding agents, duration and barriers to extended prophylaxis, where no consensus was observed across the three rounds., Conclusions: There is strong agreement around indications for extended venous thromboembolic events thromboprophylaxis after thoracic surgery, but there is little consensus regarding the agents and duration to be employed. Further research is required to better inform guideline development., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To evaluate the postoperative complications and 30-day mortality rates associated with neoadjuvant chemotherapy before major anatomic lung resections registered in the European Society of Thoracic Surgeons (ESTS) database., Methods: Retrospective analysis on 52 982 anatomic lung resections registered in the ESTS database (July 2007-31 December 2017) (6587 pneumonectomies and 46 395 lobectomies); 5143 patients received neoadjuvant treatment (9.7%) (3993 chemotherapy alone and 1150 chemoradiotherapy). To adjust for possible confounders, a propensity case-matched analysis was performed. The postoperative outcomes (morbidity and 30-day mortality) of matched patients with and without induction treatment were compared., Results: 8.2% of all patients undergoing lobectomies and 20% of all patients undergoing pneumonectomies received induction treatment. Lobectomy analysis: propensity score analysis yielded 3824 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the neoadjuvant group (626 patients, 16% vs 446 patients, 12%, P < 0.001), but 30-day mortality rates were similar (71 patients, 1.9% vs 75 patients, 2.0%, P = 0.73). The incidence of bronchopleural fistula and prolonged air leak >5 days were similar between the 2 groups (neoadjuvant: 0.5% vs 0.4%, P = 0.87; 9.2% vs 9.9%, P = 0.27). Pneumonectomy analysis: propensity score analysis yielded 1312 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the treated patients compared to those without neoadjuvant treatment (neoadjuvant 275 cases, 21% vs 18%, P = 0.030). However, the 30-day mortality was similar between the matched groups (neoadjuvant 68 cases, 5.2% vs 5.3%, P = 0.86). Finally, the incidence of bronchopleural fistula was also similar between the 2 groups (neoadjuvant 1.8% vs 1.4%, P = 0.44)., Conclusions: Neoadjuvant chemotherapy is not associated with an increased perioperative risk after either lobectomy or pneumonectomy, warranting a more liberal use of this approach for patients with locally advanced operable lung cancer., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To develop a simplified version of the Eurolung risk model to predict cardiopulmonary morbidity and 30-day mortality after lung resection from the ESTS database., Methods: A total of 82 383 lung resections (63 681 lobectomies, 3617 bilobectomies, 7667 pneumonectomies and 7418 segmentectomies) recorded in the ESTS database (January 2007-December 2018) were analysed. Multiple imputations with chained equations were performed on the predictors included in the original Eurolung models. Stepwise selection was then applied for determining the best logistic model. To develop the parsimonious models, different models were tested eliminating variables one by one starting from the less significant. The models' prediction power was evaluated estimating area under curve (AUC) with the 10-fold cross-validation technique., Results: Cardiopulmonary morbidity model (Eurolung1): the best parsimonious Eurolung1 model contains 5 variables. The logit of the parsimonious Eurolung1 model was as follows: -2.852 + 0.021 × age + 0.472 × male -0.015 × ppoFEV1 + 0.662×thoracotomy + 0.324 × extended resection. Pooled AUC is 0.710 [95% confidence interval (CI) 0.677-0.743]. Mortality model (Eurolung2): the best parsimonious model contains 6 variables. The logit of the parsimonious Eurolung2 model was as follows: -6.350 + 0.047 × age + 0.889 × male -0.055 × BMI -0.010 × ppoFEV1 + 0.892 × thoracotomy + 0.983 × pneumonectomy. Pooled AUC is 0.737 (95% CI 0.702-0.770). An aggregate parsimonious Eurolung2 was also generated by repeating the logistic regression after categorization of the numeric variables. Patients were grouped into 7 risk classes showing incremental risk of mortality (P < 0.0001)., Conclusions: We were able to develop simplified and updated versions of the Eurolung risk models retaining the predictive ability of the full original models. They represent a more user-friendly tool designed to inform the multidisciplinary discussion and shared decision-making process of lung resection candidates., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Venous thromboembolic events (VTE) after thoracic surgery (TS) can be prevented with mechanical and chemical prophylaxis. Unlike other surgical specialties, TS lacks evidence-based guidelines. In the process of developing these guidelines, an understanding of the current prophylaxis methods practiced internationally is necessary and is described in this article., Methods: A 26-item survey was distributed to members of the European Society of Thoracic Surgeons (ESTS), American Association of Thoracic Surgery (AATS), Japanese Association for Chest Surgery (JACS) and Chinese Society for Thoracic and Cardiovascular Surgery (CSTCS) electronically or in person. Participants were asked to report their current prophylaxis selection, timing of initiation and duration of prophylaxis, perceived risk factors and the presence and adherence to institutional VTE guidelines for patients undergoing TS for malignancies., Results: In total, 1613 surgeons anonymously completed the survey with an overall 36% response rate. Respondents were senior surgeons working in large academic hospitals (≥70%, respectively). More than 83.5% of ESTS, AATS and JACS respondents report formal TS thromboprophylaxis protocols in their institutions, but 53% of CSTCS members report not having such a protocol. The regions varied in the approaches utilized for VTE prophylaxis, the timing of initiation perioperatively and the use and type of extended prophylaxis. Respondents reported that multiple risk factors and sources of information impact their VTE prophylaxis decision-making processes, and these factors vastly diverge regionally., Conclusions: There is little agreement internationally on the optimal approach to thromboprophylaxis in the TS population, and guidelines will be helpful and vastly welcomed., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Neutrophil to lymphocyte ratio (NLR) has been shown to be a promising biomarker in several cancers. Prognostic biomarkers are still needed to define good candidates for lung metastasectomy for colorectal cancer. We aimed to evaluate the role of NLR., Methods: Data from 574 patients who underwent lung metastasectomy for colorectal cancer in 3 departments of thoracic surgery from 2004 to 2014 were retrospectively reviewed. Overall survival (OS) and the time to pulmonary recurrence (TTPR) were the main end points., Results: Correlations between NLR and OS (R2 = 0.53), and NLR and TTPR (R2 = 0.389) were significant (P < 0.0001 for both), with corresponding Pearson R of -0.728 (P < 0.0001) and -0.624 (P < 0.0001), respectively. A receiver operating characteristic curve analysis highlighted an NLR cut-off value of 4.05 as the best predictor of OS and TTPR. NLR ≤4.05 was observed in 238 patients (41.4%). In the univariable analysis, the median OS was 117 months for patients with NLR ≤4.05 and decreased to 40 months for patients with NLR >4.05 (P < 0.0001). The median TTPR reached 52 months in case of NLR ≤4.05 and decreased to 12 months in patients with NLR >4.05. In the multivariable analysis, NLR ≤4.05 remained an independent favourable prognostic factor on both OS [hazard ratio [HR] 0.29, 95% confidence interval (CI) 0.167-0.503; P < 0.0001] and TTPR (HR 0.346, 95% CI 0.221-0.54; P < 0.0001). Significant correlations between NLR >4.05 and KRAS (Cramer's V = 0.241, P < 0.0001) and BRAF (Cramer's V = 0.153, P = 0.003) mutations were observed., Conclusions: NLR is a simple and powerful predictor of outcomes in patients undergoing pulmonary metastasectomy for colorectal cancer., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: We queried the European Society of Thoracic Surgeons (ESTS) prospective thymic database for descriptive analysis and for comparison with the ESTS retrospective thymic database (1990-2010)., Methods: Data were retrieved (January 2007-November 2017) for 1122 patients from 75 ESTS institutions., Results: There were 484 (65%) thymomas, 207 (28%) thymic carcinomas and 49 (7%) neuroendocrine thymic tumours. Staging (Masaoka) included 483 (67%) stage I and II, 100 (14%) stage III and 70 (10%) stage IV tumours. The new International Association for the Study of Lung Cancer/International Thymic Malignancies Interest Group tumour, node and metastasis (TNM) classification was available for 224 patients and including 177 (85%) stage I-II, 37 (16%) stage IIIA and 10 (4%) stage IIIB tumours. Chemotherapy as induction and adjuvant treatment was used in 14% and 15% of the patients. Radiotherapy was almost exclusively used postoperatively (24%). A minimally invasive surgical approach (video-assisted thoracic surgery/robotic-assisted thoracic surgery) was used in 276 (33%) patients. The overall recurrence rate was 10.8% (N = 38). Compared to the ESTS retrospective database, the increased prevalence of thymic carcinomas (from 9% to 28%) and neuroendocrine thymic tumours (from 2% to 7%), an increase in the use of minimally invasive techniques (from 6% to 34%) and a wider use of chemotherapy as induction (from 9% to 15%) and adjuvant (from 2% to 16%) treatment were observed in the prospective database. The introduction of a set of variables considered essential for the data use ('minimum dataset') resulted in an increased average completeness rate., Conclusions: The reported data from the ESTS prospective thymic database confirm the recent trends in the management of thymic tumours. The ESTS prospective thymic database represents a powerful resource open to all ESTS members for the global effort to manage these rare tumours., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The European Society of Thoracic Surgeons (ESTS) registry was created 10 years ago and represents an international database collecting thoracic surgery procedures from European contributors. The purpose of the present report was to offer an overview of baseline and surgical characteristics and outcomes of patients submitted to lung resections for malignant lung disease as derived from the ESTS registry., Methods: We retrieved data about all lung resections from 2007 to 2016 performed for primary and metastatic (secondary) lung cancer. We evaluated the baseline characteristics and the surgical management of this population. Within the subgroup of patients affected by primary lung cancer, we described the preoperative mediastinal staging management and the final pathological stage of disease. Finally, we analysed the morbidity and mortality rates for the cohort of patients submitted to anatomic lung resections for primary or secondary lung cancer. Outcomes were also evaluated in relation to several risk factors: type of resection, age, comorbidity, predicted postoperative forced expiratory volume in 1 s and surgical approach., Results: We selected 62 774 patients submitted to lung resections (male 66.5%, median age 64 years). For the entire population, median predicted postoperative forced expiratory volume in 1 s was 73.3% (interquartile range: 59, 87.6), 33.8% of patients had cardiac comorbidities and 17.3% had other comorbidities. Among the patients with primary lung cancer (51 931 patients), 50.8% had Stage I disease and 23.2% Stage II disease; preoperative invasive mediastinal staging was performed in 70.3% of patients with computed tomography scan nodal enlargement and positron emission tomography scan nodal uptake. After anatomical lung resection (51 756 patients), overall morbidity was 18.5% and mortality (30 days or in-hospital) was 2.6%. Extent of resection, age ≥75 years, presence of cardiac comorbidity, predicted postoperative forced expiratory volume in 1 s <70% and open approach instead of video-assisted thoracic surgery were associated with worse outcomes., Conclusions: The results of the present report represent reliable European benchmarks for comparing the activities and outcomes of single institutions and surgeons at an international level., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: In the European Society of Thoracic Surgeons (ESTS) survey about management of malignant pleural effusions (MPE), 56% of respondents are not informed of any relevant clinical guidelines and 52%, who are aware of the existence of guidelines, declared that they are in need of updating or revision. The ESTS Pleural Diseases Working Group developed a benchmarking project on quality of previous guidelines on the management of MPE., Methods: The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was used to assess each guideline. Each item was scored on a 7-point scale. Scores for each domain were calculated. Economic data for the nations which have issued the guidelines were collected from the Organisation for Economic Cooperation and Development health statistics database., Results: Six guidelines fitted the inclusion criteria and were assessed. Five out of 6 guidelines were produced by a multinational collaboration. Observers would recommend only 2 guidelines with minimal modification. Two areas that received the best score were clarity of presentation and scope and purpose (objectives and health questions target population). The applicability of guideline domain had the lowest score. Multivariate analysis demonstrated that clarity of presentation, international guidelines and publication through medical journal were related to improved scores. A strong correlation was observed between the measures of economic status., Conclusions: The quality of guidelines assessed by the AGREE II criteria was found to be extremely variable. Guidelines achieving higher AGREE II scores were more likely to come from the European Union with the direct involvement of scientific societies in their development. It was also recognized that some fundamental unanswered questions remain about the management of MPE., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The impact of skip N2 metastases (i.e. N2 lymph node metastases without N1) on survival in surgically resected non-small lung cancer remains an intriguing and rarely investigated topic. The goal of our study was to elucidate (i) skip N2 influence on overall survival (OS) and time to recurrence (TTR) in patients with resected lung adenocarcinoma and (ii) its link with epidermal growth factor receptor ( EGFR ) and v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog ( KRAS ) mutations., Methods: A retrospective analysis of 279 consecutive patients with lung pN2 adenocarcinoma, operated in two institutions between 2003 and 2013, was conducted. OS and TTR were calculated using the Kaplan-Meier method. Crude and multivariable-adjusted comparisons by skip N2 for OS and TTR were performed using the Cox method with shared frailty (accounting for the within-centre correlation). Associations between skip N2 metastasis, clinicopathological characteristics and EGFR and KRAS mutations were investigated using the Fisher exact test and Cramér's V -test., Results: The mean age at the time of surgery was 63 years (±12), and the median follow-up time was 36 months (min 3; max 101). Skip N2 was observed in 54 patients (19%). EGFR mutations were observed in 38 patients (14%); KRAS mutations were seen in 86 patients (31%). Patients with skip N2 metastasis were predominantly non-smokers ( P  =   0.001), underwent segmentectomy or limited resections ( P  =   0.004) and were not submitted to adjuvant therapy ( P  =   0.022). Moreover, there was a correlation between EGFR mutations and skip N2 (Cramér's V : 0.25, P  <   0.001). Indeed, EGFR mutations were significantly more frequent in skip N2 tumours (33%) compared with non-skip tumours (10%), P  <   0.001. No correlation between skip N2 and KRAS mutations was observed (Cramér's V : 0.05, P  =   0.46). The multivariable-adjusted model showed a significant skip N2 protective effect on OS (hazard ratio, HR 0.503; P  =   0.014; 95% confidence interval, CI: 0.291-0.8704) but not on TTR (HR 0.788; P  =   0.446; 95% CI: 0.427-1.454)., Conclusions: In our series, lung adenocarcinoma skip N2 metastasis demonstrated a favourable prognosis. The presence of EGFR mutations could have significance in the better survival and in the specific anatomic pathway of lymphatic metastases exhibited by skip N2 tumours., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To develop models of 30-day mortality and cardiopulmonary morbidity from data on anatomic lung resections deposited in the European Society of Thoracic Surgeons (ESTS) database., Methods: Retrospective analysis of 47 960 anatomic lung resections from the ESTS database (July 2007-August 2015) (36 376 lobectomies, 2296 bilobectomies, 5040 pneumonectomies and 4248 segmentectomies). Logistic regression analyses were used to test the association between baseline and surgical variables and morbidity or mortality. Bootstrap resampling was used for internal validation and to check predictors of stability. Variables that occurred in more than 50% of the bootstrap samples were deemed reliable. User-friendly aggregate scores were then created by assigning points to each variable in the model by proportionally weighting the regression coefficients. Patients were grouped in classes of incremental risk according to their scores., Results: Cardiopulmonary morbidity and 30-day mortality rates were 18.4% (8805 patients) and 2.7% (1295 patients). The following variables were reliably associated with morbidity after logistic regression analysis (C-index 0.68): male sex ( P  < 0.0001); age ( P  < 0.0001); predicted postoperative forced expiratory volume in 1 s (ppoFEV1) ( P  < 0.0001); coronary artery disease (CAD) ( P  < 0.0001); cerebrovascular disease (CVD) ( P  < 0.0001); chronic kidney disease ( P  < 0.0001); thoracotomy approach ( P  < 0.0001); and extended resections ( P  < 0.0001). All variables occurred in more than 95% of the bootstrap samples. An aggregate score was created that stratified the patients into six classes of incremental morbidity risk ( P  < 0.0001). The following variables were reliably associated with mortality after logistic regression analysis (C-index 0.74): male sex ( P  < 0.0001); age ( P  < 0.0001); ppoFEV1 ( P  < 0.0001); CAD ( P  = 0.003); CVD ( P  < 0.0001); body mass index ( P  < 0.0001); thoracotomy approach ( P  < 0.0001); pneumonectomy ( P  < 0.0001); and extended resections ( P  = 0.002). All variables occurred in more than 80% of bootstrap samples. An aggregate score was created that stratified the patients into six classes of incremental mortality risk ( P  < 0.0001)., Conclusions: The updated ESTS morbidity and mortality models can be used to define risk-adjust outcome indicators for auditing quality of care and to counsel patients about their surgical risk., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The role of perioperative chemotherapy (POC) and targeted therapies in lung metastasectomy for colorectal cancer (CRC) is still subject to debate. We aimed to evaluate whether POC and targeted therapies were associated with different outcomes according to the mutational status., Methods: We reviewed data from 223 patients who underwent pulmonary metastasectomy for CRC from 1998 to 2015 and for whom the V-Ki-ras2 Kirsten sarcoma viral oncogene homologue (KRAS) and V-raf Murine sarcoma viral oncogene homologue B1 (BRAF) mutational statuses were known., Results: A total of 167 patients (74%) underwent POC: 62 (37%) received neoadjuvant therapy, 59 (35%) were in the adjuvant setting and 46 (28%) were in both the neoadjuvant and adjuvant settings. POC did not significantly influence either the loco-regional recurrence free survival (LRRFS) (P = 0.21) or the overall survival (OS) (P = 0.29). Furthermore, in cases of adjuvant chemotherapy, outcomes were not significantly different in cases of neoadjuvant chemotherapy or both neoadjuvant and adjuvant treatment (P = 0.26 for OS, P = 0.14 for LRRFS). For patients with KRAS mutation, perioperative bevacizumab was associated with a significant improvement in both LRRFS [70 months (41.58–98.42) vs 24 months (1.15–46.86), P = 0.001] and OS [101 vs 55 months (49.77–60.23), P = 0.004]. However, this benefit was only significant in cases of KRAS exon 2 codon 12 mutations [median OS: 101 months (83.97–118.02) vs 60 months (53–66.99), P < 0.001; median LRRFS: 76 months (64.62–87.38) vs 44 months (35.27–52.73), P < 0.001]., Conclusion: Perioperative bevacizumab appears to be beneficial in patients with exon 2 codon 12 KRAS mutations who have undergone lung metastasectomy for CRC., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The management of pIIIA-N2 non-small-cell lung cancer (NSCLC) is still controversial. In particular, there are wide variations in overall survival (OS), suggesting the existence of subgroups among N2 patients. We aimed to evaluate the prognostic value of microscopic pN2 in NSCLC., Methods: Between 1996 and 2015, the data from all 982 pathologically stage IIIA-N2 patients who underwent surgery with curative intent for NSCLC were retrospectively reviewed. Microscopic pN2 disease was defined as a nodal metastasis ranging from 0.2 to 2 mm in size., Results: With a median follow-up of 17 months (2-101), the 5-year OS for the whole cohort was 31%. Microscopic N2 was observed in 309 (31.5%) patients. Microscopic N2 was associated with better median OS compared with macroscopic N2 [42 months (95% CI 36.85-47.15) vs 23 months (95% CI 19.7-26.29), P < 0.0001, with a corresponding 5-year OS rate of 39 and 21%, respectively]. In multivariate analysis, microscopic N2 remained a favourable independent prognostic factor [HR 0.681 (95% CI 0.481-0.967), P = 0.03]. The median OS of microscopic N2 patients who benefitted from simple follow-up was significantly better than those who underwent chemotherapy, radiation therapy or both [43 months (95% CI 24.22-61.78) vs 22 months (95% CI 17.43-26.47) vs 31 months (95% CI 27.66-34.34) vs 16 months (95% CI 14.6-17.4), P = 0.008]., Conclusion: Microscopic N2 seems to be associated with better prognosis in patients with pIIIA-N2 NSCLC and these could benefit from a simple follow-up. Prospective cohort studies are necessary to confirm these preliminary results., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To describe the methodology for the development of data quality metrics in multi-institutional databases, deriving a cumulative data quality score [Aggregate Data Quality score (ADQ)]. The ESTS database was used to create and apply the metrics. The Units contributing to the ESTS database were ranked for the quality of data uploaded using the ADQ., Methods: We analysed data obtained from 96 Units contributing with at least 100 major lung resections (January 2007 to December 2014). The Units were anonymized assigning a casual numeric code. The following metrics were developed for measuring the data quality of each Unit: (i) record Completeness (COM); rate of present variables on 16 expected variables for all the records uploaded [1 - ('null values'/total expected values for the Unit) × 100, the concept of 'null value' was defined for each variable]; (ii) record Reliability (REL); rate of consistent checks on 9 checks tested for all the records uploaded [1 - (valid controls/total possible controls for the Unit) × 100, specific reliability control queries were defined]. These two metrics were rescaled using the mean and standard deviation of the entire dataset and summed, obtaining: (iii) ADQ score: [COM rescaled + REL rescaled]; it measures the cumulative data quality of a given dataset. The ADQ was used to rank the contributors., Results: The COM of ESTS database contributors varied from 98.6 to 43% and the REL from 100 to 69%. Combining the rescaled metrics, the obtained ADQ ranged between 2.67 (highest data quality) and -7.85 (lowest data quality). Comparing the rating using just the COM value to the one obtained using the ADQ, 93% of Units changed their position. The major change was the drop of 66 positions considering the ADQ list., Conclusions: We described a reproducible method for data quality assessment in clinical multi-institutional databases. The ADQ is a unique indicator able to describe data quality and to compare it among centres. It has the potential of objectively guiding projects of data quality management and improvement., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim was to verify the association of low VO2 max with postoperative morbidity and mortality after video-assisted thoracoscopic surgery (VATS) or open pulmonary lobectomy using the European Society of Thoracic Surgeons (ESTS) database., Methods: A retrospective analysis of data collected from the ESTS database was conducted. A total of 1684 lobectomy patients with available VO2 max values were included (2007-14). Patients operated through VATS (281 patients) or thoracotomy (1403 patients) were separately analysed. Propensity score analyses were performed to match patients with high (≥15 ml/kg/min) and low VO2 max (<15 ml/kg/min) for each approach. The following variables were used to construct the score: age, body mass index, predicted postoperative forced expiratory volume in 1 s (%), coronary artery disease, American Society of Anaesthesiology grade and Eastern Cooperative Oncology Group performance score. Cardiopulmonary morbidity and 30-day mortality were compared between the matched groups., Results: Mean VO2 max was 17.4 ml/kg/min. A total of 471 patients (28%) had low VO2 max. Overall postoperative cardiopulmonary morbidity and mortality rates were 30% (505 patients) and 4.1% (70 patients), respectively. Morbidity and mortality rates in low VO2 max patients were 33% (156 patients) and 6% (28 patients), respectively. After VATS, cardiopulmonary morbidity and mortality rates were 2-fold (13 of 72, 18% vs 143 of 399, 36%, P = 0.003) and 5-fold (1 of 72, 1.4% vs 27 of 399, 6.7%, P = 0.09) lower compared with thoracotomy. Matched comparison after thoracotomy (399 pairs): Mortality was significantly higher in patients with low VO2 max (27 patients, 6.7%) compared with those with high VO2 max (11 patients, 2.8%, P = 0.008). Complication rates were similar between the two groups (low VO2 max: 143 patients, 36% vs high VO2 max: 133 patients, 33%, respectively, P = 0.5). Matched comparison after vats (72 pairs): Morbidity and mortality rates of patients with low VO2 max were similar to those of patients with high VO2 max (morbidity: 13 patients, 18% vs 17 patients, 24%, P = 0.4; mortality: 1 patient, 1.4% vs 4 patients, 5.5%, P = 0.4)., Conclusions: Low VO2 max was not associated with an increased surgical risk after VAT lobectomy, which challenges the traditional operability criteria when this technique is used., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: There are no guidelines regarding the surgical approach for spontaneous pneumothorax. It has been reported, however, that the risk of recurrence following video-assisted thoracic surgery is higher than that following open thoracotomy (OT). The objective of this study was to determine whether this higher risk of recurrence following video-assisted thoracic surgery could be attributable to differences in intraoperative parenchymal resection and the pleurodesis technique., Methods: Data for 7647 patients operated on for primary or secondary spontaneous pneumothorax between 1 January 2005 and 31 December 2012 were extracted from Epithor®, the French national database. The type of pleurodesis and parenchymal resection was collected. Outcomes were (i) bleeding, defined as postoperative pleural bleeding; (ii) pulmonary and pleural complications, defined as atelectasis, pneumonia, empyema, prolonged ventilation, acute respiratory distress syndrome and prolonged air leaks; (iii) in-hospital length of stay and (iv) recurrence, defined as chest drainage or surgery for a second pneumothorax., Results: Of note, 6643 patients underwent videothoracoscopy and 1004 patients underwent OT. When compared with the thoracotomy group, the videothoracoscopy group was associated with more parenchymal resections (62.4 vs 80%, P = 0.01), fewer mechanical pleurodesis procedures (93 vs 77.5%, P < 10(-3)), fewer postoperative respiratory complications (12 vs 8.2%, P = 0.01), fewer cases of postoperative pleural bleeding (2.3 vs 1.4%, P = 0.04) and shorter hospital lengths of stay (16 vs 9 days, P = 0.01). The recurrence rate was 1.8% (n = 18) in the thoracotomy group versus 3.8% (n = 254) in the videothoracoscopy group (P = 0.01). The median time between surgery and recurrence was 3 months (range: 1-76 months)., Conclusions: In the surgical management of spontaneous pneumothorax, videothoracoscopy is associated with a higher rate of recurrence than OT. This difference might be attributable to differences in the pleurodesis technique rather than differences in the parenchymal resection., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To determine contemporary early outcomes associated with bilobectomy for lung cancer and to identify their predictors using a nationally representative general thoracic surgery database., Methods: A total of 1831 patients, who underwent elective bilobectomy for primary lung cancer between 1 January 2004 and 31 December 2013, were selected. Logistic regression analysis was performed on variables for major adverse events., Results: There were 670 upper and 1161 lower bilobectomies. Video-assisted thoracic surgery was seldom performed (2%). Induction therapy and extended resection were performed in 293 (16%) and 279 patients (15.2%), respectively. Operative mortality was 4.8% (upper: 4.5%/lower: 5%; P = 0.62), and significantly higher following extended procedures when compared with standard bilobectomy (4.3 vs 7.5%; P = 0.013). Pulmonary complication rate was 21.1%. Bronchial fistula occurred in 46 patients (2.5%) and pleural space complications in 296 (16.2%). Their respective incidence rates were significantly higher following lower than upper bilobectomy (3.5 vs 0.7%; P < 0.001 and 17.8 vs 13.3%; P = 0.007). At multivariate analysis, extended procedures [odds ratio (OR), 2.3; 95% confidence interval (CI), 1.03-5.31; P = 0.04], ASA scores of 3 or greater (OR, 2.02; 95% CI, 1.33-3.07; P < 0.001) and World Health Organization performance status 2 or greater (OR, 1.47; 95% CI, 1.01-2.13; P = 0.04) were risk predictors of mortality. Female gender (OR, 0.39; 95% CI, 0.19-0.80; P = 0.01), highest body mass index (BMI) values (OR, 0.91; 95% CI, 0.86-0.96; P = 0.001) and recent years of surgery (OR, 0.91; 95% CI, 0.84-0.99; P = 0.02) were protective. Predictors of bronchial fistula were male gender, lowest BMI values, lower bilobectomy and longest operative times. Male gender, lowest BMI values and longest operative times were also predictors of pulmonary complications, together with highest ASA scores and lowest forced expiratory volume in 1 s values., Conclusions: Risks related to lower bilobectomy lie halfway between those reported for lobectomy and pneumonectomy. Additional surgical measures to prevent pleural space complications and bronchial fistula should be encouraged with this operation. In contrast, upper bilobectomy shares more or less the same hazards as lobectomy., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Extracorporeal membrane oxygenation (ECMO) for respiratory support is increasingly used in intensive care units (ICU), but rarely during thoracic surgical procedures outside the transplantation setting. ECMO can be an alternative to cardiopulmonary bypass for major trachea-bronchial surgery and single-lung procedures without in-field ventilation. Our aim was to evaluate the intraoperative use of ECMO as respiratory support in thoracic surgery: benefits, indications and complications., Methods: This was a multicentre retrospective study (questionnaire) of use of ECMO as respiratory support during the thoracic surgical procedure. Lung transplantation and lung resection for tumour invading the great vessels and/or the left atrium were excluded, because they concern respiratory and circulatory support., Results: From March 2009 to September 2012, 17 of the 34 centres in France applied ECMO within veno-venous (VV) (n=20) or veno-arterial (VA) (n=16) indications in 36 patients. Ten VA ECMO were performed with peripheral cannulation and 6 with central cannulation; all VV ECMO were achieved through peripheral cannulation. Group 1 (total respiratory support) was composed of 28 patients without mechanical ventilation, involving 23 tracheo-bronchial and 5 single-lung procedures. Group 2 (partial respiratory support) was made up of 5 patients with respiratory insufficiency. Group 3 was made up of 3 patients who underwent thoracic surgery in a setting of acute respiratory distress syndrome (ARDS) with preoperative ECMO. Mortality at 30 days in Groups 1, 2 and 3 was 7, 40 and 67%, respectively (P<0.05). In Group 1, ECMO was weaned intraoperatively or within 24 h in 75% of patients. In Group 2, ECMO was weaned in ICU over several days. In Group 1, 2 patients with VA support were converted to VV support for chronic respiratory indications. Bleeding was the major complication with 17% of patients requiring return to theatre for haemostasis. There were two cannulation-related complications (6%)., Conclusions: VV or VA ECMO is a satisfactory alternative to in-field ventilation in complex tracheo-bronchial surgery or in single-lung surgery. ECMO should be considered and used in precarious postoperative respiratory conditions. Full respiratory support can be achieved with VV ECMO. Indications for and results of ECMO during surgery in patients with ARDS warrant further careful investigation., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: To update the recommendations for the structural characteristics of general thoracic surgery (GTS) in Europe in order to provide a document that can be used as a guide for harmonizing the general thoracic surgical practice in Europe., Methods: A task force was created to set the structural, procedural and qualification characteristics of a European GTS unit. These criteria were endorsed by the Executive Committee of the European Society of Thoracic Surgeons and by the Thoracic Domain of the European Association for Cardio-Thoracic Surgery and were validated by the European Board of Thoracic Surgery at European Union of Medical Specialists., Results: Criteria regarding definition and scope of GTS, structure and qualification of GTS unit, training and education and recommendations for subjects of particular interest (lung transplant, oesophageal surgery, minimally invasive thoracic surgery, quality surveillance) were developed., Conclusions: This document will hopefully represent the first step of a process of revision of the modern thoracic surgeons' curricula, which need to be qualitatively rethought in the setting of the qualification process. The structural criteria highlighted in the present document are meant to help and tackle the challenge of cultural and language barriers as well as of widely varying national training programmes.

Objectives: Nutritional assessment is not included yet as a major recommendation in lung cancer guidelines. The purpose of this study was thus to assess the influence on surgical outcome of the nutritional status of patients with primary lung cancer undergoing lobectomy., Methods: We queried Epithor, the national clinical database of the French Society of Thoracic and Cardiovascular Surgery, and identified a retrospective cohort of 19 635 patients having undergone lobectomy for a primary lung cancer in the years 2005-11. Their nutritional status was categorized according to the WHO definition: underweight (BMI < 18.5): 857 patients (4.4%), normal (18.5 ≤ BMI < 25): 9391 patients (47.8%), overweight (25 ≤ BMI < 30): 6721 patients (34.2%), obese (BMI ≥ 30): 2666 patients (13.6%). Operative mortality, pulmonary, cardiovascular, infectious and surgical complications rates were collected and analysed for these various BMI groups., Results: In the normal-weight category, operative mortality, pulmonary, surgical, cardiovascular and infectious complications rates were 2.7, 14.6, 13.8, 5.5 and 4.1%, respectively. When compared with that of normal BMI patients, adjusted operative mortality was significantly lower in overweight (2.3%; odd ratio (OR): 0.72 [95% confidence interval (CI): 0.59-0.89]; P = 0.002) and obese patients (1.9%, OR: 0.54 [95% CI: 0.40-0.74]; P < 0.001), and significantly higher in underweight patients (4.1%, OR: 1.89 [95% CI: 1.30-2.75]; P = 0.001). Underweight patients experienced significantly more pulmonary (21.1%; P < 0.001), surgical (23.2%; P < 0.001) and infectious (5.1%; P = 0.05) complications (P < 0.0001). Among surgical complications, prolonged air leaks (17.6%; P < 0.001) and bronchial stump dehiscence (1.5%; P = 0.001) were significantly more frequent in underweight patients than in normal BMI patients. Obesity was not associated with increased incidence of postoperative complications, except for arrhythmia (5.6%; P < 0.05), deep venous thrombosis and pulmonary embolism (1.5%; P = 0.005). Moreover, a statistical protective effect of obesity was observed regarding surgical complications (7.1%; P < 0.001)., Conclusions: Despite having an increased risk of some postoperative cardiovascular complications, obese patients should undergo surgical standard of care therapy for appropriately stage-specific lung cancer. In underweight patients, in addition to preoperative rehabilitation including a nutritional program, attention should be given to aggressive prophylactic respiratory therapy in the perioperative period, and specific intraoperative actions to prevent prolonged air leaks and bronchial stump dehiscence.