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Aims: Telepathology uses digitised image transfer to allow off‐site reporting of histopathology slides. This technology could facilitate the centralisation of pathology services, which may improve their quality and cost‐effectiveness. The benefits may be most apparent in frozen section reporting, in which turnaround times (TATs) are vital. We moved from on‐site to off‐site telepathology reporting of thoracic surgery frozen section specimens in 2016. The aim of this study was to compare TATs before and after this service change. Methods and results: All thoracic frozen section specimens analysed 4 months prior and 4 months following the service change were included. Demographics, operation, sample type, time taken from theatre, time received by laboratory, time reported by laboratory, TAT, frozen section diagnosis, final histopathological diagnosis and final TNM staging were recorded. The results were analysed with spss statistical software version 24. In total, there were 65 samples from 59 patients; 34 before the change and 31 after the change. Specimens included 51 lung, six lymph node, three bronchial, three chest wall and two pleural biopsies. Before the change, the median TAT was 25 min [interquartile range (IQR) 20–33 min]. No diagnoses were deferred. No diagnoses were changed on subsequent paraffin analysis. After the change, with the use of digital pathology, the median TAT was 27.5 min (IQR 21.75–38.5 min). This difference was not significant (P = 0.581). Diagnosis was deferred in one case (3.23%). There was one (3.23%) mid‐case technical failure resulting in the sample having to be transported by courier, resulting in a TAT of 106 min. No diagnoses were changed on subsequent paraffin analysis. Conclusions: There was no significant difference in reporting times between digital technology and an on‐site service, although one sample was affected by a technical failure requiring physical transportation of the specimen for analysis. Our study was underpowered to detect differences in accuracy. [ABSTRACT FROM AUTHOR]

OBJECTIVES: As the adoption of robotic procedures becomes more widespread, additional risk related to the learning curve can be expected. This article reports the results of a Delphi process to define procedures to optimize robotic training of thoracic surgeons and to promote safe performance of established robotic interventions as, for example, lung cancer and thymoma surgery. METHODS: In June 2016, a working panel was spontaneously created by members of the European Society of Thoracic Surgeons (ESTS) and European Association for Cardio-Thoracic Surgery (EACTS) with a specialist interest in robotic thoracic surgery and/or surgical training. An e-consensus-finding exercise using the Delphi methodology was applied requiring 80% agreement to reach consensus on each question. Repeated iterations of anonymous voting continued over 3 rounds. RESULTS: Agreement was reached on many points: a standardized robotic training curriculum for robotic thoracic surgery should be divided into clearly defined sections as a staged learning pathway; the basic robotic curriculum should include a baseline evaluation, an e-learning module, a simulation-based training (including virtual reality simulation, Dry lab and Wet lab) and a robotic theatre (bedside) observation. Advanced robotic training should include e-learning on index procedures (right upper lobe) with video demonstration, access to video library of robotic procedures, simulation training, modular console training to index procedure, transition to full-procedure training with a proctor and final evaluation of the submitted video to certified independent examiners. CONCLUSIONS: Agreement was reached on a large number of questions to optimize and standardize training and education of thoracic surgeons in robotic activity. The production of the content of the learning material is ongoing. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Uniportal approaches to video-assisted thoracoscopic surgery (VATS) lobectomy have been described in significant series. Few comparison studies between the two techniques exist. The aim was to determine whether the uniportal technique had more favourable postoperative outcomes than the multiport technique. METHODS: All VATS lobectomies undertaken at a single university hospital during August 2012 to December 2013 were studied. Patients with preoperative opiate use or chronic pain were excluded. Patients were divided into those with uniportal and multiport approaches for analysis. All continuous data were assessed for normality, and analysed with the Mann-Whitney U-tests or t-tests as appropriate. Categorical data were analysed by Fisher's exact or X2 test for trend as appropriate. RESULTS: One hundred and twenty-nine VATS lobectomies were completed. Six were excluded and data were incomplete for 13, leaving 110 (15 uniportal, 95 multiport) for analysis. The demographics of the two groups were similar. There was no significant difference in the Thoracoscore or American Society of Anesthesiologists grades. The median morphine use in the first 24 postoperative hours was 19 mg in the uniportal group and 23 mg in the multiport group, P = 0.84. The median visual analogue pain score in the first 24 h was 0 in the uniportal group and 0 in the multiport group, P = 0.65. There was no difference in the duration of patient-controlled analgesia (P = 0.97), chest drain duration (P = 0.67) or hospital length of stay (P = 0.54). There was no inpatient mortality and no unplanned admission to critical care in either group. CONCLUSIONS: Uniportal VATS lobectomy is safe, and there is no appreciable negative impact on the hospital stay or morbidity. Patientreported pain and morphine use in the first 24 h was low with either technique. Larger prospective studies are needed to quantify any benefit to a particular approach for VATS lobectomy. [ABSTRACT FROM AUTHOR]

OBJECTIVES Video-assisted thoracoscopic surgery (VATS) lobectomy is associated with improved short-term outcomes compared with thoracotomy. Definition of the hilar structures is crucial to safe VATS lobectomy. Several VATS approaches have been described. We report the effect of three surgeons in our institution undertaking standardized anterior approach (SAA) training on the proportion of isolated lobectomies subsequently completed by VATS. Predictors of successful VATS lobectomy were analysed. METHODS Three consultant surgeons undertook SAA training at two different time points. Two were performing VATS lobectomy prior to SAA training. Training involved a 2-day visit to an established SAA unit. Lobectomies performed by these surgeons between April 2011 and December 2012 (20 months), before and after training, were recorded prospectively. Bilobectomies, sleeve resections, pneumonectomies and chest wall resections were excluded. VATS lobectomy proportions before and after training were compared. Independent predictors of completion by VATS rather than thoracotomy were identified by multivariable logistic regression. RESULTS One hundred and sixty-three isolated lobectomies were performed, 97 of these by VATS (59.5%). The mean age was 68.8 (±10.5) years. Pathology was lung cancer in 137 (84.0%), other primary malignancy in 10 (6.1%), pulmonary metastases in 8 (4.9%) and benign in 8 (4.9%). The VATS lobectomy rate rose from 22.2% before SAA training to 77.3% after, P < 0.001. The effect was significant for both existing and adopting VATS lobectomy surgeons, P = 0.002 to <0.001. The median hospital stay was 4 days after VATS and 5 after thoracotomy, P < 0.001. There were 5 in-hospital deaths after thoracotomy and none after VATS lobectomy, unadjusted P = 0.01. In the final logistic regression model, SAA training was the strongest predictor of successful VATS lobectomy (odds ratio 15.16; 95% confidence interval 6.39, 35.96). CONCLUSIONS Formal training and adoption of the SAA approach were associated with a more than 3-fold increase in our VATS lobectomy rate. The effect was immediate and sustained. This may reflect easier identification of the major structures from the anterior view. In addition, standardization of surgical techniques and perioperative protocols may facilitate efficient team working. VATS lobectomy was associated with a shorter median hospital stay. Units seeking to increase their VATS lobectomy rate should consider group adoption of the SAA approach. [ABSTRACT FROM PUBLISHER]

This case report describes a 46-year-old patient with a very unusual pattern of isolated metastasis to an extralobar pulmonary sequestration following orchidectomy for seminoma. The patient underwent uncomplicated video-assisted thoracoscopic resection of the metastasis, involving the whole of the sequestration mass. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Although video-assisted thoracoscopic (VATS) lobectomy offers advantages with regard to pain, respiratory function and mobility, concern is often expressed concerning the cost of stapling devices and increased operative time. We have therefore compared the costs of VATS and open lobectomy in order to assess the overall economic sustainability of a VATS programme. Materials and methods: Between January 2004 and December 2006 346 patients underwent pulmonary lobectomy mainly for stage I or II lung cancer (93 VATS lobectomy, 253 thoracotomy). In the VATS group 47% of patients had an upper lobectomy versus 52% in the open group (p =ns). Direct medical costs (disposables, theatre time, high dependency unit stay, hospital stay) were determined and stratified by lobectomy type. Results: Mean theatre cost for a VATS lobectomy was 2533±230€ versus 1280±54€ for a thoracotomy lobectomy (p =0.00001). Mean high dependency unit (HDU) cost was 1713±236€ and 2571±80€ for a VATS and a thoracotomy lobectomy, respectively (p =0.00001). Mean cost of hospital stay for a VATS lobectomy was 3776±281€ versus 4325±154€ for an open one (p =0.00001). The overall cost for a VATS lobectomy was 8023±565€ which was less than an open lobectomy 8178±167€ (p =0.0002). VATS bilobectomy was slightly more expensive than an open one: 8702±350€ versus 8655±466€ but this difference (47€) was not significant (p =ns). Conclusion: VATS lobectomy is less expensive than conventional lobectomy. Increased theatre costs (disposables and time) are counteracted by shorter hospital stay. Importantly, the reduced HDU and ward bed stays free resources for other patients. [Copyright &y& Elsevier]

Objective: To analyze the results of extensive reconstruction of the left anterior descending coronary artery (LAD) by an autologous vein patch, with or without endarterectomy (EA), associated with left internal mammary artery grafting onto the patch. Methods: Between January 1994 and April 2001, among 5871 myocardial revascularizations, 83 patients (1.4%), 77 male (93%), with a mean age±SD of 64±8 years (range 44–84) underwent the above mentioned procedure. Seventy-three of them (88%) were in Canadian Cardiovascular Society (CCS) Class III or IV, and 78 (94%) had a three-vessel disease. Mean preoperative ejection fraction was 58±12%. Risk factors included hypertension (63%), family history (51%), hyperlipidemia (41%), smoking (38%), diabetes (19%). Mean number of anastomoses/patient was 3±0.6. Mean length of vein patch was 2.8±0.9 cm (range 2–6 cm). A total of 16% of the patients underwent associated LAD-EA (mean cardiopulmonary bypass time: 132±21 min; mean aortic crossclamp time: 81±15 min). Results: There was one hospital death (recurrent MI, 1.2%). Seven patients (8%) had a perioperative myocardial infarction, in three cases in the region supplied by the LAD (none after associated LAD-EA). Mean follow-up period was 47±20 months (range 5–90) and is 99% complete. There were five late cardiac deaths (6%). A total of 74% survivors have no symptoms, 12% are in CCS Class I–II, and 14% in III–IV. Actuarial freedom from recurrent angina at 3 and 5 years is 77 and 69%, respectively. Follow-up angiograms (49 patients, 60%) revealed a full patent LAD graft in 82% of the cases (GI), versus poor run-off/occluded graft in the remaining 18% (GII). Anginal status was significantly worse in GII patients (P<0.05). Conclusions: Extended reconstruction of the LAD coronary artery increases surgical risk. The procedure however enhances the probability for a complete revascularization in patients with an unfavourable anatomical substrate, with acceptable mid-term results. [Copyright &y& Elsevier]

We wanted to engage with NOLCP, and review our lung cancer pathway for patients with potentially resectable cancer. 1. Prioritizing performing transfer factor for patients with newly diagnosed, potentially radically treatable lung cancer in clinic. [Extracted from the article]

The article presents case study of a 68-year-old man after minithoracotomy and repositioning of an epicardial lead for his cardiac resynchronisation therapy-pacemaker to improve synchrony in dilated cardiomyopathy. It is informed that chronic obstructive pulmonary disease, hypertension, chronic kidney disease stage 3 and depression were also included in his medical history.

OBJECTIVES Video-assisted thoracoscopic surgery (VATS) for thymoma has uncertain safety and effectiveness in comparison with trans-sternal resection. This feasibility study compared short- and mid-term outcomes for patients undergoing these two procedures, highlights weaknesses in current research and makes recommendations for long-term technological evaluations in this field. METHODS Consecutive thymoma cases between 2004 and 2010 were identified. Patients were divided into two groups according to surgical approach (Group I trans-sternal; Group II VATS) and comparisons were made between groups. The primary outcome was overall survival. Secondary outcomes included operative morbidity and mortality, hospital stay, recurrence rate and disease-free survival. RESULTS Thirty-nine patients were included (Group I: n = 22 vs Group II: n = 17). There were no differences between groups at baseline for all measured covariates. No deaths occurred within 30 days of surgery. More patients in Group I developed complications (Group I: n = 10 vs Group II: n = 3; P = 0.093), while hospital stay was shorter in Group II (Group I: 6.4 ± 4.6 days vs Group II: 4.4 ± 1.8 days; P = 0.030). Five-year overall survival (Group I: 93.8 ± 6.1% vs Group II: 83.3 ± 11.2%; P = 0.425), 5-year disease-free survival (Group I: 71.0 ± 15.3% vs Group II: 83.3 ± 11.2%; P = 0.827) and recurrence rates at final follow-up (Group I: n = 2 vs Group II: n = 1; P = 0.363) were similar between the groups. CONCLUSION VATS thymectomy for thymoma is feasible, safe and has comparable mid-term oncological outcomes to trans-sternal thymectomy. Future research is required to evaluate long-term oncological outcomes of VATS thymectomy for thymoma in national registries and randomized, controlled trials. [ABSTRACT FROM AUTHOR]

The article presents a case study of a a 61-year-old man with a late presentation of left transdiaphragmatic intercostal hernias (TDIH) after mild blunt chest trauma. Symptoms reported included productive coughing, shortness of breath (SOB) upon exertion, and chest discomfort. The article discusses a thoracic computed tomography (CT) scan revealing transdiaphragmatic herniation of intraabdominal organs, diaphragmatic repair, and factors contributing to the formation of a TDIH.

Abstract: Objective: Controversy still exists about averting expenditure of health care resources on the growing elderly population. This study evaluates clinical outcome of patients aged 75 years and older operated upon for acute type A aortic dissection. Methods: Between January 1990 and April 2004, of 247 patients undergoing emergency operation for acute type A aortic dissection at our Institution, 40 patients (16%) were aged 75 years and older (mean 78±3 years, range 75–88 years) and represent the study population. On admission, 9 (22.5%) had cardiogenic shock/hypotension, 20 (50%) cardiac tamponade, 14 (35%) kidney failure, 11 (27.5%) limb ischemia, 3 (7.5%) neurologic deficit, and 1 (2.5%) myocardial ischemia. Surgical procedures included isolated replacement of the ascending aorta in 34 patients (85%), associated with total root replacement in 5 (12.5%), and with aortic valve replacement in 1 (2.5%). Eleven patients (27.5%) underwent aortic arch replacement (hemiarch: n =8, 20%; total arch: n =3, 7.5%). Results: In-hospital mortality was 30% (12 patients). Mortality tended to be higher (8/21, 38% vs 4/19, 21%; p =NS) for patients presenting with any one of the following complications: tamponade, shock, brain and/or myocardial, renal, limb malperfusion. Actuarial survival at 1, 5, and 7 years was 93±5%, 80±8%, and 80±8%, respectively, and freedom from reoperation 97±2%, 97±2%, and 97±2%, respectively. Actuarial event-free rates were 94±3%, 90±5%, and 90±5%. Seventy-four percent of survivors are in NYHA FC I, and quality of life test (RAND SF-36) revealed a generalized perception of independency and well-being, comparable to an age-matched population. Conclusions: Overall results for emergency repair of acute type A aortic dissection in the elderly justify intervention, particularly in uncomplicated cases. Expeditious referral and intervention by lowering pre-operative dissection-related complications and comorbidities might help to improve results. Survivors show functional status and quality of life similar to contemporary individuals. [Copyright &y& Elsevier]

The surgical setting is a highly complex environment where, in ideal conditions, everything should be under control to ensure a positive outcome. However, the existing complexity opens the possibility for multiple failures along the process and many of those failures are related to what is call the non-technical skills of the members of the team. We cannot eradicate human error, but we can try to avoid future mistakes in our daily practice introducing the awareness for providing a high-quality care in which patient safety is crucial. This paper presents an easy approach to concepts and teaching possibilities of those non-technical skills., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd.2019.01.48). The series “Training in Pulmonary Medicine and Surgery” was commissioned by the editorial office without any funding or sponsorship. Dr. GC reports having no conflict of interest with the current paper. Nevertheless, he was working as a consultant surgeon for the National Health System in the UK when the paper was written and after he changed to Medical Doctor for Johnson and Johnson where he is currently working. The authors have no other conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

Introduction: Gabapentin is an antiepileptic drug currently licensed to treat epilepsy and neuropathic pain but has been used off-label to treat acute postoperative pain. The GAP study will compare the effectiveness, cost-effectiveness and safety of gabapentin as an adjunct to standard multimodal analgesia versus placebo for the management of pain after major surgery., Methods and Analysis: The GAP study is a multicentre, double-blind, randomised controlled trial in patients aged 18 years and over, undergoing different types of major surgery (cardiac, thoracic or abdominal). Patients will be randomised in a 1:1 ratio to receive either gabapentin (600 mg just before surgery and 600 mg/day for 2 days after surgery) or placebo in addition to usual pain management for each type of surgery. Patients will be followed up daily until hospital discharge and then at 4 weeks and 4 months after surgery. The primary outcome is length of hospital stay following surgery. Secondary outcomes include pain, total opioid use, adverse health events, health related quality of life and costs., Ethics and Dissemination: This study has been approved by the Research Ethics Committee . Findings will be shared with participating hospitals and disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Patients will be informed of the results through patient organisations and participant newsletters., Trial Registration Number: ISRCTN63614165., Competing Interests: Competing interests: No competing interests are declared. At the time that the work was carried out, GC was employed by the University Hospitals Bristol NHS Foundation Trust, Bristol, UK. GC is currently the Medical Director Johnson and Johnson Medical Devices UK and Ireland. GC has no competing interests to declare., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

The improvement of surgical outcomes has been achieved working under the assumption that they are mainly the result of technical skills. This model, although correct, is not exhaustive and has left out many variables that affect outcomes, of which a number can be grouped under the label of non-technical skills, which is a subset of human factors. Non-technical skills are developed to facilitate a shared mental model between team members, teams and their operational environment. They include situation awareness, decision-making, communication, teamwork, leadership and performance-shaping factors. The importance of these non-technical skills has been highlighted during the investigations of severe accidents in many high-risk industries and healthcare. There is an almost untapped opportunity to improve outcomes focusing on non-technical skills because until recently there has been an under-investment of time and resources in this area compared with technical skills. This theoretical paper supports the adoption of a broader model of human performance as a function of technical and non-technical skills and the cultural and organisational context where these are at play. We also aim to highlight a pathway to increase the investment in non-technical skills following the most updated evidence., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

We describe a novel video-assisted thoracic surgery (VATS) anterior approach to lymph node station 7 after VATS left lower lobectomy., (© The Author 2016. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: Innate immune responses to pulmonary resection may be critical in the pathogenesis of important postoperative pulmonary complications and potentially longer-term survival. We sought to compare innate immunity of patients undergoing major pulmonary resection for bronchogenic carcinoma via video-assisted thoracoscopic surgery (VATS) and thoracotomy., Methods: Bronchoalveolar lavage was conducted in the contralateral lung before staging bronchoscopy and mediastinoscopy and immediately after lung resection. Blood and exhaled nitric oxide were sampled preoperatively and at 6, 24, and 48 hours postoperatively., Results: Forty patients were included (26 VATS and 14 thoracotomy). There was a lower systemic cytokine response from lung resection undertaken by VATS compared with thoracotomy [interleukin 6 (IL-6), analysis of variance (ANOVA) P = 0.026; IL-8, ANOVA P = 0.018; and IL-10, ANOVA P = 0.047]. The VATS patients had higher perioperative serum albumin levels (ANOVA P = 0.001). Lower levels of IL-10 were produced by lipopolysaccharide-stimulated blood monocytes from the VATS patients compared with the thoracotomy patients at 6 hours postoperatively (geometric mean ratio, 1.16; 95% confidence interval, 1.08-1.33; P = 0.011). No statistically significant differences in the neutrophil phagocytic capacity, overall leukocyte count, or differential leukocyte count were found between the surgical groups (ANOVA P > 0.05). No statistically significant differences in bronchoalveolar lavage fluid parameters were found. Exhaled nitric oxide levels fell postoperatively, which reached statistical significance at 48 hours (geometric mean ratio, 1.2; 95% confidence interval, 1.02-1.46; P = 0.029). There were no significant differences found between the surgical groups (ANOVA P = 0.331)., Conclusions: Overall, a trend toward greater proinflammatory and anti-inflammatory responses is seen with lung resection performed via thoracotomy compared with VATS.