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To study the impact of neoadjuvant therapies on postoperative complications and mortality among non-small-cell lung cancer (NSCLC) patients subjected to anatomic lung resection and included in the Spanish cohort of the video-assisted thoracic surgery (GE-VATS) multicenter database.The study included a total of 3085 patients from 33 centers between December 2016 and March 2018. We performed a comparative analysis of the complications and mortality in patients who received neoadjuvant therapies (n = 263) versus those who did not (n = 2822). A propensity score-matched analysis was used to adjust for potential confounders. Association between exposure in two groups and outcomes were estimated by logistic regression weighted by inverse of probability of receiving the treatment that actually received.In the unadjusted analysis, the chemotherapy (CT) and chemoradiotherapy (CRT) group presented a higher frequency of ICU readmissions, reinterventions, empyema, cardiovascular complications, a greater frequency of atrial fibrillation, and an increased need for blood product transfusions. In the adjusted group, CT and CRT patients had a higher rate of cardiovascular complications (CT p = 0.002; OR 2.29; 95% CI 1.34-3.94 and CRT p = 0.001; OR 2.90; 95% CI 1.52-5-52), arrhythmias (CT p = 0.013; OR 2.23; 95% CI 1.18-4.20 and CRT p = 0.046; OR 2.22; 95% CI 1.01-4.90) and transfussions (CT p = 0.042; OR 2.95; 95% CI 1.04-8.35 and CRT p 0.001; OR 7.74; 95% CI 3.01-19-92).Based on our series, neoadjuvant CT and CRT were associated with a higher rate of cardiovascular complications, arrhythmias and transfussions in patients with NSCLC subjected to anatomic lung resection.

OBJECTIVES The relationship between operating time and postoperative morbidity has not been fully characterized in lung resection surgery. We aimed to determine the variables associated with prolonged operative times and their influence on postoperative complications after video-thoracoscopic lobectomy. METHODS Patients undergoing thoracoscopic lobectomy for lung cancer from December 2016 to March 2018, within the prospective registry of the Spanish Video-Assisted Thoracic Surgery Group were identified. Operating time was stratified by quartiles and complication rates analysed using chi-squared test. Primary outcomes included 30-day overall, pulmonary and cardiovascular complications and wound infection. Multivariable logistic regression analyses were performed to identify variables independently associated with operating time and their influence on the occurrence of postoperative complications. RESULTS Data of 1518 cases were examined. The median operating time was 174 min (interquartile range: 130–210 min). Overall morbidity rates significantly increased with surgical duration (20.5% vs 34.4% in the 1st and 4th quartiles, respectively, P CONCLUSIONS Prolonged operating time is associated with increased odds of postoperative complications. Modifiable factors contributing to prolonged operating time may serve as a target for quality improvement.

Introducción: El objetivo del estudio es valorar el rendimiento diagnóstico de la tomografía computarizada (TC) y la tomografía por emisión de positrones (PET) en la estadificación clínica mediastínica del cáncer pulmonar quirúrgico según los datos de la cohorte prospectiva del Grupo Español de Cirugía Torácica Videoasistida (GEVATS). Métodos: Se han analizado 2.782 pacientes intervenidos por carcinoma pulmonar primario. Se ha estudiado el acierto diagnóstico en la estadificación mediastínica (cN2). Se ha realizado un análisis bivariante y multivariante de los factores que influyen en el acierto. Se ha estudiado el riesgo de pN2 inesperado en los factores con los que se recomienda una prueba invasiva de estadificación: cN1, tumor central o tamaño mayor de 3cm. Resultados: El acierto global de la TC y PET en conjunto es del 82,9% con VPP y VPN de 0,21 y 0,93. En tumores mayores de 3cm y a mayor SUVmax del mediastino, el acierto es menor, OR de 0,59 (0,44 - 0,79) y 0,71 (0,66 - 0,75), respectivamente. En el abordaje VATS el acierto es mayor, OR de 2,04 (1,52 - 2,73). El riesgo de pN2 inesperado aumenta con el número de los factores cN1, tumor central o tamaño mayor de 3cm: entre el 4,5% (0 factores) y 18,8% (3 factores), pero no hay diferencias significativas con la realización de prueba invasiva. Conclusiones: La TC y PET en conjunto tienen un elevado valor predictivo negativo. Su acierto global es menor en tumores mayores de 3cm y SUVmax del mediastino elevado, y mayor en el abordaje VATS. El riesgo de pN2 inesperado es mayor si cN1, tumor central o mayor de 3cm y no varía significativamente con prueba invasiva.

BACKGROUND Bronchopleural fistula (BPF) is a severe complication of pulmonary resection associated with high morbidity and mortality. Treatment options include both surgical and endoscopic procedures. The size of the fistula and the functional status of the patient are decisive factors in the choice of treatment. The aim of this study is to describe the experience of using ethanolamine oleate (EO) in endoscopic treatment for BPFs. METHODS A prospective observational, descriptive study, involving patients with subcentimeter BPF and treated with EO. The diagnosis of the fistula was confirmed by flexible bronchoscopy. Patients under conscious sedation received a perifistular injection of EO with a Wang 22-G needle. The procedure was repeated every to 2 weeks until definitive closure. RESULTS Eight patients were included: in 7 (87.5%), the fistula was a complication of lung cancer surgery. The number of sessions needed before the resolution of the BPF was from 1 to 4. Only 1 patient received 4 sessions. Complete closure was obtained in 6 patients (75%). None of the fistulas reopened, and there were no serious complications. CONCLUSION Sclerosis with EO through endoscopic injection enables the closure of small (

The objective of this study was to assess the diagnostic performance of combined computerised tomography (CT) and positron emission tomography (PET) in mediastinal staging of surgical lung cancer based on data obtained from the prospective cohort of the Spanish Group for Video-Assisted Thoracic Surgery (GEVATS).A total of 2782 patients underwent surgery for primary lung carcinoma. We analysed diagnostic success in mediastinal lymph node staging (cN2) using CT and PET. Bivariate and multivariate analyses were performed of the factors involved in this success. The risk of unexpected pN2 disease was analysed for cases in which an invasive testing is recommended: cN1, the tumour centrally located or the tumour diameter3 cm.The overall success of CT together with PET was 82.9% with a positive predictive value of 0.21 and negative predictive value of 0.93. If the tumour was larger than 3 cm and for each unit increase in mediastinal SUVmax, the probability of success was lower with OR 0.59 (0.44-0.79) and 0.71 (0.66-0.75), respectively. In the video-assisted thoracic surgery (VATS) approach, the probability of success was higher with OR 2.04 (1.52-2.73). The risk of unexpected pN2 increased with the risk factors cN1, the tumour centrally located or the tumour diameter3 cm: from 4.5% (0 factors) to 18.8% (3 factors) but did not differ significantly as a function of whether invasive testing was performed.CT and PET together have a high negative predictive value. The overall success of the staging is lower in the case of tumours3 cm and high mediastinal SUVmax, and it is higher when VATS is performed. The risk of unexpected pN2 is higher if the disease is cN1, the tumour centrally located or the tumour diameter3 cm but does not vary significantly as a function of whether patients have undergone invasive testing.

OBJECTIVES The aim of this study was to know the treatment effect of video-assisted thoracic surgery (VATS) on 90-day mortality after anatomical lung resection based on a nationwide cohort. METHODS This is a multicentre prospective cohort of 2721 anatomical resections for lung cancer from December 2016 to March 2018. Treatment and intention-to-treat (ITT) analyses were performed after inverse probability score weighting and different propensity score matching algorithms. Covariate balance was assessed by standardized mean differences. The estimators reported were the average treatment effect, the average treatment effect on the treated and odds ratios after conditional logistic models with 95% confidence intervals. The unconfoundedness assumption was evaluated by sensitivity analysis for average treatment effect (c-dependence) and average treatment effect on the treated (Γ). RESULTS VATS was the initial approach in 1911 patients (70.2%), though 273 cases (14.3%) had to be converted to thoracotomy. Ninety-day mortality rates were: treatment analysis (VATS 1.16% vs open 3.9%, P < 0.001), ITT analysis (VATS 1.78% vs open 3.36%, P = 0.012). After inverse probability score weighting and propensity score matching, in the treatment analysis, VATS meant absolute risk reductions between 2.25% and 2.96% and relative risk reductions between 65% and 70% [OR = 0.34 (95% confidence interval 0.15–0.79), all P-values CONCLUSIONS VATS can reduce the risk of 90-day mortality after anatomical lung resection. However, the implications of conversion to thoracotomy, comparing ITT versus treatment analysis, and the potential impact of hidden bias should deserve further attention in the future.

Resumen Introduccion El objetivo es obtener un modelo predictor de riesgo quirurgico en pacientes sometidos a resecciones pulmonares anatomicas a partir del registro del Grupo Espanol de Cirugia Toracica Videoasistida. Metodos Se recogen datos de 3.533 pacientes sometidos a reseccion pulmonar anatomica por cualquier diagnostico entre el 20 de diciembre de 2016 y el 20 de marzo de 2018. Definimos una variable resultado combinada: mortalidad o complicacion Clavien Dindo IV a 90 dias tras intervencion quirurgica. Se realizo analisis univariable y multivariable por regresion logistica. La validacion interna del modelo se llevo a cabo por tecnicas de remuestreo. Resultados La incidencia de la variable resultado fue del 4,29% (IC 95%: 3,6-4,9). Las variables que permanecen en el modelo logistico final fueron: edad, sexo, reseccion pulmonar oncologica previa, disnea (mMRC), neumonectomia derecha y DLCOppo. Los parametros de rendimiento del modelo, ajustados por remuestreo, fueron: C-statistic 0,712 (IC 95%: 0,648-0,750), Brier score 0,042 y Booststrap shrinkage 0,854. Conclusiones El modelo predictivo de riesgo obtenido a partir de la base de datos Grupo Espanol de Cirugia Toracica Videoasistida es un modelo sencillo, valido y fiable, y constituye una herramienta muy util a la hora de establecer el riesgo de un paciente que se va a someter a una reseccion pulmonar anatomica.

Measuring predicted post-operative diffusion capacity of the lung for carbon monoxide (ppoDLCO) is essential to determine patient operability and to stratify the risk of patients who are candidates for major lung cancer surgery. Studies that established surgical risk variables were based on open surgery series. The aim of our study was to analyze morbidity and mortality as a function of ppoDLCO and to compare its behavior in open and video-assisted thoracic surgery (VATS).We compared 90-day mortality and morbidity in patients undergoing open surgery versus VATS as a function of decline in ppoDLCO. Propensity score matching (using age, ASA, arterial vascular disease, BMI, gender, stage, ppoDLCO, and ppoFEVOf 2,530 patients with lung cancer and ppoDLCO values, a sample of 1,624 (812 per group) was obtained after score matching. The relative risk of mortality associated with thoracotomy in patients with ppoDLCO 60 is 2.66 (p 0.02) compared to VATS. The risk of thoracotomy in terms of overall and cardiac and respiratory morbidity is higher than that of VATS for almost all ppoDLCO values.Major resection by VATS shows lower morbidity and mortality in patients with the same ppoDLCO. A steady rise in the risk of mortality begins to occur at higher ppoDLCO values in thoracotomy (∼60) than in VATS (∼45).

The search for the least invasive approach for lung cancer surgery has developed single-incision thoracoscopic procedures under loco-regional anesthesia without tracheal intubation, including major pulmonary resections such as lobectomies and anatomical segmentectomies. We present the first report of an awake non-intubated single-incision thoracoscopic lobectomy in a patient with clinical stage IIIA adenocarcinoma after induction chemotherapy and mediastinoscopy.

Thoracic surgery has evolved into minimally invasive surgery, in terms of not only surgical approach but also less aggressive anesthesia protocols and lung-sparing resections. Nonintubated anatomic segmentectomies are challenging procedures but can be safely performed if some essentials are considered. Strict selection criteria, previous experience in minor procedures, multidisciplinary cooperation, and the 4 cornerstones (deep sedation, regional analgesia, oxygenation support and vagal blockade) should be followed. Better outcomes in postoperative recovery, including resumption of oral intake, chest tube duration, and hospital stay, and low complication and conversion rates, are encouraging but should be checked in larger multicenter prospective randomized trials.

Video-assisted thoracoscopic surgery (VATS) lung-sparing anatomical resections preserve healthy pulmonary parenchyma but also lead to good resection margins. Oncological outcomes are similar when compared with lobectomy for the treatment of early stage lung adenocarcinoma. VATS technique to perform classical anatomical segmentectomies is well defined and even in highly experienced teams, these procedures can be performed by uniportal VATS. However, the achievement of unusual central anatomical segmentectomies through Uniportal VATS remains a challenge. We describe a feasible and reproducible technique to perform uniportal VATS right lower lateral and posterior (S9–10) anatomical segmentectomy for the treatment of early stage lung cancer.

Resumen: Mujer de 51 años con impactación de aguja metálica en vía aérea un mínimo de treinta años. Tras sufrir neumonía obstructiva, se decide extracción del cuerpo extraño que debe hacerse por cirugía. Abstract: A 51-year-old woman was needle impaction on airway over thirty years. After suffering from obstructive pneumonia, it was decided to remove the foreign body by surgery. Palabras clave: Neumonía por aspiración, Lesiones por aguja, Pulmón, Videotoracoscopia, Keywords: Aspiration pneumonia, Needlestick injuries, Lung, Video-assisted thoracoscopic surgery

Unusual anatomical segmentectomies are technically demanding procedures that require a deep knowledge of intralobar anatomy and surgical skill. In the other hand, these procedures preserve more normal lung parenchyma for lesions located in specific anatomical segments, and are indicated for benign lesions, metastasis and also early stage adenocarcinomas without nodal involvement. A 32-year-old woman was diagnosed of a benign pneumocytoma in the anterior segment of the left-lower lobe (S8, LLL), so we performed a single-incision video-assisted thoracoscopic surgery (SI-VATS) anatomical S8 segmentectomy in 140 minutes under intercostal block. There were no intraoperative neither postoperative complications, the chest tube was removed at 24 hours and the patient discharged at 5th postoperative day with low pain on the visual analogue scale (VAS). Final pathologic exam reported a benign sclerosant pneumocytoma with free margins. The patient has recovered her normal activities at 3 months completely with radiological normal controls at 1 and 3 months.

Thoracic trauma is a challenging situation with potential severe chest wall and intrathoracic organ injuries. We present a case of emergent surgery in a 23-year-old man with hemorrhagic shock due to massive lung and chest wall injury after thoracic trauma in a water slide. We performed a SI-VATS approach in order to define intrathoracic and chest wall injuries, and once checked the extension of the chest wall injury, we added a middle size thoracotomy just over the affected area in order to stabilize rib fractures with Judet plates, that had caused massive laceration in left lower lobe (LLL) and injured the pericardium causing myocardical tear. After checking bronchial and vascular viability of LLL we suggested a lung parenchyma preserving technique with PTFE protected pulmonary primary suture in order to avoid a lobectomy. Chest tubes were removed on 3rd postoperative day and patient was discharged on 14th postoperative day. He has already recovered his normal activity 6 months after surgery.

Nowadays, sublobar anatomic resections are gaining momentum as a valid alternative for early stage lung cancer. Despite being technically demanding, anatomic segmentectomies can be performed by uniportal video-assisted thoracic surgery (VATS) approach to combine the benefits of minimally invasiveness with the maximum lung sparing. This procedure can be even more complex if a combined resection of multiple segments from different lobes has to be done. Here we report five cases of combined and unusual segmentectomies done by the same experienced surgeon in high volume institutions to show uniportal VATS is a feasible approach for these complex resections and to share an excellent educational resource.

In recent years, the search for a less invasive and thus, less painful approach has driven technical innovation in modern thoracic surgery. In this context, subxiphoid uniportal approach has emerged as an alternative to avoid intercostal space manipulation and decrease postoperative pain and intercostal nerve chronic impairment. Subxiphoid uniportal major lung resections have been safe and effective procedures when performed by experienced surgeons even in complex cases or unexpected intraoperative situations. We present six of these surgical scenarios such as big tumors, incomplete or absent fissures, hiliar calcified lymph nodes, active bleeding and massive adhesions to show the feasibility of subxiphoid approach to manage even these conditions.

Worldwide accepted indications of anatomical segmentectomies are mainly early stage primary adenocarcinomas, pulmonary metastasis and benign conditions. Their performance through uniportal VATS has become more and more popular due to the less invasiveness of the whole procedure under this approach. Recently, many efforts have focused on non-intubated spontaneously breathing management of lobectomies and anatomical segmentectomies, although specific selection criteria and main advantages are not completely standardized. In a 62-year-old thin man with two pulmonary residual metastasis from sigma adenocarcinoma, after chemotherapy plus antiangiogenic treatment, we indicated a single-incision video-assisted left-lower lobe (LLL) upper segmentectomy (S6) under spontaneous breathing and intercostal blockade. Total operation time was 240 minutes. Chest tube was removed at 24 hours and the patient was discharge on postoperative day 2 without any complication. Non-intubated uniportal VATS is a safe and reasonable approach for lung-sparing resections in selected patients, although more evidence is required for selecting which patients can benefit more over standard intubated procedures.

Non-intubated VATS (NI-VATS) is a novel approach that aims to benefit the patient by obtaining the minimal surgical and anaesthetic invasion. In the last years, NI-VATS approach has shown encouraging results to treat primary spontaneous pneumothorax (PSP). The aim of this review is sumarize the experience of the authors developing a programme of NI-VATS surgery for treatment of PSP from 2013 to 2019 and to summarize the evidence about NI-VATS PSP treatment in the literature.

I read with enthusiasm the paper of Wang and colleagues (1) about the use of nasal high-flow oxygen therapy during non-intubated thoracoscopic surgery. The aim was to assess if high-flow oxygen therapy improved oxygenation and carbon dioxide wash out during non-intubated thoracic surgery.

In recent years, the video-assisted thoracic surgery (VATS), and uniportal VATS approach has become the routine approach in numerous centers. Nevertheless, uniportal VATS learning curve is a challenge even for those surgeons with experience in multiportal VATS surgery. Among the surgeons who prefer the use of the multiportal VATS approach it is noteworthy that many of them are more comfortable through several ports because they feel this approach is more ergonomic. We present our routine programme of VATS surgery assisted by articulated arm (AVATS) for major resections, as a technique that allows ergonomic surgery for both, surgeon and first assistant and cooperative surgical field when is needed.

Mediastinal anesthesia for diagnostic or therapeutic procedures can present more risks during the induction phase due to potential respiratory or cardiovascular collapse for direct compression by the mediastinal mass. The anesthesiologist must assess some preoperative features of patients (including patients symptoms) before initiating the procedure and categorized them into risk groups. Awake induction under local anesthesia and spontaneous breathing can be mandatory in high risk patients. Management of the airway in these patients can be a real challenge, thus different airway intubation strategies must be kept in mind before initiating the induction of anesthesia including selective endobronchial tubes under fiberoptic guidance, rigid bronchoscope jet ventilation and tracheal stenting. Cardiopulmonary by-pass might be needed if predicted great vessels invasion or if cardiovascular or respiratory collapse appears. Although non-intubated procedures are becoming more frequent for pulmonary surgical procedures, there is still a lack of evidence of its advantages and disadvantages in mediastinal surgery, so special care must be taken before embarking in this novel approach. Most severe complications after miastenia gravis surgery appear in terms of postoperative myasthenic crisis, that should first be predicted by the anesthesiologist during preoperative assessment. Short and middle action neuromuscular blocking agents can be safely used in reduced dosis, and sugammadex seems to reverse effectively and safely their action in a very short time.

Nonintubated procedures have widely developed during the last years, thus nowadays major anatomical resections are performed in spontaneously breathing patients in some centers. In an attempt for combining less invasive surgical approaches with less aggressive anesthesia, nonintubated uniportal video-assisted thoracic surgery (VATS) lobectomies and segmentectomies have been proved feasible and safe, but there are no comparative trials and the evidence is still poor. A program in nonintubated uniportal major surgery should be started in highly experienced units, overcoming first a learning period performing minor procedures and a training program for the management of potential crisis situations when operating on these patients. A multidisciplinary approach including all the professionals in the operating room (OR), emergency protocols and a comprehensive knowledge of the special physiology of nonintubated surgery are mandatory. Some concerns about regional analgesia, vagal block for cough reflex control and oxygenation techniques, combined with some specific surgical tips can make safer these procedures. Specialists must remember an essential global concept: all the efforts are aimed at decreasing the invasiveness of the whole procedure in order to benefit patients' intraoperative status and postoperative recovery.