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Objectives: The aim of this study was to examine the impact of surgical learning curve on short-term clinical outcomes of patients after bilateral lung transplantation (LTx) performed by a surgical multidisciplinary team (MDT)., Methods: Forty-two patients underwent double LTx from December 2016 to October 2021. All procedures were performed by a surgical MDT in a newly established LTx program. The time required for bronchial, left atrial cuff and pulmonary artery anastomoses was the main end point to assess surgical proficiency. The associations between the surgeon's experience and procedural duration were examined by linear regression analysis. We employed the simple moving average technique to generate learning curves and evaluated short-term outcomes before and after achieving surgical proficiency., Results: Both total operating time and total anastomosis time were inversely associated with the surgeon's experience. On analysing the learning curve for bronchial, left atrial cuff and pulmonary artery anastomoses using moving averages, the inflection points occurred at 20, 15 and 10 cases, respectively. To assess the learning curve effect, the study cohort was divided into early (cases 1-20) and late (cases 21-42) groups. Short-term outcomes-including intensive care unit stay, in-hospital stay and severe complications-were significantly more favourable in the late group. Furthermore, there was a notable tendency for patients in the late group to experience a decreased duration of mechanical ventilation along with reduced instances of grade 3 primary graft dysfunction., Conclusions: A surgical MDT can perform double LTx safely after 20 procedures., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The use of a hybrid operating room equipped with robotic C-arm cone-beam computed tomography for single-step localization and excision of small pulmonary nodules finds high cost barriers. The new generation of 3D C-arm system not only depicts soft tissues with high contrast but also offers a more affordable and sustainable solution. This approach has been chiefly applied in the field of orthopedic surgery. In this case series, we describe the use of a mobile 3D C-arm system for localizing and removing small pulmonary nodules., Methods: Between July and September 2020, we identified 14 patients who underwent localization and removal of small pulmonary nodules with a 3D C-arm system. We retrospectively reviewed clinical records to document the feasibility and safety of the procedure., Results: The median tumour size was 7.5 mm [interquartile range (IQR): 5 - 9.75 mm], with a median distance from the pleural surface of 4.2 mm (IQR: 0.5 - 6.45 mm). We successfully visualized all of the pulmonary lesions by intraoperative CT imaging. Localization was achieved in 13 patients, who subsequently underwent complete thoracoscopic resection. The median time required to localize lesions was 41.5 min (IQR: 33.75 - 53.25 min), with a median radiation exposure (expressed through the skin absorbed dose) of 143.45 mGy (IQR: 86.1 - 194.6 mGy). Failure to localize occurred in 1 patient because of pneumothorax caused by repeated needle puncture. All patients were successfully discharged and the median length of stay was 2.5 days (IQR: 2 - 3 days)., Conclusions: This case series demonstrates the feasibility of single-step localization and excision of small pulmonary nodules using a mobile 3D C-arm., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Herein, we describe a Dyna-computed tomography-guided electromagnetic navigation bronchoscopy technique aimed at localizing deep pulmonary nodules. The method was implemented in a hybrid operating room and required the use of 2 markers (a near-infrared dye as a surface marker and a microcoil as a deep marker)., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Computed tomography (CT)-guided localization of multiple ipsilateral pulmonary nodules remains challenging. Hybrid operating rooms equipped with cone-beam CT and laser navigation systems have the potential for improving clinical workflows and patient outcomes., Methods: Patients with multiple ipsilateral pulmonary nodules requiring localization were divided according to the localization method [preoperative CT-guided (POCT group) localization versus intraoperative CT-guided (IOCT group) localization]. The 2 groups were compared in terms of procedural efficacy, safety and radiation exposure., Results: Patients in the IOCT (n = 12) and POCT (n = 42) groups did not differ in terms of demographic and tumour characteristics. Moreover, the success and complication rates were similar. Notably, the IOCT approach allowed multiple nodules to be almost simultaneously localized-resulting in a shorter procedural time [mean difference (MD) -15.83 min, 95% confidence interval (CI) -7.97 to -23.69 min] and lower radiation exposure (MD -15.59 mSv, 95% CI -7.76 to -23.42 mSv) compared with the POCT approach. However, the total time under general anaesthesia was significantly longer in the IOCT group (MD 34.96 min, 95% CI 1.48-68.42 min), despite a similar operating time. The excess time under anaesthesia in the IOCT group can be attributed not only to the procedure per se but also to a longer surgical preparation time (MD 21.63 min, 95% CI 10.07-33.19 min)., Conclusions: Compared with the POCT approach, IOCT-guided localization performed in a hybrid operating room is associated with a shorter procedural time and less radiation exposure, albeit at the expense of an increased time under general anaesthesia., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: With the increasing availability of hybrid operating rooms, single-stage tumour localization and removal under intraoperative computed tomography (CT) guidance is gaining popularity. The objective of this study was to describe the learning curve for this procedure., Methods: Over a 15-month period, a single team of thoracic surgeons without experience in intraoperative CT-guided lung tumour localization performed a total of 91 procedures in 89 patients. All these procedures were conducted in a hybrid operating room equipped with cone-beam CT and a laser navigation system. The learning curve was analysed using the cumulative sum method (target success rate 90%), whereas the moving average was used as an indicator of localization time., Results: The mean lung tumour size on preoperative CT images was 7.81 mm, whereas their mean distance from the pleural surface was 10.16 mm. The localization time (mean 21.19 min) was inversely associated with the surgeon's experience (Pearson's r = -0.6601; P < 0.001). The moving average analysis revealed that localization time stabilized after 32 procedures. There were 6 failures; of these, 2 occurred during lesion localization (as a result of needle puncture-related pneumothorax) and 4 during surgery (caused either by wire dislodgement or dye spillage). The cumulative sum analysis revealed that proficiency was achieved after 38 procedures. The mean localization time and success rates before and after procedure 38 were 32.13 min vs 13.34 min (P < 0.001) and 86.8% vs 98.1% (P = 0.078), respectively., Conclusions: The procedural time and success rates of intraoperative CT-guided lung tumour localization were optimized after 38 consecutive procedures., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: This case series illustrates the feasibility of single-stage image-guided video-assisted thoracoscopic surgery for simultaneous localization and removal of small solitary pulmonary nodules (SPNs). The procedure was performed in a hybrid operating room using C-arm cone-beam computed tomography equipped with a laser-guided navigation system., Methods: Between October 2016 and January 2017, 12 consecutive patients presenting with SPNs underwent image-guided video-assisted thoracoscopic surgery. The feasibility and safety of the procedure were assessed through a retrospective review of the patients' clinical charts., Results: The median size of SPNs was 5.5 mm [interquartile range (IQR) 4-6 mm], whereas their median distance from the pleural surface was 11.7 mm (IQR 6-11.3 mm). All of the lesions were visible on intraoperative C-arm cone-beam computed tomography images, and localization was successful in 10 patients; thereafter, complete thoracoscopic resection was successfully performed. The median time required for the localization of SPNs was 45.5 min (IQR 36-60 min), whereas the median radiation exposure (expressed through the skin absorbed dose) was 223.2 mGy (IQR 180.3-321.3 mGy). Lesion localization was unsuccessful in 2 cases because to the development of pneumothorax induced by needle puncture. In such cases, a utility thoracotomy was required for the identification of SPNs. There was no operative mortality, and the median length of postoperative stay was 4 days (IQR 3.8-4 days)., Conclusions: The results of our case series support the feasibility of image-guided video-assisted thoracoscopic surgery for detection and removal of SPNs. Future efforts should be tailored to decrease localization time and minimize radiation exposure., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Some esophageal cancer patients may be reluctant to accept the scheduled resection after neoadjuvant chemoradiotherapy (nCRT) because of its potential negative impact on quality of life as a result of high morbidity. This study was performed to investigate the survival outcomes of these patients. Between 2000 and 2012, we identified 190 patients with resectable esophageal squamous cell carcinoma (ESCC) who did not proceed to surgery following nCRT. Subjects who had a clinical complete response (cCR) and were medically fit for surgery were deemed eligible. Survival rates, recurrence patterns, and risk factors for recurrence served as the main outcome measures. The study cohort consisted of 73 patients (67 males and 6 females; mean age: 61.3 years). The 5-year overall survival was 39.6% (median survival time: 46.77 months). Cancer recurrences were observed in 44 patients (60.2%), with locoregional recurrence (LR) being the most common failure pattern (n = 35). Endoscopic findings after nCRT were the most important independent predictor of LR identified in multivariate analysis. Compared with the 'normal findings' subgroup, the odds ratios for LR in cCR patients who refused surgery were 4.774 (P = 0.026) and 2.844 (P = 0.16) in the 'scar' and 'other findings' subgroups, respectively. Patients with 'normal findings' had the lowest rate of LR (22.2%), with no recurrences occurring within the first 6 months. Sixty percent of ESCC patients who achieve cCR following nCRT but refuse esophagectomy develop disease recurrence, with LR being the most common pattern. Post-nCRT endoscopic findings may serve as a predictor for LR., (© 2016 International Society for Diseases of the Esophagus.)