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Objectives: The objective of the present study was to compare functional loss [forced expiratory volume in one second to forced vital capacity ratio (FEV1), DLCO and VO2max reduction] after VATS versus open lobectomies., Methods: We performed a prospective observational study on 195 patients who had a pulmonary lobectomy from June 2010 to November 2014 and who were able to complete a 3-months functional evaluation follow-up program. Since the VATS technique was our first choice for performing lobectomies from January 2012, we divided the patients into two groups: the OPEN group (112 patients) and the VATS group (83 patients). The open approach was intended as a muscle sparing/nerve sparing lateral thoracotomy. Fourteen baseline factors were used to construct a propensity score to match the VATS-group patients with their OPEN-group counterparts. These two matched groups were then compared in terms of reduction of FEV1, DLCO and VO2max (Mann-Whitney test)., Results: The propensity score analysis yielded 83 well-matched pairs of OPEN and VATS patients. In both groups, 3 months postoperatively, we found a reduction in FEV1, DLCO and VO2max values (OPEN patients: FEV1-10%, DLCO -11.9%, VO2max - 5.5%; VATS patients: FEV1-7.2%, DLCO-10.6%, VO2max-6.9%). The reductions in FEV1, DLCO and VO2max were similar to those in the two matched groups, with a Cohen effect size <0.2 for all the comparisons., Conclusions: In 3 months, both OPEN patients and VATS patients experienced a reduction in their preoperative functional parameters. VATS lobectomy does not offer any advantages in terms of FEV1, DLCO and exercise capacity recovery in comparison to the muscle-sparing thoracotomy approach., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To compare the recurrence rate of primary spontaneous pneumothorax (PSP) after uniportal video assisted thoracic surgery (VATS) bullectomy and mechanical pleurodesis in patients managed with a regulating pressure drainage system compared and those managed with a traditional one., Methods: Retrospective propensity score case-matched analysis of 174 consecutive patients submitted to uniportal VATS bullectomy and mechanical pleural abrasion (2007-13) in two centres. Definition of recurrence: Recurrent PSP requiring new treatment (i.e. aspiration, chest tube reinsertion, reoperation) within 12 months from the operation. All patients were managed with a single 24-Fr chest tube. Group 1 (106 patients): Tube connected to a traditional device (T) maintained on wall suction (-20 cmH2O) for 48 h. Group 2 (68 patients): Tube connected to a regulating pressure device (R) set at -20 cmH2O for 48 h. Chest tube removal criteria: No air leak (no bubbling or air flow <20 ml/min for at least 8 h) and pleural effusion <200 ml/day. Propensity score case-matching analysis was performed using the following variables: Age, gender, height, weight, side of operation, dystrophic score, length of stapled parenchyma., Results: The two groups of 68 pairs were well matched for baseline and surgical characteristics. Patients of Group 2 (R) showed a significantly lower incidence of recurrence rate compared with matched counterparts (T) (3, 4.4 vs 10, 14%, P = 0.041). There were no differences in persistent air leak incidence, chest tube duration or hospital stay between the groups. Group 2 had a higher 48-h output of pleural effusion compared with Group 1 (P < 0.0001)., Conclusions: By stabilizing the pleural pressure at the preset values, novel regulating pressure devices may enhance pleurodesis, leading to a reduced incidence of PSP recurrences after uniportal VATS bullectomy and pleural abrasion., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The objective of this analysis was to evaluate the incidence and risk factors of recurrent air leak (RAL) occurring soon after pulmonary lobectomy based on electronic airflow measurements., Methods: A prospective observational analysis of 129 consecutive patients managed with a single chest tube connected with an electronic chest drainage system. The incidence and timing of RAL among patients who had an air leak sealed within the first 24 postoperative hours was recorded. Stepwise logistic regression and bootstrap analyses were used to test the association of several baseline and surgical variables with RAL., Results: A total of 95 patients (68%) had their air leak stopped within 24 h after the operation. Twelve patients had RAL (13%) after the first stop. All RALs occurred within the first 24 h from operation. Logistic regression showed that the presence of moderate-to-severe chronic obstructive pulmonary disease [COPD; forced expiratory volume in 1 s (FEV1) <80% and FEV1/forced vital capacity ratio <0.7] was an independent risk factor associated with RAL (P = 0.02, bootstrap frequency 83%). Seven of 27 (26%) patients with COPD had RAL, a proportion significantly higher than in patients without COPD (5 of 68, 7.3%, P = 0.03)., Conclusions: A large proportion of patients with COPD developed RAL. In this high-risk group, we advise against chest tube removal in the first 24 h after operation, even in the case of absence or cessation of air leak., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The objective of this investigation was to assess satisfaction with care of patients with long hospital stay (LHS) or complications after pulmonary resection in comparison with case-matched counterparts with a regular postoperative course., Methods: This is a prospective observational analysis on 171 consecutive patients submitted to pulmonary resections (78 wedges, 8 segmentectomies, 83 lobectomies, 3 pneumonectomies) for benign (35), primary (93) or secondary malignant (43) diseases. A hospital stay >7 days was defined as long (LHS). Major cardiopulmonary complications were defined according to the ESTS database. Patient satisfaction was assessed by the administration of the EORTC IN-PATSAT32 module at discharge. The questionnaire is a 32-item self-administered survey including different scales, reflecting the perceived level of satisfaction about the care provided by doctors, nurses and other personnel. To minimize selection bias, propensity score case-matching technique was applied to generate two sets of matched patients: patients with LHS with counterparts without it; patients with complications with counterparts without it., Results: Median length of postoperative stay was 4 days (range 2-43). Forty-one patients (24%) had a hospital stay>7 days and 21 developed cardiopulmonary complications (12%). Propensity score yielded two well-matched groups of 41 patients with and without LHS. There were no significant differences in any patient satisfaction scale between the two groups. The comparison of the results of the patient satisfaction questionnaire between the two matched groups of 21 patients with and without complications did not show significant differences in any scale., Conclusions: Patients experiencing poor outcomes such as long hospital stay or complications have similar perception of quality of care compared with those with regular outcomes. Patient-reported outcome measures are becoming increasingly important in the evaluation of the quality of care and may complement more traditional objective indicators such as morbidity or length of stay., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of the present study was to verify whether the implementation of an electronic health record (EHR) in our thoracic surgery unit allows creation of a high-quality clinical database saving time and costs., Methods: Before August 2011, multiple individuals compiled the on-paper documents/records and a single data manager inputted selected data into the database (traditional database, tDB). Since the adoption of an EHR in August 2011, multiple individuals have been responsible for compiling the EHR, which automatically generates a real-time database (EHR-based database, eDB), without the need for a data manager. During the initial period of implementation of the EHR, periodic meetings were held with all physicians involved in the use of the EHR in order to monitor and standardize the data registration process. Data quality of the first 100 anatomical lung resections recorded in the eDB was assessed by measuring the total number of missing values (MVs: existing non-reported value) and inaccurate values (wrong data) occurring in 95 core variables. The average MV of the eDB was compared with the one occurring in the same variables of the last 100 records registered in the tDB. A learning curve was constructed by plotting the number of MVs in the electronic database and tDB with the patients arranged by the date of registration., Results: The tDB and eDB had similar MVs (0.74 vs 1, P = 0.13). The learning curve showed an initial phase including about 35 records, where MV in the eDB was higher than that in the tDB (1.9 vs 0.74, P = 0.03), and a subsequent phase, where the MV was similar in the two databases (0.7 vs 0.74, P = 0.6). The inaccuracy rate of these two phases in the eDB was stable (0.5 vs 0.3, P = 0.3). Using EHR saved an average of 9 min per patient, totalling 15 h saved for obtaining a dataset of 100 patients with respect to the tDB., Conclusion: The implementation of EHR allowed streamlining the process of clinical data recording. It saved time and human resource costs, without compromising the quality of data., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of the present study was to evaluate the usefulness of the Thoracic Morbidity and Mortality (TMM) scoring system in auditing the quality of care of our unit., Methods: We analysed the performance of our unit comparing the incidence of complications and mortality occurring after anatomic lung resections during two different periods: early period (January 2000 to December 2009: 830 lobectomy, 134 pneumonectomy and 78 segmentectomy) and recent period (January 2010 to August 2012: 191 lobectomy, 8 pneumonectomy and 19 segmentectomy). The cardiopulmonary complications as traditionally defined in the European Society of Thoracic Surgeons (ESTS) database were also classified according to the TMM system: this method grades the postoperative adverse events from 1 to 5 reflecting an increasing severity of management regardless the type of complication. Complications graded higher than 2 are regarded as major complications. To account for confounders, several baseline and surgical factors were used to build a propensity score that was applied to match the patients of the most recent group with their early-group counterparts. These two matched groups were compared in terms of cardiopulmonary morbidity (codified by ESTS definitions) and mortality rates and incidence of major complications according to the TMM system., Results: The propensity score analysis yielded 209 well-matched pairs of patients operated on in the two periods. The two groups had similar rates of ESTS-defined cardiopulmonary complications (recent: 38 patients vs early: 37 patients, P = 0.9). The use of the TMM system revealed a higher incidence of major (grade > 2) complications rate in the recent period (recent: 29 patients vs early: 14 patients, P = 0.02)., Conclusions: The TMM scoring system for classifying the postoperative complications revealed a decline of quality of care of our unit otherwise undetected by applying traditional outcome measures. This tool can be used as an additional graded outcome endpoint to refine internal audit of performance.

Objectives: The measurement of maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax) generated at the mouth is an accepted non-invasive clinical method for evaluating the strength of respiratory muscles. The aim of our study was to verify whether PImax and PEmax measured before and after a symptom-limited stair-climbing test are associated with complications in patients submitted to major lung resections., Methods: In a prospective cohort study of 283 consecutive patients submitted to lobectomy (231) or pneumonectomy (52) with a preoperative symptom-limited stair-climbing test, PImax and PEmax were measured before and immediately after the exercise. PImax and PEmax values were expressed as percentages of predicted values. ΔPImax and ΔPEmax were defined as the percentage difference between the pre- and postexercise values. Logistic regression analysis and the bootstrap resampling technique were performed to identify predictors of cardiopulmonary complications., Results: On average, PImax dropped by 3.6% and PEmax increased by 0.8% after the exercise. In total, 173 patients (61%) experienced a reduction in their PImax after exercise, while 150 (53%) had their PEmax reduced. Postoperative cardiopulmonary complications occurred in 74 patients (26%). Complicated patients had a greater reduction in their PImax compared with non-complicated patients (8.7% vs 2.1%, P = 0.03), whereas ΔPEmax was similar in complicated and non-complicated patients (0.7% vs 1.3%, P = 0.5). Receiver operating characteristic analysis indicated that the best cut-off for predicting complications was a ΔPImax of 10%. Stepwise logistic regression analysis and bootstrap confirmed that ΔPImax of >10 was associated with cardiopulmonary complications after adjusting for baseline and surgical factors (ΔPImax regression coefficient -0.02, P = 0.09, bootstrap frequency 51%). A progressive increase in complications was observed in patients with greater reduction in ΔPImax after exercise, particularly for values >10% reduction., Conclusion: The measurement of PImax at the mouth during exercise represents an additional parameter that can be used to refine risk stratification of lung resection candidates and to identify patients who may benefit from inspiratory muscle training.

Objectives: The objective of this study was to assess the prognostic role of preoperative quality of life (QoL) in patients operated on for early-stage non-small-cell lung cancer (NSCLC)., Methods: This is an observational analysis of 131 consecutive patients (2003-08) submitted to pulmonary lobectomy and systematic nodal dissection for pathological pT1N0 or pT2N0 stages NSCLC with a complete follow-up (median 40 months). QoL was measured by the Short Form 36v2, a multidimensional survey assessing eight domains and two composite scales (physical component score [PCS] and mental component score [MCS]). Survival was calculated by the Kaplan-Meier method. The log-rank test was used to assess differences between groups. The relationships between survival and QoL composite scales were determined by Cox proportional hazards regression analysis adjusting for the effect of several baseline and clinical variables. PCS and MCS were categorized according to their values greater or lower than 50 percentiles (general population norms)., Results: Fifty-three (40%) patients had PCS <50 and 71 (54%) had MCS <50. Results from physical functioning (P = 0.03) and general health (P = 0.03) scales were directly associated with survival. Multivariable regression showed that significant factors associated with overall survival were age >70 (hazard ratio [HR] 2.4, 95% confidence interval [95% CI] 1.2-4.8, P = 0.01) and PCS <50 (HR 2.3, 95% CI 1.4-4.4, P = 0.01). MCS, pT stage, histology, forced expiratory volume in 1 s, DLCO were not associated with prognosis. Patients with PCS >50 lived longer than those with PCS <50 (5-year overall survival 79 vs 49%, P = 0.01), in both pT1 (5-year overall survival 80 vs 49%) and pT2 stages (5-year overall survival 78 vs 48%). Cancer-specific 5-year survival was better in patients with a preoperative PCS >50 compared with those with PCS <50 (89 vs 73%, P = 0.05). Deaths due to cancer recurrence were similar in patients with PCS <50 and >50 (55 vs 53%, P = 0.9)., Conclusions: The physical component of QoL was associated with overall and cancer-specific survivals in patients operated on for early-stage NSCLC. Supportive interventions aimed at improving the perception of physical well-being should be tested to verify whether they can improve long-term prognosis after lung cancer surgery.

Objective: The objective of this study was to compare the air leak duration of two regulated chest tube modes following pulmonary lobectomy., Methods: This is a prospective randomized trial on 100 consecutive pulmonary lobectomies (2010-11) performed for lung cancer. A single 24-French chest tube was connected to an electronic system capable of maintaining the pleural pressure within preset values (regulated suction mode) or within a physiological range (regulated seal mode). Patients were randomized to two groups: Group 1, regulated individualized suction (range: -11 to -20 cmH2O, according to lobectomy type); Group 2, regulated seal (-2 cmH2O). The main endpoint was the duration of air leak (h) calculated from the end of the operation to a value consistently below 20 ml/min. Patients with prolonged air leak (>168 h) were connected to a portable device before discharge. Their air leak duration was considered as 192 h. The sample size was calculated to detect 1-day difference in air leak duration with a statistical power of 80%., Results: The two groups were well matched for several baseline and surgical characteristics. No crossovers occurred between groups. The average air leak duration (Group 1: 28 vs Group 2: 22.2, P = 0.6), and the number of patients with prolonged air leak (Group 1: 5 vs Group 2: 4, P = 0.7) and with other complications (Group 1: 6 patients vs Group 2: 7 patients, P = 0.9) were similar between the groups. Sixteen patients of Group 1 and 21 of Group 2 had an air leak present immediately after extubation. Among them, patients of Group 2 (regulated seal) had an air leak lasting 34.5 h less than those of Group 1 (regulated suction) (52.9 vs 87.4, P = 0.07)., Conclusions: Regulated seal is as effective and safe as regulated suction in managing chest tubes following lobectomy. This information demonstrates with objective data the non-superiority of regulated suction vs regulated seal and may assist in future investigations on regulated pleural pressure.

Objectives: The most recent evolution of patient management after thoracic surgery implies the concept of fast-tracking. Since 2008, our unit has implemented a programme based on clinical protocols and standardized pathways of care aimed to reduce the postoperative stay after major lung resection. The objective of this study was to verify the safety of this policy by monitoring the patient readmission rate., Methods: This is a prospective observational study on 914 consecutive pulmonary lobectomies performed at our institution from January 2000 to October 2010. Since we started the fast-tracking program in January 2008, we divided the patients into two groups: early period (678 patients, 2000-2007) and recent period (236 patients, 2008-October 2010). Several baseline and operative factors were used to build a propensity score that was applied to match the recent group patients with their early group counterparts. These two matched groups were then compared in terms of early outcomes and readmission rate. Readmission was defined as a re-hospitalization for any cause related to the operation within 30 days after discharge. We excluded from the analysis those patients with in-hospital mortality., Results: Propensity score yielded 232 well-matched pairs operated on in the early (non-fast-tracked patients) and most recent period (fast-tracked patients). The fast-tracking management resulted in a postoperative stay reduction of 2.8 days (P < 0.0001), with a 3-fold higher proportion of patients discharged before the sixth postoperative day (P < 0.0001). Nevertheless, we did not observe any differences in terms of readmission rate between the two periods., Conclusions: In our experience, the implementation of a fast-tracking program after pulmonary lobectomy was very effective and safe. It led to a postoperative reduction of hospital stay without an increase in the readmission rate.

Objectives: Digitalized chest drainage systems allow for quantification of air leak and measurement of intrapleural pressure. Little is known about the value of intrapleural pressure during the postoperative phase and its role in the recovering process after pulmonary resection. The objective of this investigation was to measure the values of pleural pressure immediately before the removal of chest tube after different types of pulmonary lobectomy., Methods: Prospective observational analysis on 203 consecutive patients submitted to pulmonary lobectomy during a 12-month period at two centres. Multiple measurements were recorded in the last hour before the removal of chest tube and averaged for the analysis. All patients were seated in bed in a 45° up-right position or in a chair, had a single chest tube and were not connected to suction during the evaluation period. Analysis of variance (ANOVA) was used to assess the differences in pleural pressure between different types of lobectomies., Results: The average maximum, minimum and differential pressures were -6.1, -19.5 and 13.3 cmH(2)O, respectively. The average pressures were similar in all types of lobectomies (ANOVA, P = 0.2) and ranged from -11 to -13 cmH(2)O, with the exception of right upper bilobectomy (-20 cmH(2)O, all P-values vs. other types of lobectomies <0.05). Similar values were also recorded for maximum pressures (range -4.4 to -8.4 cmH(2)O) and minimum pressures (-31.6 cmH(2)O vs. ranged from -15.4 to -20.5 cmH(2)O, all P-values <0.01). The average pleural pressure was not associated with FEV1 (P = 0.9), DLCO (P = 0.2) or FEV1/FVC ratio (P = 0.6), when tested with linear regression. Similarly, the average pleural pressure was similar in patients with and without COPD (-12.1 vs. -13.0 cmH(2)O, P = 0.4). The ANOVA test was used to assess differences in pressures between different lobectomies., Conclusions: The so-called water seal status may actually correspond to intrapleural pressures ranging from -13 to -20 cmH(2)O. Modern electronic chest drainage devices allow a stable control of the intrapleural pressure. Thus, the values found in this study may be used as target pressures for different types of lobectomies, in order to favour lung recovery after surgery.

Objective: The aim of this study was to assess the immediate influence of chest tube removal on chest pain and forced expiratory volume in 1 s (FEV1) after pulmonary resection., Methods: Prospective longitudinal investigation on 104 consecutive patients (53 wedge/segmentectomies and 51 lobectomies; 69 muscle and nerve-sparing lateral thoracotomy and 35 video-assisted thoracoscopic surgery (VATS)). Post-operative chest pain was controlled in all patients by a standardized combination of oral and intravenous non-opioid analgesics. All patients had one chest tube (24 French). Static and dynamic (after forced expiratory effort) pain and FEV1 were assessed before and 1 h after the chest tube removal by the same operator. No additional analgesics were administered before or after the chest tube removal. The pain level was assessed by the numeric pain scale [range: 0 (no pain)-10 (excruciating pain)]. FEV1 was assessed by a portable spirometer. Bronchodilators were not used in these patients. Pre- and post-removal measurements were compared by the Wilcoxon signed rank test., Results: The average pre-removal static and dynamic pain scores were 2.6 and 4.1, respectively. The static and dynamic pain scores decreased by 42 and 41%, respectively, after the tube removal (P < 0.0001). The average FEV1 before the chest tube removal was 1.5 l or 53% of the predicted value and increased by 13% after the tube removal (P = 0.0004). In total, 56 and 78% of patients reported static and dynamic pain scores improvement and 67% showed an FEV1 improvement after the chest tube removal. Similar results were observed in patients operated on through VATS or thoracotomy. Compared with patients whose chest tube was removed later, those who had their chest tube removed before post operative day 3 (POD3), showed a greater reduction in the static pain score (41 vs. 31%, P = 0.05) and greater improvement in FEV1 (18 vs. 0.01%, P = 0.02)., Conclusions: The removal of a chest tube reduces pain and improves ventilatory function, independent of surgical access and particularly in the early post-operative phase. A fast track chest tube removal policy may favour patients' recovery.

The objective of this investigation was to verify the impact of the learning curve involved after the introduction of a novel electronic chest drainage device on the duration of chest tube usage following pulmonary lobectomy. Propensity score case-matched analysis was used to compare the first consecutive 51 lobectomy patients managed with an electronic chest drainage (E) device with 51 controls managed with a traditional device (T). There was no difference in the characteristics of the two matched groups. Compared with patients managed with a traditional device, those with the electronic one had 1.9-day shorter duration of chest tube drainage (2.5 vs. 4.4 days; P<0.0001) and a 1.5-day shorter hospital stay (4.5 vs. 6 days; P=0.0003). Consequently, they had an average reduction in hospital costs of €751 (€1802 vs. €2553; P=0.0002). Compared with those in group T, patients in group E had a consistently shorter duration of chest tube use in relation to the very first patients treated. The learning curve sloped down for the first 40 patients before reaching a plateau, when the maximum benefit of using the electronic device was evident. Compared with traditional devices, the use of a novel electronic chest drainage system was beneficial from its initial application. The inherent learning curve was short and did not affect the efficiency of the system.

Objectives: The interpretation of studies on quality of life (QoL) after lung surgery is often difficult owing to the use of multiple instruments with inconsistent scales and metrics. Although a more standardized approach would be desirable, the most appropriate instrument to be used in this setting is still largely undefined. The aim of the study was to assess the respective ability of two validated QoL instruments (European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30/L13 and Short Form (36) Health Survey (SF-36)) to detect perioperative changes in QoL of patients submitted to pulmonary resection for non-small-cell lung cancer (NSCLC)., Methods: A prospective study on 33 consecutive patients (May 2009-December 2009) was submitted to pulmonary resection. All patients completed both EORTC QLQ-C30 with lung module 13 and SF-36 pre- and postoperatively (3 months). Preoperative changes of all SF-36 and EORTC scales were assessed by using the Cohen's effect-size method. External convergence between different instruments (SF-36 vs EORTC) was assessed by measuring the correlation of scales evaluating the same concepts (physical, psychosocial, and emotional). The correlation coefficients between standardized perioperative changes (effect sizes) of objective functional parameters (forced expiratory volume in 1s (FEV1) and diffusion lung capacity for carbon monoxide (DLCO)) and SF-36 or EORTC scales were also investigated., Results: A poor correlation (r < 0.5) was detected between most of the scales of the two instruments measuring the same QoL concepts, indicating that they may be complementary in investigating different aspects of QoL. Only the SF-36 and EORTC social functioning scales and the SF-36 mental health and EORTC emotional functioning scales had a correlation coefficient >0.5. In general, EORTC was more sensitive in detecting physical or emotional declines but was more conservative in detecting improvements. Both SF-36 and EORTC showed poor correlations (r < 0.5) between perioperative changes in QoL and FEV1 or DLCO, confirming that objective parameters cannot be surrogates to the subjective perception of QoL. In particular, there was a poor correlation between perceived changes in dyspnea and objective changes in FEV1 or DLCO., Conclusions: EORTC behaved similarly to SF-36 in assessing perioperative changes in generic QoL scales, but, with the use of its lung module, provided a more detailed evaluation of specific symptoms. For this reason, EORTC should be regarded as the instrument of choice for measuring QoL in the thoracic surgery setting., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: In pulmonary lobectomy, the dissection through the fissure to gain access to the pulmonary artery may increase the risk of postoperative air leak. For several anatomic reasons, this risk is especially high after right upper lobectomies (RULs). The objective of this investigation was to verify the efficacy of an anterior fissureless lobectomy (FL) technique in reducing the incidence and duration of air leak after RUL., Methods: An observational analysis was performed of 206 consecutive patients (2002-2009) submitted to RUL for non-small-cell lung cancer. Operations were performed through a muscle-sparing lateral thoracotomy. Patients with completely developed fissures were excluded. No sealants or buttressing material were used. For group TR (traditional resection, 146 patients), RUL was performed by traditional intra-fissure dissection of the pulmonary artery; for group FL (60 patients), RUL was carried out by fissureless division of all hilar vascular structures. Several perioperative variables were used in identifying propensity score-matched pairs of patients undergoing traditional and fissureless lobectomies. The matched groups were then compared in terms of incidence of prolonged air leak, air leak duration, operation time, chest tubes duration, hospital stay and costs., Results: Propensity score analysis yielded 58 well-matched pairs of patients operated by traditional or fissureless RUL. Compared to those in the traditional group, patients in group FL had a mean reduction in air leak duration, duration of chest tube and postoperative stay of 1.1, 1.4 and 1.2 days, respectively. This translated into an average hospital cost saving of 569 € per patient., Conclusions: The use of an anterior fissureless technique during RUL reduced the duration of air leak and hospital costs without increasing the surgical time. Given its simplicity and efficacy, we regard it as a useful tool for implementing fast-tracking policies and cutting hospital costs., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: Severe impairment in quality of life (QoL) is one of the major patients' fears about lung surgery. Its prediction can be valuable information for both patients and physicians. The objective of this study was to identify predictors of clinically relevant decline of the physical and emotional components of QoL after lung resection., Methods: This is a prospective observational study on 172 consecutive patients submitted to lobectomy or pneumonectomy (2007-2008). QoL was assessed before and 3 months after operation through the administration of the Short Form 36v2 survey. The relevance of the perioperative changes in physical component summary (PCS) and mental component summary (MCS) scales was measured by the Cohen's effect size (mean change of the variable divided by its baseline standard deviation). An effect size >0.8 is regarded as large and clinically relevant. QoL changes were dichotomized according to this threshold. Logistic regression and bootstrap analyses were used to identify reliable predictors of large decline in PCS and MCS., Results: A total of 48 patients (28%) had a large decline in the PCS scale and 26 (15%) in the MCS scale. Patients with a better preoperative physical functioning (p=0.0008) and bodily pain (p=0.048) scores and those with worse mental health (p=0.0007) scores were those at higher risk of a relevant physical deterioration. Patients with a lower predicted postoperative forced expiratory volume in 1s (ppoFEV1; p=0.04), higher preoperative scores of social functioning (p=0.02) and mental health (p=0.06) were those at higher risk of a relevant emotional deterioration. The following logistic equations were derived to calculate the risk of decline in physical or emotional components of QoL, respectively: risk of physical decline: lnR/(1+R): -11.6+0.19XPF, physical functioning+0.05XBP, bodily pain-0.05XMH, mental health; risk of emotional decline: ln R₁/(1+R₁): -8.06-0.03XppoFEV1+0.11XSF+0.055XMH., Conclusions: A consistent proportion of patients undergoing lung resection exhibit an important postoperative worsening in their QoL. We were able to identify reliable risk factors and predictive equations estimating this decline. These findings may be used as selection criteria for efficacy trials on perioperative physical rehabilitation or psychological treatments, during preoperative counseling, in the surgical decision-making process and for selecting those patients who would benefit from physical and emotional supportive programs., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The objective of this investigation was to compare postoperative morbidity and early and late mortality in patients after pneumonectomy for non-small-cell lung cancer (NSCLC) with or without induction neo-adjuvant therapy., Methods: This is an observational study performed on prospectively collected data at four tertiary referral centres (2000-2007). Of 225 pneumonectomies for NSCLC, 81 patients underwent neo-adjuvant chemotherapy. Several perioperative variables were used in identifying propensity score-matched pairs of patients with and without induction treatment. The matched groups were then compared in terms of morbidity, early (30-day or in-hospital) and 90-day mortality., Results: The overall cardiopulmonary morbidity, early mortality and 90-day mortality rates were 30% (67 patients), 7.1% (16 patients) and 9.8% (22 patients), respectively. Propensity score analysis yielded 56 well-matched pairs of patients with and without induction chemotherapy. The two groups had similar early and late mortality rates: four versus four (p=1) and seven versus seven (p=1), respectively. Moreover, the incidence of cardiopulmonary morbidity and bronchopleural fistula were also similar in both the groups: 19 versus 17 patients (Fisher's exact test p=0.7) and two versus three patients (Fisher's exact test, p=0.7), respectively. Twenty-one patients with induction chemo-radiotherapy were analysed separately and compared with well-matched counterparts without any induction treatment. No significant differences were identified in terms of early mortality (1 vs 0, p=1), 90-day mortality (1 vs 0, p=1), cardiopulmonary complications (5 vs 5, p=1) and bronchopleural fistula (1 vs 1, p=1)., Conclusions: Current regimens of induction treatment do not seem to increase the risk of morbidity, early mortality and late mortality after pneumonectomy in properly selected patients. This study warrants confirmation from future multicentre prospective randomised trials powered on early outcomes., (Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The objective of this investigation was to assess the quality of life (QoL) before and after pulmonary lobectomy in patients with chronic obstructive pulmonary disease (COPD) and to compare these values with a case-matched population of patients with normal respiratory function., Methods: This is an observational analysis performed on a prospective dataset of 220 consecutive patients submitted to pulmonary lobectomy for lung cancer (2006-2008). Patients submitted to extended procedures (chest wall resection and superior sulcus) were excluded from the analysis. Pre- and postoperative (3 months) QoL were assessed in all patients through the administration of the Short Form 36v2 (SF36v2) health survey, a generic QoL instrument assessing eight health physical and mental concepts. Propensity score was used to match COPD patients (according to the NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria: forced expiratory volume in 1s/forced expiratory vital capacity (FEV1/FVC) ratio <0.7 and FEV1 <80%) with counterparts without COPD. QoL scales were compared between the two matched groups by means of the Mann-Whitney test., Results: Propensity score yielded 50 well-matched pairs of patients with and without COPD. Compared with non-COPD patients, those with COPD had a threefold higher rate of cardiopulmonary morbidity (14 cases vs 5 cases, 28% vs 10%, p=0.04), lower reduction in FEV1 (6% vs 13%, p=0.0002), but lower residual postoperative FEV1 values (62% vs 74%, p<0.0001). Postoperative carbon monoxide lung diffusion capacity (DLCO) (69% vs 65%, p=0.1) and VO(2 max) (15.3 ml kg(-1)min(-1) vs 14.3 ml kg(-1)min(-1)p=0.4) values were similar between the groups. Although most of the preoperative and postoperative QoL domains in both groups were reduced compared with normal population (<50), we were not able to find differences between the groups in any of the preoperative and postoperative physical and mental QoL scales., Conclusions: The evidence of an acceptable QoL in COPD patients may help both patients and physicians in the surgical decision-making process in the face of high rates of complications., (Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The objective of this randomised trial was to assess the effectiveness of a new fast-track chest tube removal protocol taking advantage of digital monitoring of air leak compared to a traditional protocol using visual and subjective assessment of air leak (bubbles)., Methods: One hundred and sixty-six patients submitted to pulmonary lobectomy for lung cancer were randomised in two groups with different chest tube removal protocols: (1) in the new protocol, chest tube was removed based on digitally recorded measurements of air leak flow; (2) in the traditional protocol, the chest tube removal was based on an instantaneous assessment of air leak during daily rounds. The two groups were compared in terms of chest tube duration, hospital stay and costs., Results: The two groups were well matched for several preoperative and operative variables. Compared to the traditional protocol, the new digital recording protocol showed mean reductions in chest tube duration (p=0.0007), hospital stay (p=0.007) of 0.9 day, and a mean cost saving of euro 476 per patient (p=0.008). In the new chest tube removal protocol, 51% of patients had their chest tube removed by the second postoperative day versus only 12% of those in the traditional protocol., Conclusions: The application of a chest tube removal protocol using a digital drainage unit featuring a continuous recording of air leak was safe and cost effective. Although future studies are warranted to confirm these results in other settings, the use of this new protocol is now routinely applied in our practice., (Copyright 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: To assess in a randomized clinical trial the influence of perioperative short-term ambroxol administration on postoperative complications, hospital stay and costs after pulmonary lobectomy for lung cancer., Methods: One hundred and forty consecutive patients undergoing lobectomy for lung cancer (April 2006-November 2007) were randomized in two groups. Group A (70 patients): ambroxol was administered by intravenous infusion in the context of the usual therapy on the day of operation and on the first 3 postoperative days (1000 mg/day). Group B (70 patients): fluid therapy only without ambroxol. Groups were compared in terms of occurrence of postoperative complications, length of stay and costs., Results: There were no dropouts from either group and no complications related to treatment. The two groups were well matched for perioperative and operative variables. Compared to group B, group A (ambroxol) had a reduction of postoperative pulmonary complications (4 vs 13, 6% vs 19%, p=0.02), and unplanned ICU admission/readmission (1 vs 6, 1.4% vs 8.6%, p=0.1) rates. Moreover, the postoperative stay and costs were reduced by 2.5 days (5.6 vs 8.1, p=0.02) and 2765 Euro (2499 Euro vs 5264 Euro, p=0.04), respectively., Conclusions: Short-term perioperative treatment with ambroxol improved early outcome after lobectomy and may be used to implement fast-tracking policies and cut postoperative costs. Nevertheless, other independent trials are needed to verify the effect of this treatment in different settings.

The objective of this study was to assess the residual quality of life (QoL) in elderly patients submitted to major lung resection for lung cancer. From July 2004 through August 2007 a total of 218 patients, 85 of whom were elderly (70 years), had complete preoperative and postoperative (3 months) quality of life measures assessed by the Short Form 36v2 health survey. QoL scales were compared between elderly and younger patients. Furthermore, limited to the elderly group, we compared the preoperative with the postoperative SF36v2 measures and the physical component summary (PCS) and mental component summary (MCS) scores between high-risk patients and low-risk counterparts. The postoperative SF36 PCS (50.3 vs. 50, P=0.7) and MCS (50.6 vs. 49, P=0.2) and all SF36 domains did not differ between elderly and younger patients. Within the elderly, the QoL returns to the preoperative values three months after the operation. Moreover, we did not find any significant differences between elderly higher-risk patients and their lower-risk counterparts postoperatively. The information that residual QoL in elderly patients will be similar to the one experienced by younger and fitter individuals may help them in their decision to proceed with surgery.

We aimed to verify the clinical and economic effects of uniportal video-assisted thoracic surgery (VATS) in patients with primary spontaneous pneumothorax (PSP) compared to traditional three-port VATS technique. We analyzed 51 consecutive patients (23 three-port VATS and 28 uni-port VATS), treated by bullectomy and pleural abrasion, to detect differences between the two groups with regard to intraoperative management, postoperative course, pain, paraesthesia and costs. Data about pain and paraesthesia were collected by telephonic interview within a minimum follow-up period of six months. Compared to three-port VATS, patients treated by the uni-port VATS were discharged more quickly (3.8 days vs. 4.9 days, P=0.03) and experienced paraesthesia less frequently (35% vs. 94%, P<0.0001). No difference in chronic pain was observed between the two groups (numeric pain score: 0.6 uni-port vs. 1.3 three-port, P=0.2). Compared to three-port VATS, we found a significant reduction in postoperative costs for the patients operated on by the uni-port technique (euro1407 vs. euro1793, P=0.03), without any increase in surgical costs. In conclusion, uniportal VATS appears to offer better clinical (postoperative stay and rate of paraesthesia) and economic (postoperative costs) results than the standard three-port VATS for treating primary spontaneous pneumothorax.

Objective: Non-univocal conclusions have been published regarding the definition of oxygen desaturation in relation to postoperative outcome. We aimed to verify whether oxygen desaturation during a maximal stair-climbing test was associated with postoperative cardiopulmonary complications and to assess which definition of oxygen desaturation (oxygen saturation <90% or desaturation >4% with respect to rest level) discriminated better between complicated and uncomplicated patients., Methods: Five hundred and thirty-six patients performing a maximal stair-climbing test prior to major lung resection were analyzed. All patients performed the test on room air. Patients with and without cardiopulmonary complications were compared in terms of several preoperative and operative characteristics by univariate analysis, including the presence of oxygen desaturation at peak exercise (saturation <90% or desaturation >4%). Logistic regression analysis was then performed and validated by bootstrap procedure to identify predictors of complications and to see whether the exercise oxygen desaturation retained its significancy after multivariable adjustment., Results: Twenty-seven patients had an exercise oxygen saturation below 90%, but this parameter was not significantly associated with complications. Seventy-five patients experienced an exercise desaturation greater than 4%, which was a significant result associated with postoperative complications at univariate analysis (p=0.008) (36% complication rate). After adjusting for age, ppoFEV1, ppoDLCO, type of operation, height reached at stair-climbing test and cardiac co-morbidity, a desaturation greater than 4% retained its significance at logistic regression and proved to be stable at bootstrap., Conclusions: A stair-climbing test is an intense constant workload exercise, challenging a large amount of muscle mass, and appears particularly appropriate to elicit oxygen desaturation, which in turn may be a reliable marker of deficits in the oxygen transport system. A desaturation >4% appears a better cut-off definition than a saturation level <90% in predicting the occurrence of complications. The risk of complications was approximately two-fold higher in patients with oxygen desaturation >4% at peak exercise.

Introduction and Objective: There is a low correlation between predicted postoperative FEV1 (ppoFEV1) and FEV1 measured the days after pulmonary resection, when most complications are developed. The hypothesis of this investigation is that ppoFEV1 does not predict postoperative morbidity in patients undergoing lung resection when immediate postoperative FEV1 is considered in the predictive model., Methods: One hundred ninety-eight consecutive patients undergoing lobectomy or pneumonectomy were included in a prospective, multiinstitutional study., Independent Variables: age, body mass index, ppoFEV1, surgical approach (VATS or muscle-sparing thoracotomy), type of analgesia (epidural or intraveous), postoperative visual analogue pain score and FEV1 measured the day after the operation. Target variable: occurrence of postoperative cardio-respiratory complications. Method of analysis: classification tree (CART) dividing the population at random in two subsets and developing a bootstrap set of 100 trees resampling training data. The relative importance of each variable and the accuracy of both initial and committee trees to predict the outcome were presented., Results: One hundred seventy-seven lobectomies and 21 pneumonectomies were included. Overall cardio-respiratory morbidity was 22%. According to CART results, first day FEV1 was the most important variable to classify cases as primary splitter and as a surrogate of each primary splitter (100% importance). Patient age followed (51%) and ppoFEV1 was third (43%) with a score similar to postoperative pain score (42%) and type of analgesia (36%). Sensitivity and specificity of the initial tree were, respectively, 0.5 and 0.7; values for committee tree were 0.5 sensitivity and 0.7 specificity., Conclusion: Postoperative cardio-respiratory complications are more related to FEV1 measured in the first postoperative day than to ppoFEV1 value.

We report a case of bilateral staged uniportal video-assisted thoracic surgery (VATS) pulmonary resections for synchronous early stage squamous cell carcinoma in a patient with limited respiratory reserve. Wide wedge resections and lymph nodes sampling were performed. Postoperative respiratory function and pain scores were unaffected by the bilateral operations. Uniportal VATS proved to be a feasible alternative to more traditional procedures (three portal VATS or minithoracotomy) in case lesser resections are required for compromised respiratory function and may contribute to increase operability in high-risk patients.

This work was aimed at developing risk-adjusted outcome models for profiling the internal quality of care after major lung resection. One thousand and sixty-two patients submitted to lobectomy (845) or pneumonectomy (217) from 1994 through 2004 at our unit were analyzed. Risk-adjusted models of 30-day or in-hospital morbidity, mortality and failure-to-rescue (death/complication ratio) were developed by stepwise logistic regression analyses and validated by bootstrap procedures. The regression equations were then used to estimate the outcome risks in 3 successive periods of activity (early: 1994-1997; intermediate: 1998-June/2001; late: July/2001-2004). Observed and predicted morbidity, mortality and failure-to-rescue rates were compared within each period by the z-test. The following regression models were developed: Predicted morbidity: ln R/1-R=-2.1+0.035 x age-0.02 x FVC+0.6 x extended resection+0.7 x cardiac co-morbidity (c-index=0.68). Predicted mortality: ln R/1-R=-7.6+0.08 x age-0.04 x ppoFEV1+1.6 x extended resection+1.2 x cardiac co-morbidity+1.1 x cerebrovascular co-morbidity (c-index=0.83). Predicted failure-to-rescue: ln R/1-R=-6.7+0.06 x age+1.5 x extended resection+1.2 x cerebrovascular co-morbidity (c-index=0.71). No differences were noted between observed and predicted outcome rates within each period, despite apparent unadjusted differences between periods. The use of risk-adjusted outcome models prevented misleading information derived from the unadjusted analysis of performance. We are currently using these models for internal quality-of-care audit purposes.

The study was aimed at assessing the influence of the elective ICU admission on the early outcome after major lung resection by analyzing the different postoperative management policies of two centers. Center A managed all patients in a dedicated ward, resorting to ICU for complications requiring invasive assisted ventilation. In center B, high-risk patients were electively transferred to ICU immediately after operation. Propensity score was used to match those patients of center B electively admitted to ICU (96 of 157), with counterparts from center A (96 of 205). The outcome of these matched pairs were then compared. There was a trend of reduced total morbidity (23% vs. 35%, respectively; P=0.06), cardiovascular (13.5% vs. 23%, respectively; P=0.09) and pulmonary complication rates (9.3% vs. 18%, respectively; P=0.09), but a longer postoperative hospital stay (11.5 vs. 9.7, respectively; P=0.015) in the patients electively admitted to ICU, compared to matched center A patients. Mortality rates were not different (7.3% vs. 7.3%; P=1). Since the elective postoperative ICU admission did not show a clear-cut outcome benefit over the management in a dedicated ward, this practice should be limited to highly selected patients in order to efficiently utilize the available resources.

The objective of the study was to develop regression models for the prediction of the decline of the forced expiratory volume in one second (FEV1) and the carbon monoxide lung diffusion capacity (DLCO) early after major lung resection. One hundred and ninety patients submitted to pulmonary lobectomy or pneumonectomy for lung cancer performed preoperative and early postoperative (mean 10.9 after operation) pulmonary function tests. One hundred and fifty of these patients also underwent DLCO measurements by the single breath method. The decline of FEV1 and DLCO were expressed as percentage losses from preoperative values. Stepwise multiple regression analyses were performed to develop two models estimating the percent reduction of FEV1 and DLCO from preoperative values. The multivariate procedures were then validated by bootstrap analyses. The following regression equations were derived: estimated percent reduction in FEV1 = 21.34 - (0.47 x age) + (0.49 x percentage of functioning parenchyma removed during operation) + (17.91 x COPD-index); estimated percent reduction in DLCO = 35.99 - (0.31 x age) - (36.47 x FEV1/FVC ratio) + (0.33 x DLCO) + (0.54 x percentage of functioning parenchyma removed during operation). The comparison between observed and estimated losses of FEV1 and DLCO (by using these regression equations) was not significantly different. We think the regression models generated in this study may be reliably used for risk stratification purposes.

Objectives: The objective of this study was to develop a logistic model for internal audit in a population of elderly patients submitted to lung resection., Methods: Three hundred twenty-six patients older than 70 years of age and submitted to lung resection for lung carcinoma were retrospectively analyzed. Univariate and logistic regression analyses yielded a model for the prediction of postoperative complications that was validated by bootstrap resampling analysis. The model was then used to assess the performance of our unit during two successive periods of activity ('early', 1993-1999; 'late', 2000-2003)., Results: Significant independent predictors of postoperative complications were a low ppoFEV1 (P < 0.0001) the presence of concomitant cardiac disease (P = 0.01) and extended resection (P = 0.03). The observed morbidity rate in the late period was higher than that in the early period (48.3 vs. 33.8%; P = 0.008). The predicted morbidity rate was also higher in the late period, compared to that in the early period (44 vs. 39%; P = 0.003). Moreover, no differences were noted between predicted and observed morbidity rates in each of the two periods (early, P = 0.4 late, P = 0.5)., Conclusions: We showed that applying a model of risk-adjustment in elderly patients submitted to lung resection was useful for the internal evaluation of the quality of care and prevented misleading information derived by the comparison of the crude rates of the observed morbidity.

Objective: To identify predictors of postoperative exercise oxygen desaturation (EOD) in patients submitted to lobectomy or pneumonectomy for lung carcinoma., Patients and Methods: A consecutive series of 227 patients with non-small cell lung cancer submitted to lobectomy or pneumonectomy from January 2000 through October 2002 were prospectively analyzed. Maximal stair-climbing tests were performed preoperatively (the day before the operation) and postoperatively (on average, 9.2 days after operation) in room air for all patients. A fall in oxygen saturation during the exercise below 90% was termed 'desaturation'. Univariate and multivariate analyses were performed to identify predictors of postoperative EOD., Results: Thirty-five patients (15.4%) developed postoperative EOD. After multivariate analysis, the only independent predictor of postoperative EOD resulted a reduction in oxygen saturation during the preoperative exercise (P=0.0004)., Conclusions: Patients with a reduction in oxygen saturation during the preoperative exercise test are at increased risk to develop a postoperative EOD below 90%. A postoperative exercise test should be performed in all these patients. Should EOD be confirmed, an intermittent home oxygen therapy is recommended in order to facilitate recovery from operation and improve the quality of life.

Objective: The aim of the study was to use the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) to assess the performance of our thoracic surgery unit during two successive periods of activity., Methods: From 1992 through 1997, 801 candidates for thoracic procedures at our institution were considered for the study. After validation of the logistic regression model, including the POSSUM score, observed and POSSUM-predicted morbidities were compared within two groups of patients divided by year of operation (group 1: 1992-1994, n=362; group 2: 1995-1997, n=439) by means of the z-test for the comparison of a proportion with an expected value., Results: The POSSUM-predicted morbidity was significantly lower than the observed one in the first period of activity of our unit (19.6 vs. 24.3%, respectively; z-test for the comparison of a proportion with an expected value, 2.25; P=0.01), whereas no difference was found in the second period (20.5 vs. 19.1%, respectively; z-test for the comparison of a proportion with an expected value, -0.71; P=0.76)., Conclusions: The result suggests a worse-than-expected performance of our unit in the first period of activity, showing that POSSUM can be reliably applied as an instrument of internal comparative audit in a thoracic surgery unit.