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Objective To conduct a population-level analysis of temporal trends and risk factors for high symptom burden in patients receiving surgery for non-small-cell lung cancer (NSCLC). Summary background data A population-level overview of symptoms after curative intent surgery is necessary to inform decision making and supportive care for patients with lung cancer. Methods Retrospective cohort study of patients receiving surgery for stage I-III NSCLC between January 2007-September 2018. Prospectively collection Edmonton Symptom Assessment System (ESAS) scores, linked to provincial administrative data, were used to describe the prevalence, trajectory and predictors of moderate-to-severe symptoms in the year following surgery. Results A total of 5,350 patients, with 28,490 unique ESAS assessments, were included in the analysis. Moderate-to-severe tiredness (68%), poor wellbeing (63%) and shortness of breath (60%) were the most common symptoms reported. The rise and fall in the proportion of patients experiencing moderate-to-severe symptoms after surgery coincided with the median time to first (58 days, IQR: 47-72) and last cycle of chemotherapy (140 days, IQR: 118-168), respectively. There was eventual stabilization, albeit above the pre-operative baseline, within 6-7 months after surgery. Female sex (RR 1.09-1.26), lower income (RR 1.08-1.23), stage III disease (RR 1.15-1.43), adjuvant therapy (RR 1.09-1.42), chemotherapy within two weeks of an ESAS assessment (RR 1.14-1.73), and pneumonectomy (RR 1.05-1.15) were associated with moderate-to-severe symptoms following surgery. Conclusions Knowledge of population-level prevalence, trajectory and predictors of moderate-to-severe symptoms after surgery for NSCLC can be used to facilitate shared decision making and improve symptom management throughout the course of illness.

Uniportal video-assisted thoracoscopic surgery (U-VATS) can achieve traditional clinical outcomes comparable to those of multiportal video-assisted thoracoscopic surgery (M-VATS). This study aimed to compare patient-reported outcomes between U-VATS and M-VATS for lung cancer lobectomy in the early postoperative period.This comparative analysis used data from a longitudinal prospective study (Perioperative Symptom Study of Lung Cancer [CN-PRO-Lung 1]). Symptom severity, functional status, and quality of life were compared between groups using generalized estimation equation models. Symptom severity and functional status were reported as proportion of patients with clinically meaningful severe scores on 0- to 10-point scales assessed using the MD Anderson Symptom Inventory-Lung Cancer module.Of the 174 patients included, 102 (58.6%) underwent U-VATS lobectomy and 72 (41.4%) underwent M-VATS lobectomy. After adjusting for confounders, patients in the U-VATS group reported less severe pain (P = .02), fatigue (P = .001), constipation (P = .01), coughing (P = .003), shortness of breath (P.001), and disturbed sleep (P = .007) during the 6-day postoperative hospitalization than did patients in the M-VATS group. Moreover, fewer patients reported severe impairment in walking (P = .033) or their capacity to enjoy life (P = .027) in the U-VATS group. Meanwhile, there were no significant between-group differences in the quality of life scores, operative time, chest tube duration, length of hospital stay, or early complication rate (grade II or higher) (all P.05).U-VATS may produce fewer severe symptoms and better functional status than M-VATS for lung cancer lobectomy in the early postoperative period.

BACKGROUND Measuring variation in perioperative outcomes to accurately discriminate performance between surgical providers may be limited by reliability. We aimed to evaluate reliability estimates of metrics associated with lung cancer resection. METHODS We performed a retrospective cohort study utilizing the 2015 National Cancer Database to identify patients undergoing lung cancer resection. Primary outcomes were reliability estimates for perioperative outcomes and for measures of adherence to clinical benchmarks, generated through hierarchical multi-level modeling techniques. RESULTS We identified 27,300 patients undergoing resection. Overall risk- and reliability-adjusted 30- and 90-day mortality rates were 1.7% and 3.3%, respectively; 61.0% and 41.1% of eligible patients received stage-appropriate adjuvant and neoadjuvant therapy. Video-assisted thoracoscopic surgery (VATS) was performed in 59.6% of cases with clinical stage I disease. The mean reliability of 30- and 90-day mortality was 0.11 (standard deviation (SD) 0.09) and 0.22 (SD 0.15), respectively; for performing VATS for stage I disease, 0.97 (SD 0.04). When stratified by hospital volume quartile, the mean reliability of 30-day mortality was 0.04 (SD 0.03) in the lowest and 0.20 (SD 0.10) in the highest quartile. Only 14% of hospitals met an established 0.7 reliability benchmark for 30- and 90-day mortality, but over 97% of hospitals exceeded these benchmarks for providing stage-appropriate systemic therapy and performing VATS for stage I disease. CONCLUSIONS Metrics used to compare lung cancer surgical performance between providers have varying levels of reliability. Reliability should be considered when profiling providers, which will become particularly important as lung cancer treatment under screening programs continues to expand.

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in surgical patients. Thoracic surgery patients are at increased risk due to inherent technical and disease-specific factors. Other surgical specialties have adopted postdischarge extended VTE prophylaxis; however evidence is scarce in thoracic surgery. This study aims to identify VTE risk factors and associated mortality among surgical lung cancer patients.Using administrative databases all patients in the province of Ontario undergoing lung cancer surgery from 2007 to 2017 were identified. Logistic regression identified VTE risk factors at 90 days and 1 year postoperatively. A flexible parametric survival analysis compared mortality and survival up to 5 years after surgery between patients with and without VTE.Of 65,513 patients diagnosed with lung cancer, 12,626 (19.3%) underwent surgery. VTE incidence at 90 days and 1 year postoperatively was 1.3% and 2.7%, respectively. Open and more extensive resections carried an increased VTE risk, with pneumonectomy conferring the highest risk (odds ratio, 2.36; P.001). Stage III and IV disease carried a 3.19 and 4.97 times higher risk of VTE, respectively, compared with stage I (P.001). The hazard ratio for mortality at 1 year for patients with VTE was 2.01 (P.001). Patients suffering a VTE had reduced 5-year survival.Patients undergoing pneumonectomy and those with advanced stage have an increased VTE risk. Patients suffering a thrombotic complication have an increased risk of mortality and decreased 5-year survival. Accordingly strategies to reduce VTE risk should be considered in patients undergoing high-risk operations to reduce the mortality of VTEs.

This study aimed to investigate the oncologic outcomes of video-assisted thoracoscopic (VATS) left upper trisegmentectomy (LTS) vs left upper lobectomy (LUL) for patients presenting with stage I non-small cell lung cancer (NSCLC).A retrospective analysis identified 1543 consecutive patients presenting to Shanghai Pulmonary Hospital (Shanghai, China) with NSCLC for VATS LTS or LUL from 2013 to 2017. After propensity-score matching for patient demographics and tumor characteristics, 273 pairs were identified. Disease-free survival (DFS) and overall survival (OS) were estimated by the Kaplan-Meier method and compared using the log-rank test.The median follow-up time was 51.5 months. There were no significant differences in operative duration (2.11 ± 0.64 hours vs 2.49 ± 5.96 hours; P = .30), total blood loss (106.19 ± 170.83 mL vs 97.07 ± 149.34 mL; P = .51), and operative complications (10% vs 8%; P = .37) between the LUL and LTS groups. Patients undergoing LUL had longer postoperative hospital stays (5.55 ± 3.00 days vs 4.87 ± 2.33 days; P = .003), greater tumor margin distance (3.3 ± 1.2 cm vs 3.1 ± 0.9 cm; P.001), and greater number of lymph nodes harvested (8.0 ± 3.2 vs 6.8 ± 3.3; P.001) than patients undergoing LTS, but the margin-to-tumor ratio was not statistically different (2.5 ± 1.6 vs 2.3 ± 1.1; P = 0.11). Median DFS (49.5 months vs 54.3 months; P = .77) and OS (49.5 months vs 55.0 months; P = .88) were not significantly different between patients undergoing LTS and those undergoing LUL, and similar outcomes were noted across subgroups of patients stratified by tumor stage, pathologic type, and radiographic manifestations.VATS LTS and LUL had comparable oncologic outcomes for stage I NSCLC, regardless of tumor pathologic types and radiologic findings, as long as negative margins were confirmed.

Introduction Outcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections. Methods Retrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients’ age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann–Whitney U test for continuous variables. Results A total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p = 0.369), major complications (RATS: 9% vs VATS: 9.2%; p = 0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p = 1; pneumonia RATS:0%, VATS:4.6%, p = 0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p = 0.718) and reoperation (RATS: 3%, VATS: 1.5%, p = 1) were comparable between both groups. The median length of stay was 3 days in both groups (p = 0.101). Conclusions A RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.

Background Prolonged air leak (PAL) (>5 days) after robotic-assisted pulmonary lobectomy is a significant complication. This study aimed to determine patient- and surgeon-related factors that can predict PAL after robotic lobectomy for lung cancer. Methods This study was a retrospective review of a single-center experience of robotic-assisted lobectomy for lung cancer. Perioperative variables, including surgeon case experience, patient demographics, diffusion capacity of lung for carbon monoxide, forced expiratory volume in 1 second, body mass index, and smoking status were evaluated. Results A total of 305 robotic-assisted lobectomies performed by 4 surgeons met inclusion criteria from June 2016 to February 2019. The 30-day postoperative mortality was 1.2%. PAL developed in 27 of 305 (8.8%) patients. Surgeons’ robotic experience was grouped by 10-case increments. When adjusted for age and sex, the odds for PAL decreased by 15% for every 10 robotic lobectomies the surgeons performed (odds ratio [OR], 0.85; 95% CI, 0.74-0.99; P = .0384). Logistic regression models showed a linear transition curve at the 50th case. Female sex (OR, 2.62; 95% CI, 1.03-6.69; P = .0314) and younger age (OR, 0.61; 95% CI, 0.41-0.91; P = .0184) were statistically significant risk factors for PAL. Cumulative sum analysis similarly showed a strong association between experience and PAL. Preoperative diffusing capacity of lung for carbon monoxide, forced expiratory volume in 1 second, body mass index, and smoking status were not statistically significant predictive factors. Conclusions These results show that surgeon robotic case experience is associated with the rate of postoperative PAL: as the number of robotic lobectomies increases, the rate of PAL significantly decreases. It is imperative to emphasize that a learning curve exists for this approach that directly affects patient outcomes.

Background Our objective is to assess feasibility, safety, and to describe outcomes for patients discharged by postoperative day one (POD1) after robotic segmentectomy and lobectomy. Methods A retrospective analysis of a prospectively collected database of a quality improvement initiative by a single surgeon. Factors associated with discharge by POD1 were evaluated using a multivariate logistic regression model. Results From January 2018 to July 2020, 253 patients underwent robotic anatomic pulmonary resection of which 134 (53%) discharged by POD1, 67% post segmentectomy and 41% post lobectomy. Discharge by POD1 improved with experience and was achieved in 97% of patients post segmentectomy and 68% post lobectomy in the final quartile. Thirty-one (12%) patients were discharged home with a chest tube, including 7 (2.8%) on POD1. On multivariate analysis, never smokers and segmentectomy were associated with discharge by POD1. Conversely, decreased baseline performance status and perioperative complications were associated with discharge after POD1. There were 10 (4.0%) minor morbidities, 6 (2.4%) major morbidities, and no 30 or 90-day mortalities. There were 4 readmissions (1.6%), of which one (0.4%) was after POD1 discharge. Patient satisfaction remained high throughout the study period. Conclusions With experience and communication, select patients can be discharged home on POD1 after robotic segmentectomy and lobectomy with excellent outcomes and high satisfaction. Discharge by POD1 was associated with never smokers and segmentectomy, and inversely associated with decreased baseline performance status and perioperative complications.

Summary Background Pediatric thoracoscopic lobectomy is a technically challenging procedure that may result in better pain control, better cosmetic results, and shorter hospital stay. However, data describing the learning curve of total thoracoscopic lobectomy (TTL) have yet to be obtained. To evaluate our learning curve for TTL in children, we reviewed the safety and efficiency of our initial experiences with TTL in pediatric patients with congenital lung malformation. Methods This was a retrospective study of all pediatric patients undergoing TTL between March 2011 and January 2017. Cumulative summation (CUSUM) analysis of operative time (OT) was used. Results One hundred patients were retrospectively analyzed and chronologically divided into three phases: the ascending (A), plateau (B), and descending (C) phases of CUSUM of OT. Phases A, B, and C comprised 35, 22, and 43 cases, respectively. OT decreased significantly from phases A to B (P = 0.035) and B to C (P = 0.019). Age and weight of patients both reduced significantly from phase A to B (p = 0.017 and p = 0.012, respectively), while the two measures did not vary from phase B to C (p = 0.987 and p = 0.874, respectively). Chest tube duration and length of hospital stay had similar trend. All complications occurred in five cases in phase A (5/35). Six cases were converted to open surgery (6%). Four conversions occurred within phase A and two in phase C (4/35 vs 2/43, p = 0.490). There were no mortalities. Conclusions Repeated standardized training plays a role in overcoming the learning curve for thoracoscopic lobectomy in children, and CUSUMOT indicates that a learning curve of approximately 57 cases is required in our institute.

Although preoperative immunotherapy is increasingly utilized for non-small cell lung cancer, there remains a paucity of robust clinical data on its safety and long-term survival. Our objective was to evaluate the perioperative outcomes and survival associated with immunotherapy followed by surgery for patients with non-small cell lung cancer.Outcomes of patients with non-small cell lung cancer who underwent lung resection after preoperative chemotherapy with or without radiation or immunotherapy (with or without chemotherapy or chemoradiation) in the National Cancer Database (2010 to 2017) were evaluated using Kaplan-Meier analysis, multivariable logistic regression, multivariable Cox proportional hazards analysis, and propensity score-matched analysis.From 2010 to 2017, 236 patients (2.2%) received immunotherapy and 10 715 patients received preoperative chemotherapy followed by surgery. There were no significant differences between the immunotherapy and preoperative chemotherapy groups with regard to margin positivity (8.5% [n = 20] vs 7.5% [n = 715], P = .98), 30-day readmission (4.2% [n = 10] vs 4.1% [n = 440], P = .87), and 30-day mortality (0.4% [n = 1] vs 2.4% [n = 253], P = .25). The immunotherapy and preoperative chemotherapy groups had similar overall survival (5-year survival 63% [95% confidence interval, 50% to 74%] vs 51% [95% confidence interval, 50% to 52%], log rank P = .06; multivariable adjusted hazard ratio 0.98; 95% confidence interval, 0.67 to 1.41; P = .90). A propensity score matched analysis of 344 patients, well matched by preoperative characteristics, showed no significant differences in short-term outcomes and overall survival (log rank P = 1.00) between the two groups.In this national analysis, preoperative immunotherapy followed by surgery for non-small cell lung cancer was found to be safe and feasible with similar short-term outcomes and overall survival when compared with preoperative chemotherapy followed by surgery.

Trousseau’s syndrome is a paraneoplastic syndrome and a pathological condition that causes cerebral stroke symptoms due to hypercoagulation associated with malignant tumours. There have been many cases of advanced lung cancer, but few reports have described surgery for lung cancer with Trousseau’s syndrome. We encountered a 76-year-old man suspected of having Trousseau’s syndrome associated with lung cancer. He was transferred to our hospital on the second day after the onset. After admission, he was treated with heparin and edaravone, and his condition improved. On the 12th day after the onset, we performed left pneumonectomy and lymph node dissection (ND2a-2). The final pathological results were adenocarcinoma, pathological stage was T4 (tumour size: 77 mm, pulmonary artery invasion) N1(#11, #12u) M0, stage IIIA. He has been recurrence free for 23 months since the surgery. In the future, we need to follow his condition carefully.

Segmentectomy is gaining popularity as a parenchyma-sparing alternative for anatomic lung resection. This study sought to investigate temporal changes in patient selection, case volume, and outcomes for segmentectomy using the Society of Thoracic Surgeons (STS) National Database.The STS General Thoracic Database was queried for patients who had undergone segmentectomy as the primary procedure between 2002 and 2018. The American College of Surgeons Oncology Group definition of high-risk patients on the basis of pulmonary function and major cardiovascular comorbidities was applied. Annual trends of case volume, patient risk profile, surgical indication, approach, and outcomes were analyzed.A total of 10 629 patients were analyzed from 310 contributing centers. The annual segmentectomy volume more than doubled from4 per center in 2009 to 8.6 per center by 2017. Lung cancer was the most common indication (70.1%), followed by benign disease (15.6%) and metastatic tumors (14.3%). Although the operative indication remained constant, the subset of high-risk patients (24.5%) decreased gradually over time (slope, -0.6% per year; P = .001). After 2012, segmentectomies were most commonly performed minimally invasively (video-assisted thoracoscopic surgery, 58.3%; robotic surgery, 19.4%), with a steadily declining use of thoracotomy (overall, 22.3%; slope, -2.4%/y; P = .001). Overall complication rates decreased over the study period from 41.7% to 26.1% (slope, -0.57%/y; P = .001). The overall major complication rate was 4.6% (range, 2.0%-7.1%), 30-day mortality was 1.0% (range, 0.7%-5.0%), and both have been trending downward since 2009 (P = .01).Segmentectomies are increasingly performed nationally, with a steady decline in the subset of high-risk patients over time. Complication rates have decreased significantly, parallel to the increasing use of minimally invasive techniques by video-assisted thoracoscopic surgery and robotic surgery.

Background Postpneumopnectomy syndrome (PPS) is an extreme rotation and malposition of mediastinum causing dynamic and symptomatic central airway compression, arising after pneumonectomy or more uncommonly, in congenital single-lung physiology. Affected patients present with severe respiratory compromise. Intrathoracic prosthesis placement is an evolving technique in children that mitigate the effects of thoracic dead space. Research Question Assessment of clinical recovery and functional benefit in children undergoing placement of intrathoracic prosthesis following pneumonectomy or in congenital single lung situations. Study Design and Methods Retrospective chart review of patients at Great Ormond Street Hospital from 2010 and 2020 was performed of all patients who underwent intrathoracic tissue expander placement. We summarize the outcomes of twenty-four children, including those with both congenital and postpneumonectomy PPS etiology. Results 24 children who underwent placement of intrathoracic prosthesis for PPS in the study period with median age of 3.5 months and weight of 5 kg. Single lung etiology was congenital in 15 children (6 agenesis, 9 hypoplasia), and postpneumonectomy in 9 children. In seven patients, there was associated long segment tracheal stenosis. Pre-operative ECMO was required in 2 patients, and pre-operative ventilation was required in 12 patients – all of whom had congenital single lung. Intrathoracic prosthesis placement was concurrent with intracardiac repair in 5 patients. There were no operative deaths, but one early postoperative death related to septicaemia. Median follow up was 75 months with 10 patients on continued respiratory support and 3 on nocturnal support with good quality of life. Two children needed reoperations for replacement of prosthesis. Conclusion The use of tissue expanders is within the armamentarium of most plastic surgeons’ practice. We also therefore advocate for a collaborative team approach involving Plastic and Cardiothoracic Surgery for surgical treatment of these patients. This multidisciplinary strategy has improved management of this rare and debilitating condition of PPS, thereby offering significant improvements in general progress of these sick children having single lung physiology. Evidence is still lacking on functional outcomes in these children and further work is necessary to prove that this is indeed achievable.

We sought to evaluate the role of robotic-assisted lung surgery on hospital volume using difference in difference (DID). We propose hospital adoption of robotic thoracic technology increases total volume of specific procedures as compared to non-robotic hospitals.The 2010-2015 Florida Agency for Health Care Administration dataset was queried for open, video-assisted thoracoscopic, and robotic-assisted thoracic surgeries. Incident Rate Ratios (IRR) from DID analysis determined the significance of robotic technology. For each technique, length of stay and elements of charges were compared to determine statistical significance.A total of 28,484 lung resection procedures performed at 162 hospitals, 65 of which had robotic capabilities were included. Robotic hospitals experienced an 85% increase in total lung surgical volume (IRR 1.85, p-value0.001). This increase in volume was consistent for each lung resection procedure separately.Hospital adoption of robotic technology significantly increases the overall lung surgical volume for select lung resection procedures.

Background Video-assisted thoracic surgery (VATS) has been widely used in the surgical treatment of thoracic diseases, and it suggested surgical and oncological advantages compared with open surgery. However, reports on the application of VATS in surgery of small cell lung cancer (SCLC) are scarce. This study aimed to explore the advantages and disadvantages of different surgical approaches in the treatment of pathological stage T1(pT1) SCLC in terms of safety, clinical outcomes, and lymph node dissection. Patients and Methods Patients who underwent lobectomy for pT1 SCLC between January 2014 and September 2017 were identified from the National Collaborative Lung Cancer Database (LinkDoc Database). The patients were stratified based on the surgery approach (VATS or open lobectomy). Perioperative outcomes and long-term survival were analyzed using SPSS software. Results A total of 169 patients with pT1 SCLC met the criteria and were enrolled for this study, including 110 cases of VATS lobectomies and 59 cases of open lobectomies. VATS lobectomy was associated with less blood loss than open surgery (168.1 ± 237.4 vs. 340.0 ± 509.8 mL, P = .002). Open lobectomy harvested more N2 LNs (11.8 ± 8.2 vs. 8.4 ± 5.8, P = .048) and identified more metastasis positive LNs (3.1 ± 6.0 vs. 1.4 ± 3.0, P = .050). Open lobectomy associated with longer overall survival (OS) but has no statistical difference (23.4 ± 13.2 vs. 20.2 ± 10.9, P = .070). Conclusion Open lobectomy had better lymph node dissection results, and comparable postoperative complications, postoperative hospital stay, and OS to VATS lobectomy. Further studies may still be needed to confirm the recommendation of thoracoscopic approach as a routine surgical procedure for operable SCLC, and until then, open surgery should still be considered.

Serratus anterior plane block (SAPB) has been proven to be an efficient way to control postoperative pain. This study explored whether the use of continuous SAPB in combination with flurbiprofen could improve early pulmonary function in lung cancer patients undergoing video-assisted thoracoscopic surgery (VATS).From July 2019 to April 2020, patients who scheduled for elective lung resection undergoing VATS were randomly allocated to receive patient-controlled SAPB in combination with intravenous flurbiprofen or patient-controlled intravenous analgesia. Postoperative pulmonary function variables, including forced expiratory volume in 1 second, and forced vital capacity were collected before and 24, 48, and 72 hours after Surgical Procedure. Pain intensity was measured at rest and on coughing. Comfort scores during breathing exercises, postoperative pulmonary complications, and adverse events were recorded.A substantial reduction in lung function was exhibited in both groups after Surgical Procedure (P .001), but lung function variables in the continuous SAPB group were significantly higher (P .001) throughout the postoperative period up to 72 hours, regardless of the surgical procedure type. Meanwhile, there were significant differences of pain intensity at rest and on coughing between the groups (P .001). The incidence of pneumonia, pulmonary atelectasis, hypoxemia, vomiting, and the comfort score in the continuous SAPB group was significantly lower (P.05).Postoperative acute pain treatment with continuous SAPB in combination with flurbiprofen enhanced pulmonary function and reduced postoperative pulmonary complications in lung cancer patients undergoing VATS.

The purpose of the study was to evaluate the effect of pressure controlled volume guaranteed ventilation in children requiring one lung ventilation during pulmonary resection. Patients were randomly assigned to the lung protective ventilation combined with pressure controlled volume guaranteed group (PCV-VG group) or the lung protective ventilation combined with volume controlled ventilation group (VCV group). Both groups received tidal-volume ventilation of 8 ml kg−1 body weight during two lung ventilation and 6 ml kg−1 during OLV, with sustained 5 cmH2O positive end-expiratory pressure. Data collections were mainly performed at 10 min after induction of anaesthesia during TLV (T1), 5 min after OLV initiation (T2) and 5 min after complete CO2 insufflations (T3). In total, 63 patients were randomly assigned to the VCV (n = 31) and PCV-VG (n = 32) groups. The PCV-VG group exhibited lower PIP than the VCV group at T1 (16.8 ± 2.3 vs. 18.7 ± 2.7 cmH2O, P = 0.001), T2 (20.2 ± 2.7 vs. 22.4 ± 3.3 cmH2O, P = 0.001), and T3 (23.8 ± 3.2 vs. 26.36 ± 3.7 cmH2O, P = 0.01). Static compliance was higher in the PCV-VG group at T1, T2, and T3 (P = 0.01). After anaesthesia induction, lung aeration deteriorated, but with no immediate postoperative difference in both groups. Postoperative lung aeration improved and returned to normal from 2.5 h postextubation in both groups. PH was lower and PaCO2 was higher in VCV group than PCV-VG group during one lung ventilation. No differences were observed in PaO2-FiO2-ratio at T2 and T3, the incidence of postoperative pulmonary complications, intraoperative desaturation and the length of hospital stay. In paediatric patients, who underwent pulmonary resection requiring one lung ventilation, PCV-VG was superior to VCV in its ability to provide lower PIP, higher static compliance and lower PaCO2 at one lung ventilation during pneumothorax. However, its beneficial effects on different pathological situations in pediatric patients need more investigation.

Aim: To describe initial treatment patterns and survival of patients diagnosed with non-small-cell lung cancer (NSCLC) in Denmark, before immune checkpoint inhibitor and later-generation tyrosine kinase inhibitor use. Patients & methods: Adults diagnosed with incident NSCLC (2005–2015; follow-up: 2016). Initial treatments and overall survival (OS) are reported. Results: 31,939 NSCLC patients (51.6% stage IV) were included. Increasing use of curative radiotherapy/chemoradiation for stage I, II/IIIA and IIIB NSCLC coincided with improved 2-year OS. Systemic anticancer therapy use increased for patients with stage IV non-squamous NSCLC (53.0–60.6%) but not squamous NSCLC (44.9–47.3%). 1-year OS improved in patients with stage IV non-squamous NSCLC (23–31%) but not squamous NSCLC (22–25%). Conclusion: Trends indicated improved OS as treatments evolved between 2005 and 2015, but the effect was limited to 1-year OS in stage IV disease.

To determine if wedge resection is equivalent to lobectomy for Stage I Non-Small Cell Lung Cancer (NSCLC) and to evaluate the impact of radiologic and pathologic variables not available in large national databases. Records were reviewed from 2010-2016 for patients with pathologic Stage I NSCLC who underwent wedge resection or lobectomy. Propensity score matching was performed on pre-operative variables and patients with ≥1 lymph node removed. Clinical variables were compared. Kaplan-Meier curves and multivariable Cox proportional hazard models for 5-year overall survival (OS), disease-free (DFS), and locoregional-recurrence-free survival (LRFS) were created. A total of 1086 patients met inclusion criteria; 391 lobectomies and 695 wedge resections. Propensity score matching yielded 167 pairs of lobectomy and wedge resection patients. Complications were fewer for wedge resections than lobectomies, 19.2% for wedge resection patients vs 34.1% for lobectomy patients, p0.01. OS was equivalent between groups, 86.2% for lobectomy patients vs 83.4% for wedge resection patients p = 0.47. DFS was similar, 79.0% for lobectomy patients vs 72.5% for wedge resection patients p = 0.10. Overall LRFS was worse in wedge resection patients vs lobectomy patients, 82.0% vs 93.4% p0.01. However, in the matched wedge resection patients with a margin10 mm the LRFS was equal to that of lobectomy patients, 86.4% for wedge resection patients vs 91.8% for lobectomy patients p = 0.140. Patients with Stage I NSCLC can experience similar OS, DFS, and LRFS with wedge resection as compared to lobectomy, when wedge resection margins are10 mm and appropriate lymph node dissection is performed.

A 48-year-old woman with extensive clarithromycin-resistant Mycobacterium avium complex pulmonary disease (MAC-PD) was successfully treated by left lower lobectomy and lingulectomy following combination treatment of intravenous/inhaled amikacin plus bronchial occlusion by Endobronchial Watanabe Spigots (EWSs). A left pneumonectomy was initially indicated for removing all the lesions, but the procedure would have been barely tolerated by the patient. However, her preoperative combination treatment sufficiently reduced the lesions requiring resection to allow surgical preservation of the left upper division. This novel approach might be promising for patients with Mycobacterium avium complex lung disease whose pulmonary reserve will not allow an extensive parenchymal resection.

The ninth edition of lung cancer staging system recommends that specific driver mutations should be considered as prognostic factors in survival models. This study comprehensively investigated the prognostic value of Kirsten rat sarcoma viral oncogene homolog (KRAS) mutation in patients with resected lung adenocarcinomas according to different clinicopathologic and radiologic characteristics.In total, 1464 patients with completely resected primary lung adenocarcinomas were examined for KRAS mutations from November 2008 to March 2015. Age, sex, smoking status, performance status, tumor-node-metastasis stage, radiologic features, and histologic subtypes were collected. Competing risk model was used to estimate the cumulative incidence rate of recurrence. Cox regression multivariable analyses on recurrence-free survival (RFS) and overall survival (OS) were performed.KRAS mutations were more frequent in male subjects (P .001), current/former smokers (P .001), invasive mucinous adenocarcinoma (P .001), and solid tumors (P .001). In general, KRAS-mutated patients had greater cumulative recurrence rate (hazard ratio [HR], 1.95; 95% confidence interval [CI], 1.23-3.08; P .001) and worse overall survival (OS; HR, 1.88; 95% CI, 1.23-2.87; P .001) than KRAS wild-type patients. The OS (P .001) of patients harboring KRAS-G12C/V mutations was shorter than that of other KRAS-mutated patients. Cox multivariable analyses demonstrated that KRAS mutations were independently associated with worse RFS (HR, 5.34; 95% CI, 2.53-11.89; P = .001) and OS (HR, 2.63; 95% CI, 1.03-6.76; P = .044) in part-solid lung adenocarcinomas. For stage I patients, Cox multivariable analyses revealed that KRAS mutation was an independent risk factor for RFS (HR, 2.05; 95% CI, 1.19-3.56; P = .010) and OS (HR, 2.38; 95% CI, 1.29-4.40; P = .005).In this study, we revealed that KRAS mutations was an independent prognostic factor in part-solid tumors and in stage I lung adenocarcinomas. These findings may contribute to the ninth edition of lung cancer staging project.

Lung volume reduction surgery continues to have a high morbidity despite National Emphysema Treatment Trial selection criteria. This study evaluated the association between analytic morphomics on chest computed tomography scans and outcomes after lung volume reduction surgery. In a retrospective review of 85 lung volume reduction surgery patients from 1998-2013, dorsal muscle group area, subcutaneous and visceral fat area, and bone mineral density were assessed using analytic morphomics. Lung density was divided into five levels of increasing density (Lung density 1, emphysema; 2, normal lung; 4-5, scarring). Outcomes including survival, hospital length of stay, readmission at 30 days, and pulmonary complications were analyzed using univariate and multivariable techniques. Pulmonary complications developed in 27.1% (23/85). Mortality at 90 days was 9.4% (8/85). On multivariable analysis, lower bone mineral density (Odds ratio 0.61; 95% confidence interval 0.39-0.95) was associated with decreased survival, longer length of stay (0.83; 0.77-0.89), and readmissions (0.39; 0.15-1.00). Higher lung density 5:lung density 2 volume (1.84; 1.05-3.23), possibly due to scarring, was associated with pulmonary complications and longer length of stay (1.32; 1.23-1.41) while lower subcutaneous fat area:height was associated with readmissions which may reflect decreased metabolic reserve (0.35; 0.13-0.93). Patients with signs of frailty including lower bone mineral density may be at increased risk of adverse outcomes including decreased survival after lung volume reduction surgery. The results of this hypothesis-generating study will need to be confirmed in larger, multicenter trials to determine whether analytic morphomics can improve risk stratification and patient selection.

PURPOSE To investigate the accuracy of a segment-counting method in predicting lung function and volume after stapler-based thoracoscopic segmentectomy in comparison with lobectomy. METHODS Between 2014 and 2018, patients who underwent these procedures were retrospectively reviewed. Thoracic computed tomography and spirometry data before and 1 year after the surgery were assessed. We evaluated the differences between the predicted values using a segment-counting method and the actual postoperative values for lung function and volume in each group. Sub-analyses were also performed to assess the impact of the number of staples and resected segments in predicting patient outcomes. RESULTS We included 116 patients (segmentectomy, 69; lobectomy, 47). Actual postoperative lung function and volume values matched the predicted values in the stapler-based segmentectomy group, and significantly exceeded the predictions in the lobectomy group (P

A 62-year-old woman with a history of lung resection for lung cancer was admitted to our hospital due to cough, which became progressively more severe. She was diagnosed with chronic empyema with bronchopleural fistula (BPF) of the right upper bronchial stump. Although a pedicled muscle flap was transposed to the empyema cavity, the fistula remained. We used a vacuum-assisted closure system after open-window thoracotomy and observed the cavity reduction with expansion of the transposed muscle flap. We quantitatively evaluated the dynamics of the cavity change using a three-dimensional image analysis system. A reduction of the volume of the muscle flap by prolonged empyema and expansion of the muscle flap was observed immediately after vacuum-assisted management. However, expansion of the right residual lung was not recognized. Pedicled muscle flap transposition followed by vacuum-assisted management after open-window thoracotomy may be effective for treating chronic empyema caused by BPF.