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Objectives: This study reports the results of an international expert consensus process evaluating the assessment of intraoperative air leaks (IAL) and treatment of postoperative prolonged air leaks (PAL) utilizing a Delphi process, with the aim of helping standardization and improving practice., Methods: A panel of 45 questions was developed and submitted to an international working group of experts in minimally invasive lung cancer surgery. Modified Delphi methodology was used to review responses, including 3 rounds of voting. The consensus was defined a priori as >50% agreement among the experts. Clinical practice standards were graded as recommended or highly recommended if 50-74% or >75% of the experts reached an agreement, respectively., Results: A total of 32 experts from 18 countries completed the questionnaires in all 3 rounds. Respondents agreed that PAL are defined as >5 days and that current risk models are rarely used. The consensus was reached in 33/45 issues (73.3%). IAL were classified as mild (<100 ml/min; 81%), moderate (100-400 ml/min; 71%) and severe (>400 ml/min; 74%). If mild IAL are detected, 68% do not treat; if moderate, consensus was not; if severe, 90% favoured treatment., Conclusions: This expert consensus working group reached an agreement on the majority of issues regarding the detection and management of IAL and PAL. In the absence of prospective, randomized evidence supporting most of these clinical decisions, this document may serve as a guideline to reduce practice variation., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Chronic obstructive pulmonary disease (COPD) increases postoperative morbidity and is associated with diminished long-term survival after lung cancer resection. Whether this is also true for mild-to-moderate COPD is uncertain. We conducted a retrospective analysis of all the patients who underwent lung cancer surgery between 2002 and 2012 in a university-affiliated hospital. The severity of airflow limitation was stratified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) from stage 1 to 4. Data from 1456 cases of lung cancer surgery were reviewed and 1126 patients were included in the study: 672 (59.7%) patients had COPD (GOLD 1, n = 340; GOLD 2, n = 282; GOLD 3, n = 50) and 454 patients had a normal spirometry (controls). Following lung cancer resection, patients with COPD had a higher rate of postoperative morbidities of any kind ( p < 0.0001), in particular, pneumonia (7.0% vs. 3.7%; p = 0.0251) and prolonged air leak (17.0% vs. 8.2%; p < 0.0001) than controls. In-hospital mortality was increased in GOLD 3 COPD but the incidence of other postoperative complications was not influenced by COPD severity. Neither COPD nor its severity influenced long-term survival in this population. To conclude, patients with COPD undergoing lung cancer surgery were at higher risk of postoperative complications than patients with normal respiratory function but the procedure was considered safe. The presence of COPD itself did not influence long-term survival. The results of our study apply mainly to patients with a GOLD 1 and 2 COPD since only a small number of patients with GOLD 3 COPD were involved.

Objectives: Our goal was to report the results of the first consensus paper among international experts in uniportal video-assisted thoracoscopic surgery (UniVATS) lobectomy obtained through a Delphi process, the objective of which was to define and standardize the main procedural steps, optimize its indications and perioperative management and identify elements to assist in future training., Methods: The 40 members of the working group were convened and organized on a voluntary basis by the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). An e-consensus finding exercise using the Delphi method was applied to require 75% agreement for reaching consensus on each question. Repeated iterations of anonymous voting continued for 3 rounds., Results: Overall, 31 international experts from 18 countries completed all 3 rounds of questionnaires. Although a technical quorum was not achieved, most of the responders agreed that the maximum size of a UniVATS incision should be ≤4 cm. Agreement was reached on many points outlining the currently accepted definition of a UniVATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions., Conclusions: The UVIG Consensus Report stated that UniVATS offers a valid alternative to standard VATS techniques. Only longer follow-up and randomized controlled studies will predict whether UniVATS represents a valid alternative approach to multiport VATS for major lung resections or whether it should be performed only in selected cases and by selected centres. The next step for the ESTS UVIG is the establishment of a UniVATS section inside the ESTS databases., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Platypnea-orthodeoxia syndrome is a rare and poorly understood condition related to the development of a right-to-left intracardiac shunt at the atrial level through a benign and silent patent foramen ovale. It is usually recognized after major lung resection, recurrent pulmonary embolism or chronic lung disease. Orthostatic dyspnea and cyanosis is the prominent clinical presentation. Symptoms increase in the upright position and are relieved by recumbency. Our report describes the clinical course of a patient with severe hypoxemia after left pneumonectomy attributable to a right-to-left shunting through an atrial septal defect.