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The aim of this study was to establish the relationship between the occurrence of a surgical site infection (SSI) and the presence of a central venous catheter-related infection (CVCRI). The Department of Thoracic and Cardiovascular Surgery, University Hospital, Rouen, has carried out a prospective epidemiological survey of all nosocomial infections (pneumonia, SSI and CVCRI) since 1997. The study group included all consecutive patients who underwent cardiac surgery over a 10-year period from 1997 to 2007. A nested case-control study was conducted to identify the risk factors for SSI after CVCRI. Cases were patients with SSI after CVCRI and controls were randomized from patients who presented with CVCRI not followed by SSI. In total, 7557 patients were included and 133 SSIs (1.7%) were identified. The rate of superficial SSI was 0.7% [95% confidence interval (CI): 0.5-0.9] and of mediastinitis was 1.0% (95% CI: 0.8-1.2). Among the 133 cases of SSI, 12 (9.0%; 95% CI: 5.0-14.8) occurred after a CVCRI with identical micro-organisms. CVCRI [adjusted odds ratio (aOR): 5.2; 95% CI: 3.2-8.5], coronary artery bypass grafting (aOR: 2.9; 95% CI: 1.6-5.2), and obesity (aOR: 11.4; 95% CI: 1.0-130.1) were independent factors associated with SSI. The new finding of this study is that patients with CVCRI were 5.2 times more likely to develop SSI compared to patients without CVCRI. [ABSTRACT FROM AUTHOR]

Background: Chronic giant diaphragmatic hernia is a severe disease with challenging diagnosis and treatment. Given the risk of loss of domain, the use of botulinum toxin A is an option but has been minimally studied in diaphragmatic hernia surgery., Case Report: We present a case of a giant diaphragmatic hernia in a 66-years-old patient who showed a 12-year history of progressive chronic respiratory insufficiency. There were not notion of traumatic injuries. The CT-scan showed a giant diaphragmatic hernia with herniation of small bowel, right liver, omentum and transverse colon., Method: We assessed the risk of loss of domain using a 3D volumetry based on the Sabbagh score and decided to use Botox injection before laparoscopic reduction of the hernia due to the high risk of complications related to the loss of domain. A computed tomography was performed 24 months after surgery and showed no evidence of recurrence. The patient presented an excellent functional result with a normal physical activity., Conclusion: This report is among the first to highlight the utility of 3D reconstruction in assessing the risk associated with loss of domain and in preparing the abdominal wall with botulinum toxin A for diaphragmatic hernia repair., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Nachtergaele, Khalil, Martre, Baste and Roussel.)

Objectives: Evaluate theoretical and practical training of thoracic surgeons-in-training in robotic-assisted thoracic surgery (RATS) in France., Methods: A survey was distributed to thoracic surgeons-in-training in France from November 2022 to February 2023., Results: We recruited 101 thoracic surgeons-in-training (77% response rate). Over half had access to a surgical robotics system at their current institution. Most (74%) considered robotic surgery training essential, 90% had attended a robotic procedure. Only 18% had performed a complete thoracic robotic procedure as the main operator. A complete RATS procedure was performed by 42% of fellows and 6% of residents. Of the remaining surgeons, 23% had performed part of a robotic procedure. Theoretical courses and simulation are well developed; 72% of residents and 91% of fellows had undergone simulation training in the operating room, at training facilities, or during congress amounting to <10 h (for 73% of the fellows and residents), 10-20 h (17%), 20-30 h (8%) or >30 h (3%). Access to RATS was ≥1 day/week in 71% of thoracic departments with robotic access. Fellows spent a median of 2 (IQR 1-3) semesters in departments performing robotic surgery. Compared with low-volume centres, trainees at high-volume centres performed significantly more complete robotic procedures (47% vs 13%; P = 0.001), as did fellows compared with residents., Conclusions: Few young surgeons perform complete thoracic robotic procedures during practical training, and access remains centre dependent. Opportunities increase with seniority and exposure; however, increasing availability of robotic devices, theoretical formation, and simulation courses will increase opportunities., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: To determine safety and survival outcomes associated with lobectomy, segmentectomy and wedge resection for early-stage lung cancer by quiring the French population-based registry EPIdemiology in THORacic surgery (EPITHOR)., Methods: Retrospective analysis of 19 452 patients with stage c IA lung carcinoma who underwent lobectomy, segmentectomy or wedge resection between 2016 and 2022 with curative-intent. Main outcome measures were 90-day mortality and 5-year overall survival estimates. Proportional hazards regression and propensity score matching were used to adjust outcomes for key patient, tumour and practice environment factors., Results: The treatment distribution was 72.2% for lobectomy, 21.5% for segmentectomy and 6.3% for wedge. Unadjusted 90-day mortality rates were 1.6%, 1.2% and 1.1%, respectively (P = 0.10). Unadjusted 5-year overall survival estimates were 80%, 78% and 70%, with significant inter-group survival curves differences (P < 0.0001). Multivariable proportional hazards regression showed that wedge was associated with worse overall survival [adjusted hazard ratio (AHR), 1.23 (95% confidence interval 1.03-1.47); P = 0.021] compared with lobectomy, while no significant difference was disclosed when comparing segmentectomy to lobectomy (1.08 [0.97-1.20]; P = 0.162). The three-way propensity score analyses confirmed similar 90-day mortality rate for wedge resection and segmentectomy compared with lobectomy (hazard ratio: 0.43; 95% confidence interval 0.16-1.11; P = 0.081 and 0.99; 0.48-2.10; P = 0.998, respectively), but poorer overall survival (1.45; 1.13-1.86; P = 0.003 and 1.31; 1-1.71; P = 0.048, respectively)., Conclusions: Wedge resection was associated with comparable 90-day mortality but lower overall survival when compared to lobectomy. Overall, all types of sublobar resections may not offer equivalent oncologic effectiveness in real-world settings., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Postoperative complications may occur after major lung surgery for non-small cell lung cancer (NSCLC), with a high rate of morbidity and mortality. The main objective of this study was to assess the relevance of preoperative Leicester Cough Questionnaire (LCQ) to predict postoperative complications after major lung resection for any indication., Methods: This was a retrospective cohort study conducted in the Thoracic Surgery Department of Rouen University Hospital from November 21st, 2022, to June 2nd, 2023. Patients aged ≥18 years who underwent major lung resection for any indications and filled an LCQ self-questionnaire were included., Results: Seventy-one patients were eligible for our study. One patient was lost to follow-up upon hospital discharge. Nineteen (27.1%) postoperative complications of grade ≥2 according to the Clavien-Dindo classification were observed. The mean LCQ total score was 18.11±2.56. The area under the receiver operating characteristic (ROC) curve for the LCQ result to predict postoperative complications of grade ≥2 within 30 days following the surgical intervention was 0.60 [95% confidence interval (CI): 0.45, 0.75]., Conclusions: This study failed to demonstrate the relevance of a preoperative LCQ to predict postoperative complications after major lung surgery. However, the statistical precision of this study was insufficient to show a moderate predictive performance. Further studies conducted in larger populations are needed., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1324/coif). The authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Despite robot-assisted surgery (RAS) becoming increasingly common, little is known about the impact of the underlying work organization on the stress levels of members of the operating room (OR) team. To this end, assessing whether RAS may impact work-related stress, identifying associated stress factors and surveying relevant measurement methods seems critical. Using three databases (Scopus, Medline, Google Scholar), a systematic review was conducted leading to the analysis of 20 articles. Results regarding OR team stress levels and measurement methods were heterogeneous, which could be explained by differing research conditions (i.e., lab. vs. real-life). Relevant stressors such as (in)experience with RAS and quality of team communication were identified. Development of a common, more reliable methodology of stress assessment is required. Research should focus on real-life conditions in order to develop valid and actionable knowledge. Surgical teams would greatly benefit from discussing RAS-related stressors and developing team-specific strategies to handle them., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objectives: Robotic-assisted thoracic surgery (RATS) is increasingly used in our specialty. We surveyed European Society of Thoracic Surgeons membership with the objective to determine current status of robotic thoracic surgery practice including training perspectives., Methods: A survey of 17 questions was rolled out with 1 surgeon per unit responses considered as acceptable., Results: A total of 174 responses were obtained; 56% (97) were board-certified thoracic surgeons; 28% (49) were unit heads. Most responses came from Italy (20); 22% (38) had no robot in their institutions, 31% (54) had limited access and only 17% (30) had full access including proctoring. Da Vinci Xi was the commonest system in 56% (96) centres, 25% (41) of them had dual console in all systems, whereas RATS simulator was available only in half (51.18% or 87). Video-assisted thoracic surgery (VATS) was the most commonly adopted surgical approach in 81% of centres (139), followed by thoracotomy in 67% (115) and RATS in 36% (62); 39% spent their training time on robotic simulator for training, 51% on robotic wet/dry lab, which being no significantly different to 46-59% who had training on VATS platform. There was indeed huge overlap between simulator models or varieties usage; 52% (90) reported of robotic surgery not a part of training curriculum with no plans to introduce it in future. Overall, 51.5% (89) responded of VATS experience being helpful in robotic training in view of familiarity with minimally invasive surgery anatomical views and dissection; 71% (124) reported that future thoracic surgeons should be proficient in both VATS and RATS. Half of the respondents found no difference in earlier chest drain removal with either approach (90), 35% (60) reported no difference in postoperative pain and 49% (84) found no difference in hospital stay; 52% (90) observed better lymph node harvest by RATS., Conclusions: Survey concluded on a positive response with at least 71% (123) surgeons recommending to adopt robotics in future., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: To assess the current practice of pulmonary metastasectomy at 15 European Centres. Short- and long-term outcomes were analysed., Methods: Retrospective analysis on patients ≥18 years who underwent curative-intent pulmonary metastasectomy (January 2010 to December 2018). Data were collected on a purpose-built database (REDCap). Exclusion criteria were: previous lung/extrapulmonary metastasectomy, pneumonectomy, non-curative intent and evidence of extrapulmonary recurrence at the time of lung surgery., Results: A total of 1647 patients [mean age 59.5 (standard deviation; SD = 13.1) years; 56.8% males] were included. The most common primary tumour was colorectal adenocarcinoma. The mean disease-free interval was 3.4 (SD = 3.9) years. Relevant comorbidities were observed in 53.8% patients, with a higher prevalence of metabolic disorders (32.3%). Video-assisted thoracic surgery was the chosen approach in 54.9% cases. Wedge resections were the most common operation (67.1%). Lymph node dissection was carried out in 41.4% cases. The median number of resected lesions was 1 (interquartile range 25-75% = 1-2), ranging from 1 to 57. The mean size of the metastases was 18.2 (SD = 14.1) mm, with a mean negative resection margin of 8.9 (SD = 9.4) mm. A R0 resection of all lung metastases was achieved in 95.7% cases. Thirty-day postoperative morbidity was 14.5%, with the most frequent complication being respiratory failure (5.6%). Thirty-day mortality was 0.4%. Five-year overall survival and recurrence-free survival were 62.0% and 29.6%, respectively., Conclusions: Pulmonary metastasectomy is a low-risk procedure that provides satisfactory oncological outcomes and patient survival. Further research should aim at clarifying the many controversial aspects of its daily clinical practice., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Introduction: Non-small cell lung cancer (NSCLC) is often associated with compromised lung function. Real-world data on the impact of surgical approach in NSCLC patients with compromised lung function are still lacking. The objective of this study is to assess the potential impact of minimally invasive surgery (MIS) on 90-day post-operative mortality after anatomic lung resection in high-risk operable NSCLC patients., Methods: We conducted a retrospective multicentre study including all patients who underwent anatomic lung resection between January 2010 and October 2021 and registered in the Epithor database. High-risk patients were defined as those with a forced expiratory volume in 1 s (FEV 1 ) or diffusing capacity of the lung for carbon monoxide ( D LCO ) value below 50%. Co-primary end-points were the impact of risk status on 90-day mortality and the impact of MIS on 90-day mortality in high-risk patients., Results: Of the 46 909 patients who met the inclusion criteria, 42 214 patients (90%) with both preoperative FEV 1 and D LCO above 50% were included in the low-risk group, and 4695 patients (10%) with preoperative FEV 1 and/or preoperative D LCO below 50% were included in the high-risk group. The 90-day mortality rate was significantly higher in the high-risk group compared to the low-risk group (280 (5.96%) versus 1301 (3.18%); p<0.0001). In high-risk patients, MIS was associated with lower 90-day mortality compared to open surgery in univariate analysis (OR=0.04 (0.02-0.05), p<0.001) and in multivariable analysis after propensity score matching (OR=0.46 (0.30-0.69), p<0.001). High-risk patients operated through MIS had a similar 90-day mortality rate compared to low-risk patients in general (3.10% versus 3.18% respectively)., Conclusion: By examining the impact of surgical approaches on 90-day mortality using a nationwide database, we found that either preoperative FEV 1 or D LCO below 50% is associated with higher 90-day mortality, which can be reduced by using minimally invasive surgical approaches. High-risk patients operated through MIS have a similar 90-day mortality rate as low-risk patients., Competing Interests: Conflict of interest statement: The statistical analysis in this work was financially supported by the Marc Laskar grant. J-M. Baste and P-B. Pagès receive consulting fees from Medtronic and from Intuitive Surgical. P-A. Thomas is a consultant for Ethicon Endosurgery, AstraZeneca and Europrisme. A. Seguin-Givelet is a speaker for AstraZeneca and Medtronic. H. Etienne, J. Iquille, P.E. Falcoz, L. Brouchet, J-P. Berthet, F. Le Pimpec Barthes, J. Jougon, M. Filaire, V. Anne, S. Renaud, T. D'Annoville, J.P. Meunier, C. Jayle, C. Dromer, A. Legras, P. Rinieri, S. Jaillard, V. Margot, M. Dahan and P. Mordant have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright ©The authors 2024.)

Objective: The aim of this study was to determine if robotic-assisted lobectomy (RPL-4) is cost-effective and offers improved patient-reported health utility for patients with early-stage non-small cell lung cancer when compared with video-assisted thoracic surgery lobectomy (VATS-lobectomy)., Background: Barriers against the adoption of RPL-4 in publicly funded health care include the paucity of high-quality prospective trials and the perceived high cost of robotic surgery., Methods: Patients were enrolled in a blinded, multicentered, randomized controlled trial in Canada, the United States, and France, and were randomized 1:1 to either RPL-4 or VATS-lobectomy. EuroQol 5 Dimension 5 Level (EQ-5D-5L) was administered at baseline and postoperative day 1; weeks 3, 7, 12; and months 6 and 12. Direct and indirect costs were tracked using standard methods. Seemingly Unrelated Regression was applied to estimate the cost effect, adjusting for baseline health utility. The incremental cost-effectiveness ratio was generated by 10,000 bootstrap samples with multivariate imputation by chained equations., Results: Of 406 patients screened, 186 were randomized, and 164 analyzed after the final eligibility review (RPL-4: n=81; VATS-lobectomy: n=83). Twelve-month follow-up was completed by 94.51% (155/164) of participants. The median age was 68 (60-74). There were no significant differences in body mass index, comorbidity, pulmonary function, smoking status, baseline health utility, or tumor characteristics between arms. The mean 12-week health utility score was 0.85 (0.10) for RPL-4 and 0.80 (0.19) for VATS-lobectomy ( P =0.02). Significantly more lymph nodes were sampled [10 (8-13) vs 8 (5-10); P =0.003] in the RPL-4 arm. The incremental cost/quality-adjusted life year of RPL-4 was $14,925.62 (95% CI: $6843.69, $23,007.56) at 12 months., Conclusion: Early results of the RAVAL trial suggest that RPL-4 is cost-effective and associated with comparable short-term patient-reported health utility scores when compared with VATS-lobectomy., Competing Interests: W.C.H.: advisory board and speakers bureau for Astra Zeneca, data safety monitoring committee for Roche/Genentech, speakers bureau for Minogue Medical, grant funding from Intuitive Surgical. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Segmentectomy may be indicated for T1a-cN0 non-small-cell lung cancer. However, several patients are upstaged pT2a at final pathological examination due to visceral pleural invasion (VPI). As resection is usually not completed to lobectomy, this may raise issue of potential worse prognosis. The aim of this study is to compare prognosis of VPI upstaged cT1N0 patients operated on by segmentectomy or lobectomy., Methods: Data of patients from 3 centres were analysed. This was a retrospective study, of patients operated on from April 2007 to December 2019. Survival and recurrence were assessed by Kaplan-Meier method and cox regression analysis., Results: Lobectomy and segmentectomy were performed in 191 (75.4%) and in 62 (24.5%) patients, respectively. No difference in 5-year disease-free survival rate between lobectomy (70%) and segmentectomy (64.7%) was observed. There was no difference in loco-regional recurrence, nor in ipsilateral pleural recurrence. The distant recurrence rate was higher (P = 0.027) in the segmentectomy group. Five-year overall survival rate was similar for both lobectomy (73%) and segmentectomy (75.8%) groups. After propensity score matching, there was no difference in 5-year disease-free survival rate (P = 0.27) between lobectomy (85%) and segmentectomy (66.9%), and in 5-year overall survival rate (P = 0.42) between the 2 groups (lobectomy 76.3% vs segmentectomy 80.1%). Segmentectomy was not impacting neither recurrence, nor survival., Conclusions: Detection of VPI (pT2a upstage) in patients who underwent segmentectomy for cT1a-c non-small-cell lung cancer does not seem to be an indication to extend resection to lobectomy., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Lungsco01 is the first study assessing the real benefits and the medico-economic impact of video-thoracoscopy versus open thoracotomy for non-small cell lung cancer in the French context., Methods: Two hundred and fifty nine adult patients from 10 French centres were randomised in this prospective multicentre randomised controlled trial, between July 29, 2016, and November 24, 2020. Survival from surgical intervention to day 30 and later was compared with the log-rank test. Total quality-adjusted-life-years (QALYs) were calculated using the EQ-5D-3L®. For medico-economic analyses at 30 days and at 3 months after surgery, resources consumed were valorised (€ 2018) from a hospital perspective. First, since mortality was infrequent and not different between the two arms, cost-minimisation analyses were performed considering only the cost differential. Second, based on complete cases on QALYs, cost-utility analyses were performed taking into account cost and QALY differential. Acceptability curves and the 95% confidence intervals for the incremental ratios were then obtained using the non-parametric bootstrap method (10,000 replications). Sensitivity analyses were performed using multiple imputations with the chained equation method., Results: The average cumulative costs of thoracotomy were lower than those of video-thoracoscopy at 30 days (€9,730 (SD = 3,597) vs. €11,290 (SD = 4,729)) and at 3 months (€9,863 (SD = 3,508) vs. €11,912 (SD = 5,159)). In the cost-utility analyses, the incremental cost-utility ratio was €19,162 per additional QALY gained at 30 days (€36,733 at 3 months). The acceptability curve revealed a 64% probability of efficiency at 30 days for video-thoracoscopy, at a widely-accepted willingness-to-pay threshold of €25,000 (34% at 3 months). Ratios increased after multiple imputations, implying a higher cost for video-thoracoscopy for an additional QALY gain (ratios: €26,015 at 30 days, €42,779 at 3 months)., Conclusions: Given our results, the economic efficiency of video-thoracoscopy at 30 days remains fragile at a willingness-to-pay threshold of €25,000/QALY. The economic efficiency is not established beyond that time horizon. The acceptability curves given will allow decision-makers to judge the probability of efficiency of this technology at other willingness-to-pay thresholds., Trial Registration: NCT02502318., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Non-small cell lung cancer (NSCLC) is now described as an extremely heterogeneous disease in its clinical presentation, histology, molecular characteristics, and patient conditions. Over the past 20 years, the management of lung cancer has evolved with positive results. Immune checkpoint inhibitors have revolutionized the treatment landscape for NSCLC in both metastatic and locally advanced stages. The identification of molecular alterations in NSCLC has also allowed the development of targeted therapies, which provide better outcomes than chemotherapy in selected patients. However, patients usually develop acquired resistance to these treatments. On the other hand, thoracic surgery has progressed thanks to minimally invasive procedures, pre-habilitation and enhanced recovery after surgery. Moreover, within thoracic surgery, precision surgery considers the patient and his/her disease in their entirety to offer the best oncologic strategy. Surgeons support patients from pre-operative rehabilitation to surgery and beyond. They are involved in post-treatment follow-up and lung cancer recurrence. When conventional therapies are no longer effective, salvage surgery can be performed on selected patients.

Objectives: Adequate pain management after thoracoscopic surgery is a major issue in the prevention of respiratory complications. The combination of the paravertebral block (PVB) with the serratus anterior plane block (SAPB) may decrease postoperative pain. The objective of this study was to evaluate the impact of the combination of PVB and SAPB on the consumption of morphine and pain after video- or robot-assisted thoracic surgery., Methods: The main objective of this randomized controlled trial was to compare the cumulative postoperative morphine consumption at 24 h between a group having PVB (PVB group) and a group having PVB and SAPB (PV-SAPB group). Postoperative pain at 6 and 24 h and morphine-related complications were also assessed., Results: A total of 112 patients were included with 56 in each group. There was no difference in median cumulative morphine consumption at 24 h between the 2 groups (P = 0.1640). At 6 h, the median postoperative pain was higher in the PVB group compared to the PV-SAPB group (3 [0; 4] vs 2 [0; 3], P = 0.0231). There were no differences between the 2 groups for pain at 24 h and morphine-related complications., Conclusions: We did not find any difference in morphine consumption between the 2 groups. Our results suggest that the combination of PVB and SAPB for video-assisted thoracic surgery or robot-assisted thoracic surgery is safe effective and reliable and could be an alternative to PVB alone in certain indications., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background and Objective: Respiratory muscle activity is increased in patients with chronic respiratory disease. 18 F-FDG-PET/CT can assess respiratory muscle activity. We hypothesized that respiratory muscles metabolism was correlated to lung function impairment and was associated to prognosis in patients undergoing lung cancer surgery based on the research question whether respiratory muscle metabolism quantitatively correlates with the severity of lung function impairment in patients? Does respiratory muscle hypermetabolism have prognostic value?, Methods: Patients undergoing 18 F-FDG-PET/CT and pulmonary function tests prior to lung cancer surgery were identified. Maximum Standardized Uptake Value (SUVm) were measured in each respiratory muscle group (sternocleidomastoid, scalene, intercostal, diaphragm), normalized against deltoid SUVm. Respiratory muscle hypermetabolism was defined as SUVm >90th centile in any respiratory muscle group. Clinical outcomes were collected from a prospective cohort., Results: One hundred fifty-six patients were included, mostly male [110 (71%)], 53 (34%) with previous diagnosis of COPD. Respiratory muscle SUVm were: scalene: 1.84 [1.51-2.25], sternocleidomastoid 1.64 [1.34-1.95], intercostal 1.01 [0.84-1.16], diaphragm 1.79 [1.41-2.27]. Tracer uptake was inversely correlated to FEV1 for the scalene (r = -0.29, p < 0.001) and SCM (r = -0.17, p = 0.03) respiratory muscle groups and positively correlated to TLC for the scalene (r = 0.17, p = 0.04). Respiratory muscle hypermetabolism was found in 45 patients (28.8%), who had a lower VO 2 max (15.4 [14.2-17.5] vs. 17.2 mL/kg/min [15.2-21.1], p = 0.07) and poorer overall survival when adjusting to FEV1% (p < 0.01)., Conclusion: Our findings show respiratory muscle hypermetabolism is associated with lung function impairment and has prognostic significance. 18 F-FDG/PET-CT should be considered as a tool for assessing respiratory muscle activity and to identify high-risk patients., (© 2023 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.)

Introduction: The prevention of respiratory complications is a major issue after thoracic surgery for lung cancer, and requires adequate post-operative pain management. The erector spinae plane block (ESPB) may decrease post-operative pain. The objective of this study was to evaluate the impact of ESPB on pain after video or robot-assisted thoracic surgery (VATS or RATS)., Methods: The main outcome of this retrospective study with a propensity score analysis (PSA) was to compare the post-operative pain at 24 h at rest and at cough between a group that received ESPB and a group that received paravertebral block (PVB). Post-operative morphine consumption at 24 h and complications were also assessed., Results: One hundred and seven patients were included: 54 in the ESPB group and 53 in the PVB group. The post-operative median pain score at rest and cough was lower in the ESPB group compared to the PVB group at 24 h (respectively, at rest 2 [1; 3.5] vs. 2 [0; 4], p = 0.0181, with PSA; ESPB -0.80 [-1.50; -0.10], p = 0.0255, and at cough (4 [3; 6] vs. 5 [4; 6], p = 0.0261, with PSA; ESPB -1.48 [-2.65; -0.31], p = 0.0135). There were no differences between groups concerning post-operative morphine consumption at 24 h and respiratory complications., Conclusions: Our results suggest that ESPB is associated with less post-operative pain at 24 h than PVB after VATS or RATS for lung cancer. Furthermore, ESPB is an acceptable and safe alternative compared to PVB.

Introduction: We aimed to compare postoperative outcomes after pulmonary resection for lung cancer after open thoracotomy (OT), video-assisted (VATS), and robotic-assisted (RA) thoracic surgery using a propensity score analysis., Methods: From 2010 to 2020, 38,423 patients underwent resection for lung cancer. In total, 58.05% (n = 22,306) were operated by thoracotomy, 35.35% (n = 13,581) by VATS, and 6.6% (n = 2536) by RA. A propensity score was used to create balanced groups with weighting. End points were in-hospital mortality, postoperative complications, and length of hospital stay, reported by odds ratios (ORs) and 95% confidence intervals (CIs)., Results: VATS decreased in-hospital mortality compared with OT (OR, 0.64; 95% CI, 0.58-0.79; P  < .0001) but not compared with RA (OR, 1.09; 95% CI, 0.77-1.52; P  = .61). VATS reduced major postoperative complications compared with OT (OR, 0.83; 95% CI, 0.76-0.92; P  < .0001) but not RA (OR, 1.01; 95% CI, 0.84-1.21; P  = .17). VATS reduced prolonged air leaks rate compared with OT (OR, 0.9; 95% CI, 0.84-0.98; P  = .015) but not RA (OR, 1.02; 95% CI, 0.88-1.18; P  = .77). As compared with OT, VATS and RA decreased the incidence of atelectasis (respectively: OR, 0.57; 95% CI, 0.50-0.65; P  < .0001 and OR, 0.75; 95% CI, 0.60-0.95; P  = .016); the incidence of pneumonia (OR, 0.75; 95% CI, 0.67-0.83; P  < .0001 and OR, 0.62; 95% CI, 0.50-0.78; P  < .0001); and the number of postoperative arrhythmias (OR, 0.69; 95% CI, 0.61-0.78; P  < .0001 and OR, 0.75; 95% CI, 0.59-0.96; P  = .024). Both VATS and RA resulted in shorter hospital stays (-1.91 days [-2.24; -1.58]; P  < .0001 and -2.73 days [-3.1; -2.36]; P  < .0001, respectively)., Conclusions: RA appeared to decrease postoperative pulmonary complications as well as VATS compared with OT. VATS decreased postoperative mortality as compared with RA and OT., (© 2023 The Author(s).)

Background: Oxygen uptake (V̇O2) and heart rate (HR) kinetics during a constant work-rate test (CWRT) are used to evaluate the response to exercise in healthy subjects as well as subjects with various pathologies., Objectives: This study aimed to explore the feasibility of these measures and their responsiveness to a prehabilitation program in patients with non-small cell lung cancer (NSCLC)., Method: This study is preregistered (NCT04041297) ancillary analysis of a subgroup of individuals with NSCLC included in the Preo-Dens study (NCT03936764). Thirty individuals performed a moderate-CWRT before and after a 15-session prehabilitation program between July 2019 and April 2021. V̇O2 and HR on-kinetics were extracted from the first 240 s of breath-by-breath data using Box-Jenkins transfer functions., Results: Pre/post V̇O2 on-kinetic feature values were reliable for 25/30 participants, and pre/post HR kinetic feature values were reliable for 19/30. V̇O2 time constant (τ) and mean response time reduced from pre-post prehabilitation (mean difference -7.8 s; 95% CI: -14.6 to -1.0, and -8.4 s; 95% CI: -14.7 to -2.0, respectively). For HR on-kinetics, τ did not change from pre-post prehabilitation (median difference -4.0 s; 95% CI: -36.0 to +11.0). V̇O2 and HR response amplitudes reduced significatively from pre-post prehabilitation (mean difference -38.6 mL/min; 95% CI: -73.3 to -3.9, and -3.1 beats/min; 95% CI: -6.4 to -0.2, respectively)., Conclusion: V̇O2 on-kinetic analysis during moderate-CWRT is feasible in individuals with scheduled NSCLC resection, and results are responsive to prehabilitation. These results support a true speeding of the adaptation of aerobic metabolism after a 15-session prehabilitation program., (© 2023 S. Karger AG, Basel.)

Background: Minimally invasive lung resections can be particularly challenging in obese patients. We hypothesized robotic surgery (RTS) is associated with less conversion to thoracotomy than video-assisted thoracoscopic surgery (VATS) in obese populations., Methods: The Society of Thoracic Surgeons General Thoracic Surgery Database, Epithor French National Database, and McMaster University Thoracic Surgical Database were queried for obese (body mass index ≥30 kg/m 2 ) patients who underwent VATS or RTS lobectomy or segmentectomy for clinical T1-2, N0-1 non-small cell lung cancer between 2015 and 2019. Propensity score adjusted logistic regression analysis was used to compare the rate of conversion to thoracotomy between the VATS and RTS cohorts., Results: Overall, 8108 patients (The Society of Thoracic Surgeons General Thoracic Surgery Database: n = 7473; Epithor: n = 572; McMaster: n = 63) met inclusion criteria with a mean (SD) age of 66.6 (9) years and body mass index of 34.7 (4.5) kg/m 2 . After propensity score adjusted multivariable analysis, patients who underwent VATS were >5-times more likely to experience conversion to thoracotomy than those who underwent RTS (odds ratio, 5.33; 95% CI, 4.14-6.81; P < .001). There was a linear association between the degree of obesity and odds ratio of VATS conversion to thoracotomy compared with RTS. VATS patients had a longer mean length of stay (5.0 vs 4.3 days, P < .001), higher rate of respiratory failure (2.8% [168 of 5975] vs 1.8% [39 of 2133], P = .026), and were less likely to be discharged to their home (92.5% [5525 of 5975] vs 94.3% [2012 of 2133]; P = .013) compared with RTS patients., Conclusions: In obese patients, RTS anatomic lung resection is associated with a lower rate of conversion to thoracotomy than VATS., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The routine use of mechanical circulatory support during lung transplantation (LTx) is still controversial. The use of prophylactic human albumin (HA) or hypertonic sodium lactate (HSL) prime in mechanical circulatory support during LTx could prevent ischemia−reperfusion (IR) injuries and pulmonary endothelial dysfunction and thus prevent the development of pulmonary graft dysfunction. The objective was to investigate the impact of cardiopulmonary bypass (CPB) priming with HA and HSL compared to a CPB prime with Gelofusine (GF) on pulmonary endothelial dysfunction in a lung IR rat model. Rats were assigned to four groups: IR-CPB-GF group, IR-CPB-HA group, IR-CPB-HSL group and a sham group. The study of pulmonary vascular reactivity by wire myograph was the primary outcome. Glycocalyx degradation (syndecan-1 and heparan) was also assessed by ELISA and electron microscopy, systemic and pulmonary inflammation by ELISA (IL-1β, IL-10, and TNF-α) and immunohistochemistry. Clinical parameters were evaluated. We employed a CPB model with three different primings, permitting femoral−femoral assistance with left pulmonary hilum ischemia for IR. Pulmonary endothelium-dependent relaxation to acetylcholine was significantly decreased in the IR-CPB-GF group (11.9 ± 6.2%) compared to the IR-CPB-HA group (52.8 ± 5.2%, p < 0.0001), the IR-CPB-HSL group (57.7 ± 6.3%, p < 0.0001) and the sham group (80.8 ± 6.5%, p < 0.0001). We did not observe any difference between the groups concerning glycocalyx degradation, and systemic or tissular inflammation. The IR-CPB-HSL group needed more vascular filling and developed significantly more pulmonary edema than the IR-CPB-GF group and the IR-CPB-HA group. Using HA as a prime in CPB during Ltx could decrease pulmonary endothelial dysfunction’s IR-mediated effects. No effects of HA were found on inflammation.

Objectives: The reporting of patient safety incidents (PSIs) occurring in minimally invasive thoracic surgery (MITS) is crucial. However, previous reports focused mainly on catastrophic events whereas minor events are often underreported., Methods: All voluntary reports of MITS-related PSIs were retrospectively extracted from the French REX database for 'in-depth analysis'. From 2008 to 2019, we retrospectively analysed and graded events according to the WHO classification of PSIs: near miss events, no harm incidents and harmful incidents. Causes and corrective measures were analysed according to the human-technology-organization triad., Results: Of the 5145 cardiothoracic surgery PSIs declared, 407 were related to MITS. Among them, MITS was performed for primary lung cancer in 317 (78%) and consisted in a lobectomy in 249 (61%) patients. PSIs were: near miss events in 42 (10%) patients, no harm incidents in 81 (20%) patients and harmful incidents in 284 (70%) patients (mild: n = 163, 40%; moderate: n = 78, 19%; severe: n = 36, 9%; and deaths: n = 7, 2%). Human factors represented the most important cause of PSIs with 267/407 (65.6%) cases, including mainly vascular injuries (n = 90; 22%) and non-vascular injuries (n = 43; 11%). Pulmonary arteries were the most affected site with 57/91 cases (62%). In all, there were 7 deaths (2%), 53 patients required second surgery (13%) and 30 required additional lung resection (7%)., Conclusions: The majority of reported MITS -related PSIs were non-catastrophic. Human factors were the main cause of PSIs. Systematic reporting and analysis of these PSIs will allow surgeon and his team to avoid a large proportion of them., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Intraoperative conversion from video-assisted thoracic surgery (VATS) to thoracotomy may occur during anatomical lung resection. The objectives of the present study were to identify risk factors for intraoperative conversion and to develop a predictive score., Methods: We performed a multicentre retrospective analysis of French thoracic surgery departments that contributed data on anatomical lung resections to the Epithor database over a 10-year period (from January-2010 to December-2019). Using univariate and multivariate logistic regression analyses, we determined risk factors for intraoperative conversion and elaborated the Epithor conversion score (ECS). The ECS was then validated in a cohort of patients operated on between January- and June-2020., Results: From January-2010 to December-2019, 210,037 patients had been registered in the Epithor database. Of these, 55,030 had undergone anatomical lung resection. We excluded patients who had upfront a thoracotomy or robotic-assisted thoracoscopic surgery (n = 40,293) and those with missing data (6,794). Hence, 7943 patients with intent-to-treat VATS were assessed: 7100 with a full VATS procedure and 843 patients with intraoperative conversion to thoracotomy (conversion rate: 10.6%). Thirteen potential risk factors were identified among patients' preoperative characteristics and planned surgical procedures and were weighted accordingly to give the ECS. The score showed acceptable discriminatory power (area under the curve: 0.62 in the development cohort and 0.64 in the validation cohort) and good calibration (P = 0.23 in the development cohort and 0.30 in the validation cohort)., Conclusions: Thirteen potential preoperative risk factors were identified, enabling us to develop and validate the ECS-an easy-to-use, reproducible tool for estimating the risk of intraoperative conversion during VATS., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Reinforced staple lines are less susceptible to leaks or bleeding and may consequently reduce morbidity and complications during or after surgery. However, their safety and benefits as well as the best form of reinforcement are still under debate. This study evaluates the safety of a stapler with pre-attached buttressing material based on adverse events (AEs) in thoracic surgery., Methods: A multi-center prospective study was conducted to assess the use of stapler reloads with pre-attached staple line reinforcement material in thoracic surgery. The primary endpoint was the rate of device-related AEs reported within 30 days of lung cancer thoracic surgery. AEs, bleeding ≥50 mL, leaks, and 30-day readmissions were reported as additional outcomes., Results: A total of 40 patients underwent lobectomy (n=22), wedge resection (n=10), or other thoracic surgery (n=8). Access was open (n=9) or by video-assisted thoracoscopic surgery (VATS, n=31). One patient was lost to follow-up. Intraoperatively, there were no cases of bleeding ≥50 mL requiring staple line intervention, and three cases (8%) experienced minor leaks that were treated conservatively. Bleeding unrelated to the staple line occurred in 20 patients intraoperatively (50%) and 21 patients postoperatively (54%). Three patients were readmitted (8%) for procedure-related causes and deemed unrelated to the investigational device. Of the AEs reported, one device-related event occurred intraoperatively, associated with minor bleeding. The other 33 AEs were related to infection (15%), bleeding (12%), or leak (9%). There were no deaths during the follow-up period., Conclusions: This study demonstrates that AEs related to the use of reinforced reloads and occurring during or within 30 days of lung cancer surgery pose minimal safety concerns., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-220/coif). All authors (or their institutions) received study sponsorship, support for data analysis, medical writing support, and research support provided by Covidien (now owned by Medtronic PLC; Mansfield, MA). EL reports grants from AstraZeneca, grants from Boehringer Ingelheim, grants and personal fees from Medela, grants from Lily Oncology, personal fees from Beigene, personal fees from Roche, personal fees from BMS, outside the submitted work; In addition, EL has a patent P52435GB pending to Imperial Innovations, and a patent P57988GB pending to Imperial Innovations and is the founder of My Cancer Companion, a mobile phone application with the aims of improving health, wellbeing and length of life with cancer. JMB reports other from Medtronic, other from Intuitive Surgery, outside the submitted work. The authors have no other conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

Background: Adequate postoperative morphine consumption and pain management after thoracic surgery are major issues in the prevention of respiratory complications. Opioid-free anesthesia (OFA) may decrease morphine consumption and postoperative pain. The objective of this study was to evaluate the impact of OFA on the consumption of morphine and pain after video-assisted thoracic surgery or robotic-assisted thoracic surgery., Methods: The main objective of this retrospective study with propensity score analysis (PSA) was to compare the cumulative postoperative morphine consumption at 48 hours between an OFA group receiving dexmedetomidine, lidocaine, and ketamine; and an opioid anesthesia (OA) group receiving remifentanil plus morphine. Postoperative pain at 24 and 48 hours and respiratory and hemodynamics complications were also assessed., Results: Eighty-one patients were included, 48 in the OFA group and 33 in the OA group. The cumulative postoperative morphine consumption at 48 hours was lower in the OFA group than in the OA group (28.5 mg [0 to 62.25 mg] vs 55 mg [34 to 79.5 mg], P = .002, with PSA; OFA -27.67 mg [-46 mg to -11.5 mg], P = .002). The postoperative pain score was significantly lower in the OFA group compared with the OA group at 24 hours (2 [0 to 4] vs 3 [2 to 5], P = .064, with PSA; OFA -1.40 [-2.47 to -0.33], P = .0088) and 48 hours (0 [0 to 3] vs 2.5 [0 to 5], P = .034, with PSA; OFA -1.87 [-3.45 to -0.28], P = .021). There were no differences between groups concerning respiratory or hemodynamic complications., Conclusions: Our results suggest that OFA after video-assisted thoracic surgery or robotic-assisted thoracic surgery is safe and is associated with less postoperative morphine cumulative consumption and pain at 48 hours., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

In the era of increasing availability of high-resolution chest computed tomography, the diagnosis and management of solitary pulmonary nodules (SPNs) has become a common challenging clinical problem. Meanwhile, surgical techniques have improved, and minimally invasive approaches such as robot- and video-assisted surgery are becoming standard, rendering the palpation of such lesions more difficult, not to mention pure ground-glass opacities, which cannot be felt even in open surgery. In this article, we explore the role of bronchoscopy in helping surgeons achieve successful minimally invasive resections in such cases.

Objectives: Our goal was to report our midterm results using imaging-assisted modalities with robotic segmentectomies for non-small-cell lung cancer (NSCLC)., Methods: This was a retrospective study of all robotic segmentectomies, with confirmed NSCLC, performed at our general and thoracic surgery unit in the Rouen University Hospital (France), from January 2012 through December 2019. Benign and metastatic lesions were excluded. Data were extracted from the EPITHOR French nationwide database., Results: A total of 121 robotic segmentectomies were performed for 118 patients with a median age of 65 (interquartile range: 60, 69) years. The majority had clinical stage T1aN0M0 (71.9%) or T1bN0M0 (13.2%). The mean (standard deviation) number of resected segments was 1.93 (1.09) with 80.2% imaging-assisted segmentectomies. Oriented (according to tumour location) or systematic lymphadenectomy or sampling was performed for 72.7%, 23.1% and 4.1% of patients. The postoperative course was uneventful for 94 patients (77.7%), whereas 34 complications occurred for 27 patients (22.3%), including 2 patients (1.7%) with Clavien-Dindo ≥III complications. The mean thoracic drainage duration was 4.12 days, and the median hospital stay was 4 days (interquartile range: 3, 5) after the operation. The 2-year survival rate was 93.9% (95% confidence interval: 86.4-97.8%). Excluding stage IV (n = 3) and stage 0 tumours (n = 6), the 2-year survival rate was 95.7% (95% confidence interval: 88.4-98.8%) compared to an expected survival rate of 94.0% according to stage-specific survival rates found in a large external reference cohort., Conclusions: Imaging-guided robotic-assisted thoracic surgery segmentectomy seems to be useful and oncological with good midterm results, especially for patients with early-stage NSCLC., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Nowadays, video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are known to be safe and efficient surgical procedures to treat early-stage non-small cell lung cancer (NSCLC). We assessed whether RATS increased disease-free survival (DFS) compared with VATS for lobectomy and segmentectomy., Methods: This retrospective cohort study included patients treated for resectable NSCLC performed by RATS or VATS, in our tertiary care center from 2012 to 2019. Patients' data were prospectively recorded and reviewed in the French EPITHOR database. Primary outcomes were 5-year DFS for lobectomy and 3-year DFS for segmentectomy, compared by propensity-score adjusted difference of Kaplan-Meier estimates., Results: Among 844 lung resections, 436 VATS and 234 RATS lobectomies and 46 VATS and 128 RATS segmentectomies were performed. For lobectomy, the adjusted 5-year DFS was 60.9% (95% confidence interval (CI) 52.9-68.8%) for VATS and 52.7% (95%CI 41.7-63.7%) for RATS, with a difference estimated at -8.3% (-22.2-+4.9%, p = 0.24). For segmentectomy, the adjusted 3-year DFS was 84.6% (95%CI 69.8-99.0%) for VATS and 72.9% (95%CI 50.6-92.4%) for RATS, with a difference estimated at -11.7% (-38.7-+7.8%, p = 0.21)., Conclusions: RATS failed to show its superiority over VATS for resectable NSCLC.

Introduction: Exercise training before lung resection for non-small cell lung cancer is believed to decrease postoperative complications (POC) by improving cardiorespiratory fitness. However, this intervention lacks a strong evidence base., Aim: To assess the effectiveness of preoperative exercise training compared with usual care on POC and other secondary outcomes in patients with scheduled lung resection., Methods: A systematic search of randomised trials was conducted by two authors. Meta-analysis was performed, and the effect of exercise training was estimated by risk ratios (RR) and mean differences, with their CIs. Clinical usefulness was estimated according to minimal important difference values (MID)., Results: Fourteen studies involving 791 participants were included. Compared with usual care, exercise training reduced overall POC (10 studies, 617 participants, RR 0.58, 95% CI 0.45 to 0.75) and clinically relevant POC (4 studies, 302 participants, Clavien-Dindo score ≥2 RR 0.42, 95% CI 0.25 to 0.69). The estimate of the effect of exercise training on mortality was very imprecise (6 studies, 456 participants, RR 0.66, 95% CI 0.20 to 2.22). The main risks of bias were a lack of participant blinding and selective reporting. Exercise training appeared to improve exercise capacity, pulmonary function and also quality of life and depression, although the clinical usefulness of the changes was unclear. The quality of the evidence was graded for each outcome., Conclusion: Preoperative exercise training leads to a worthwhile reduction in postoperative complications. These estimates were both accurate and large enough to make recommendations for clinical practice., Competing Interests: Competing interests: TB declares receiving grants from Fisher and Paykel and from KerNel Biomedical, both unrelated to this study., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Questions: How well do the 6-minute stepper test (6MST) and sit-to-stand test (STST) predict complications after minimally invasive lung cancer resection? Do the 6MST and STST provide supplementary information on the risk of postoperative complications in addition to the prognostic variables that are currently used, such as age and the American Society of Anesthesiology (ASA) score?, Design: Prospective inception cohort study with follow-up for 90 days., Participants: Consecutive sample of adults undergoing major lung resection with video-assisted thoracic surgery (VATS) or robot-assisted thoracic surgery (RATS)., Outcome Measures: Patients had a preoperative functional evaluation with the 6MST and STST. The number of steps, heart rate change, saturation and dyspnoea during the 6MST and the number of lifts during the STST were recorded. Complications graded ≥ 2 on the Clavien-Dindo classification were recorded for 90 days after surgery., Results: Between November 2018 and November 2019, 118 patients with a mean age of 65 years (SD 9) were included and analysed. Their surgeries were via VATS in 88 (75%) and via RATS in 30 (25%). For predicting a postoperative complication graded ≥ 2 on the Clavien-Dindo classification, the area under the Receiver Operating Characteristic curve was: 0.82 (95% CI 0.75 to 0.90) for the number of steps during the 6MST, with an optimum cut-off of 140 steps; and 0.85 (95% CI 0.77 to 0.93) for the number of lifts during the STST, with an optimum cut-off of 20 lifts., Conclusion: The 6MST and STST predicted morbidity and mortality after lung cancer resection via minimally invasive surgery. The preoperative use of these exercise tests in clinical practice may be useful for risk stratification., Registration: NCT03824977., (Copyright © 2022 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Mainly constituted of glycosaminoglycans and proteoglycans, the glycocalyx is anchored in the plasma membrane, covering, in particular, the extracellular face of the arterial endothelium. Due to its complex three-dimensional (3D) architecture, the glycocalyx interacts with a wide variety of proteins, contributing to vascular permeability, the flow of mechanotransduction, and the modulation of local inflammatory processes. Alterations of glycocalyx structure mediate the endothelial dysfunction and contribute to the aggravation of peripheral vascular diseases. Therefore, the exploration of its ultrastructure becomes a priority to evaluate the degree of injury under physiopathological conditions and to assess the impact of therapeutic approaches. The objective of this study was to develop innovative approaches in electron microscopy to visualize the glycocalyx at the subcellular scale. Intravenous perfusion on rats with a fixing solution containing aldehyde fixatives enriched with lanthanum ions was performed to prepare arterial samples. The addition of lanthanum nitrate in the fixing solution allowed the enhancement of the staining of the glycocalyx for transmission electron microscopy (TEM) and to detect elastic and inelastic scattered electrons, providing complementary qualitative information. The strength of scanning electron microscopy (SEM) was used on resin-embedded serial sections, allowing rapid and efficient large field imaging and previous correlative TEM observations for ultrastructural fine details. To demonstrate the dynamic feature of the glycocalyx, 3D tomography was provided by dual-beam focus-ion-beam-SEM (FIB-SEM). These approaches allowed us to visualize and characterize the ultrastructure of the pulmonary artery glycocalyx under physiological conditions and in a rat pulmonary ischemia-reperfusion model, known to induce endothelial dysfunction. This study demonstrates the feasibility of combined SEM, TEM, and FIB-SEM tomography approaches on the same sample as the multiscale visualization and the identification of structural indicators of arterial endothelial glycocalyx integrity., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Chevalier, Selim, Castro, Cuvilly, Baste, Richard, Pareige and Bellien.)

Background: Retrospective data demonstrates that robotic-assisted thoracoscopic surgery provides many benefits, such as decreased postoperative pain, lower mortality, shorter length of stay, shorter chest tube duration, and reductions in the incidence of common postoperative pulmonary complications, when compared to video-assisted thoracoscopic surgery. Despite the potential benefits of robotic surgery, there are two major barriers against its widespread adoption in thoracic surgery: lack of high-quality prospective data, and the perceived higher cost of it. Therefore, in the face of these barriers, a prospective randomized controlled trial comparing robotic- to video-assisted thoracoscopic surgery is needed. The RAVAL trial is a two-phase, international, multi-centered, blinded, parallel, randomized controlled trial that is comparing robotic- to video-assisted lobectomy for early-stage non-small cell lung cancer that has been enrolling patients since 2016., Methods: The RAVAL trial will be conducted in two phases: Phase A will enroll 186 early-stage non-small cell lung cancer patients who are candidates for minimally invasive pulmonary lobectomy; while Phase B will continue to recruit until 592 patients are enrolled. After consent, participants will be randomized in a 1:1 ratio to either robotic- or video-assisted lobectomy, and blinded to the type of surgery they are allocated to. Health-related quality of life questionnaires will be administered at baseline, postoperative day 1, weeks 3, 7, 12, months 6, 12, 18, 24, and years 3, 4, 5. The primary objective of the RAVAL trial is to determine the difference in patient-reported health-related quality of life outcomes between the robotic- and video-assisted lobectomy groups at 12 weeks. Secondary objectives include determining the differences in cost-effectiveness, and in the 5-year survival data between the two arms. The results of the primary objective will be reported once Phase A has completed accrual and the 12-month follow-ups are completed. The results of the secondary objectives will be reported once Phase B has completed accrual and the 5-year follow-ups are completed., Discussion: If successfully completed, the RAVAL Trial will have studied patient-reported outcomes, cost-effectiveness, and survival of robotic- versus video-assisted lobectomy in a prospective, randomized, blinded fashion in an international setting., Trial Registration: ClinicalTrials.gov, NCT02617186. Registered 22-September-2015. https://clinicaltrials.gov/ct2/show/NCT02617186., Competing Interests: The authors have declared that no competing interests exist.

Question: In people with non-small cell lung cancer, what is the effect of condensing 15 prehabilitation sessions into a 3-week regimen compared with a 5-week regimen?, Design: Randomised controlled trial with concealed allocation, intention-to-treat analysis and blinded assessment of the primary outcome., Participants: People with diagnosed or suspected non-small cell lung cancer and moderate-to-high risk of postoperative complications., Intervention: Fifteen supervised prehabilitation sessions delivered with either a dense regimen of five sessions/week for 3 weeks (experimental group) or a non-dense regimen of three sessions/week for 5 weeks (control group)., Outcome Measures: The primary outcome was the change in cardiorespiratory fitness measured by the V̇O 2peak in ml/kg/min. The secondary outcomes were the change in other variables of interest measured during cardiopulmonary exercise testing, non-invasive nutritional markers, quadriceps maximal voluntary isometric contractions, maximal inspiratory pressure, quality of life, adherence and postoperative complications., Results: Changes with the experimental regimen were similar to or better than changes with the control regimen for: V̇O 2peak (MD 1.2 ml/kg/min, 95% CI -0.1 to 2.6); V̇E/V̇CO 2 slope (MD -3.6 points, 95% CI -8.7 to 1.5); and work rate at ventilatory threshold (MD 3.7 W, 95% CI -5.6 to 13.0). The two regimens had similar effects on: peak work rate (MD 1.3 W, 95% CI -6.4 to 9.0), V̇O 2 at ventilatory threshold (MD 0.0 ml/kg/min, 95% CI -1.4 to 1.4); body mass index (MD -0.2 kg/m 2 , 95% CI -0.5 to 0.1); and maximal inspiratory pressure (MD -0.7 cmH 2 O, 95% CI -9.8 to 8.4). The relative effect was uncertain for quadriceps maximal voluntary isometric contractions, quality of life and complications., Conclusion: Condensing prehabilitation sessions led to similar or better improvement in cardiorespiratory fitness and did not decrease adherence or increase adverse events. This could increase the number of patients who can be referred for prehabilitation, despite short presurgical periods., Trial Registration: NCT03936764., (Copyright © 2021 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Background: Immune checkpoint inhibitors (ICIs) are the standard of care for non-resectable non-small-cell lung cancer and are under investigation for resectable disease. Some authors have reported difficulties during lung surgery following ICI treatment. This retrospective study investigated the perioperative outcomes of lung resection in patients with preoperative ICI., Methods: Patients with major lung resection after receiving ICIs were included as cases and were compared to patients who received preoperative chemotherapy without ICI. Surgical, clinical, and imaging data were collected., Results: A total of 25 patients were included in the ICI group, and 34 were included in the control group. The ICI patients received five (2-18) infusions of ICI (80% with pembrolizumab). Indications for surgery varied widely across groups ( p < 0.01). Major pathological response was achieved in 44% of ICI patients and 23.5% of the control group ( p = 0.049). Surgery reports showed a higher rate of tissue fibrosis/inflammation in the ICI group ( p < 0.01), mostly in centrally located tumours (7/13, 53.8% vs. 3/11, 27.3% of distal tumours, p = 0.24), with no difference in operating time ( p = 0.81) nor more conversions ( p = 0.46) or perioperative complications ( p = 0.94). There was no 90-day mortality. Disease-free survival was higher in the ICI group (HR = 0.30 (0.13-0.71), p = 0.02)., Conclusions: This study further supports the safety and feasibility of lung resection in patients following preoperative treatment with ICI.

Hypoxic areas are typically resistant to treatment. However, the fluorine-18-fluoroazomycin-arabinoside (FAZA) and fluorine 18 misonidazole (FMISO) tracers have never been compared in non small cell lung cancer (NSCLC). This study compares the capability of 18F-FAZA PET/CT with that of 18F-FMISO PET/CT for detecting hypoxic tumour regions in early and locally advanced NSCLC patients. We prospectively evaluated patients who underwent preoperative PET scans before surgery for localised NSCLC (i.e., fluorodeoxyglucose (FDG)-PET, FMISO-PET, and FAZA-PET). The PET data of the three tracers were compared with each other and then compared to immunohistochemical analysis (GLUT-1, CAIX, LDH-5, and HIF1-Alpha) after tumour resection. Overall, 19 patients with a mean age of 68.2 ± 8 years were included. There were 18 lesions with significant uptake (i.e., SUVmax >1.4) for the F-MISO and 17 for FAZA. The mean SUVmax was 3 (±1.4) with a mean volume of 25.8 cc (±25.8) for FMISO and 2.2 (±0.7) with a mean volume of 13.06 cc (±13.76) for FAZA. The SUVmax of F-MISO was greater than that of FAZA ( p = 0.0003). The SUVmax of F-MISO shows a good correlation with that of FAZA at 0.86 (0.66-0.94). Immunohistochemical results are not correlated to hypoxia PET regardless of the staining. The two tracers show a good correlation with hypoxia, with FMISO being superior to FAZA. FMISO, therefore, remains the reference tracer for defining hypoxic volumes.

Imaging findings after thoracic surgery can be misleading. Knowledge of the normal post-operative anatomy helps the radiologist to recognise life-threatening complications and conversely not to wrongly evoke a complication in cases of trivial post-operative abnormalities. In this educational article, we reviewed the expected patterns after thoracic surgery including sublobar resection, lobectomy, pneumonectomy and related techniques. Imaging aspects of frequent and less common complications and their typical imaging features are then presented., (© 2021. The Author(s).)

Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form, available at: http://dx.doi.org/10.21037/jtd-2020-epts-03. The series “European Perspectives in Thoracic Surgery (2020) - the Seven Edition” was commissioned by the editorial office without any funding or sponsorship. JMB reports personal fees from Intuitive Surgery, personal fees from Johnson and Johnson, personal fees from Medtronic, during the conduct of the study. ALS reports other from Medtronic, outside the submitted work. CP reports personal fees from covidien, during the conduct of the study. The other authors have no other conflicts of interest to declare.

Non-small cell lung cancers (NSCLC) are different today, due to the increased use of screening programs and of innovative systemic therapies, leading to the diagnosis of earlier and pre-invasive tumors, and of more advanced and controlled metastatic tumors. Surgery for NSCLC remains the cornerstone treatment when it can be performed. The role of surgery and surgeons has also evolved because surgeons not only perform the initial curative lung cancer resection but they also accompany and follow-up patients from pre-operative rehabilitation, to treatment for recurrences. Surgery is personalized, according to cancer characteristics, including cancer extensions, from pre-invasive and local tumors to locally advanced, metastatic disease, or residual disease after medical treatment, anticipating recurrences, and patients' characteristics. Surgical management is constantly evolving to offer the best oncologic resection adapted to each NSCLC stage. Today, NSCLC can be considered as a chronic disease and surgery is a valuable tool for the diagnosis and treatment of recurrences, and in palliative conditions to relieve dyspnea and improve patients' comfort.

Background: Anatomical segmentectomy is an alternative to lobectomy for early-stage lung cancer (LC) or in patients at high risk. The main objective of this study was to compare the morbidity and mortality associated with these two types of pulmonary resection using data from the French National Epithor database., Methods: All patients who underwent lobectomy or segmentectomy for early-stage LC from January 1 st 2014 to December 31 st 2016 were identified in the Epithor database. The primary endpoint was morbidity; the secondary endpoint was postoperative mortality. Propensity score matching was implemented and used to balance groups. The results were reported as odds ratios (OR) and 95% confidence intervals (CI)., Results: During the study period, 1,604 segmentectomies (9.78%) and 14,786 lobectomies (90.22%) were performed. After matching, the segmentectomy group experienced significantly less atelectasis (OR 0.54; 95% CI: 0.4-0.75, P<0.0001), pneumonia (OR 0.72; 95% CI: 0.55-0.95, P=0.02), prolonged air leaks (OR 0.75; 95% CI: 0.64-0.89, P=0.001) or bronchopleural fistula (OR 0.35; 95% CI: 0.14-0.83, P=0.017), and fewer patients had at least one complication (OR 0.7; 95% CI: 0.62-0.78, P<0.0001). According to the Clavien-Dindo classification, postoperative complications were significantly less severe in the segmentectomy group (OR 0.52; 95% CI: 0.37-0.74, P<0.0001). There was no significant difference in postoperative mortality at 30 days (OR 0.67; 95% CI: 0.38-1.20, P=0.18), 60 days (OR 0.78; 95% CI: 0.42-1.47, P=0.4), or 90 days (OR 0.77; 95% CI: 0.45-1.34, P=0.36)., Conclusions: Anatomical segmentectomy is an alternative surgical approach that could reduce postoperative morbidity, but it does not appear to affect mortality., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-20-2203). JMB reports personal fees from INTUITIVE SURGICAL, outside the submitted work. PBP reports personal fees from INTUITIVE SURGICAL, personal fees from MEDTRONIC, outside the submitted work. The other authors have no conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

Objectives: Endothelial dysfunction during ischaemia-reperfusion (IR) is a major cause of primary graft dysfunction during lung transplantation. The routine use of cardiopulmonary bypass (CPB) during lung transplantation remains controversial. However, the contribution of CPB to pulmonary endothelial dysfunction remains unclear. The objective was to investigate the impact of CPB on endothelial dysfunction in a lung IR rat model., Methods: Rats were allocated to 4 groups: (i) Sham, (ii) IR, (iii) CPB and (iv) IR-CPB. The primary outcome was the study of pulmonary vascular reactivity by wire myograph. We also assessed glycocalyx degradation by enzyme-linked immunosorbent assay and electron microscopy and both systemic and pulmonary inflammation by enzyme-linked immunosorbent assay and immunohistochemistry. Rats were exposed to 45 min of CPB and IR. We used a CPB model allowing femoro-femoral support with left pulmonary hilum ischaemia for IR., Results: Pulmonary endothelium-dependent relaxation to acetylcholine was markedly reduced in the IR-CPB group (10.7 ± 9.1%) compared to the IR group (50.5 ± 5.2%, P < 0.001), the CPB group (54.1 ± 4.7%, P < 0.001) and the sham group (80.8 ± 6.7%, P < 0.001), suggesting that the association of pulmonary IR and CPB increases endothelial dysfunction. In IR-CPB, IR and CPB groups, vasorelaxation was completely abolished when inhibiting nitric oxide synthase, suggesting that this relaxation process was mainly mediated by nitric oxide. We observed higher syndecan-1 plasma levels in the IR-CPB group in comparison with the other groups, reflecting an increased degradation of glycocalyx. We also observed higher systemic inflammation in the IR-CPB group as shown by the increased plasma levels of IL-1β, IL-10., Conclusions: CPB significantly increased the IR-mediated effects on pulmonary endothelial dysfunction. Therefore, the use of CPB during lung transplantation could be deleterious, by increasing endothelial dysfunction., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The feasibility of segmental resection for early-stage non-small cell lung cancer (NSCLC) is still controversial. This study aimed to compare survival outcomes following lobectomy and segmental resection in patients with pathological T1cN0M0 (tumor size 21-30 mm) NSCLC., Methods: Patients diagnosed between 1998 and 2016 with pathological stage IA NSCLC and with tumors measuring 21-30 mm were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. The observational outcomes were cancer-specific survival (CSS) and overall survival (OS) at 5 years. Univariate survival analysis was carried out to identify potential prognostic factors of prolonged survival. Cox proportional hazards model was used to adjust for confounding factors. Additionally, pairwise comparisons were conducted between lobectomy and segmental resection for CSS and OS, and forest plots were drawn., Results: Of the 9,580 patients analyzed, 400 patients (4.2%) underwent segmental resections. Patients with older age (P<0.001), smaller tumors (P<0.001), and left-sided tumors (P=0.002) were more likely to receive segmental resection. No difference was found in the operative mortality rates between the segmental resection group and the lobectomy group (1.0% vs . 1.2%, P=0.707). The CSS (HR, 1.429; 95% CI, 1.166-1.752; P=0.001) and OS (HR, 1.348; 95% CI, 1.176-1.544; P<0.001) in the segmental resection group were significantly worse than those in the lobectomy group. Subgroup analyses by age, year of diagnosis, sex, tumor size, histology, grade, and the number of dissected lymph nodes also confirmed that lobectomy was associated with improved CSS and OS., Conclusions: Lobectomy and thorough removal of lymph nodes should continue to be the recommended standard of care for patients with surgically resectable stage IA NSCLC with tumor size of 21-30 mm., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tlcr-20-1217). RHP reports that he received speaker fee from Medtronic. The other authors have no conflicts of interest to declare., (2021 Translational Lung Cancer Research. All rights reserved.)