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To study the impact of neoadjuvant therapies on postoperative complications and mortality among non-small-cell lung cancer (NSCLC) patients subjected to anatomic lung resection and included in the Spanish cohort of the video-assisted thoracic surgery (GE-VATS) multicenter database.The study included a total of 3085 patients from 33 centers between December 2016 and March 2018. We performed a comparative analysis of the complications and mortality in patients who received neoadjuvant therapies (n = 263) versus those who did not (n = 2822). A propensity score-matched analysis was used to adjust for potential confounders. Association between exposure in two groups and outcomes were estimated by logistic regression weighted by inverse of probability of receiving the treatment that actually received.In the unadjusted analysis, the chemotherapy (CT) and chemoradiotherapy (CRT) group presented a higher frequency of ICU readmissions, reinterventions, empyema, cardiovascular complications, a greater frequency of atrial fibrillation, and an increased need for blood product transfusions. In the adjusted group, CT and CRT patients had a higher rate of cardiovascular complications (CT p = 0.002; OR 2.29; 95% CI 1.34-3.94 and CRT p = 0.001; OR 2.90; 95% CI 1.52-5-52), arrhythmias (CT p = 0.013; OR 2.23; 95% CI 1.18-4.20 and CRT p = 0.046; OR 2.22; 95% CI 1.01-4.90) and transfussions (CT p = 0.042; OR 2.95; 95% CI 1.04-8.35 and CRT p 0.001; OR 7.74; 95% CI 3.01-19-92).Based on our series, neoadjuvant CT and CRT were associated with a higher rate of cardiovascular complications, arrhythmias and transfussions in patients with NSCLC subjected to anatomic lung resection.

BACKGROUND Lung resection represents the main curative treatment modality of non-small cell lung cancer. Patients with high-risk to develop postoperative pulmonary complications have been classified as “high-risk patients.” Characterizing this population could be important to improve their approach and rehabilitation. AIM To identify the differences between high and low-risk patients in exercise capacity and self-perceived health status after hospitalization. METHODS A longitudinal observational prospective cohort study was carried out. Patients undergoing lung resection were recruited from the “Hospital Virgen de las Nieves” (Granada) and divided into two groups according to the risk profile criteria (age ≥ 70 years, forced expiratory volume in 1 s ≤ 70% predicted, carbon monoxide diffusion capacity ≤ 70% predicted or scheduled pneumonectomy). Outcomes included were exercise capacity (Fatigue Severity Scale, Unsupported Upper-Limb Exercise, handgrip dynamometry, Five Sit-to-stand test, and quadriceps hand-held dynamometry) and patient-reported outcome (Euroqol-5 dimensions 5 Levels Visual Analogue Scale). RESULTS In total, 115 participants were included in the study and divided into three groups: high-risk, low-risk and control group. At discharge high-risk patients presented a poorer exercise capacity and a worse self-perceived health status (P < 0.05). One month after discharge patients in the high-risk group maintained these differences compared to the other groups. CONCLUSION Our results show a poorer recovery in high-risk patients at discharge and 1 mo after surgery, with lower self-perceived health status and a poorer upper and lower limb exercise capacity. These results are important in the rehabilitation field.

Resumen Introduccion El tratamiento mas adecuado en la mayoria de los pacientes con cancer de pulmon en estadio inicial es la reseccion quirurgica. A pesar de evaluar anteriormente que el estado de cada paciente sea el adecuado para detectar posibles complicaciones inherentes a la intervencion quirurgica, no se ha alcanzado ningun consenso sobre los factores que son de «alto riesgo» en esos pacientes. Nuestro estudio tuvo como objetivo analizar la morbilidad y la incidencia de mortalidad asociada con esta intervencion quirurgica en nuestro entorno con un estudio multicentrico y descubrir los parametros de riesgo. Metodos Se trata de un estudio de analisis prospectivo con 3.307 pacientes operados de carcinoma broncopulmonar en 24 hospitales. Las variables de estudio fueron edad, sistema TNM, sexo, estadio, tabaquismo, abordaje quirurgico, reseccion quirurgica, escala ECOG, tratamiento neoadyuvante, comorbilidad, valores espirometricos y morbimortalidad intra- y postoperatoria. Se realizo un analisis de regresion logistica multivariante de los factores pronosticos de morbilidad y mortalidad. Resultados Registramos el 34,2% de morbilidad postoperatoria y el 2,1% de mortalidad postoperatoria. Sexo, infarto de miocardio, angina, ECOG ≥ 1, EPOC, DLCO Conclusiones Las principales variables que deben tenerse en cuenta al evaluar a pacientes con cancer de pulmon para realizarles una intervencion quirurgica son sexo, infarto de miocardio, angina, ECOG, EPOC, DLCO, estado clinico patologico, reseccion quirurgica y abordaje quirurgico.

Introduction: The most suitable treatment in most early-stage lung cancer patients is surgical resection. Despite previously assessing each patient's status being relevant to detect possible complications inherent to surgery, no consensus has been reached on which factors are "high risk'' in such patients. Our study aimed to analyse the morbidity and the mortality incidence associated with this surgery in our setting with a multicentre study and to detect risk parameters. Methods: A prospective analysis study with 3,307 patients operated for bronchopulmonary carcinoma in 24 hospitals. Study variables were age, TNM, gender, stage, smoking habit, surgery approach, surgical resection, ECOG, neoadjuvant therapy, comorbidity, spirometric values, and intraoperative and postoperative morbidity and mortality. A multivariate logistic regression analysis of the morbidity and mortality predictor factors was done. Results: We recorded 34.2% postoperative morbidity and 2.1% postoperative mortality. Gender, myocardial infarction, angina, ECOG >= 1, COPD, DLCO

Resumen Introduccion El objetivo es obtener un modelo predictor de riesgo quirurgico en pacientes sometidos a resecciones pulmonares anatomicas a partir del registro del Grupo Espanol de Cirugia Toracica Videoasistida. Metodos Se recogen datos de 3.533 pacientes sometidos a reseccion pulmonar anatomica por cualquier diagnostico entre el 20 de diciembre de 2016 y el 20 de marzo de 2018. Definimos una variable resultado combinada: mortalidad o complicacion Clavien Dindo IV a 90 dias tras intervencion quirurgica. Se realizo analisis univariable y multivariable por regresion logistica. La validacion interna del modelo se llevo a cabo por tecnicas de remuestreo. Resultados La incidencia de la variable resultado fue del 4,29% (IC 95%: 3,6-4,9). Las variables que permanecen en el modelo logistico final fueron: edad, sexo, reseccion pulmonar oncologica previa, disnea (mMRC), neumonectomia derecha y DLCOppo. Los parametros de rendimiento del modelo, ajustados por remuestreo, fueron: C-statistic 0,712 (IC 95%: 0,648-0,750), Brier score 0,042 y Booststrap shrinkage 0,854. Conclusiones El modelo predictivo de riesgo obtenido a partir de la base de datos Grupo Espanol de Cirugia Toracica Videoasistida es un modelo sencillo, valido y fiable, y constituye una herramienta muy util a la hora de establecer el riesgo de un paciente que se va a someter a una reseccion pulmonar anatomica.

Measuring predicted post-operative diffusion capacity of the lung for carbon monoxide (ppoDLCO) is essential to determine patient operability and to stratify the risk of patients who are candidates for major lung cancer surgery. Studies that established surgical risk variables were based on open surgery series. The aim of our study was to analyze morbidity and mortality as a function of ppoDLCO and to compare its behavior in open and video-assisted thoracic surgery (VATS).We compared 90-day mortality and morbidity in patients undergoing open surgery versus VATS as a function of decline in ppoDLCO. Propensity score matching (using age, ASA, arterial vascular disease, BMI, gender, stage, ppoDLCO, and ppoFEVOf 2,530 patients with lung cancer and ppoDLCO values, a sample of 1,624 (812 per group) was obtained after score matching. The relative risk of mortality associated with thoracotomy in patients with ppoDLCO 60 is 2.66 (p 0.02) compared to VATS. The risk of thoracotomy in terms of overall and cardiac and respiratory morbidity is higher than that of VATS for almost all ppoDLCO values.Major resection by VATS shows lower morbidity and mortality in patients with the same ppoDLCO. A steady rise in the risk of mortality begins to occur at higher ppoDLCO values in thoracotomy (∼60) than in VATS (∼45).

BACKGROUND The clinical relevance of inpatient step counts after lung surgery remains unknown. OBJECTIVE The aim of this study was to identify those factors related to physical activity measured by step count, during the inpatient stay, and its relationship with symptom severity and perceived health status at hospital admission, discharge, and 1 month after discharge. METHODS We studied the inpatient step count of 73 participants who underwent lung resection surgery. The number of steps was measured using a triaxial accelerometer. The health status and the severity of symptoms were examined at hospital admission, discharge, and 1 month after discharge. RESULTS Of the 73 participants, 35 were active and 38 were sedentary during the hospitalization. The mean number of steps walked during 3 inpatient days was 6689 ± 3261 and 523 ± 2273 (P < .001) for the active and sedentary groups, respectively. The dyspnea and fatigue scores in the sedentary group across data collection points (hospital admission, discharge, and follow-up) were significantly worse (P < .01). In regard to pain, the sedentary group presented worse results, than the active group, at discharge and follow-up (P < .01). The correlation analysis indicated significant but weak correlations (r < 0.500) between inpatient steps per day and symptom severity at 1-month follow-up (T2) after surgery. CONCLUSION Inpatient step count may be a risk factor for symptom severity and perceived health status during hospitalization and within the first month after lung resection surgery. IMPLICATIONS FOR PRACTICE Nurses should consider recommending physical activity during hospitalization for patients after lung resection.

The objective of this study was to investigate the impact of a program of major video-assisted surgery on care quality in a Unit of Thoracic Surgery.A descriptive comparative study was conducted of 793 major thoracic procedures performed between 2009 and 2012. Quality indicators and hospital performance before [2009-2010] and after (2011 and 2012) the implementation of the program.The incidence of surgical complications decreased significantly from 6.32%/7.88% (2009/2010, respectively) to 1.87%/1.67% (2011/2012, respectively) [95% CI for 7.08% (4.20-9.96%); 95% CI for 1.76% (0.44-3.08%) P0.001, respectively]. The mean hospital stay was reduced from 8.5/7.8 days in 2009/2010, respectively, to 6.3/5.8 days in 2011/2012, respectively. Mortality rates were 0.57%, 0.60%, 0.93% and 0.43% in 2009, 2010, 2011, and 2012, respectively (P=0.624, 95% CI: -0.6, 0.7). The percentages of emergency readmissions in 2009/2010 were 1.16%/1.23%, respectively vs. 2.80%/0.84% in 2011/2012.The implementation of the video-assisted thoracic surgery (VATS) program in the unit of Thoracic Surgery Care resulted in a significant improvement in care quality, with a reduction of length of hospital stay, but without any changes in mortality or the percentage of readmissions at 30 post-operative days.

Introduction: Our study sought to know the current implementation of video-assisted thoracoscopic surgery (VATS) for anatomical lung resections in Spain. We present our initial results and describe the auditing systems developed by the Spanish VATS Group (GEVATS). Methods: We conducted a prospective multicentre cohort study that included patients receiving anatomical lung resections between 12/20/2016 and 03/20/2018. The main quality controls consisted of determining the recruitment rate of each centre and the accuracy of the perioperative data collected based on six key variables. The implications of a low recruitment rate were analysed for "90-day mortality" and "Grade IIIb-V complications". Results: The series was composed of 3533 cases (1917 VATS; 54.3%) across 33 departments. The centres' median recruitment rate was 99% (25-75th:76-100%), with an overall recruitment rate of 83% and a data accuracy of 98%. We were unable to demonstrate a significant association between the recruitment rate and the risk of morbidity/mortality, but a trend was found in the unadjusted analysis for those centres with recruitment rates lower than 80% (centres with 95-100% rates as reference): grade IIIb-V OR= 0.61 (p = 0.081), 90-day mortality OR = 0.46 (p = 0.051). Conclusions: More than half of the anatomical lung resections in Spain are performed via VATS. According to our results, the centre's recruitment rate and its potential implications due to selection bias, should deserve further attention by the main voluntary multicentre studies of our speciality. The high representativeness as well as the reliability of the GEVATS data constitute a fundamental point of departure for this nationwide cohort. (C) 2020 SEPAR. Published by Elsevier Espana, S.L.U. All rights reserved.

Introduction: High-risk lung resection patients present postoperative pulmonary complications, which could be associated to a reduced upper-limb (UL) exercise capacity, decreasing functional independence. Objective: To identify the differences between high and low-risk lung resection patients in UL exercise capacity at discharge and in the following month. Methods: We carried out an observational prospective cohort study, including 65 patients who underwent lung resection in the Thoracic Surgery Service of the “Hospital Virgen de las Nieves” (Granada). Patients were divided into two groups according to the risk profile criteria. Outcomes included were the UL exercise capacity, assessed by the Unsupported Upper-limb Exercise (UULEX), which included a record of the dyspnea and fatigue levels, before and after the test. Results: 29 patients were included in the low-risk group and 36 in the high-risk one. The high-risk group presented significant differences in the UULEX test for the UL fatigue pre and posttest, time and dyspnea at discharge (p Conclusions: High-risk patients present a reduced UL exercise capacity compared to the low-risk group at discharge. This difference remains in the follow-up.

Background Pulmonary parenchymal destruction is consequence of Chronic Obstructive Pulmonary Disease (COPD), which results in degradation of the extracellular matrix and the appearance of peripheral pulmonary cells. The aim of this study is to demonstrate the feasibility of the detection and isolation of Circulating Pulmonary Cells (CPCs) in peripheral blood of patients with COPD. Methods 17 COPD patients were enrolled in this prospective study to isolate CPCs. Peripheral blood samples for CPC analysis were processed using positive immunomagnetic methods combined with a double immunocytochemistry. Two antibodies, anti-cytokeratin and anti-CD44v6 were used to confirm the epithelial nature of the isolated cells and their lung origin respectively. Results CK/CD44v6 positive CPCs were identified in 6 of 17 COPD patients (35.2% of the total) (range: 1–2 cells). No CPCs were detected in any of the 10 healthy volunteers. The COPD CPCs + patients showed a trend towards greater severity of the disease. Conclusions This study suggest the feasibility to detect CPCs in peripheral blood of patients with COPD and its potential use as prognostic marker.

Mortality following surgery for lung cancer increases at 90 days. The objective of this study was to determine the rate, factors, time to death, hospital stay until discharge, time to death after discharge and causes of mortality at 90 days following surgery for lung cancer.A prospective follow-up study was performed in a cohort of 378 patients who underwent surgery for lung cancer between January 2012 and December 2016. Data on preoperative status, postoperative complications, and mortality were collected.Rates of mortality were 1.6% vs. 3.2% at 30 and 90 days, respectively. Half of deaths occurred between 31 and 90 postoperative days following discharge. The variables found to be related to mortality at 90 days were a Charlson Index3 (p 0.001), a history of stroke (p = 0.036), postoperative pneumonia (p = 0.001), postoperative pulmonary or lobar collapse (p = 0.001), reintubation (p 0.001) and postoperative arrhythmia (p = 0.0029). The risk of mortality was also observed to be associated with the type of surgical technique -being higher for thoracotomy as compared to video-assisted thoracoscopy (VATS) (p = 0.011) -, and hospital readmission after discharge (p 0.001). Adjusted odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. Multivariate analysis revealed that a Charlson Index3 (p = 0.001) OR 2.0 (1.55,2.78), a history of stroke (p = 0.018) OR 5.1 (1.81, 32.96) and postoperative pulmonary or lobar collapse (p = 0.001) OR 8.5 (2.41,30.22) were independent prognostic factors of mortality. The most common causes of death were related to respiratory (58.3%) and cardiovascular (33.2%) complications.Mortality at 90 days following surgery for lung cancer doubles 30-day mortality, which is a relevant finding of which both, patients and healthcare should be aware. Half the deaths within 90 days after surgery for lung cancer occur after discharge. Specific outpatient follow-up programs should be designed for patients at a higher risk of 90-day mortality.

BACKGROUND The purpose of this study was to assess the rate, cause, and factors associated with readmissions following pulmonary resection for lung cancer and their relationship with 90-day mortality. METHODS A prospective cohort study was conducted of 379 patients who underwent surgery for lung cancer at the university hospitals Granada, Spain between 2012 and 2016. RESULTS The rate of readmissions within 30 postoperative days was 6.2%. The most common reason for readmission was subcutaneous emphysema (21.7%), pneumonia (13%), and pleural empyema (8.5%). A higher probability of requiring urgent readmission was associated with a higher Charlson index (OR 2.0,95% confidence interval 1.50-2.67, P = 0.001); peripheral arterial vasculopathy (OR 4.8, 95%CI 1.27-18.85, P = 0.021); a history of stroke (OR 8.2, 95%CI 1.08-62.37, P = 0.04); postoperative atelectasis (OR 4.7, 95%CI 1.21-18.64, P = 0.026); and air leaks (OR 12.6, 95%CI 4.10-38.91, P = 0.001).The prediction multivariable model for readmission represents an area under the curve (ROC) of 0.90. Mortality at 90 postoperative days in the group of readmitted patients was 13% versus 1.5 for the group of patients who did not require readmission (P

Background Sloughing and gangrene of a complete lung are only very infrequently encountered complications of necrotizing pneumonia and fulminant pulmonary abscess formation. Thus far the role of emergent pneumonectomy is not established. Methods The outcome of patients who underwent anatomic lung resection for lung gangrene at 3 centers for thoracic surgery during the last 13 years was retrospectively analyzed. Only cases of necrotizing pneumonia were included whereas malignant lesions were excluded. Results Overall 44 patients were indentified (average age 56.3 years). Pulmonary sepsis (27 of 44), pleural empyema (29 of 44), persistent air leakage (14 of 44), and respiratory failure with mechanical ventilation (14 of 44) were present preoperatively. The mean Charlson comorbidity index was 2.77. Procedures were segmentectomy (7), lobectomy (26), and pneumonectomy (11). In-hospital mortality was 7 of 44; 2 following pneumonectomy and 5 after lobectomy. In comparing the pneumonectomy group with the lobectomy group we found no significant differences in age ( p = 0.59), Charlson comorbidity index ( p = 0.18), and postoperative mortality ( p = 1). Charlson comorbidity index 3 or greater (odds ratio [OR], 8.41; 95% confidence interval [CI], 0.88 to 421.71; p = 0.04), preoperative pleural empyema (OR, 3.56; 95% CI, 0.37 to 179.62; p = 0.39) and preoperative persistent air leak (OR, 7.34; 95% CI, 1.00 to 89.98; p = 0.02) were associated with higher risk for fatal outcome. Furthermore, patients with sepsis ( p = 0.03) and patients sustaining acute renal failure ( p = 0.04) had significantly higher mortality. Conclusions Pulmonary sepsis and its complications as well as preexisting comorbidity are the major reasons for fatal outcome, whereas the extent of surgical resection shows no significant influence. Emergent pneumonectomy as ultimate ratio is not only justified but also life saving. Further improvement seems achievable by earlier surgical intervention before the onset of pulmonary sepsis.

Resumen Introduccion La mediastinitis necrosante descendente (MND) consiste en una infeccion grave que aparece como complicacion de una infeccion orofaringea. Aun existe controversia a proposito del tratamiento quirurgico y si esta indicado un abordaje transtoracico rutinario. En este articulo presentamos nuestra experiencia en el tratamiento de la mediastinitis necrosante descendente y revisamos en la bibliografia las diferentes opciones de abordaje propuestas. Material y metodos Estudio observacional retrospectivo de los pacientes con mediastinitis necrosante descendente intervenidos entre 1988 y 2009. Se analizan variables demograficas, origen de la infeccion, estadio de la enfermedad segun la clasificacion de Endo, tecnica quirurgica realizada y evolucion. Resultados En dicho periodo se intervino a 29 pacientes. El tratamiento quirurgico consistio en el drenaje y desbridamiento radical a nivel cervical y mediastinico. El drenaje mediastinico se realizo por via transcervical en 10 casos y transtoracica en 19, en funcion de la extension de la mediastinitis. De ellos, 24 presentaron buena evolucion y 5 fallecieron (mortalidad 17,2%). Conclusiones De acuerdo con nuestros resultados y las conclusiones de los principales autores, se debe realizar un tratamiento quirurgico precoz y agresivo que incluya un abordaje transtoracico en casos de mediastinitis extendida.

Introduction Descending necrotizing mediastinitis (DNM) is a serious infection which occurs as a complication of oropharyngeal infection. Its surgical management and the routine transthoracic approach remain controversial. In this article we report our experience in the management of this disease, and review the different surgical approaches that have been reported in the medical literature. Materials and methods A retrospective review of the clinical records of 29 patients treated between 1988 and 2009 was made. Several demographic variables were analyzed, origin of the initial infection, stage of the disease according to Endo's classification, surgical technique and outcome. Results Surgical treatment consisted of both cervical and mediastinal drainage and radical debridement. The mediastinal drainage was made through a transcervical approach in 10 cases and transthoracic in 19, depending on the extent of the mediastinitis. The outcome was satisfactory in 24 patients and 5 died (mortality 17.2%). Conclusions According to our results and the conclusions of the main authors, we recommend a prompt and aggressive surgery with a transthoracic approach in cases of widespread DNM.

The hand and eye coordination of the surgeon is one of the most important factor minimally invasive thoracic surgery. Virtual Simulation is a powerful training tool in surgery. At present, the main problems of the learning process are to reduce the learning time and to improve specific skills by the simulation. There are different options to perform tests: working with animals, with artificial tissues to simulate the pressure, and even simulators through joystick. The main disadvantage is the high cost of this systems and the complexity to replicate the situation during a real operations. In this paper, a virtual reality system is presented. This system allows to reduce the learning time and to improve the hand and eye coodination of the surgeon. Moreover, it is a low cost, portable and easy-to-use solution for future surgeons.

Spontaneous hemomediastinum is a rare pathological event due to bleeding disorders, mediastinal organ hemorrhage or idiopathic causes. It usually presents with chest pain and dyspnea, which can lead to confusion with other clinical conditions. The election diagnostic method is computed tomography and treatment depends on underlying etiology, aimed on controlling hemorrhages, if present. In this paper, we present a case of spontaneous hemomediastinum and hemothorax after bronchial artery aneurysm dissection treated with endovascular embolization and chest drainage.

La figura 1 muestra la tomografia axial computarizada de exostosis costal solitaria en el quinto arco costal con crecimiento intratoracico, hemotorax e imagen videotoracoscopica de la lesion osea de borde incisivo antes de su reseccion. El osteocondroma o exostosis costal es el tumor oseo benigno mas frecuente a nivel toracico. Con frecuencia presenta un crecimiento intratoracico que puede causar una laceracion pulmonar y hemotorax1 tras sufrir traumatismo toracico cerrado, como el caso de la imagen clinica. La videotoracoscopia2 derecha permitio una