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To investigate factors associated with the ability to receive adjuvant chemotherapy in patients with pathological N1 and N2 stage after anatomic lung resections for non-small cell lung cancer (NSCLC). Multicenter retrospective analysis on 707 consecutive patients found pathologic N1 (pN1) or N2 (pN2) disease following anatomic lung resections for NSCLC (2014-2019). Multiple imputation logistic regression was used to identify factors associated with adjuvant chemotherapy and to develop a model to predict the probability of starting this treatment. The model was externally validated in a population of 253 patients. In the derivation set, 442 patients were pN1 and 265 pN2. 58% received at least 1 cycle of adjuvant chemotherapy. The variables significantly associated with the probability of starting chemotherapy after multivariable regression analysis were: younger age (p < 0.0001), Body Mass Index (BMI) (p = 0.031), Forced Expiratory Volume in 1 second (FEV1) (p = 0.037), better performance status (PS) (p < 0.0001), absence of chronic kidney disease (CKD) (p = 0.016), resection lesser than pneumonectomy (p = 0.010). The logit of the prediction model was: 6.58 -0.112 x age +0.039 x BMI +0.009 x FEV1 -0.650 x PS -1.388 x CKD -0.550 x pneumonectomy. The predicted rate of adjuvant chemotherapy in the validation set was 59.2 and similar to the observed 1 (59%, p = 0.87) confirming the model performance in external setting. This study identified several factors associated with the probability of initiating adjuvant chemotherapy after lung resection in node-positive patients. This information can be used during preoperative multidisciplinary meetings and patients counseling to support decision-making process regarding the timing of systemic treatment. ispartof: SEMINARS IN THORACIC AND CARDIOVASCULAR SURGERY vol:35 issue:2 pages:387-398 ispartof: location:United States status: published

OBJECTIVE: To describe our experience with lung transplantation (LTx) from donors ≥70 years and compare short- and long-term outcome to a propensity-matched cohort of donors

The technique for bronchial stump suturing following lung resection which is currently applied in the Department of Thoracic Surgery at the University Hospitals Leuven, Belgium owes its name to the Dutch surgeon Dr. Klinkenbergh (1891-1985). A true pioneer of cardiothoracic surgery in Europe, Dr. Klinkenbergh dedicated himself to the surgical treatment of pulmonary tuberculosis. His work was praised by his peers for his precision and the reasoning behind every gesture. The Klinkenbergh technique consists in performing two running sutures which cross each other 'in the same manner as the laces of a shoe' to close the bronchus, limiting the occurrence of broncho-pleural fistulas. In our experience with more than 100 patients in the last 5 years (2016-2020) who underwent open pneumonectomy for benign or malignant disease, less than 2% developed post-operative broncho-pleural fistulas. ispartof: ACTA CHIRURGICA BELGICA vol:121 issue:6 pages:449-454 ispartof: location:England status: published

Background E-learning has become an important tool in surgical education in the last decade. The European Society of Thoracic Surgeons launched its e-learning platform in 2013 and started its educational webinars series in 2018. The aim of this paper is to discuss the introduction, evolution and impact of the educational webinars within this e-learning platform. Methods Twenty-four English spoken webinars discussing different subdomains in general thoracic surgery (21 expert talks, 2 pro-con debates and 1 multidisciplinary case discussion) were analyzed. An online questionnaire on timing, quality and technical aspects of the webinars was sent to 3012 registrants. Results The webinars reached 3128 unique registrants from 76 countries worldwide. The mean number of registrants was 355 with 171 live attendees (48%) and 155 replay watchers (36%). Hundred and twenty-six attendees (13.1% of people who registered for at least 4 webinars) completed the questionnaire. Timing and duration of the webinars were rated ‘‘very good’’ to ‘‘excellent’’ in 78%, and the quality of the webinar content and the expertise of the webinar presenters were rated ‘‘very good’’ to ‘‘excellent’’ in 88% and 90%, respectively. The impact on knowledge and clinical practice was scored with a weighted average of 7.27 out of 10 and 6.79 out of 10, respectively. Conclusions The ESTS educational webinars were effective in delivering up-to-date knowledge to almost half of the countries around the globe. The impact of these events on knowledge and clinical practice were rated high. New e-learning tools should be added to the surgical educational curriculum

OBJECTIVES The purpose of this study was to evaluate the diagnosis of, clinical signs of and strategy for congenital cystic adenomatoid malformations (CCAM). METHODS In this retrospective study, patients who had thoracic surgery for CCAM lesions at the University Hospitals of Leuven from July 1993 to July 2016 were identified. Data on diagnosis, prenatal ultrasound findings, clinical signs, lesion site, CCAM type, associated anomalies, imaging, surgical approach and postoperative morbidity were reviewed. The Fisher exact and Mann–Whitney tests were used as appropriate. RESULTS A total of 55 patients were identified with CCAM. In 65% (n = 36/55), CCAM was detected on prenatal ultrasound scans. Prenatal symptoms due to hydrops or mass effect were present in 22% (n = 8/36), 6 of whom eventually needed prenatal intervention (thoracoamniotic shunting or intrauterine puncture). Elective surgery was performed in 40% of patients (n = 22/55); others developed clinical signs that indicated the need for semi-urgent surgery, with clinical signs of pulmonary infection and respiratory distress being the most common. Most patients had a single lobectomy via a minithoracotomy. Postoperative complications and length of stay were significantly higher in patients with CCAM with preoperative clinical signs. CONCLUSIONS Surgery in asymptomatic patients with CCAM can be performed safely with few postoperative complications and can be planned at a young age in patients with a high risk of developing clinical signs later in life.

Background Although most guidelines suggest performing a positron emission tomography/computed tomography (PET/CT) with somatostatin receptor (SSTR) ligands for staging of pulmonary carcinoid tumours (PC), only a limited number of studies have evaluated the role of this imaging tool in this specific patient population. The preoperative differentiation between typical carcinoid (TC) and atypical carcinoid (AC) and the extent of dissemination (N/M status) are crucial factors for treatment allocation and prognosis of these patients. Therefore, we performed a pathology-based retrospective analysis of the value of SSTR PET/CT in tumour grading and detection of nodal and metastatic involvement of PC and compared this with the previous literature and with [18F]FDG PET/CT in a subgroup of patients. Methods SSTR PET/CT scans performed between January 2007 and May 2020 in the context of PC were included. If available, [18F]FDG PET/CT images were also evaluated. The maximum standardized uptake (SUVmax) values of the primary tumour, of the pathologically examined hilar and mediastinal lymph node stations, as well as of the distant metastases, were recorded. Tumoural SUVmax values were related to the tumour type (TC versus AC) for both SSTR and [18F]FDG PET/CT in diagnosing and differentiating both tumour types. Nodal SUVmax values were compared to the pathological status (N+ versus N−) to evaluate the diagnostic accuracy of SSTR PET/CT in detecting lymph node involvement. Finally, a mixed model analysis of all pathologically proven distant metastatic lesions was performed. Results A total of 86 SSTR PET/CT scans performed in 86 patients with PC were retrospectively analysed. [18F]FDG PET/CT was available in 46 patients. Analysis of the SUVmax values in the primary tumour showed significantly higher SSTR uptake in TC compared with AC (median SUVmax 18.4 vs 3.8; p = 0.003) and significantly higher [18F]FDG uptake in AC compared to TC (median SUVmax 5.4 vs 3.5; p = 0.038). Receiver operating characteristic (ROC) curve analysis resulted in an area under the curve (AUC) of 0.78 for the detection of TC on SSTR PET/CT and of 0.73 for the detection of AC on [18F]FDG PET/CT. A total of 267 pathologically evaluated hilar and mediastinal lymph node stations were analysed. ROC analysis of paired SSTR/[18F]FDG SUVmax values for the detection of metastasis of TC in 83 lymph node stations revealed an AUC of 0.91 for SSTR PET/CT and of 0.74 for [18F]FDG PET/CT (difference 0.17; 95% confidence interval − 0.03 to 0.38; p = 0.10). In a sub-cohort of 10 patients with 12 distant lesions that were pathologically examined due to a suspicious aspect on SSTR PET/CT, a positive predictive value (PPV) of 100% was observed. Conclusion Our findings confirm the higher SSTR ligand uptake in TC compared to AC and vice versa for [18F]FDG uptake. More importantly, we found a good diagnostic performance of SSTR PET/CT for the detection of hilar and mediastinal lymph node metastases of TC. Finally, a PPV of 100% for SSTR PET/CT was found in a small sub-cohort of patients with pathologically investigated distant metastatic lesions. Taken together, SSTR PET/CT has a very high diagnostic value in the TNM assessment of pulmonary carcinoids, particularly in TC, which underscores its position in European guidelines.

Video Abstract Download : Download video (50MB) Lung transplantation from a donor previously infected with SARS-CoV-2

Primary graft dysfunction (PGD) is a major obstacle after lung transplantation (LTx), associated with increased early morbidity and mortality. Studies in liver and kidney transplantation revealed prolonged anastomosis time (AT) as an independent risk factor for impaired short- and long-term outcomes. We investigated if AT during LTx is a risk factor for PGD. In this retrospective single-center cohort study, we included all first double lung transplantations between 2008 and 2016. The association of AT with any PGD grade 3 (PGD3) within the first 72 h post-transplant was analyzed by univariable and multivariable logistic regression analysis. Data on AT and PGD was available for 427 patients of which 130 (30.2%) developed PGD3. AT was independently associated with the development of any PGD3 ≤72 h in uni- (odds ratio [OR] per 10 min 1.293, 95% confidence interval [CI 1.136-1.471], p

PURPOSE: The surgical strategy for congenital diaphragmatic hernia (CDH) repair remains debated and mainly depends on the training and preference of the surgeon. Our aim was to evaluate the occurrence and nature of surgical reinterventions within the first year of life, following repair through thoracotomy as compared to laparotomy. METHODS: This is a retrospective bi-centric cohort study comparing postero-lateral thoracotomy (n = 55) versus subcostal laparotomy (n = 62) for CDH repair (IRB: MP001882). We included neonates with isolated, left-sided, Bochdalek-type CDH who were operated on between 2000 and 2017, and had a minimum follow-up of 1 year. Excluded were patients treated prenatally and/or had extra-corporeal membrane oxygenation. Outcomes were occurrence and nature of surgical reinterventions and mortality by 1 year of life. RESULTS: Both groups had comparable neonatal severity risk profiles. The overall surgical reintervention rate by 1 year of age was higher in the thoracotomy group (29.1% vs. 6.5%; p = 0.001), mainly because of a higher prevalence of acute bowel complications (18.1% vs. 3.2%; p = 0.012) requiring surgery, such as perforation, obstruction and volvulus. At 1 year of follow-up, groups were similar in terms of recurrence (5.5% vs. 1.6%; p = 0.341), surgical interventions related to severe gastroesophageal reflux disease (3.6% vs. 1.6%; p = 0.600) and mortality (5.5% vs. 6.6%; p = 1.000). CONCLUSION: Postnatal CDH repair through thoracotomy was associated with a higher rate of surgical reinterventions within the first year of life, especially for severe acute gastro-intestinal complications. There seemed to be no difference in recurrence and mortality rate. TYPE OF STUDY: Retrospective Comparative Cohort Study. LEVEL OF EVIDENCE: Level III. ispartof: JOURNAL OF PEDIATRIC SURGERY vol:55 issue:10 pages:2105-2110 ispartof: location:United States status: published

OBJECTIVES We queried the European Society of Thoracic Surgeons (ESTS) database with the aim to assess cardiopulmonary morbidity and 30-day mortality of segmentectomies and lobectomies in patients with a Eurolung-predicted mortality above the upper interquartile and classified as high risk. METHODS A total of 61 492 patients registered in the ESTS database (2007–2018) and submitted to lobectomy (55 353) or segmentectomy (6139) were divided into high risk or low risk according to a Eurolung-predicted mortality cut-off of 2.5% (corresponding in our population to the upper interquartile). Predicted versus observed mortalities were compared within each type of operation by using binomial test of proportion. Observed morbidity and mortality rates were compared between the 2 procedures using the χ2 test. RESULTS A total of 14 007 lobectomies and 1251 segmentectomies were classified as high risk. In the high-risk group, the cardiopulmonary morbidity and 30-day mortality rates observed in segmentectomies were lower than in lobectomies (morbidity: 12% vs 17%, P CONCLUSIONS Segmentectomy was found associated with a 0.65 relative risk of mortality rate compared to lobectomy in patients deemed at higher surgical risk.

Although most guidelines suggest performing a positron emission tomography/computed tomography (PET/CT) with somatostatin receptor (SSTR) ligands for staging of pulmonary carcinoid tumours (PC), only a limited number of studies have evaluated the role of this imaging tool in this specific patient population. The preoperative differentiation between typical carcinoid (TC) and atypical carcinoid (AC) and the extent of dissemination (N/M status) are crucial factors for treatment allocation and prognosis of these patients. Therefore, we performed a pathology-based retrospective analysis of the value of SSTR PET/CT in tumour grading and detection of nodal and metastatic involvement of PC and compared this with the previous literature and with [SSTR PET/CT scans performed between January 2007 and May 2020 in the context of PC were included. If available, [A total of 86 SSTR PET/CT scans performed in 86 patients with PC were retrospectively analysed. [Our findings confirm the higher SSTR ligand uptake in TC compared to AC and vice versa for [

Organ transplantation is hampered by shortage of suitable organs. In countries with a legal framework, organ donation following euthanasia is an option labeled "donation after cardio-circulatory death category V" (DCD-V). We describe our experience with lung transplantation (LTx) after euthanasia and evaluate post-transplant outcome using a matched comparison to DCD-III (withdrawal from life-sustaining therapy) and donation after brain death (DBD).All bilateral LTx between 2007 and 2020 were retrospectively analyzed. Matching was performed for recipient age and gender, indication for LTx, mean pulmonary artery pressure, extracorporeal life support, and donor age, which resulted in 1:2 DCD-III and 1:3 DBD matching. Primary graft dysfunction (PGD), chronic lung allograft dysfunction (CLAD), and patient survival were analyzed.A total of 769 LTx were performed of which 22 from DCD-V donors (2.9%). Thirteen women and 9 men expressed their wish to become organ donor after euthanasia. Euthanasia request was granted for irremediable neuromuscular (N = 9) or psychiatric (N = 8) disorder or unbearable and unrecoverable pain (N = 5). PGD (grade 3, within 72 hours post-transplant) was 23.8% in the DCD-V cohort, which is comparable to DCD-III (27.9%; p = 1.00) and DBD (32.3%; p = .59). CLAD-free 3- and 5-year survival were 86.4% and 62.8%, respectively, and comparable to DCD-III (74.4% and 60.0%; p = .62) and DBD (72.6% and 55.5%; p = .32). Five-year patient survival was 90.9%, not significantly different from both DCD-III (86.0%; p = 1.00) and DBD (78.1%; p = .36).We observed that LTx with DCD-V allografts is feasible and safe, yielding no evidence for differences in short- and long-term outcome compared to matched cohorts of DCD-III and DBD.

OBJECTIVE: To evaluate the morbidity and mortality of neonates with left-sided isolated congenital diaphragmatic hernia (CDH) according to gestational age at delivery. METHODS: This was a retrospective study of fetuses diagnosed prenatally with isolated left-sided CDH that were delivered in the University Hospitals of Antoine Béclère-Bicêtre and Leuven between 1 January 2010 and 31 December 2018. The Kaplan-Meier method was used to calculate cumulative survival at 28 days after birth according to gestational age at delivery. The association between gestational age at delivery, as a continuous variable, and survival at 28 days was modeled using a fractional polynomial. Adjustment for position of the liver, management center and mode of delivery was performed. The association was also evaluated according to the severity of CDH, as defined by the observed-to-expected lung-to-head ratio (o/e-LHR), which was classified as severe (o/e-LHR 45%). RESULTS: We included 213 fetuses with isolated left-sided CDH, with a median gestational age at delivery of 38 + 2 weeks (interquartile range, 37 + 0 to 39 + 1 weeks). The survival rates at 28 days and at 6 months were 66.7% (142/213) and 64.3% (137/213), respectively. Kaplan-Meier analysis showed a higher survival rate at 28 days for babies delivered between 37 + 0 and 38 + 6 weeks than for those delivered at or after 39 + 0 weeks (log-rank test, P

ispartof: JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY vol:162 issue:5 pages:1387-1388 ispartof: location:United States status: published

ispartof: Current Challenges in Thoracic Surgery status: accepted

OBJECTIVES The American College of Chest Physicians functional guidelines classify patients with predicted postoperative forced expiratory volume in 1 s or predicted postoperative carbon monoxide lung diffusion capacity METHODS All patients who had anatomical lung resection for lung cancer (2007–2019) and were deemed of moderate risk were identified in the European Society of Thoracic Surgeons database. Cardiopulmonary morbidity and 30-day mortality of these patients were assessed by the type of operation. RESULTS A total 2016 patients were identified. The incidence of cardiopulmonary complications in this group was 21% after lobectomy (294/1435), 29% after bilobectomy (33/112), 22% after pneumonectomy (72/333) and 16% after segmentectomy (22/136) (analysis of variance P = 0.07). The 30-day mortality was 3.4% after lobectomy (49/1435), 8.9% after bilobectomy (10/112), 7.8% after pneumonectomy (26/333) and 3.7% after segmentectomy (5/136) (analysis of variance P = 0.0005). The 30-day mortality rate was 1.6-fold higher in patients with a VO2max between 10 and 15 ml/kg/min compared to those with a higher VO2max [49/861 (5.7%) vs 41/1155 (3.5%); P = 0.022]. For operations that were less extensive than a pneumonectomy and were performed by minimally invasive surgery, there was no difference in mortality between patients with a VO2max between 10 and 15 ml/kg/min and those with a higher VO2max [7/181 (3.8%) vs 11/272 (4.0%); P = 0.92]. On the other hand, after open surgery, the mortality of patients with a lower VO2max (10–15 ml/kg/min) was higher than that of those with a higher VO2max [26/501 (5.1%) vs 20/721 (2.8%); P = 0.034]. Linear regression adjusting for the extent and access of the operation confirmed that within the moderate-risk group a VO2max CONCLUSIONS Morbidity and mortality rates found in this study are not negligible and reinforce the recommendation to ensure careful patient discussion and informed decision-making prior to lung cancer resection surgery.

Background: The disease severity in patients with a congenital diaphragmatic hernia (CDH) is highly variable. To compare patient outcomes, set up clinical trials and come to severity-based treatment guidelines, a performant prediction tool early in neonatal life is needed.Objective: The primary purpose of this study was to validate the CDH study group (SG) prediction model for survival in neonates with CDH, including patients who had fetal therapy. Secondary, we aimed to assess its predictive value for early morbidity.Methods: This is a retrospective single-center study at the University Hospitals Leuven on all infants with a diagnosis of CDH live-born between April 2002 and December 2016. The prediction model of the CDHSG was applied to evaluate its performance in determining mortality risk. Besides, we examined its predictive value for early morbidity parameters, including duration of ventilation, respiratory support on day 30, time to full enteral feeding and length of hospital stay.Results: The CDHSG prediction model predicted survival well, with an area under the curve of 0.796 (CI: 0.720-0.871). It had poor value in predicting infants who needed respiratory support on day 30 (area under the curve (AUC) 0.606; CI: 0.493-0.719), and correlated poorly with duration of ventilation, time to full enteral feeding and length of hospital stay.Conclusion: The CDHSG prediction model was in our hands also a useful tool in predicting mortality in neonates with CDH in the fetal treatment era. Correlation with early morbidity was poor.RationaleObjectives: (1) Validation of the CDHSG prediction model for survival in a cohort of neonates with CDH, in whom fetal endoscopic tracheal occlusion was applied according to the severity of lung hypoplasia. (2) Evaluation of performance of the model in the prediction of early morbidity.Main results: (1) Confirmation of the predictive value of the model for survival in neonates with CDH in the era of fetal therapy. (2) No correlation of the model with early morbidity parameters. ispartof: JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE vol:33 issue:11 pages:1818-1823 ispartof: location:England status: published

We describe the case of a term baby boy born via vaginal delivery at 39 weeks gestation with oesophageal atresia, tracheaoesophageal fistula, situs inversus abdominalis and azygos continuation. The azygos continuation was diagnosed after cardiac echo and confirmed on cardiac catherisation after an unexpected umbilical line position on thoracoabdominal X-ray. The baby underwent a right-sided thoracotomy on day 1 of life for repair of the oesophageal atresia. A double fistula, of both the proximal and distal segments, of the oesophagus with short segment stenosis was confirmed. The tracheo-oesophageal fistulae were ligated and divided and the oesophageal atresia repaired by primary anastomosis without complications. The azygos vein was not ligated.

OBJECTIVES The objective of this study was to evaluate the performance of 3 thoracic surgery centres using the Eurolung risk models for morbidity and mortality. METHODS This was a retrospective analysis performed on data collected from 3 academic centres (2014-2016). Seven hundred and twenty-one patients in Centre 1, 857 patients in Centre 2 and 433 patients in Centre 3 who underwent anatomical lung resections were analysed. The Eurolung1 and Eurolung2 models were used to predict risk-adjusted cardiopulmonary morbidity and 30-day mortality rates. Observed and risk-adjusted outcomes were compared within each centre. RESULTS The observed morbidity of Centre 1 was in line with the predicted morbidity (observed 21.1% vs predicted 22.7%, P = 0.31). Centre 2 performed better than expected (observed morbidity 20.2% vs predicted 26.7%, P

Background Osteochondroma is the most common benign tumor of the bone. It is usually asymptomatic, but complications may result from mechanical injury to adjacent anatomic structures, such as the diaphragm and lung, when located intrathoracically. Case Report We report the unusual occurrence of a large hemothorax and lacerated right diaphragm in a 41-year-old woman caused by vertebral osteochondroma affecting the eleventh thoracic vertebra. Thoracoscopic exploration with resection of the osteochondroma and repair of the diaphragm was performed. Why Should an Emergency Physician Be Aware of This? Spontaneous hemothorax is a potential life-threatening condition when the initial diagnosis is postponed and hemodynamic instability and hypovolemic shock occurs. Osteochondroma as a cause of spontaneous hemothorax is uncommon but may require urgent surgical intervention with video-assisted thoracoscopic surgery of thoracotomy to control the hemorrhage and prevent recurrence.

Introduction The role of postoperative radiation therapy (PORT) in patients with completely resected non-small cell lung cancer (NSCLC) with pathologically involved mediastinal lymph nodes (N2) remains unclear. Despite a reduction of local recurrence (LR), its effect on overall survival (OS) remains unproven. Therefore we conducted a review of the current literature. Methods To investigate the benefit and safety of modern PORT, we identified published phase III trials for PORT. We investigated modern PORT in low-risk (ypN0/1 and R0) and high-risk (ypN2 and/or R1/2) patients with stage III-N2 NSCLC treated with induction chemotherapy and resection. Results Seventeen phase III trials using PORT were selected. Of all PORT N2 studies, 4 were eligible for evaluation of LR, all in high-risk patients only. In these high-risk patients receiving PORT, the mean LR rate at 5 years was 20.9% (95% CI 16–24). Two trials were suitable to assess LR rates after chemotherapy and surgery without PORT. In these low-risk patients, the mean 5-year LR was 33.1% (95% CI 27–39). No significant difference in non-cancer deaths between PORT vs. non-PORT patients was observed in N2 NSCLC. Conclusion PORT is worth the controversy because data illustrate that PORT may increase the OS. However, prospective randomized trials are needed to verify this.

Introduction We investigated patients with contemporarily staged and treated stage III-N2 NSCLC treated with induction chemotherapy and surgery with or without postoperative radiotherapy (PORT). We focused on survival and toxicity and investigated what additional PORT may offer in patients with ypN2 status or incomplete resection. Methods We identified 161 patients with pathologically proven, resectable stage III-N2 NSCLC from our prospective database who were treated between 1998 and 2012. Of these patients, 150 without progressive disease after chemotherapy underwent resection. Patients with ypN2 status or R1/2 resection received three-dimensional PORT (n = 70) to a dose of 50 to 66 Gy in 2-Gy fractions. Results The mean follow-up time was 49 months. The 5-year overall survival (OS) rate was 35.1% in intention-to-treat analysis; relapse-free survival was 31.8%, the cumulative local recurrence (LR) rate was 50.9%, and the distant metastasis rate was 63.4%. The 5-year OS, relapse-free survival, and cumulative LR and distant metastasis rates were 32.0%, 32.9%, 47.0%, and 63.9% in the PORT group versus 38.1%, 30.7%, 54.1%, and 63.2% in the non-PORT group. These results were not significantly different, even though patients in the PORT group had worse prognostic features. Cardiac toxicity was higher in the non-PORT group ( p = 0.02), but pulmonary toxicity was similar ( p = 0.15). There was no difference between the two groups regarding dyspnea ( p = 0.32), cough ( p = 0.37), forced expiratory volume in 1 second ( p = 0.30), and diffusing capacity of the lung for carbon monoxide ( p = 0.61). Conclusions A similar outcome (OS, LR, and toxicity) was seen in both patient groups (PORT versus non-PORT group). Despite the limitations of this retrospective study, PORT can be both effective and safe for patients with stage III-N2 NSCLC with an R1/R2 resection or yN2 after induction chemotherapy and surgery.

OBJECTIVES To develop a simplified version of the Eurolung risk model to predict cardiopulmonary morbidity and 30-day mortality after lung resection from the ESTS database. METHODS A total of 82 383 lung resections (63 681 lobectomies, 3617 bilobectomies, 7667 pneumonectomies and 7418 segmentectomies) recorded in the ESTS database (January 2007–December 2018) were analysed. Multiple imputations with chained equations were performed on the predictors included in the original Eurolung models. Stepwise selection was then applied for determining the best logistic model. To develop the parsimonious models, different models were tested eliminating variables one by one starting from the less significant. The models’ prediction power was evaluated estimating area under curve (AUC) with the 10-fold cross-validation technique. RESULTS Cardiopulmonary morbidity model (Eurolung1): the best parsimonious Eurolung1 model contains 5 variables. The logit of the parsimonious Eurolung1 model was as follows: −2.852 + 0.021 × age + 0.472 × male −0.015 × ppoFEV1 + 0.662×thoracotomy + 0.324 × extended resection. Pooled AUC is 0.710 [95% confidence interval (CI) 0.677–0.743]. Mortality model (Eurolung2): the best parsimonious model contains 6 variables. The logit of the parsimonious Eurolung2 model was as follows: −6.350 + 0.047 × age + 0.889 × male −0.055 × BMI −0.010 × ppoFEV1 + 0.892 × thoracotomy + 0.983 × pneumonectomy. Pooled AUC is 0.737 (95% CI 0.702–0.770). An aggregate parsimonious Eurolung2 was also generated by repeating the logistic regression after categorization of the numeric variables. Patients were grouped into 7 risk classes showing incremental risk of mortality (P CONCLUSIONS We were able to develop simplified and updated versions of the Eurolung risk models retaining the predictive ability of the full original models. They represent a more user-friendly tool designed to inform the multidisciplinary discussion and shared decision-making process of lung resection candidates.

OBJECTIVES The role of segmentectomy in early-stage non-small-cell lung cancer (NSCLC) remains a matter of debate. We performed a meta-analysis to evaluate the oncological outcomes following segmentectomy versus lobectomy for stage I, stage IA only and stage IA METHODS We systematically searched the literature for articles reporting on overall survival (OS), cancer-specific survival (CSS) or recurrence-free survival (RFS). The hazard ratios (HRs) were retrieved and pooled using an inverse variance-weighted approach. RESULTS Twenty-eight studies were included in the analysis. In stage I, segmentectomy was found to be inferior to lobectomy for all 3 outcomes with HR: 1.25 (P = 0.01) for OS, 1.59 (P = 0.02) for CSS and 1.40 (P CONCLUSIONS For stages I and IA, lobectomy showed superior results whereas for tumours

Sleeve resection allows for preservation of lung parenchyma and improved long-term outcomes when compared with pneumonectomy. Little is known about minimally invasive sleeve resection, especially indications, feasibility, technical aspects, complications, and outcomes. We reviewed our institutional experience with sleeve resections via a minimally invasive approach.We performed a retrospective review of a prospectively maintained database from 01/01/2010 to 11/01/2017. Indications, operative details, pathology, postoperative complications were reviewed and longer-term follow-up was reviewed.Fifteen patients were identified (5 males, 10 females). Details are presented inIn experienced centers, sleeve resection via a minimally invasive approach is feasible with acceptable morbidity and mortality. Results in this small series appear comparable with the open approach.

Congenital diaphragmatic hernia (CDH) is a rare condition characterized by a congenital defect in the diaphragm. Abdominal organs are displaced into the thorax through the diaphragmatic defect, hereby causing lung hypoplasia. Survivors also present with long-term functional gastro-intestinal morbidity such as gastro-esophageal reflux, esophageal dysfunction and poor nutritional status. Congenital esophageal dysmotility and surgical disruption of the esophago-gastric junction (EGJ) may contribute to this esophageal dysfunction. The aim of this study was to characterize esophageal function in young infants born with CDH.High resolution solid state manometry was used to investigate the esophageal function in 9 postoperative infants born with CDH (6 M, median age 23 days). A total of 416 liquid swallows were analyzed (range 27-70 swallows per patient; mean 46 swallows). All data are presented as median (IQR).We included 9 patients: 8 with a left diaphragmatic defect, 5 with a "liver up" defect, 4 underwent a fetal tracheal occlusion procedure because of severe lung hypoplasia, 8 needed a patch to close a large diaphragmatic defect. Across patients, length of peristaltic defects was 0.4 (0.3,0.6) cm. Distal contractile integral (DCI) was 357 (249,428) mmHg.sec.cm. Distal Latency (DL) was 4.9 (3.6,5.6) sec, whereby 5/9 patients had a DL less than 4.5 sec. EGJ resting pressure was 37 (17,60) mmHg. The integrated relaxation pressure (IRP4) was 14 (9,19) mmHg with IRP4 over 15 mmHg in 4 patients.We investigated the esophageal body and EGJ function in 9 patients with CDH using high resolution manometry. This pilot study shows that the distal contractile integral is reduced in all infants with CDH. This reflects weak esophageal contractile strength and supports the congenital foregut dysmotility hypothesis. Surprisingly, deglutitive relaxation pressures were increased in only 4/9 patients suggesting that EGJ outflow obstruction post hernia repair of the crural diaphragm, is only partially contributing to the esophageal motor dysfunction observed in patients with CDH.

Introduction Neuroendocrine tumors are rare bronchial carcinomata often presenting in a central airway. Resection usually includes a sleeve of the bronchus with the underlying lobe. Case report We present a 19-year old male with retro-obstructive pneumonia from a tumor in the right mainstem bronchus. Bronchoscopy showed an obstructive mass confirmed as being a typical carcinoid on biopsy. Sleeve resection of the mainstem bronchus only was successfully performed sparing the entire right lung. Discussion and conclusion This type of limited tumoral resection should be reserved for carefully selected patients with a low-grade neoplasm without extrabronchial extension and with both tumor-negative lymph nodes and bronchial margins on frozen section.

OBJECTIVES To describe the methodology for the development of data quality metrics in multi-institutional databases, deriving a cumulative data quality score [Aggregate Data Quality score (ADQ)]. The ESTS database was used to create and apply the metrics. The Units contributing to the ESTS database were ranked for the quality of data uploaded using the ADQ. METHODS We analysed data obtained from 96 Units contributing with at least 100 major lung resections (January 2007 to December 2014). The Units were anonymized assigning a casual numeric code. The following metrics were developed for measuring the data quality of each Unit: (i) record Completeness (COM); rate of present variables on 16 expected variables for all the records uploaded [1 - ('null values'/total expected values for the Unit) × 100, the concept of 'null value' was defined for each variable]; (ii) record Reliability (REL); rate of consistent checks on 9 checks tested for all the records uploaded [1 - (valid controls/total possible controls for the Unit) × 100, specific reliability control queries were defined]. These two metrics were rescaled using the mean and standard deviation of the entire dataset and summed, obtaining: (iii) ADQ score: [COM rescaled + REL rescaled]; it measures the cumulative data quality of a given dataset. The ADQ was used to rank the contributors. RESULTS The COM of ESTS database contributors varied from 98.6 to 43% and the REL from 100 to 69%. Combining the rescaled metrics, the obtained ADQ ranged between 2.67 (highest data quality) and -7.85 (lowest data quality). Comparing the rating using just the COM value to the one obtained using the ADQ, 93% of Units changed their position. The major change was the drop of 66 positions considering the ADQ list. CONCLUSIONS We described a reproducible method for data quality assessment in clinical multi-institutional databases. The ADQ is a unique indicator able to describe data quality and to compare it among centres. It has the potential of objectively guiding projects of data quality management and improvement.

OBJECTIVES The aim was to verify the association of low VO2 max with postoperative morbidity and mortality after video-assisted thoracoscopic surgery (VATS) or open pulmonary lobectomy using the European Society of Thoracic Surgeons (ESTS) database. METHODS A retrospective analysis of data collected from the ESTS database was conducted. A total of 1684 lobectomy patients with available VO2 max values were included (2007-14). Patients operated through VATS (281 patients) or thoracotomy (1403 patients) were separately analysed. Propensity score analyses were performed to match patients with high (≥15 ml/kg/min) and low VO2 max (

Patients with clinical N1 (cN1) non-small cell lung cancer (NSCLC) based on PET-CT imaging are often found to have occult mediastinal nodal involvement (N2-disease) at invasive staging or resection although the PET-CT was negative on the mediastinum. Two multicenter prospective studies in patients with PET-negative mediastinum but suspected cN1-disease were performed to measure sensitivity of two invasive mediastinal staging strategies to detect mediastinal nodal disease, one with endosonography and one with video-assisted mediastinoscopy (VAM) or video-assisted mediastinoscopic lymphadenectomy (VAMLA). Consecutive patients with operable and resectable cN1 (suspected) NSCLC underwent endosonography, if negative followed by mediastinoscopy in the first study (n=100). In the second study with identical inclusion criteria, patients (n=105) underwent a VAM or VAMLA [VAM(LA)]. All patients underwent FDG-PET and CT scan prior to invasive mediastinal staging. The primary study outcome was sensitivity to detect N2-disease. Secondary endpoints were the prevalence of N2-disease, negative predictive value (NPV) and accuracy of the invasive staging procedure. In both studies, 25% of patients with cN1 disease on imaging had eventually pathology-proven N2-disease. Endosonography alone reached a sensitivity (38%) to detect mediastinal nodal disease. Invasive mediastinal staging with VAM(LA) had a sensitivity of 73% to detect N2-disease. The NPV was 92% and accuracy 93%. At endosonography, a mean of 2.1 mediastinal nodal stations were biopsied vs. 3.9 at VAM(LA). VAM(LA) has a satisfactory sensitivity of 73% to detect mediastinal nodal disease in cN1 lung cancer and could be the technique of choice for pre-resection mediastinal lymph node assessment in this patient group with a one in four chance of occult positive mediastinal nodes after negative PET-CT. ispartof: Mediastinum vol:4 pages:6- ispartof: location:China status: Published online

Heterogeneity of lung tumor endothelial cell (TEC) phenotypes across patients, species (human/mouse), and models (in vivo/in vitro) remains poorly inventoried at the single-cell level. We single-cell RNA (scRNA)-sequenced 56,771 endothelial cells from human/mouse (peri)-tumoral lung and cultured human lung TECs, and detected 17 known and 16 previously unrecognized phenotypes, including TECs putatively regulating immune surveillance. We resolved the canonical tip TECs into a known migratory tip and a putative basement-membrane remodeling breach phenotype. Tip TEC signatures correlated with patient survival, and tip/breach TECs were most sensitive to vascular endothelial growth factor blockade. Only tip TECs were congruent across species/models and shared conserved markers. Integrated analysis of the scRNA-sequenced data with orthogonal multi-omics and meta-analysis data across different human tumors, validated by functional analysis, identified collagen modification as a candidate angiogenic pathway.

ispartof: JOURNAL OF CLINICAL ONCOLOGY vol:36 issue:29 pages:2897-+ ispartof: location:United States status: published

Transplant type for end-stage pulmonary vascular disease remains debatable. We compared recipient outcome after heart-lung (HLT) versus double-lung (DLT) transplantation. Single-center analysis (38 HLT-30 DLT; 1991-2014) for different causes of precapillary pulmonary hypertension (PH): idiopathic (22); heritable (two); drug-induced (nine); hepato-portal (one); connective tissue disease (four); congenital heart disease (CHD) (24); chronic thromboembolic PH (six). HLT decreased from 91.7% [1991-1995] to 21.4% [2010-2014]. Re-intervention for bleeding was higher after HLT; (P = 0.06) while primary graft dysfunction grades 2 and 3 occurred more after DLT; (P

OBJECTIVES: Current guidelines recommend preoperative invasive mediastinal staging in centrally located tumours with negative mediastinum on positron emission tomography-computed tomography, based on a 20-30% prevalence of occult mediastinal disease (pN2-3). However, a uniform definition of central tumour location is lacking. Our objective was to determine the best definition in predicting occult pN2-3. METHODS: A single-institution database was queried for patients with (suspected) non-small-cell lung cancer staged cN0 after positron emission tomography-computed tomography and referred to invasive staging and/or primary surgery. We evaluated 5 definitions: inner 1/3, inner 2/3, contact with bronchovascular structures, ≤2 cm from bronchus or endobronchial visualization. RESULTS: Between 2005 and 2015, 813 patients were eligible (cT1: 42%, cT2: 28%, cT3: 17% and cT4: 11%). Invasive mediastinal staging and resection were performed in 30% and 97% of patients, respectively. Any nodal upstaging (pN+) was found in 21% of patients, of whom pN2-3 was found in 8%. Central tumour location demonstrated 4 times higher odds for any pN+ [for inner 1/3 vs outer 2/3, odds ratio 3.90 (95% confidence interval 2.24-6.77), P

Minimally invasive surgery (MIS) in thoracic surgery became quite popular during the last years. The aim of introducing and performing more MIS is to reduce surgical trauma, pain and complications in patients. Training in MIS increases operative time and thus cost in theatre but thus improves with experience. For a resident, the cases should be well selected with experienced supervision in a suitable setting with supporting staff and optimal instruments. Understanding the anatomy of the lung, using simulators, and attending workshops makes the learning curve shorter. ispartof: Journal of Visualized Surgery vol:4 issue:85 pages:1-7 ispartof: location:China status: Published online

In patientswith clinical N1 NSCLC, videomediastinoscopy outperforms endosonography as a mediastinal staging toolhttp://ow.ly/ShP330iWzN2

OBJECTIVES To minimize air leak after anatomical lung resections, many video-assisted thoracic surgery (VATS) surgeons use a 'fissureless' technique, using staplers to divide the hilar bronchovascular structures first and the main part of the fissure last. We describe a cohort of 198 consecutive patients operated with an alternative fissureless technique, opening the fissure completely with staplers at an early stage of the VATS anatomical lung resection. METHODS To open the incomplete fissure first and with staplers, a tunnel dissection is started anterior between the triangle of pulmonary veins and the parenchyma. After identification of the pulmonary artery, the anvil of a first stapler is placed on top of the artery and the anterior part of the fissure is divided. Dissection between artery and parenchyma is continued until the fissure is completely stapled. From a prospectively managed single institution database, we retrieved 405 patients scheduled for VATS anatomical resection between October 2009 and December 2014. The patients were categorized in four consecutive periods: a learning curve with the first 50 cases of VATS lobectomy technique (LC), a period of consecutive 'hilum first, fissure last' (HF), a transition group (TG) during which both techniques were used and a period of consecutive 'fissure first, hilum last' (FF). RESULTS No significant differences in operating time, frequency of prolonged air leak or hospital stay were observed between HF (n = 45) and FF (n = 198). Chest tubes were removed earlier in the FF period (6.9 vs 5.2 days, P = 0.025). Excluding the learning curve, we found 2 patients (2.8%) operated 'hilum first' with an intraoperative complication that potentially could have been avoided by a 'fissure first' technique. CONCLUSIONS By making a tunnel between the bronchovascular structures and parenchyma from anteriorly to posteriorly, one can open the fissure completely with staplers at an early stage of an anatomical lung resection. This combines the advantages of both the 'fissureless' hilum first technique and classic (open) fissure first dissection, i.e. minimal air leak and optimal anatomical overview before bronchovascular structures are divided, potentially avoiding inadvertent transections. A cohort of 198 consecutive patients operated with this alternative fissureless technique demonstrates the feasibility and non-inferiority regarding hospital stay, chest tube duration, operation time and complications in comparison with the hilum first technique.