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OBJECTIVES To identify and prioritize technical procedures for simulation-based training to be integrated into the thoracic surgical curriculum. METHODS A 3-round Delphi survey was conducted from February 2022 to June 2022 among 34 key opinion leaders in thoracic surgery from 14 countries worldwide. The 1st round was a brainstorming phase to identify technical procedures that a newly qualified thoracic surgeon should be able to perform. All the suggested procedures were categorized, qualitatively analysed and sent to the 2nd round. The second round investigated: the frequency of the identified procedure at each institution, the number of thoracic surgeons that should be able to perform these procedures, the degree of risk to the patient if the procedure is performed by a non-competent thoracic surgeon and the feasibility of simulation-based education. In the 3rd round, elimination and re-ranking of the procedures from the 2nd round were performed. RESULTS Response rates in the 3 iterative rounds were 80% (28 out of 34), 89% (25 out of 28) and 100% (25 out of 25) in the 1st, 2nd and 3rd round, respectively. Seventeen technical procedures were included for simulation-based training in the final prioritized list. The top 5 procedures were Video-Assisted Thoracoscopic Surgery (VATS) lobectomy, VATS segmentectomy, VATS mediastinal lymph node dissection, diagnostic flexible bronchoscopy and robotic-assisted thoracic surgery port placement, robotic-assisted thoracic surgery docking and undocking. CONCLUSIONS The prioritized list of procedures represents a consensus of key thoracic surgeons worldwide. These procedures are suitable for simulation-based training and should be integrated in the thoracic surgical curriculum., OBJECTIVES: To identify and prioritize technical procedures for simulation-based training to be integrated into the thoracic surgical curriculum. METHODS: A 3-round Delphi survey was conducted from February 2022 to June 2022 among 34 key opinion leaders in thoracic surgery from 14 countries worldwide. The 1st round was a brainstorming phase to identify technical procedures that a newly qualified thoracic surgeon should be able to perform. All the suggested procedures were categorized, qualitatively analysed and sent to the 2nd round. The second round investigated: the frequency of the identified procedure at each institution, the number of thoracic surgeons that should be able to perform these procedures, the degree of risk to the patient if the procedure is performed by a non-competent thoracic surgeon and the feasibility of simulation-based education. In the 3rd round, elimination and re-ranking of the procedures from the 2nd round were performed. RESULTS: Response rates in the 3 iterative rounds were 80% (28 out of 34), 89% (25 out of 28) and 100% (25 out of 25) in the 1st, 2nd and 3rd round, respectively. Seventeen technical procedures were included for simulation-based training in the final prioritized list. The top 5 procedures were Video-Assisted Thoracoscopic Surgery (VATS) lobectomy, VATS segmentectomy, VATS mediastinal lymph node dissection, diagnostic flexible bronchoscopy and robotic-assisted thoracic surgery port placement, robotic-assisted thoracic surgery docking and undocking. CONCLUSIONS: The prioritized list of procedures represents a consensus of key thoracic surgeons worldwide. These procedures are suitable for simulation-based training and should be integrated in the thoracic surgical curriculum.

Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multicentre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.

Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures, and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training, and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multi-centre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.

Objectives: Since video-assisted thoracic surgery (VATS) was first performed in the early 1990s, there have been many developments, and the conversion rate has decreased over the years. This article highlights the specific outcomes of patients undergoing conversion to thoracotomy despite initially scheduled VATS lung resection. Methods: We retrospectively reviewed 501 patients who underwent thoracoscopic anatomic lung resection (i.e. lobectomy, segmentectomy or bilobectomy) between 1 January 2012 and 1 August 2017 at our institution. We explored the risk factors for surgical conversion and adverse events occurring in patients who underwent conversion to thoracotomy. Results: A total of 44/501 patients underwent conversion during the procedure (global rate: 8.8%). The main reasons for conversion were (i) anatomical variation, adhesions or unexpected tumour extension (37%), followed by (ii) vascular causes (30%) and (iii) unexpected lymph node invasion (20%). The least common reason for conversion was technical failure (13%). We could not identify any specific risk factors for conversion. The global complication rate was significantly higher in converted patients (40.9%) than in complete VATS patients (16.8%) (P = 0.001). Postoperative atrial fibrillation was a major complication in converted patients (18.2%) [odds ratio (OR) 5.09, 95% confidence interval (CI) 1.80-13.27; P = 0.001]. Perioperative mortality was higher in the conversion group (6.8%) than in the VATS group (0.2%) (OR 33.3, 95% CI 3.4-328; P = 0.003). Conclusions: Through the years, the global conversion rate has dramatically decreased to <10%. Nevertheless, patients who undergo conversion represent a high-risk population in terms of complications (40.9% vs 16.8%) and perioperative mortality (6.8% vs 0.2%).

A best evidence topic was constructed according to a structured protocol. The question addressed was whether size-reduced or lobar lung transplantation (LLTx) offers the same benefit as classic lung transplantation (LTx). Of the 147 papers found using the reported search, 9 were selected to provide the best evidence. Details of the studies regarding authors, date, journal, country of publication, study type, group studied, relevant outcomes and results are given. All studies reported survival rates of LLTx and most compared it with classical LTx. No statistical differences were reported in medium term and long term. Two of the studies reported a higher incidence of postoperative complications, such as the need for cardiopulmonary bypass, reperfusion oedema or primary graft dysfunction, and longer intubation or intensive care unit stay times. Although the largest study showed a significantly worse 1-year survival in LLTx, a sub-analysis considering patients successfully discharged showed similar outcomes at 1, 3 and 5 years when compared with classic LTx patients. We conclude that LLTx is a valid therapeutic option for recipients with significant donor size mismatch, offering similar outcomes as classical LTx in the medium term and long term.

Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures, and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training, and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multi-centre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.

Background: Current treatment options for stage III non-small cell lung cancer (NSCLC) consist of different combinations of chemotherapy, surgery, radiotherapy and immunotherapy. Treatment choices are highly individual decisions, in which adverse events (AEs) are relevant for decision-making. This study aims to analyse reporting of AEs in prospective stage III NSCLC trials, focussing on trials including radiotherapy and/or surgery. Methods: PubMed was searched for prospective studies dealing with stage III NSCLC from January 1987 to April 2019. Meta-analyses were screened as a positive control. Pearson’s Chi-squared test and smooth kernel distribution were used to estimate distributions. Data was resampled using bootstrapping. Results: Out of 1193 initially identified studies, 119 met the inclusion criteria. Of these, 31 had a surgical procedure in any study arm. Grade 3 and 4 AEs were reported in 94.12% and 92.44% of the included studies, respectively. Reporting of grade 5 AEs was provided in 87.39% of cases. Grade 1 and 2 AEs were less commonly reported at 53.78% and 63.03%, respectively. One study did not mention any AEs. Of the 31 treatment arms including any form of surgery, AEs were not reported in 10. Overall, 231 different AE items were reported, only 18 of them were included in at least 20% of the analysed studies. Conclusion: Overall, AE reporting in stage III NSCLC was inconsistent and inhomogeneous. Studies including surgical study arms often reported only treatment-related deaths in regards of surgical AEs. Underreporting of AEs prohibits the extraction of patient-relevant information for decision-making and represents a suboptimal use of invested resources.