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Background Receiving information about their disease and treatment is very important to patients with cancer. There is an association between feeling appropriately informed and better quality of life. This audit aimed to estimate patient satisfaction with perioperative information in those undergoing surgery for lung cancer and any change in satisfaction over time. Methods A questionnaire (EORTC-Info-25) was administered prospectively to patients preoperatively and up to six months postoperatively. The preoperative questionnaire was completed by 292 patients and 88 free text comments were completed. Intrapersonal responses were compared over time. Results Patients were highly satisfied with information prior to surgery. The overall helpfulness of information did not change over time but satisfaction with the amount of information decreased. Patients who received more information about ‘the disease’ and ‘things you can do to help yourself get well’ were less likely to report a drop in satisfaction (Odds Ratio 0.858, 95% Confidence interval 0.765 to 0.961, p = 0.008 and OR 0.102, 95% CI 0.018 to 0.590, p = 0.011 respectively). Free text responses revealed patients most frequently wanted more information on the disease, aftercare and self-care. Suffering complications from surgery was not associated with a change in satisfaction with information postoperatively. Conclusions Patients want to know more about their diagnosis, but also how to recover and cope with issues once they have gone home after surgery. Postoperative satisfaction with information may improve if patients are given more information on these topics.

OBJECTIVES : Video-assisted thoracoscopic surgical (VATS) lobectomy is increasingly used for curative intent lung cancer surgery compared to open thoracotomy due to its minimally invasive approach and associated benefits. However, the effects of the VATS approach on postoperative pulmonary complications (PPC), rehabilitation and physiotherapy requirements are unclear; our study aimed to use propensity score matching to investigate this. METHODS Between January 2012 and January 2016 all consecutive patients undergoing lobectomy via thoracotomy or VATS were prospectively observed. Exclusion criteria included VATS converted to thoracotomy, re-do thoracotomy, sleeve/bilobectomy and tumour size >7 cm diameter (T3/T4). All patients received physiotherapy assessment on postoperative day 1 (POD1), and subsequent treatment as deemed appropriate. PPC frequency was measured daily using the Melbourne Group Scale. Postoperative length of stay (LOS), high dependency unit (HDU) LOS, intensive therapy unit (ITU) admission and in-hospital mortality were observed. Propensity score matching (PSM) was performed using previous PPC risk factors (age, ASA score, body mass index, chronic obstructive pulmonary disease, current smoking) and lung cancer staging. RESULTS Over 4 years 736 patients underwent lobectomy with 524 remaining after exclusions; 252 (48%) thoracotomy and 272 (52%) VATS cases. PSM produced 215 matched pairs. VATS approach was associated with less PPC (7.4% vs 18.6%; P

The mediastinum contains a number of organs and structures of various origins, and thus it can be the host of many pathologies and tumours including benign and malignant. Managing a patient with mediastinal tumour must begin with multidisciplinary approach. Treating mediastinal tumours varies between watchful waiting, surgery, chemotherapy, radiotherapy, hormonal therapy and a combination of all these modalities, and thus accurate diagnosis is crucial in management. Knowledge of correlation between patient demographics and type of tumours, commonest tumours in various compartments of the mediastinum, biochemistry testing in relation to certain tumours and radiological characteristics of the mediastinal tumours can provide focused examination and increase the yield of accurate diagnosis.

Background Interventional bronchoscopy is effective in the management of patients with symptomatic airway obstruction for both malignant and benign conditions. The main aim of this study is to report our experience with emergency interventional bronchoscopy in patients with symptomatic airway obstruction and identify prognostic factors for survival. Methods This is a retrospective observational study of patients undergoing emergency interventional bronchoscopy over a 4-year period. Survival times were analyzed separately for patients with benign and malignant airway obstruction by the Kaplan-Meier method. Results Between June 2009 and July 2013, 168 emergency interventional bronchoscopies were performed in 112 patients for airway obstruction. The median age was 63 years (range, 20 to 86), and 91 patients (54%) patients were female. Seventy-two cases (43%) had airway obstruction due to malignant disease. There were 3 in-hospital deaths (2.7%). Median survival of the study population was 5.6 months (range, 0 to 51) with a median follow-up of 7.3 months (range, 0 to 51). Median survival for patients with malignant airway obstruction was 3.5 months (range, 0 to 21), and 9.8 months (range, 0.1 to 51) for those with benign disease. Airway intervention facilitated palliative chemotherapy in 32 patients (44%) of those with malignant airway obstruction. At multivariate analysis in patients with malignant airway obstruction, presence of stridor (hazard ratio 1.919, 95% confidence interval: 1.082 to 3.404, p = 0.026) and not receiving postprocedure chemotherapy (hazard ratio 2.05, 95% confidence interval: 1.156 to 3.636, p = 0.014) were independent prognostic factors for death. Conclusions Emergency interventional bronchoscopy for airway obstruction is safe, relieved symptoms, and facilitated palliative chemotherapy, which improved survival.

Background: Video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer is associated with a risk of postoperative pulmonary complications (PPC) with associated poor outcomes. Despite this, the provision of postoperative physiotherapy after VATS is variable. We aimed to identify baseline factors associated with problems amenable to physiotherapy after VATS lobectomy. Methods: The prospective cohort study included all cancer patients undergoing VATS lobectomy over 4 years (2012-2016). From postoperative day 1 (POD1), patients were sat out by nursing staff and assisted to mobilise. Physiotherapy assessment on POD1 determined presence of issues amenable to intervention, and treatment was commenced as deemed necessary. Outcome measures included PPC development, hospital and high dependency unit (HDU) length of stay (LOS), intensive therapy unit admission (ITU) and in-hospital mortality. Results: Of 285 patients, 209 (73%) received physiotherapy for reduced mobility, 23 (8%) received therapies sputum clearance and 65 (23%) for lung volume loss. The 76 (27%) patients not requiring physiotherapy had a reduced hospital and HDU LOS (p Conclusion: We have identified preoperative factors associated with issues amenable to physiotherapy following VATS lobectomy; these patients may benefit from pulmonary rehabilitation and physiotherapy for better postoperative outcome.

OBJECTIVES: In patients undergoing corrective surgery for pectus excavatum, there is evidence of improvement in cardiopulmonary func- tion. It is unclear how much of this improvement is attributable to improved chest wall function. Thus, we observed changes in chest wall function in response to an incremental load exercise pre- and postoperatively. METHODS: Using optoelectronic plethysmography, total and regional chest wall volumes were measured in 7 male patients with severe pectus excavatum who underwent a Nuss correction. Rib cage and abdominal volumes were recorded at rest and during exercise (incre- mental cycle ergometry), pre- and postoperatively in conjunction with spirometry. RESULTS: Tidal volume increases during exercise are blunted compared with baseline measurements at 6 days (�36 ± 7%) partially recover- ing at 6 months postoperatively (�18 ± 22%). This is mirrored by changes in spirometry. Tidal volume decreased during exercise initially in all compartments, but persisted in the rib cage compartment. An increase of 44% (P= 0.009) in exercise tolerance was found 6 months after surgical correction. CONCLUSIONS: Six months after Nuss correction in pectus patients, there was a decrease in rib cage mobility. Despite reduction, patients had a significant improvement in exercise tolerance. Therefore, we conclude that early postoperative improvement in exercise capacity is not due to changes in chest wall function. The longer term effects on chest wall function are yet to be defined.

OBJECTIVES The aim of the study was to develop a multistranded pragmatic rehabilitation programme for operable lung cancer patients, that looks into feasibility, process indicators, outcome measures, local adaptability, compliance and potential cost benefit. METHODS An outpatient-based complex intervention, rehabilitation for operated lung cancer (ROC) programme, was developed to optimize physical status, prepare for the inpatient journey and support through recovery after surgery. It includes exercise classes, smoking cessation, dietary advice and patient education and was tested in an enriched cohort study within a regional thoracic unit over 18 months. RESULTS A multistranded pragmatic rehabilitation programme pre- and post-surgery is feasible. Fifty-eight patients received the intervention and 305 received standard care. Both groups were matched for age, lung function comorbidity and type of surgery. Patients in the intervention group attended exercise classes twice a week until surgery, which was not delayed. Patients attended four sessions presurgery (range 1–15), resulting in an improvement of 20 m (range −73–195, P = 0.001) in a 6-min walk test and 0.66 l in forced expiratory volume in 1 s (range −1.85 from 1.11, P = 0.009) from baseline to presurgery. Fifty-four percentage of smokers in the intervention group stopped smoking. Sixteen percentage of patients were identified as being at risk of malnourishment and received nutritional intervention. There was a trend in patients in the intervention group towards experiencing fewer postoperative pulmonary complications than those in the non-intervention group (9 vs 16%, respectively, P = 0.21) and fewer readmissions to hospital because of complications (5 vs 14% respectively, P = 0.12). CONCLUSION Chronic obstructive pulmonary disease-type pulmonary rehabilitation before and after lung cancer surgery is viable, and preliminary results suggest improvement in physical measures. A multicentre, randomized controlled trial is warranted to confirm clinical efficacy.

Background Smoking is a risk factor for postoperative pulmonary complications (PPC) following non-small cell lung cancer (NSCLC) surgery. The optimal timing for preoperative smoking cessation has not been identified. Our study aimed to observe the impact of preoperative smoking cessation on PPC incidence and other postoperative outcomes including long-term survival. Methods A prospective study included consecutive patients following resection for NSCLC in a regional thoracic centre over a 4-year period (2010–2014). Patients were stratified according to self-reported preoperative smoking status. The primary endpoint was PPC incidence, which was assessed from postoperative day one onwards using the Melbourne Group Scale. Secondary endpoints included short-term outcomes (hospital length of stay [LOS], intensive therapy unit [ITU] admission, 30-day hospital readmission rate) and long-term survival. Results Four hundred and sixty-two patients included 111 (24%) current smokers, 55 (12%) ex-smokers

Pleural effusions are commonly drained with Seldinger intercostal drains. One uncommon but serious risk of drain insertion is that of a foreign body being retained in the pleural cavity following removal. We report a case in which the tip of the drain was retained in the pleural space following difficult insertion of a Seldinger intercostal drain in a district general hospital. Prompt recognition and clear patient communication are important at the occurrence of an unusual complication. Surgical removal of the foreign body was performed following transfer. We report this case to raise awareness that insertion and withdrawal of drains over the guidewire during insertion may damage the drain and highlight the need for doctors who insert chest drains to perform a count of instruments during ward or clinic-based procedures as well as those performed in theatres. We now include removable parts of chest drains in our theatre instrument count.

Objectives: We aimed to audit outcomes of pectus surgery and investigate potential predictive factors of pectus recurrence. Methods: A retrospective review of 297 patients who underwent repair of pectus deformity between 1994 and 2014. Patients medical records were reviewed for demographics; type of surgical correction; length of hospital stay; postoperative complications; pectus recurrence and duration of bar stay. Survival analysis methods and repeated events analysis were performed to identify predictor factor for pectus recurrence. Results: A total of 297 patients were included (262 males; 35 females), with a mean age of 19.8 years (range 9 to 45). Mean length of hospital stay was 4.7 days (range 1 to 21). Hundred and sixty-seven patients had surgery for pectus excavatum; 116 for carinatum. Hundred and fifty-three patients received a modified Ravitch without bar insertion; 72 with insertion of bar. Fifty-three patients underwent Nuss repair. Eighty-five patients had their bars removed, on an average of 18.5 months after surgery. The main complications were wound infection (3%) and postoperation bleeding (2.3%). Pectus recurrence rate was 9.4% (28/297). Type of operation was a highly significant factor of pectus first recurrence (P = 0.0002). A repeated event analysis, confirmed that patients treated with a bar were 2.7 times more likely to have further recurrences (P = 0.0078; 95% CI 1.3-5.8). In those patient treated with a bar, time of bar removal was a statistically significant predictive factor of first recurrence (P = 0.0112; OR: 1.054; 95% CI 1.054-1.011). Presence of postoperative complications only marginally failed to yield statistically significant results (P = 0.064). Conclusions: Pectus surgery can be performed with low morbidity. Type of operation, bar insertion and length of bar stay are predictive factors of pectus recurrence.

Postoperative pulmonary complications (PPC) such as atelectasis and pneumonia are common following lung resection. PPCs have a significant clinical impact on postoperative morbidity and mortality. We studied the long-term effects of PPCs and sought to identify independent risk factors.A prospective observational study involved all patients following lung resection in a regional thoracic centre over 4 years. PPCs were assessed daily in hospital using the Melbourne group scale based on chest X-ray, white cell count, fever, purulent sputum, microbiology, oxygen saturations, physician diagnosis and intensive therapy unit (ITU)/high-dependency unit readmission. Follow-up included hospital length of stay (LOS), 30-day readmissions, and mortality.86 of 670 patients (13%) who had undergone a lung resection developed a PPC. Those patients had a significantly longer hospital LOS in days (13, 95% CI 10.5-14.9 vs 6.3, 95% CI 5.9 to 6.7; p0.001) and higher rates of ITU admissions (28% vs 1.9%; p0.001) and 30-day hospital readmissions (20.7% vs 11.9%; p0.05). Significant independent risk factors for development of PPCs were COPD and smoking (p0.05), not age. Excluding early postoperative deaths, developing a PPC resulted in a significantly reduced overall survival in months (40, 95% CI 34 to 44 vs 46, 95% CI 44 to 47; p=0.006). Those who developed a PPC had a higher rate of non-cancer-related deaths (11% vs 5%; p=0.020). PPC is a significant independent risk factor for late deaths in non-small cell lung cancer patients (HR 2.0, 95% CI 1.9 to 3.2; p=0.006).Developing a PPC after thoracic surgery is common and is associated with a poorer long-term outcome.

The Thoracoscore mortality risk model has been incorporated into the British Thoracic Society guidelines on the radical management of patients with lung cancer. The discriminative and predictive ability to predict mortality and post-operative pulmonary complications (PPCs) in this group of patients is uncertain. A prospective observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 42 months. 128 out of 703 subjects developed a PPC. 16 (2%) patients died in hospital. In a logistic regression analysis the Thoracoscore was not a significant predictor of mortality (OR 1.07, 95% CI 0.99-1.17; p=0.11) but was a significant predictor of PPCs (OR 1.08, 95% CI 1.03-1.13; p=0.002). However, the area under the receiver operator characteristic curve for the Thoracoscore was 0.68 (95% CI 0.56-0.80) for predicting mortality and 0.64 (95% CI 0.59-0.69) for PPCs, indicating limited discriminative ability. In a logistic regression analysis, another risk model, the European Society Objective Score, was predictive of mortality (OR 1.43, 95% CI 1.11-1.83; p=0.006) and PPCs (OR 1.48, 95% CI 1.30-1.68; p

Postoperative pulmonary complications (PPC) are the most frequently observed complications following lung resection, of which pneumonia and atelectasis are the most common. PPCs have a significant clinical and economic impact associated with increased observed number of deaths, morbidity, length of stay and associated cost. The aim of this study was to assess the incidence and impact of PPCs and to identify potentially modifiable independent risk factors.A prospective observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 13 months. PPC was assessed using a scoring system based on chest x-ray, raised white cell count, fever, microbiology, purulent sputum and oxygen saturations.Thirty-four of 234 subjects (14.5%) had clinical evidence of PPC. The PPC patient group had a significantly longer length of stay (LOS) in hospital, high dependency unit (HDU) LOS, higher frequency of intensive care unit (ITU) admission and a higher number of hospital deaths. Older patients, body mass index (BMI)or =30 kg/m(2), preoperative activity400 m, American Society of Anesthesiologists (ASA) scoreor =3, smoking history, chronic obstructive pulmonary disease (COPD), lower preoperative forced expiratory volume in 1 s (FEV(1)) and predicted postoperative (PPO) FEV(1) were all significantly (p0.05) associated with PPC on univariate analysis. Multivariate analysis confirmed that age75 years, BMIor =30 kg/m(2), ASAor =3, smoking history and COPD were significant independent risk factors in the development of PPC (p0.05).The clinical impact of PPCs is marked. Significant independent preoperative risk factors have been identified in current clinical practice. Potentially modifiable risk factors include BMI, smoking status and COPD. The impact of targeted therapy requires further evaluation.

Background Surgical resection of colorectal liver metastases (CLM) is an established form of treatment. Limited data exists on the value of sequential hepatic and pulmonary metastasectomy. We analysed patients who underwent sequential liver and lung resections for CLM. Methods A total of 910 patients who underwent liver resection for CLM between January 2000 and December 2007, were analysed to identify patients with resectable pulmonary metastases ( n = 43; 4.7%). Patient demographics, overall survival and survival difference between synchronous and metachronous pulmonary metastasectomy groups were compared. In addition, outcomes in the ‘liver and lung resection’ group were compared with a matched group of ‘liver resection only’ patients (matched for age, primary disease stage, interval to liver resection and liver disease stage). Results Forty-three patients (median age 62, range 43–83 years, 22 males) underwent sequential liver and lung resection. A total of 36 patients underwent major hepatic resections, 18 patients had bilobar disease and the median number of liver lesions resected was 3 (range 1–5 lesions). Ten patients had synchronous liver and lung metastases. The median interval between liver and lung metastasectomy was 25 months (range 2–88 months). A total of two patients underwent major lobectomies, three patients had bilateral disease and the median number of lung lesions resected was one (range 1–3). The 1-, 3- and 5-year overall survival rates after first metastasectomy were 100%, 87.1% and 53.9%, respectively, with a median survival of 42 months. Patients Undergoing metachronous pulmonary metastasectomy had better 1-, 3- and 5-year survival rates than those with synchronous disease (100%, 88.9% and 60.9% vs. 100%, 75% and 0%, respectively; P = 0.02, log rank test). There was no significant survival difference between the ‘liver and lung resection’ and the ‘liver resection only’ groups. Conclusion Sequential liver and lung resection for CLM is associated with good long-term survival in selected patients, except in those presenting with synchronous lung and liver metastases.

IntroductionLung cancer is the leading cause of cancer-related death worldwide. The discovery of new biomarkers could aid early diagnosis and monitoring of recurrence following tumor resection.MethodsWe have prospectively collected serum from 97 lung cancer patients undergoing surgery with curative intent and compared their serum proteomes with those of 100 noncancer controls (59 disease-free and 41 with a range of nonmalignant lung conditions). We initially analyzed serum from 67 lung cancer patients and 73 noncancer control subjects by surface-enhanced laser desorption/ionization time-of-flight mass spectrometry using immobilized metal affinity capture ProteinChip arrays and subsequently validated our findings with an independent analysis of 30 lung cancer patients and 27 noncancer subjects.ResultsThe data from both experiments show many significant differences between the serum proteomes of lung cancer patients and nondiseased control subjects, and a number of these polypeptides have been identified. However, the profiles of patients with benign lung diseases resembled those of lung cancer patients such that very few significant differences were found when these cohorts were compared.ConclusionsThis report provides clear evidence of the need to account for the confounding effects of benign diseases when designing lung cancer serum biomarker discovery projects.

The management of patients with lung cancer has undergone significant improvement in the last decade in the United Kingdom. The 5-year survival for all patients diagnosed with lung cancer had remained unchanged at 5% over the previous decade, well behind Europe and the United States. Together, government and medical bodies produced guidelines based on best available evidence. The dissemination of these guidelines into clinical practice became the remit of Cancer Networks. The establishment of Multidisciplinary teams (MDTs) has streamlined care and allowed individual teams to discuss patients' management within a wider body of expertise. The Cancer Network quality assurance team assesses the MDTs to ensure that standards are maintained. Though the efficacy of the MDTs in improving quality and consistency of care for patients with lung cancer is irrefutable, the effects on overall survival rates are less certain. The majority of patients have advanced incurable disease at presentation. Changes in awareness of the general public and in the primary care setting are required to address this issue. Severe co-morbidities in patients with potentially curable disease can also preclude operative treatment. The delivery of specialized care for patients with lung cancer has improved dramatically in the United Kingdom with the advent of national guidelines and the local MDT. These measures may not be enough in remedying the poor long-term survival of patients with lung cancer in the United Kingdom without attention to underlying cause. A holistic attitude to the "Big Three" smoking-induced diseases offers hope of novel approach to this problem.

Introduction: The physiological benefits of pectus surgery are widely accepted.The purpose of the study was to assess the short and long term outcomes of both pectus excavatum and carinatum surgery and identify factors associated with a poor outcome. Methods: Retrospective cohort study of 297 patients who underwent primary or recurrent repair of pectus deformity from 1994 to 2014. Patients records were reviewed for demographics;type of pectus and surgical correction;post-operative complications and pectus recurrence. Results: 297 patients were included (262males;35females),mean age of 19.8 years(range,9 to 45).170 patients had surgery for pectus excavatum (PE);127 for carinatum(PC).Pectus correction was solely performed with modified Ravitch with and without bar insertion until 2008.237 patients received a modified Ravitch(160 without a bar)and 53 patients underwent Nuss repair.There were no hospital mortalities.The main complications were wound infection(4.4%);post-op bleeding/haematoma(3%).The pectus recurrence rate was 9.8%(29/297).Our cohort was subdivided in 5 distinct groups:NUSS;Ravitch with and without bar for PE and PC respectively(4).PE patients treated with Nuss had less post op complications compared to Ravitch with bar(7.5%vs30%,p=0.016).Those who developed a complication tended to have a higher chance of recurrence(10%vs25 %,p=0.08).Patients treated with Ravitch with a bar had increased chance of recurrence(PE,hazard ratio(HR)=4.2,CI 1.2 to 26.8,p=0.045;PC,HR=7 CI 1.8–22 p

Introduction: Smoking is a risk factor for postoperative pulmonary complications (PPCs) following curative-intent surgery for lung cancer (P.Agostini et al, Thorax 2010;65:815-8). Risk modification is via smoking cessation programmes; whether surgery should be delayed for this is a debated topic. Aims & Objectives: To study the impact of smoking on postoperative outcome including long-term survival. Methods: A prospective observational study was carried out on all patients following curative-intent lung cancer resection in a regional thoracic centre over 4 years. Preoperative smoking status was self-reported by all patients. Data included patient demographics, PPCs, hospital length of stay (LOS), intensive treatment unit (ITU) admission and mortality. Results: Of 460 patients, 24% were current smokers, 12% ex-smokers 6 weeks, and 11% never smokers. Independent risk factors associated with smoking status using multivariate analysis were FEV1% predicted, COPD and BMI (p Conclusions: Preoperatively, 1 in 4 patients continue to smoke. Current smokers have higher postoperative morbidity with no significant survival difference within our short follow-up period. Further research into effective short-term smoking abstinence programmes is needed.

Introduction: Neutrophil/lymphocyte ratio (NLR) is a prognostic marker for curative-intent surgery for cancer. Few studies have investigated NLR in lung cancer (NSCLC) patients, and any association between NLR and postoperative pulmonary complications (PPC) and readmission has not been explored. Aims & Objectives: To study the prognostic role of NLR on postoperative outcome. Methods: A prospective observational study was carried out on all NSCLC patients following lung resection in the UK's largest thoracic surgical centre over 4 years. All patients had pre-operative bloods (including NLR), demographics and postoperative histological diagnosis with staging obtained. Follow up data included record of PPCs, hospital length of stay (LOS), 30-day hospital re-admission for complications and mortality. Results: Of 463 patients, the mean NLR was 3.5±2.2. Risk factors which were significantly associated with elevated NLR on univariate analysis included advancing age, BMI, stage and male sex (p 5 had a significantly increased frequency of 30-day hospital readmission for complications (25.8% vs. 12.9%; p 5 had a significantly higher mortality of all causes (41.7% vs. 16.8; p5 have a higher rate of hospital readmission with complications and a poorer survival.

Background: Pectus is the most common congenital disorder. Awareness amongst primary care physicians and the general public is poor.We studied the effects of introducing a patient information website on referral and activity patterns. Methods: The thoracic Surgery Team at Heartlands Hospital produced an innovative information website, www.pectus.co.uk, accessible to the general public, providing information about pectus deformities; management options and advice about surgery.Referral patterns and number of cases where studied before and after the introduction of the website in 2010.Patients9 satisfaction post-op was assessed using the Brompton9s single step questionnaire(SSQ). Results: The website had considerable traffic with 2,179 hits in 2012 4,983 in 2013 and 4,904 so far in 2014 (google analytics 1.9.14). This has led to 1421 contacts and 372 email enquiries.These emails have resulted in an increase numbers of patients who have been assessed and go on to have surgery.81% of patients who visited the website and then underwent surgery,found the website useful.We asked 60 patients who were operated from 2008 to 2014 to complete the SSQ.96% reported improved overall health post-op;85% had improved exercise tolerance;9/10 had normal post-op social activity and they were satisfied with cosmesis. A statistically significant improvement in average self-esteem was noted(4.3vs7.7/10,p Conclusion: The introduction of a patient pectus information website has significantly improved access to specialised services. Patients are overall highly satisfied with the surgical outcomes.

Introduction Postoperative pulmonary complications (PPC), such as pneumonia and atelectasis are associated with poor outcomes following thoracotomy and lung resection, with risk factors identified.1,2 Video-assisted thoracoscopic surgery (VATS) is increasingly performed, however, there are varying reports regarding the incidence of PPC with little is known about their effect on short-term outcomes or potential risk factors. Methods A prospective observational study of consecutive patients undergoing VATS lobectomy was performed in a regional centre (2012–2016). Exclusion criteria included re-do VATS/completion lobectomy. All patients received physiotherapy assessment/intervention as necessary from postoperative day 1 (POD1). The presence of PPC was determined daily using the Melbourne Group Scale. Outcomes included hospital length of stay (LOS), intensive therapy unit (ITU) admission and hospital mortality. Results 287 patients underwent VATS lobectomy, 2 patients undergoing completion lobectomy were excluded. Of 285 patients; 137 were male (48%), median (IQR) age of 69 years (13) and mean (±SD) FEV1 of 87% (±19). PPC developed in 21 patients (7.4%); the median day that PPC developed was postoperative day 3 (Figure 1). Patients who developed a PPC had a significantly longer hospital LOS (4 vs 3 days), higher rate of ITU admission (25% vs 0%) and higher hospital mortality (14% vs 0%) (p Conclusions Patients undergoing VATS remain at risk of developing a PPC associated with significantly worse short-term morbidity and mortality. Patients that develop a PPC following VATS required increased postoperative physiotherapy compared to non-PPC patients. Current smoking is an independent risk factor for PPC development following VATS, thus vigorous addressing of preoperative smoking cessation is urgently needed. References Agostini P, et al. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Thorax 2010;65(9):815–8. Lugg ST, et al. Long-term impact of developing a postoperative pulmonary complication after lung surgery. Thorax 2016;71(2):171–6.

Background Early mobility is considered important in minimising pulmonary complication, length of stay (LOS) and enhancing recovery following major surgery. We aimed to observe and measure the reduction in early postoperative physical activity following major thoracic surgery, identifying any potentially limiting factors, and factors predictive of reduced activity. Methods Patients undergoing thoracotomy and lung resection were prospectively observed for the purposes of this study. All patients were routinely assisted to mobilise by physiotherapists from postoperative day 1, and continued daily with exercise and progression of mobility as per usual practice. Physical activity was measured with SenseWear Pro 3 armband physiologic motion sensors between postoperative day 1–4. The motion sensors recorded step count, time spent in ‘sedentary’/ ‘moderate’ activity, and energy expenditure. Frequency of postoperative pulmonary complication (PPC) and postoperative LOS were also observed. Multivariate analyses were performed using forward stepwise logistic regression; results are displayed as odds ratio (95% confidence intervals). Results n = 99, median (interquartile range) steps 472 (908) over combined postoperative days 2/ 3, sedentary activity (

Objective: To evaluate the role of video-assisted thoracoscopy (VAT) in the staging of non-small cell lung cancer (NSCLC). Methods: In 30 patients (18 male, 12 female, median age 62 (50‐78) years) VAT was used to assess the operability of NSCLC in cases where doubt existed after conventional staging investigations had been performed. Results: VAT was used to assess direct tumour invasion of adjacent organs in 17 patients (mediastinal invasion in 14 and chest wall invasion in 3 patients). In 4 patients with limited respiratory reserve, VAT confirmed the need only for lobectomy prior to thoracotomy. Mediastinal lymph node biopsy was performed in 5 patients with significant (\1.5 cm) lymphadenopathy on CT scan. VAT was also used to assess bilateral lesions in 4 patients with suspected synchronous tumours. Conversion to thoracotomy was necessary in 4 patients for technical reasons. Successful resection was possible in 17 of the remaining 26 cases, while unnecessary thoracotomy was avoided in 9 patients (30%) with unresectable or benign disease. In 4 patients deemed inoperable on CT scan, VAT staging enabled subsequent resection. Conclusions: Video-assisted thoracoscopy appears to have a complementary role in staging NSCLC when other methods are equivocal. It has the potential for increased sensitivity over conventional staging methods. © 1997 Elsevier Science B.V.

Background Following thoracotomy, patients frequently receive routine respiratory physiotherapy which may include incentive spirometry, a breathing technique characterised by deep breathing performed through a device offering visual feedback. This type of physiotherapy is recommended and considered important in the care of thoracic surgery patients, but high quality evidence for specific interventions such as incentive spirometry remains lacking. Methods 180 patients undergoing thoracotomy and lung resection participated in a prospective single-blind randomised controlled trial. All patients received postoperative breathing exercises, airway clearance and early mobilisation; the control group performed thoracic expansion exercises and the intervention group performed incentive spirometry. Results No difference was observed between the intervention and control groups in the mean drop in forced expiratory volume in 1 s on postoperative day 4 (40% vs 41%, 95% CI −5.3% to 4.2%, p=0.817), the frequency of postoperative pulmonary complications (PPC) (12.5% vs 15%, 95% CI −7.9% to 12.9%, p=0.803) or in any other secondary outcome measure. A high-risk subgroup (defined by ≥2 independent risk factors; age ≥75 years, American Society of Anaesthesiologists score ≥3, chronic obstructive pulmonary disease (COPD), smoking status, body mass index ≥30) also demonstrated no difference in outcomes, although a larger difference in the frequency of PPC was observed (14% vs 23%) with 95% CIs indicating possible benefit of intervention (−7.4% to 2.6%). Conclusions Incentive spirometry did not improve overall recovery of lung function, frequency of PPC or length of stay. For patients at higher risk for the development of PPC, in particular those with COPD or current/recent ex-smokers, there were larger observed actual differences in the frequency of PPC in favour of the intervention, indicating that investigations regarding the physiotherapy management of these patients need to be developed further.

Introduction Video-assisted thoracoscopic surgical (VATS) lobectomy is increasingly used for curative intent lung cancer surgery compared to open thoracotomy due to its minimally invasive approach and associated benefits. However, the effect of the VATS approach on postoperative pulmonary complications (PPC), rehabilitation and physiotherapy requirements is unclear; our study aimed to use propensity score matching to investigate this. Methods Between January 2012 and January 2016 all consecutive patients undergoing lobectomy via thoracotomy or VATS were prospectively observed. Exclusion criteria included VATS converted to thoracotomy, re-do thoracotomy, sleeve/bi-lobectomy and tumour size >7 cm diameter (T3/T4). All patients received physiotherapy assessment on postoperative day 1 (POD1), and subsequent treatment as deemed appropriate. PPC frequency was measured daily using the Melbourne Group Scale. 1 Postoperative length of stay (LOS), high dependency unit (HDU) LOS, intensive therapy unit (ITU) admission and in-hospital mortality were observed. Propensity score matching (PSM) was performed using previous identified PPC risk factors (age, ASA score, BMI, COPD, current smoking) and lung cancer staging. Results Over 4 years 736 patients underwent lobectomy with 524 remaining after exclusions; 252 (48%) thoracotomy and 272 (52%) VATS cases. PSM produced 215 matched pairs. VATS approach was associated with less PPC (7.4% Vs 18.6%; p Conclusions This study demonstrates that patients undergoing VATS lobectomy developed less PPC and had improved associated outcomes compared to thoracotomy. Patients were more mobile earlier, required half the physiotherapy resources, having fewer pulmonary and mobility issues. Reference Agostini P, et al . Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Thorax 2010; 65 (9):815–8.

Introduction Monitoring patients at risk of mesothelioma, earlier diagnosis and improving diagnostic tests are top research priorities set by the James Lind Alliance. Chest wall motion (CWM) can be quantified using structured light plethysmography (SLP). During SLP a single source of visible light projects a chequerboard grid onto the anterior chest wall of a patient; two spaced cameras record changes in the contours of the grid to calculate thoracic volume changes. This study aimed to assess whether there are quantifiable differences in CWM between benign pleural disease and mesothelioma using SLP. Methods Patients attending the preoperative assessment clinic for an elective diagnostic pleural biopsy were prospective recruited. After giving consent, patients underwent a timed 5 minute SLP recording of tidal breathing whilst resting in an upright seated position. Recordings were done prior to surgery and analysis of the SLP recording was performed by a blinded technician. Histology results were collected after surgery and Mann Whitney U two tailed tests of SLP values performed. Results Fifteen patients were recruited with a median age 71 (23–93 range), 90% were male. Patients subsequently diagnosed with mesothelioma (n = 4) had significantly different values in three measurements: the inspiratory to expiratory time ratio (Ti/Te, p = 0.009), breath phase between ribcage and abdomen (breath phase RC2AB, p = 0.013) and the variation in ratio of inspiratory flow at 50% of tidal motion to expiratory flow at 50% of tidal motion (IE50 IQR, p = 0.004). Median and interquartile ranges for breath phase (a measure of CWM synchrony) are shown in Figure 1. The recording process was highly acceptable to patients. Conclusions Mesothelioma affects the ratio of time for inspiration and expiration as well as synchrony in CWM and variability of the breathing pattern. SLP is rapid, portable, non-invasive, requires minimal operator training and involves no radiation. The differences found indicate that CWM measurement is a promising tool to diagnose or exclude mesothelioma and potentially to monitor patients at risk of mesothelioma, further studies using SLP in this context are indicated.

Objectives Recruitment into surgical trials historically has been fraught with difficulty. We examine whether developing a multi-disciplinary research team has aided recruitment, data collection, patient retention and so success of clinical trials. In addition we look at effects on the patient experience of the surgical pathway. Methods We evaluated the development and impact of a specialist thoracic trained research team of nurses and allied health care professionals in a regional thoracic unit from 2009–2015. We assessed the impact on the recruitment into National Institute for Health Research Clinical Research Network (NIHR CRN) thoracic surgery portfolio trials. Patient experience was captured through a survey (n = 30) and research team feedback through interviews (n = 5). During the development, clear leadership and support networks were created, new members were trained by specialist thoracic research nurses to obtain competences in both research and thoracic surgery to enable confident valid informed consent and the collection of robust quality data. Results Since the development of a specialised thoracic surgery research team in 2010 the number trials have steadily increased and along with number of team members whilst clinical activity remained constant. The number of patient consented into clinical trials increased 7 fold (Table 1). From staff interviews a recurring theme was that a clear team structure and a specialist training aided them to be better patient advocate not only in research but in the clinical pathway. Patients universally agreed that involvement of the research team helped reduce their anxiety about their surgery and so enhanced patients experience. Conclusion The impact of a dedicated research team goes well beyond research but improves clinical care. Having a clear support system and a specialist trained team has increased recruitment and retention into thoracic surgical trials and enhanced the patient’s experience of research and the surgical pathway.

Vitamin D stimulates transcription of antiangiogenic and apoptotic factors that may suppress tumours, while vitamin D binding protein (DBP) may be a biomarker in murine lung cancer models. We sought to ascertain whether the vitamin D axis is altered in lung cancer or influences prognosis. 148 lung cancer patients, 68 other intrathoracic cancer patients and 33 noncancer controls were studied for up to 5 yrs. Circulating DBP and vitamin D levels were compared between groups and their effect on survival assessed by Cox regression analysis. Expression of DBP and vitamin D receptor (VDR) was examined in lung cancer cell lines and in normal and tumour lung tissue by Western blot and immunohistochemistry. Low serum DBP levels predicted lung cancer-specific death (p=0.04), and DBP was poorly expressed in lung cancer cells on Western blot and immunohistochemistry. Vitamin D did not predict cancer survival and VDR expression was variable in tumours. Preservation of serum DBP is a significant independent factor associated with better cancer outcome in operated lung cancer patients. Given the established role of DBP in macrophage activation and clearance of abnormal cells, further study on its involvement in lung cancer is merited.

Objectives To evaluate the recognition of postoperative pulmonary complications (PPC) following thoracotomy and lung resection using three PPC scoring tools. \ud \ud Design Prospective observational study. \ud \ud Setting Regional thoracic centre. \ud \ud Participants One hundred and twenty-nine consecutive thoracotomy and lung resection patients (October 2007 and April 2008). \ud \ud Main outcome measures PPC assessment was performed on a daily basis using three sets of criteria described by Brooks-Brunn, Gosselink et al. and Reeve et al.: the Brooks-Brunn Score (BBS), Gosselink Score (GS) and Melbourne Group Scale (MGS), respectively. The results were compared with treatment for PPC and clinical outcomes including mortality, postoperative length of stay and high dependency unit length of stay. \ud \ud Results PPC frequency was 13% (17/129) with the MGS, 6% (8/129) with the GS and 40% (51/129) with the BBS. The clinically observed incidence of treated (requiring antibiotic therapy or bronchoscopy) PPC was 12% (16/129). \ud \ud Conclusion PPC treatment following thoracotomy is common. Of the three scoring tools, the MGS outperforms the BBS and the GS in terms of PPC recognition following thoracotomy and lung resection. Patients with a PPC-positive MGS score have a worse outcome as defined by mortality, high dependency unit length of stay and postoperative length of stay. The MGS is an easy-to-use multidisciplinary scoring tool, but further work is required into its use in minimally invasive surgery and in targeting high-risk groups for therapy.

Surface-enhanced laser desorption/ionisation time-of-flight mass spectrometry (SELDI-TOF-MS) can be used to analyse peptides and proteins in clinical samples. A prospective study was undertaken on patients undergoing curative resection for non-small cell lung cancer (NSCLC): we used SELDI-TOF-MS to compare the proteomic profiles of serum from these patients both before surgical resection and after resection (disease-free) to identify potential biomarkers. Student t-tests were used, and a P-value of

Background Vitamin D-binding protein (DBP) genetic polymorphisms have been associated with chronic obstructive pulmonary disease (COPD). DBP has an indirect role in macrophage activation; thus it was hypothesised that DBP is present in the airway and contributes to lung disease by this mechanism. Methods 471 PiZZ subjects with a1-antitrypsin deficiency (AATD) were genotyped for tag single nucleotide polymorphisms (SNPs) covering the DBP gene (GC), together with known functional variants, prior to seeking association with COPD phenotypes. 140 subjects with usual COPD and 480 controls were available for replication. Vitamin D and DBP levels were measured by tandem mass spectrometry and ELISA, respectively, in serum and DBP in the sol phase of sputum in a subset of 60 patients. Concentrations were related to phenotype and to alveolar macrophage activation. Results rs2070741 was associated with airway bacterial colonisation (p¼0.04) and bronchiectasis (p¼0.01), as was rs7041 (p¼0.03) which also influenced vitamin D concentrations (p¼0.01). The GC2 variant predisposed to bronchiectasis in AATD (p¼0.04) and protected against COPD (p¼0.05); the latter association was replicated in usual COPD versus controls (p¼0.04). Circulating DBP related inversely to forced expiratory volume in 1 s (FEV1 )( p ¼0.02), in direct contrast to vitamin D, where deficiency related to low FEV1 (p¼0.04). Sol DBP related directly to alveolar macrophage activation (p¼0.004). Conclusions The genetic association of DBP with COPD may be mediated by effects on macrophage activation, since DBP relates to FEV1, and affects macrophage activation. Vitamin D effects may be independent of this, relating more strongly to innate immunity.