[Delphi Expert Consensus of the German Society for Thoracic Surgery on Segmentectomy for Non-small Cell Lung Cancer]. / Delphi-Experten-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über die anatomische Segmentresektion bei nicht kleinzelligem Lungenkarzinom.

BACKGROUND: Findings from two recently published randomised controlled trials have shown favourable oncological results of segmentectomy for early-stage NSCLC < 2 cm. This has generated a growing interest in this procedure, which is however considered technically more challenging than lobectomy. The aim of the working group of the German Society for Thoracic Surgery (DGT) was to address, via an expert consensus project, topics concerning implementation of segmentectomy in lung cancer surgery. METHODS: The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung cancer centres in Germany. The steering group predefined a priori the threshold of consensus of 75% or greater. The results were discussed in an expert meeting, leading to a final Delphi poll for selected topics and questions. RESULTS: Thirty-eight questions on segmentectomy for NSCLC were proposed in two rounds and voted on. After the final Delphi process, a consensus was reached for the following topics: non-inferiority of segmentectomy vs. lobectomy for tumours < 2 cm, segmentectomy as an alternative if lobectomy is functionally not feasible, use of intraoperative techniques for identification of intersegmental borders. No consensus could be reached for topics such as frozen section for intraoperative ascertainment of radicality, as also for the indication of a re-do lobectomy in case of an occult N1 lymph node status. CONCLUSION: Our manuscript depicts the results of a Delphi process in 2020/2021 involving experts of the German Society for Thoracic Surgery on the implementation of segmentectomy in lung cancer patients. In general, a very high rate of consensus was documented for the majority of the topics concerning the indication and execution of lung segmentectomy.

Survival outcomes in a prospective randomized multicenter Phase III trial comparing patients undergoing anatomical segmentectomy versus standard lobectomy for non-small cell lung cancer up to 2 cm.

OBJECTIVES: The oncological equivalence of anatomical segmentectomy for early stage non-small cell lung cancer (NSCLC) is still controversial. Primary aim of this study was survival outcomes in combination with improved quality of life after segmentectomy compared with lobectomy in patients with pathological stage Ia NSCLC (up to 2 cm, 7th edition) MATERIALS AND METHODS: We conducted a prospective, randomized, multicenter phase III trial to confirm the non-inferiority of segmentectomy to lobectomy in regard to prognosis (trial No. DRKS00004897). Patients were randomized to undergo either segmentectomy or lobectomy and followed up for 5-years survival and tumor recurrence. The 5-year hazard ratio comparing lobectomy with segmentectomy was required to remain above 0.5. RESULTS: Between October 2013 and June 2016, 108 patients with verified or suspected NSCLC up to 2 cm diameter were enrolled; 54 were assigned to lobectomy and 54 (1 drop-out) to segmentectomy. In-hospital and 90 days mortality was 0% in both groups. Overall survival at 5 years was 86.52% in the lobectomy compared to 78.21% in the segmentectomy group (HR = 0.61, (95% CI 0.23-1.66), p-value of non-inferiority test, p-ni = 0.687). Disease free survival was 77.29% for the lobectomy and 77.96% for the segmentectomy patients (HR = 1.50, (95% CI 0.60-3.76), p-ni = 0.019). At a median follow-up of 5 years, no differences were noted in either the locoregional or distant recurrent disease in both groups (9.4% vs 7.4%, p-ni = 0.506). CONCLUSION: Overall survival, locoregional and distant recurrences was not significantly difference for patients undergoing either segmentectomy or lobectomy for stage Ia NSCLC. The targeted non-inferiority of segmentectomy to lobectomy could not be proven for primary endpoint overall survival, but was significant for the secondary endpoint of disease free survival.

The impact of gender bias in cardiothoracic surgery in Europe: a European Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery survey.

OBJECTIVES: The European Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery designed a questionnaire to assess the impact of gender bias on a cardiothoracic surgery career. METHODS: A 46-item survey investigating gender bias was designed using online survey software from December 2020 to January 2021. All European Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery members and non-members included in the mailing lists were invited to complete an electronic survey. Descriptive statistics and a comparison between gender groups were performed. RESULTS: Our overall response rate was 11.5% (1118/9764), of which 36.14% were women and 63.69% were men. Women were more likely to be younger than men (P < 0.0001). A total of 66% of the women reported having no children compared to only 19% of the men (P < 0.0001). Only 6% of women vs 22% of men were professors. More women (72%) also reported never having been a formal mentor themselves compared to men (38%, P < 0.0001). A total of 35% of female respondents considered leaving surgery because of episodes of discrimination compared to 13% of men; 67% of women said that they experienced being unfairly treated due to gender discrimination. Of the male surgeons, 31% reported that they were very satisfied with their career compared to only 17% of women (P < 0.0001). CONCLUSIONS: Women in cardiothoracic surgery reported significantly high rates of experiences with bias that may prevent qualified women from advancing to positions of leadership. Efforts to mitigate bias and support the professional development of women are at the centre of newly formed European committees.

["Tissue Handling" in Thoracic Surgery - Results of a Delphi Expert Consensus Conference of the German Society for Thoracic Surgery]. / "Gewebehandling" in der Thoraxchirurgie ­ Ergebnisse einer Delphi-Konsensuskonferenz der Deutschen Gesellschaft für Thoraxchirurgie.

BACKGROUND: The aim of this working group of the German Society for Thoracic Surgery (DGT) was to develop an expert consensus based on the Delphi method to define "tissue handling" and depict intraoperative handling of specific anatomical structures during thoracic surgery. METHODS: Invited experts (thoracic surgery specialists; n = 93) completed two consecutive rounds of electronic Delphi questions on four main topics: transection of lung parenchyma, dissection/separation of pulmonary vessels, angioplasty/vascular anastomoses, and bronchus settling closure/plasty/anastomosis. Consensus was set at ≥ 75% agreement. At the subsequent expert conference, the results of the Delphi surveys were discussed and TED voting was used to try to reach consensus. RESULTS: In each case, 66 (71%) answers were given in the first round of questions and 33 (35%) in the second round. Disputed questions were evaluated again by a final vote at the expert conference (54 participants; average participation 55%). The term "tissue handling" includes all procedures for dissection, transection, sealing, and reconstruction of various autologous tissues in the context of thoracic surgery (100% consensus). Similarly, the term "angioplasty expansion" was defined with a 97% consensus. Consensus was reached mainly for the technique of transecting the lung parenchyma using stapling suture devices, the recommendation of covering anastomoses as well as bronchial stump after pretreatment (> 75%). CONCLUSIONS: This expert consensus describes for the first time the concept of tissue handling in thoracic surgery. Furthermore, this Delphi process led to a comprehensive current inventory of different intraoperative procedures in German thoracic surgery with derived consensual recommendations for tissue handling of lung parenchyma, vessels and bronchial structures.

Endoscopic lung volume reduction with endobronchial valves in very low D LCO patients: results from the German Registry - Lungenemphysemregister e.V.

BACKGROUND: Endoscopic lung volume reduction (ELVR) with valves has been suggested to be the key strategy for patients with severe emphysema and concomitant low diffusing capacity of the lung for carbon monoxide (D LCO). However, robust evidence is still missing. We therefore aim to compare clinical outcomes in relation to D LCO for patients treated with ELVR. METHODS: We assessed D LCO at baseline and 3 months follow-up and compared pre- and postprocedural pulmonary function test, quality of life, exercise capacity and adverse events. This is a retrospective subanalysis of prospectively collected data from the German Lung Emphysema Registry. RESULTS: In total, 121 patients treated with ELVR were analysed. Thirty-four patients with a D LCO ≤20% and 87 patients with a D LCO >20% showed similar baseline characteristics. After ELVR, there was a decrease of residual volume (both p<0.001 to baseline) in both groups, and both demonstrated better quality of life (p<0.01 to baseline). Forced expiratory volume in 1 s (FEV1) improved significantly only in patients with a D LCO >20% (p<0.001 to baseline). Exercise capacity remained almost unchanged in both groups (p=0.3). The most frequent complication for both groups was a pneumothorax (D LCO ≤20%: 17.6% versus D LCO >20%: 16.1%; p=0.728). However, there were no significant differences in other adverse events between both groups. CONCLUSIONS: ELVR improves lung function as well as quality of life in patients with D LCO >20% and D LCO ≤20%. Adverse events did not differ between groups. Therefore, ELVR should be considered as a treatment option, even in patients with a very low D LCO.

From female surgical resident to academic leaders: challenges and pathways forward.

Despite an increasing number of female surgeons it is still very difficult for them to get into high rank positions. What are the obstacles for women to achieve a professional level where they can lead teams, departments or organisations or be invited as speakers in meetings or for editorial comments? Besides the general attitude still existing in many societies that women are responsible for child care there is a clear difference in self-presentation of women compared to their male counterparts. Women tend to underestimate their competence and skills whereas (often male) decision makers expect candidates to present themselves in a rather self-confident way. This unrecognized bias and the "glass ceiling" are encountered by many women in their career. Prestigious activities like publishing papers, presenting at conferences or working in committees are predominantly searched for by male colleagues whereas it is not uncommon for women to be confined to tasks in clinical workflow. Another bias is calling women by their first names instead of their full names, professional titles and achievements. Women should always introduce themselves by full name. Mentoring is a helpful career tool for female surgeons. A mentor can assist a mentee with strategic planning and help to redefine her way especially after a setback. When she clearly communicates her needs and expectations to seniors it shows her ambition and willingness to advance her career. Finding sponsorship is even more beneficial as a sponsor can use his influence to promote a woman to a high rank position. Surgical women´s associations exist worldwide. They enable young professionals to get in contact to female leaders/role models and exchange views with female colleagues. Institutional programs for (gender) equity are installed in some places to facilitate scientific and professional career advancement. Women are as capable as men although it is a greater challenge.

[Delphi Expert Consensus of the German Thoracic Surgery Society on Perioperative Management of Oncological Anatomical Lung Resections]. / Delphi-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über das perioperative Management bei onkologischen anatomischen Lungenresektionen.

BACKGROUND: Anatomical lung resection for curative treatment of a tumour disease is the most common selective procedure in oncological thoracic surgery. The goal of the working group of the German Thoracic Surgery Society (DGT) was to achieve a consensus on the perioperative management of selective oncological lung resection procedures. METHODS: The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung centres. Consensus was considered as a rate of ≥ 75%. After statistical analysis of the results, an expert meeting took place and a final Delphi process poll was used in order to reach consensus for controversial topics. RESULTS: Fourteen questions on the perioperative management of anatomical oncological lung resections were proposed and voted on. A consensus was reached for the following topics: preoperative infectiological screening, extended respiratory diagnostics for impaired lung function, use of a cardiac risk assessment score, postoperative monitoring, prophylaxis for venous thromboembolism, control bronchoscopy after sleeve resections or pneumonectomy, blood gas test before discharge from the hospital. No consensus was reached for the following topics: preoperative endobronchial microbiological diagnostics, pleural rinsing, standardised clinical chemistry blood test postoperatively. CONCLUSION: Our manuscript depicts the results of a Delphi process in 2018/2019 involving experts of the German Thoracic Surgery Society from high volume departments certified for thoracic surgery and/or lung cancer surgery. In general, a very high rate of consensus was documented for the majority of the topics concerning the perioperative management of oncological anatomical selective lung resection procedures. The most important topic for which no consensus could be reached was preoperative endobronchial microbiological diagnostic testing.

[Lymphadenectomy during Potentially Curative Pulmonary Metastasectomy - Recommendations of an Expert Consensus Panel using the Delphi Process]. / Die Lymphadenektomie im Rahmen der kurativ intendierten Lungenmetastasenchirurgie ­ Konsensusempfehlungen einer Expertengruppe basierend auf dem Delphi-Verfahren.

BACKGROUND: The aim of the consensus approach was to improve the quality of care by agreement on definitions and standards, in order to harmonise lymphadenectomy during lung metastasectomy. METHODS: The Delphi process consisted of two rounds of anonymous voting before discussion at a consensus meeting to reach final consensus within a group of experts. Consensus was assumed when > 75% of the panel agreed. RESULTS: Of 76 invited experts (board certified thoracic surgeons leading high-volume thoracic departments), 49 and 47 participated in the first and second round questionnaire, respectively. 43 experts attended the consensus meeting and reached consensus on the following: surgical approach for solitary subpleurally located lung metastasis is videothoracoscopy compared to anterolateral thoracotomy for multiple lung metastases. Lymphadenectomy is performed irrespective of the surgical approach. Systematic lymphadenectomy or sampling are core elements of pulmonary metastasectomy for colorectal, renal and non-seminomatous testicular cancer. The size of pulmonary metastasis does not influence lymphadenectomy per se. Pulmonary metastasectomy is not abolished in case of intraoperatively detected lymph node metastases. CONCLUSIONS: An expert group agreed on recommendations for lymphadenectomy during pulmonary metastasectomy using the Delphi process.

[Delphi Expert Consensus of the German Thoracic Surgery Society on the Management of Chest Tube Drainage]. / Delphi-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über das Management von Thoraxdrainagen.

BACKGROUND: Chest tubes are a valuable instrument and are used on a daily basis - not only by thoracic surgeons but also by a variety of medical specialists who treat pneumothorax or pleural effusions. The goal of the working group of the German Thoracic Society (DGT) was to achieve a consensus on the management of chest tube/drainage using the Delphi process. METHODS: The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung cancer centres. Consensus was considered as rate of ≥ 75%. After statistical analysis of the results, an expert meeting took place and a final Delphi process poll was used in order to reach consensus for controversial topics. RESULTS: Thirteen questions on the management of chest tubes were proposed and voted on. A consensus was reached for the following topics: conditions for chest tube insertion, size of drainage/tube, technique of insertion, diagnostic measures after insertion and prior to removal, post-interventional management, documentation, number of chest tubes after anatomical lung resection, use of fibrinolytic agents, type of negative pressure. No consensus was reached for the following topics: autologous blood pleurodesis, reduction of suction in cases of persistent air leakage. CONCLUSION: Our manuscript depicts the results of a Delphi process in 2017 - 1018 involving experts of the German Thoracic Society from high volume departments certified for thoracic surgery. A very high rate of consensus was documented for topics such as chest tube insertion, peri-interventional management and removal algorithm. The most important topic for which there was no consensus was the case of persistent air leakage. The resulting expert recommendations of the Delphi process could be used as a starting point for internal clinical procedures.