Uniportal Video-Assisted Thoracoscopic Surgery Completion Lobectomy Long after Wedge Resection or Segmentectomy in the Same Lobe: A Bicenter Study.

BACKGROUND: Completion lobectomy (CL) following a prior resection in the same lobe may be complicated by severe pleural or hilar adhesions. The role of uniportal video-assisted thoracoscopic surgery (U-VATS) has never been evaluated in this setting. METHODS: Data were collected from two Italian centers. Between 2015 and 2022, 122 patients (60 men and 62 women, median age 67.7 ± 8.913) underwent U-VATS CL at least 4 weeks after previous lung surgery. RESULTS: Twenty-eight (22.9%) patients were affected by chronic obstructive pulmonary disease (COPD) and twenty-five (20.4%) were active smokers. Among the cohort, the initial surgery was performed using U-VATS in 103 (84.4%) patients, triportal-VATS in 8 (6.6%), and thoracotomy in 11 (9.0%). Anatomical segmentectomy was the initial surgery in 46 (37.7%) patients, while hilar lymphadenectomy was performed in 16 (13.1%) cases. CL was performed on 110 (90.2%) patients, segmentectomy on 10 (8.2%), and completion pneumonectomy on 2 (1.6%). Upon reoperation, moderate pleural adhesions were observed in 38 (31.1%) patients, with 2 (1.6%) exhibiting strong adhesions. Moderate hilar adhesions were found in 18 (14.8%) patients and strong adhesions in 11 (9.0%). The median operative time was 203.93 ± 74.4 min. In four (3.3%) patients, PA taping was performed. One patient experienced intraoperative bleeding that did not require conversion to thoracotomy. Conversion to thoracotomy was necessary in three (2.5%) patients. The median postoperative drainage stay and postoperative hospital stay were 5.67 ± 4.44 and 5.52 ± 2.66 days, respectively. Postoperative complications occurred in 34 (27.9%) patients. Thirty-day mortality was null. Histology was the only factor found to negatively influence intraoperative outcomes (p = 0.000). Factors identified as negatively impacting postoperative outcomes at univariate analyses were male sex (p = 0.003), age > 60 years (p = 0.003), COPD (p = 0.014), previous thoracotomy (p = 0.000), previous S2 segmentectomy (p = 0.001), previous S8 segmentectomy (p = 0.008), and interval between operations > 5 weeks (p= 0.005). In multivariate analysis, only COPD confirmed its role as an independent risk factor for postoperative complications (HR: 5.12, 95% CI (1.07-24.50), p = 0.04). CONCLUSIONS: U-VATS CL seems feasible and safe after wedge resection and anatomical segmentectomy.

A Machine Learning Approach for Postoperative Outcome Prediction: Surgical Data Science Application in a Thoracic Surgery Setting.

BACKGROUND: The use of innovative methodologies, such as Surgical Data Science (SDS), based on artificial intelligence (AI) could prove to be useful for extracting knowledge from clinical data overcoming limitations inherent in medical registries analysis. The aim of the study is to verify if the application of an AI analysis to our database could develop a model able to predict cardiopulmonary complications in patients submitted to lung resection. METHODS: We retrospectively analyzed data of patients submitted to lobectomy, bilobectomy, segmentectomy and pneumonectomy (January 2006-December 2018). Fifty preoperative characteristics were used for predicting the occurrence of cardiopulmonary complications. The prediction model was developed by training and testing a machine learning (ML) algorithm (XGBOOST) able to deal with registries characterized by missing data. We calculated the receiver operating characteristic curve, true positive rate (TPR), positive predictive value (PPV) and accuracy of the model. RESULTS: We analyzed 1360 patients (lobectomy: 80.7%, segmentectomy: 11.9%, bilobectomy 3.7%, pneumonectomy: 3.7%) and 23.3% of them experienced cardiopulmonary complications. XGBOOST algorithm generated a model able to predict complications with an area under the curve of 0.75, a TPR of 0.76, a PPV of 0.68. The model's accuracy was 0.70. The algorithm included all the variables in the model regardless of their completeness. CONCLUSIONS: Using SDS principles in thoracic surgery for the first time, we developed an ML model able to predict cardiopulmonary complications after lung resection based on 50 patient characteristics. The prediction was also possible even in the case of those patients for whom we had incomplete data. This model could improve the process of counseling and the perioperative management of lung resection candidates.

Uniportal video-assisted thoracoscopic thymectomy: the glove-port with carbon dioxide insufflation.

BACKGROUND: Since 2004, uniportal video-assisted thoracic surgery (VATS) approach was progressively widespread and also applied in the treatment of thymoma, with promising results. We report the first series of patients who undergone uniportal VATS thymectomy using a homemade glove-port with carbon dioxide (CO2) insufflation. The aim of this article is to analyze the safety and feasibility to perform an extended thymectomy (ET). METHODS: A prospective, single-centre, short-term observational study including patients with mediastinal tumours undergoing scheduled uniportal VATS resection using a glove-port with CO2. Operations were performed through a single incision of 3.5 cm at the fifth intercostal space, right or left anterior axillary line. A 5 mm-30° camera and working instruments were employed through a glove-port with CO2. RESULTS: Thirty-eight patients (20 men; mean age 61.6 years) underwent ET between September 2016 and October 2019. Thirteen patients had a history of Myasthenia Gravis (MG) with thymoma and 8 had incidental findings of thymoma. Additionally, 8 mediastinal cysts and 9 thymic hyperplasia were included. Mean diameter of the tumor was 5.1 cm (range, 1.6-14 cm) and mean operation time was 143 minutes. Mean postoperative drainage duration and hospital stay were 2.3 and 4.3 days, respectively. Mean blood loss was 41 mL. There was no occurrence of surgical morbidity or mortality. During the follow-up period (1-36 months), no recurrence was noted. CONCLUSIONS: Our results suggest that uniportal VATS thymectomy through glove-port and CO2 is safe and feasible procedure, even with large thymomas. Furthermore, the glove-port system represents a valid, cheap and widely available alternative to the commercial devices usually adopted in thoracic surgery.

Uniportal video-assisted thoracoscopic left superior segmentectomy.

Obtaining adequate margins when performing lung cancer resection is crucially important. Therefore, during thoracoscopic segmentectomy, where the direct palpation of the tumor is not always possible, it is mandatory to accurately identify the intersegmental plane in order to achieve a satisfactory oncological and surgical result. In this video tutorial, we demonstrate a uniportal video-assisted thoracoscopic (VATS) superior segmentectomy of the left lower lobe, adopting two different techniques for identifying the intersegmental plane: the inflation-deflation method and selective resected segmental inflation, and we present the pros and cons of each. With the inflation/deflation technique, which is the most common maneuver used, we inflated the whole lung after occlusion of the target segmental bronchus, inducing collapse of the superior segment and inflation of the remaining lobe. However, this inexpensive and easy method often makes identification of the intersegmental plane unreliable because of the collateral ventilation. Moreover, because of the expansion of inflated segments, it limits thoracic working space during the VATS procedure. In contrast, selective resected segmental inflation guarantees an optimal surgical space even during a VATS procedure. In this case, we directly inflated the segmental bronchus of the superior segment through a butterfly needle in order to selectively expand only the selected segment. The careful demarcation of the intersegmental plane is mandatory in order to obtain adequate margins and achieve a high success rate for thoracoscopic segmentectomy. Although a one-size-fits-all method is not feasible, we strongly recommend  making every effort for identifying it as best as possible; indeed, its inadequate demarcation may be the main cause of unsatisfactory surgical and oncological results in terms of locoregional recurrence and long-term survival.

Computed tomography-guided microcoil placement for localizing small pulmonary nodules before uniportal video-assisted thoracoscopic resection.

PURPOSE: The increasing number of computed tomography (CT) performed allows the more frequent identification of small, solid pulmonary nodules or ground-glass opacities. Video-assisted thoracic surgery (VATS) represents the standard in most lung resections. However, since VATS limit is the digital palpation of the lung parenchyma, many techniques of nodule localization were developed. The aim of this study was to determine the feasibility and safety of CT-guided microcoil insertion followed by uniportal VATS wedge resection (WR). MATERIALS AND METHODS: Retrospective study in a single institution, including patients undergone CT-guided microcoil insertion prior to uniportal VATS resection between May 2015 and December 2018. The lesion was identified using fluoroscopy. RESULTS: Forty-six consecutive patients were enrolled (22 male and 24 female). On CT: 5 cases of GGO, 2 cases of semisolid nodules, 39 cases of solid nodules. The median pathologic tumor size was 1.21 cm. Neither conversion to thoracotomy nor microcoil dislodgement was recorded. All patients underwent uniportal VATS WR (9/46 underwent completion lobectomy after frozen section). WR median time was 105 min (range 50-150 min). No patients required intraoperative re-resection for positive margins. After radiological procedure, 1 case of hematoma and 2 cases of pneumothorax were recorded. Four complications occurred in the postoperative period. The mean duration of chest drain and length of stay were 2.9 and 4.6 days, respectively. CONCLUSIONS: CT-guided microcoil insertion followed by uniportal VATS resection was a safe and feasible procedure having a minimal associated complications rate and offering surgeons the ease of localization of small intrapulmonary nodules.

Video-assisted thoracic surgery lobectomy does not offer any functional recovery advantage in comparison to the open approach 3 months after the operation: a case matched analysis†.

OBJECTIVES: The objective of the present study was to compare functional loss [forced expiratory volume in one second to forced vital capacity ratio (FEV1), DLCO and VO2max reduction] after VATS versus open lobectomies. METHODS: We performed a prospective observational study on 195 patients who had a pulmonary lobectomy from June 2010 to November 2014 and who were able to complete a 3-months functional evaluation follow-up program. Since the VATS technique was our first choice for performing lobectomies from January 2012, we divided the patients into two groups: the OPEN group (112 patients) and the VATS group (83 patients). The open approach was intended as a muscle sparing/nerve sparing lateral thoracotomy. Fourteen baseline factors were used to construct a propensity score to match the VATS-group patients with their OPEN-group counterparts. These two matched groups were then compared in terms of reduction of FEV1, DLCO and VO2max (Mann-Whitney test). RESULTS: The propensity score analysis yielded 83 well-matched pairs of OPEN and VATS patients. In both groups, 3 months postoperatively, we found a reduction in FEV1, DLCO and VO2max values (OPEN patients: FEV1-10%, DLCO -11.9%, VO2max - 5.5%; VATS patients: FEV1-7.2%, DLCO-10.6%, VO2max-6.9%). The reductions in FEV1, DLCO and VO2max were similar to those in the two matched groups, with a Cohen effect size <0.2 for all the comparisons. CONCLUSIONS: In 3 months, both OPEN patients and VATS patients experienced a reduction in their preoperative functional parameters. VATS lobectomy does not offer any advantages in terms of FEV1, DLCO and exercise capacity recovery in comparison to the muscle-sparing thoracotomy approach.

Recurrent air leak soon after pulmonary lobectomy: an analysis based on an electronic airflow evaluation†.

OBJECTIVES: The objective of this analysis was to evaluate the incidence and risk factors of recurrent air leak (RAL) occurring soon after pulmonary lobectomy based on electronic airflow measurements. METHODS: A prospective observational analysis of 129 consecutive patients managed with a single chest tube connected with an electronic chest drainage system. The incidence and timing of RAL among patients who had an air leak sealed within the first 24 postoperative hours was recorded. Stepwise logistic regression and bootstrap analyses were used to test the association of several baseline and surgical variables with RAL. RESULTS: A total of 95 patients (68%) had their air leak stopped within 24 h after the operation. Twelve patients had RAL (13%) after the first stop. All RALs occurred within the first 24 h from operation. Logistic regression showed that the presence of moderate-to-severe chronic obstructive pulmonary disease [COPD; forced expiratory volume in 1 s (FEV1) <80% and FEV1/forced vital capacity ratio <0.7] was an independent risk factor associated with RAL (P = 0.02, bootstrap frequency 83%). Seven of 27 (26%) patients with COPD had RAL, a proportion significantly higher than in patients without COPD (5 of 68, 7.3%, P = 0.03). CONCLUSIONS: A large proportion of patients with COPD developed RAL. In this high-risk group, we advise against chest tube removal in the first 24 h after operation, even in the case of absence or cessation of air leak.

Regulated drainage reduces the incidence of recurrence after uniportal video-assisted thoracoscopic bullectomy for primary spontaneous pneumothorax: a propensity case-matched comparison of regulated and unregulated drainage†.

OBJECTIVES: To compare the recurrence rate of primary spontaneous pneumothorax (PSP) after uniportal video assisted thoracic surgery (VATS) bullectomy and mechanical pleurodesis in patients managed with a regulating pressure drainage system compared and those managed with a traditional one. METHODS: Retrospective propensity score case-matched analysis of 174 consecutive patients submitted to uniportal VATS bullectomy and mechanical pleural abrasion (2007-13) in two centres. Definition of recurrence: Recurrent PSP requiring new treatment (i.e. aspiration, chest tube reinsertion, reoperation) within 12 months from the operation. All patients were managed with a single 24-Fr chest tube. Group 1 (106 patients): Tube connected to a traditional device (T) maintained on wall suction (-20 cmH2O) for 48 h. Group 2 (68 patients): Tube connected to a regulating pressure device (R) set at -20 cmH2O for 48 h. Chest tube removal criteria: No air leak (no bubbling or air flow <20 ml/min for at least 8 h) and pleural effusion <200 ml/day. Propensity score case-matching analysis was performed using the following variables: Age, gender, height, weight, side of operation, dystrophic score, length of stapled parenchyma. RESULTS: The two groups of 68 pairs were well matched for baseline and surgical characteristics. Patients of Group 2 (R) showed a significantly lower incidence of recurrence rate compared with matched counterparts (T) (3, 4.4 vs 10, 14%, P = 0.041). There were no differences in persistent air leak incidence, chest tube duration or hospital stay between the groups. Group 2 had a higher 48-h output of pleural effusion compared with Group 1 (P < 0.0001). CONCLUSIONS: By stabilizing the pleural pressure at the preset values, novel regulating pressure devices may enhance pleurodesis, leading to a reduced incidence of PSP recurrences after uniportal VATS bullectomy and pleural abrasion.

Patient satisfaction with health-care professionals and structure is not affected by longer hospital stay and complications after lung resection: a case-matched analysis.

OBJECTIVES: The objective of this investigation was to assess satisfaction with care of patients with long hospital stay (LHS) or complications after pulmonary resection in comparison with case-matched counterparts with a regular postoperative course. METHODS: This is a prospective observational analysis on 171 consecutive patients submitted to pulmonary resections (78 wedges, 8 segmentectomies, 83 lobectomies, 3 pneumonectomies) for benign (35), primary (93) or secondary malignant (43) diseases. A hospital stay >7 days was defined as long (LHS). Major cardiopulmonary complications were defined according to the ESTS database. Patient satisfaction was assessed by the administration of the EORTC IN-PATSAT32 module at discharge. The questionnaire is a 32-item self-administered survey including different scales, reflecting the perceived level of satisfaction about the care provided by doctors, nurses and other personnel. To minimize selection bias, propensity score case-matching technique was applied to generate two sets of matched patients: patients with LHS with counterparts without it; patients with complications with counterparts without it. RESULTS: Median length of postoperative stay was 4 days (range 2-43). Forty-one patients (24%) had a hospital stay>7 days and 21 developed cardiopulmonary complications (12%). Propensity score yielded two well-matched groups of 41 patients with and without LHS. There were no significant differences in any patient satisfaction scale between the two groups. The comparison of the results of the patient satisfaction questionnaire between the two matched groups of 21 patients with and without complications did not show significant differences in any scale. CONCLUSIONS: Patients experiencing poor outcomes such as long hospital stay or complications have similar perception of quality of care compared with those with regular outcomes. Patient-reported outcome measures are becoming increasingly important in the evaluation of the quality of care and may complement more traditional objective indicators such as morbidity or length of stay.

Real-time database drawn from an electronic health record for a thoracic surgery unit: high-quality clinical data saving time and human resources.

OBJECTIVES: The aim of the present study was to verify whether the implementation of an electronic health record (EHR) in our thoracic surgery unit allows creation of a high-quality clinical database saving time and costs. METHODS: Before August 2011, multiple individuals compiled the on-paper documents/records and a single data manager inputted selected data into the database (traditional database, tDB). Since the adoption of an EHR in August 2011, multiple individuals have been responsible for compiling the EHR, which automatically generates a real-time database (EHR-based database, eDB), without the need for a data manager. During the initial period of implementation of the EHR, periodic meetings were held with all physicians involved in the use of the EHR in order to monitor and standardize the data registration process. Data quality of the first 100 anatomical lung resections recorded in the eDB was assessed by measuring the total number of missing values (MVs: existing non-reported value) and inaccurate values (wrong data) occurring in 95 core variables. The average MV of the eDB was compared with the one occurring in the same variables of the last 100 records registered in the tDB. A learning curve was constructed by plotting the number of MVs in the electronic database and tDB with the patients arranged by the date of registration. RESULTS: The tDB and eDB had similar MVs (0.74 vs 1, P = 0.13). The learning curve showed an initial phase including about 35 records, where MV in the eDB was higher than that in the tDB (1.9 vs 0.74, P = 0.03), and a subsequent phase, where the MV was similar in the two databases (0.7 vs 0.74, P = 0.6). The inaccuracy rate of these two phases in the eDB was stable (0.5 vs 0.3, P = 0.3). Using EHR saved an average of 9 min per patient, totalling 15 h saved for obtaining a dataset of 100 patients with respect to the tDB. CONCLUSION: The implementation of EHR allowed streamlining the process of clinical data recording. It saved time and human resource costs, without compromising the quality of data.

The use of the Thoracic Morbidity and Mortality system for the internal analysis of performance: a case-matched temporal audit.

OBJECTIVES: The aim of the present study was to evaluate the usefulness of the Thoracic Morbidity and Mortality (TMM) scoring system in auditing the quality of care of our unit. METHODS: We analysed the performance of our unit comparing the incidence of complications and mortality occurring after anatomic lung resections during two different periods: early period (January 2000 to December 2009: 830 lobectomy, 134 pneumonectomy and 78 segmentectomy) and recent period (January 2010 to August 2012: 191 lobectomy, 8 pneumonectomy and 19 segmentectomy). The cardiopulmonary complications as traditionally defined in the European Society of Thoracic Surgeons (ESTS) database were also classified according to the TMM system: this method grades the postoperative adverse events from 1 to 5 reflecting an increasing severity of management regardless the type of complication. Complications graded higher than 2 are regarded as major complications. To account for confounders, several baseline and surgical factors were used to build a propensity score that was applied to match the patients of the most recent group with their early-group counterparts. These two matched groups were compared in terms of cardiopulmonary morbidity (codified by ESTS definitions) and mortality rates and incidence of major complications according to the TMM system. RESULTS: The propensity score analysis yielded 209 well-matched pairs of patients operated on in the two periods. The two groups had similar rates of ESTS-defined cardiopulmonary complications (recent: 38 patients vs early: 37 patients, P = 0.9). The use of the TMM system revealed a higher incidence of major (grade > 2) complications rate in the recent period (recent: 29 patients vs early: 14 patients, P = 0.02). CONCLUSIONS: The TMM scoring system for classifying the postoperative complications revealed a decline of quality of care of our unit otherwise undetected by applying traditional outcome measures. This tool can be used as an additional graded outcome endpoint to refine internal audit of performance.

Can maximal inspiratory and expiratory pressures during exercise predict complications in patients submitted to major lung resections? A prospective cohort study.

OBJECTIVES: The measurement of maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax) generated at the mouth is an accepted non-invasive clinical method for evaluating the strength of respiratory muscles. The aim of our study was to verify whether PImax and PEmax measured before and after a symptom-limited stair-climbing test are associated with complications in patients submitted to major lung resections. METHODS: In a prospective cohort study of 283 consecutive patients submitted to lobectomy (231) or pneumonectomy (52) with a preoperative symptom-limited stair-climbing test, PImax and PEmax were measured before and immediately after the exercise. PImax and PEmax values were expressed as percentages of predicted values. ΔPImax and ΔPEmax were defined as the percentage difference between the pre- and postexercise values. Logistic regression analysis and the bootstrap resampling technique were performed to identify predictors of cardiopulmonary complications. RESULTS: On average, PImax dropped by 3.6% and PEmax increased by 0.8% after the exercise. In total, 173 patients (61%) experienced a reduction in their PImax after exercise, while 150 (53%) had their PEmax reduced. Postoperative cardiopulmonary complications occurred in 74 patients (26%). Complicated patients had a greater reduction in their PImax compared with non-complicated patients (8.7% vs 2.1%, P = 0.03), whereas ΔPEmax was similar in complicated and non-complicated patients (0.7% vs 1.3%, P = 0.5). Receiver operating characteristic analysis indicated that the best cut-off for predicting complications was a ΔPImax of 10%. Stepwise logistic regression analysis and bootstrap confirmed that ΔPImax of >10 was associated with cardiopulmonary complications after adjusting for baseline and surgical factors (ΔPImax regression coefficient -0.02, P = 0.09, bootstrap frequency 51%). A progressive increase in complications was observed in patients with greater reduction in ΔPImax after exercise, particularly for values >10% reduction. CONCLUSION: The measurement of PImax at the mouth during exercise represents an additional parameter that can be used to refine risk stratification of lung resection candidates and to identify patients who may benefit from inspiratory muscle training.

Major morbidity after lung resection: a comparison between the European Society of Thoracic Surgeons Database system and the Thoracic Morbidity and Mortality system.

OBJECTIVE: The Thoracic Morbidity and Mortality (TM&M) classification system is a method for univocally coding the postoperative adverse events by their complexity of management. The aim of the present study was to compare the distribution of the severity of complications according to the TM&M system versus the distribution according to the classification proposed by European Society of Thoracic Surgeons (ESTS) Database in a population of patients submitted to lung resection in our unit. METHODS: 457 patients with any type of complications (326 lobectomy, 60 pneumonectomy, 71 wedge/segmentectomy) out of 1,518 patients submitted to pulmonary resections (January 2000-April 2011) were analyzed. Each complication was graded from I to V (TM&M system), reflecting an increasing severity of management. We verified the distribution of the different grades of complications and analyzed their frequency among those defined as "major cardio-pulmonary complications" by the ESTS Database. RESULTS: According to the TM&M system, 0.6% of complications were regarded as grade I, 66.3% as grade II, 9.5% as grade IIIa, 4.4% as grade IIIb, 6.8% as grade IVa, 3.3% as grade IVb and 9.1% as grade V. According to the ESTS definitions, 290 complications were regarded as "major". Sixty two percent of them were reclassified as minor complications (grade I or II) by the TM&M classification system. CONCLUSIONS: The application of the TM&M grading system questions the traditional classification of complications following lung resection. This grading system may be used as an additional endpoint for outcome analyses.

Development of a patient-centered aggregate score to predict survival after lung resection for non-small cell lung cancer.

OBJECTIVE: The objective of this analysis was to develop a survival aggregate score (SAS), including objective and subjective patient-based parameters, and assess its prognostic role after major anatomic resection for non-small cell lung cancer. METHODS: A total of 245 patients underwent major lung resections for non-small cell lung cancer with preoperative evaluation of quality of life (Short-Form 36v2 survey) and complete follow-up. The Cox multivariable regression and bootstrap analyses were used to identify prognostic factors of overall servival, which were weighted to construct the scoring system and summed to generate the SAS. RESULTS: Cox regression analysis showed that the factors negatively associated with overall survival and used to construct the score were 36-item short-form health survey physical component summary score less than 50 (hazard ratio [HR], 1.7; P = .008), aged older than 70 years (HR, 1.9; P = .002), and carbon monoxide lung diffusion capacity less than 70% (HR, 1.7; P = .01). Patients were grouped into 4 risk classes according to their SAS. The 5-year overall survival was 78% in class SAS0, 59% in class SAS1, 42% in class SAS2, and 14% in class SAS3 (log-rank test, P < .0001). SAS maintained its association with overall survival in patients with stages pT1 (log-rank test, P = .01), pT2 (log-rank test, P = .02), or pT3-4 (log-rank test, P = .001), and in those with stages pN0 (log-rank test, P = .0005) or pN1-2 (log-rank test, P = .02). The 5-year cancer-specific survival was 83% in class SAS0, 71% in class SAS1, 63% in class SAS2, and 17% in class SAS3 (log-rank test, P < .0001). CONCLUSIONS: This system may be used to refine stratification of prognosis for clinical and research purposes.

Patient satisfaction after pulmonary resection for lung cancer: a multicenter comparative analysis.

BACKGROUND: Patient satisfaction reflects the perception of the customer about the level of quality of care received during the episode of hospitalization. OBJECTIVE: To compare the levels of satisfaction of patients submitted to lung resection in two different thoracic surgical units. METHODS: Prospective analysis of 280 consecutive patients submitted to pulmonary resection for neoplastic disease in two centers (center A: 139 patients; center B: 141 patients; 2009-2010). Patients' satisfaction was assessed at discharge through the EORTC-InPatSat32 module, a 32-item, multi-scale self-administered anonymous questionnaire. Each scale (ranging from 0 to 100 in score) was compared between the two units. Multivariable regression and bootstrap were used to verify factors associated with the patients' general satisfaction (dependent variable). RESULTS: Patients from unit B reported a higher general satisfaction (91.5 vs. 88.3, p = 0.04), mainly due to a significantly higher satisfaction in the doctor-related scales (doctors' technical skill: p = 0.001; doctors' interpersonal skill: p = 0.008; doctors' availability: p = 0.005, and doctors information provision: p = 0.0006). Multivariable regression analysis and bootstrap confirmed that level of care in unit B (p = 0.006, bootstrap frequency 60%) along with lower level of education of the patient population (p = 0.02, bootstrap frequency 62%) were independent factors associated with a higher general patient satisfaction. CONCLUSION: We were able to show a different level of patient satisfaction in patients operated on in two different thoracic surgery units. A reduced level of patient satisfaction may trigger changes in the management policy of individual units in order to meet patients' expectations and improve organizational efficiency.

Predicted versus observed peak oxygen consumption after major pulmonary resection.

BACKGROUND: The aim of this study was to verify the accuracy of predicted postoperative peak VO(2) in predicting the actual peak VO(2) after major pulmonary resection. METHODS: This was a prospective longitudinal series of 110 consecutive patients who underwent lobectomy (101 patients) or pneumonectomy (9 patients), with complete preoperative and postoperative (3 months) cardiopulmonary exercise testing (CPET). Predicted postoperative peak VO(2) was calculated by subtracting from the preoperative peak VO(2) the contribution of unobstructed pulmonary segments removed during operation. Predicted postoperative peak VO(2) and actual postoperative peak VO(2) were compared by the paired sign test. RESULTS: The average value of preoperative peak VO(2) was 16.8 mL/kg/min or 64.1% of predicted. The actual value of postoperative peak VO(2) was 15.9 mL/kg/min or 64.4% of predicted. The actual postoperative peak VO(2) was higher than the predicted postoperative peak VO(2) (15.9 versus 13.1 mL/kg/min; p < 0.0001; 64.4% versus 50.1%; p < 0.0001). Of the 23 patients with a predicted postoperative peak VO(2) less than 10 mL/kg/min, 19 had an actual postoperative peak VO(2) greater than 10 mL/kg/min (average value 13.3 mL/kg/min). All 11 patients with a predicted postoperative peak VO(2) less than 35% of predicted had an actual postoperative peak VO(2) greater than 35% of predicted (average value, 55.8%). CONCLUSIONS: The prediction of postoperative peak V̇O(2) using the segmental technique was inaccurate. The use of predicted postoperative peak VO(2) for patient selection must be cautioned against; future studies are warranted to refine its estimation.

Minute ventilation-to-carbon dioxide output (VE/VCO2) slope is the strongest predictor of respiratory complications and death after pulmonary resection.

BACKGROUND: This study assessed whether the minute ventilation-to-carbon dioxide output (VE/VCO2) slope, a measure of ventilatory efficiency routinely measured during cardiopulmonary exercise testing (CPET), is an independent predictor of respiratory complications after major lung resections. METHODS: Prospective observational analysis was performed on 225 consecutive candidates after lobectomy (197 patients) or pneumonectomy (28 patients) from 2008 to 2010. Inoperability criteria were peak oxygen consumption (VO2) of less than 10 mL/kg/min in association with predicted postoperative forced expiratory volume in 1 second of less than 30% and diffusion capacity of the lung for carbon monoxide of less than 30%. All patients performed a symptom-limited CPET on cycle ergometer. Respiratory complications (30 days or in-hospital) were prospectively recorded: pneumonia, atelectasis requiring bronchoscopy, respiratory failure on mechanical ventilation exceeding 48 hours, adult respiratory distress syndrome, pulmonary edema, and pulmonary embolism. Univariable and multivariable regression analyses were used to identify independent predictors of respiratory complications. RESULTS: Cardiopulmonary morbidity and mortality rates were 23% (51 patients) and 2.2% (5 patients). The 25 patients with respiratory complications had a significantly higher VE/VCO2 slope than those without complications (34.8 vs 30.9, p=0.001). Peak VO2 was not associated with respiratory complications. Logistic regression and bootstrap analyses showed that, after adjusting for other baseline and perioperative variables, the strongest predictor of respiratory complications was VE/VCO2 slope (regression coefficient, 0.09; bootstrap frequency, 89%; p=0.004). Patients with a VE/VCO2 slope exceeding 35 had a higher incidence of respiratory complications (22% vs 7.6%, p=0.004) and mortality (7.2% vs. 0.6%, p=0.01). CONCLUSIONS: VE/VCO2 slope is a better predictor of respiratory complications than peak VO2. This inexpensive and operator-independent variable should be considered in the clinical practice to refine operability selection criteria.

Does fast-tracking increase the readmission rate after pulmonary resection? A case-matched study.

OBJECTIVES: The most recent evolution of patient management after thoracic surgery implies the concept of fast-tracking. Since 2008, our unit has implemented a programme based on clinical protocols and standardized pathways of care aimed to reduce the postoperative stay after major lung resection. The objective of this study was to verify the safety of this policy by monitoring the patient readmission rate. METHODS: This is a prospective observational study on 914 consecutive pulmonary lobectomies performed at our institution from January 2000 to October 2010. Since we started the fast-tracking program in January 2008, we divided the patients into two groups: early period (678 patients, 2000-2007) and recent period (236 patients, 2008-October 2010). Several baseline and operative factors were used to build a propensity score that was applied to match the recent group patients with their early group counterparts. These two matched groups were then compared in terms of early outcomes and readmission rate. Readmission was defined as a re-hospitalization for any cause related to the operation within 30 days after discharge. We excluded from the analysis those patients with in-hospital mortality. RESULTS: Propensity score yielded 232 well-matched pairs operated on in the early (non-fast-tracked patients) and most recent period (fast-tracked patients). The fast-tracking management resulted in a postoperative stay reduction of 2.8 days (P < 0.0001), with a 3-fold higher proportion of patients discharged before the sixth postoperative day (P < 0.0001). Nevertheless, we did not observe any differences in terms of readmission rate between the two periods. CONCLUSIONS: In our experience, the implementation of a fast-tracking program after pulmonary lobectomy was very effective and safe. It led to a postoperative reduction of hospital stay without an increase in the readmission rate.

The impact of chest tube removal on pain and pulmonary function after pulmonary resection.

OBJECTIVE: The aim of this study was to assess the immediate influence of chest tube removal on chest pain and forced expiratory volume in 1 s (FEV1) after pulmonary resection. METHODS: Prospective longitudinal investigation on 104 consecutive patients (53 wedge/segmentectomies and 51 lobectomies; 69 muscle and nerve-sparing lateral thoracotomy and 35 video-assisted thoracoscopic surgery (VATS)). Post-operative chest pain was controlled in all patients by a standardized combination of oral and intravenous non-opioid analgesics. All patients had one chest tube (24 French). Static and dynamic (after forced expiratory effort) pain and FEV1 were assessed before and 1 h after the chest tube removal by the same operator. No additional analgesics were administered before or after the chest tube removal. The pain level was assessed by the numeric pain scale [range: 0 (no pain)-10 (excruciating pain)]. FEV1 was assessed by a portable spirometer. Bronchodilators were not used in these patients. Pre- and post-removal measurements were compared by the Wilcoxon signed rank test. RESULTS: The average pre-removal static and dynamic pain scores were 2.6 and 4.1, respectively. The static and dynamic pain scores decreased by 42 and 41%, respectively, after the tube removal (P < 0.0001). The average FEV1 before the chest tube removal was 1.5 l or 53% of the predicted value and increased by 13% after the tube removal (P = 0.0004). In total, 56 and 78% of patients reported static and dynamic pain scores improvement and 67% showed an FEV1 improvement after the chest tube removal. Similar results were observed in patients operated on through VATS or thoracotomy. Compared with patients whose chest tube was removed later, those who had their chest tube removed before post operative day 3 (POD3), showed a greater reduction in the static pain score (41 vs. 31%, P = 0.05) and greater improvement in FEV1 (18 vs. 0.01%, P = 0.02). CONCLUSIONS: The removal of a chest tube reduces pain and improves ventilatory function, independent of surgical access and particularly in the early post-operative phase. A fast track chest tube removal policy may favour patients' recovery.

Predictors of postoperative decline in quality of life after major lung resections.

OBJECTIVE: Severe impairment in quality of life (QoL) is one of the major patients' fears about lung surgery. Its prediction can be valuable information for both patients and physicians. The objective of this study was to identify predictors of clinically relevant decline of the physical and emotional components of QoL after lung resection. METHODS: This is a prospective observational study on 172 consecutive patients submitted to lobectomy or pneumonectomy (2007-2008). QoL was assessed before and 3 months after operation through the administration of the Short Form 36v2 survey. The relevance of the perioperative changes in physical component summary (PCS) and mental component summary (MCS) scales was measured by the Cohen's effect size (mean change of the variable divided by its baseline standard deviation). An effect size >0.8 is regarded as large and clinically relevant. QoL changes were dichotomized according to this threshold. Logistic regression and bootstrap analyses were used to identify reliable predictors of large decline in PCS and MCS. RESULTS: A total of 48 patients (28%) had a large decline in the PCS scale and 26 (15%) in the MCS scale. Patients with a better preoperative physical functioning (p=0.0008) and bodily pain (p=0.048) scores and those with worse mental health (p=0.0007) scores were those at higher risk of a relevant physical deterioration. Patients with a lower predicted postoperative forced expiratory volume in 1s (ppoFEV1; p=0.04), higher preoperative scores of social functioning (p=0.02) and mental health (p=0.06) were those at higher risk of a relevant emotional deterioration. The following logistic equations were derived to calculate the risk of decline in physical or emotional components of QoL, respectively: risk of physical decline: lnR/(1+R): -11.6+0.19XPF, physical functioning+0.05XBP, bodily pain-0.05XMH, mental health; risk of emotional decline: ln R1/(1+R1): -8.06-0.03XppoFEV1+0.11XSF+0.055XMH. CONCLUSIONS: A consistent proportion of patients undergoing lung resection exhibit an important postoperative worsening in their QoL. We were able to identify reliable risk factors and predictive equations estimating this decline. These findings may be used as selection criteria for efficacy trials on perioperative physical rehabilitation or psychological treatments, during preoperative counseling, in the surgical decision-making process and for selecting those patients who would benefit from physical and emotional supportive programs.