[Impact of the COVID-19 pandemic on thoracic surgery training in Spain]. / Impacto de la pandemia por COVID-19 en la formación de los cirujanos torácicos en España.

In the more than 2 years since its emergence, the SARS-CoV-2 pandemic has prompted important changes in healthcare systems and their organization. The aim of this study is to determine the implications in specialized thoracic surgery training as well as the repercussions on thoracic surgery residents. With this objective, the Spanish Society of Thoracic Surgery has conducted a survey among all its trainees and those who had finished their residency during the last 3 years. It consisted of 24 multiple-answer closed questions about the impact of the pandemic on their services, their training, and their personal experience. The response rate was 42% (52 out of a target population of 120). The effect of the pandemic on thoracic surgery services was high or extreme according to 78.8% of the participants. Academic activities were completely cancelled in 42.3% of the cases, and 57.7% of the respondents were required to treat hospitalized COVID patients (25% part-time, and 32.7% full-time). More than 80% of the survey participants believed that changes during the pandemic negatively affected their training, and 36.5% would prefer to extend their training period. In sum, we observe how the pandemic has had deep negative effects on specialized training in thoracic surgery in Spain.

Nonoperative Management of a Large Extrapleural Hematoma after Blunt Chest Trauma.

BACKGROUND: An extrapleural hematoma (EH) is an uncommon and potentially life-threatening condition defined as the accumulation of blood in the extrapleural space between the parietal pleura and the endothoracic fascia. EH usually occurs after blunt thoracic trauma causing fractures of the sternum and ribs, which can tear the intercostal or internal mammary vessels. Typical radiological findings of EH are a biconvex opacity on the involved hemithorax and the so-called displaced "extrapleural fat sign." CASE REPORT: We present a case of a 36-year-old man with an isolated scapular fracture after a high-energy blunt chest trauma complicated with a large contralateral EH that was successfully managed nonoperatively with transcatheter arterial embolization (TAE) and image-guided drainage with a pig-tail catheter. To the best of our knowledge there is only one previous report describing a large EH after blunt thoracic trauma without rib fractures. Only two previous cases of large EHs have been treated initially with TAE, but both patients ultimately required open surgery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with EH can present with respiratory distress and hypotension, so early identification is important to facilitate proper treatment. EH has characteristic radiological findings, and contrast-enhanced computed tomography is not only the best imaging tool for confirming an EH, but also the best technique for detecting the source of the bleeding and other serious thoracic complications that may not be evident on chest x-ray studies.

Implementation of the Versius robotic surgical system for thoracic surgery: first clinical evaluation of feasibility and performance.

OBJECTIVES: The aim of this study is to demonstrate the ability of the Versius surgical system to successfully and safely complete a range of thoracic procedures aligned with Stage 2a (Development) of the Idea, Development, Exploration, Assessment and Long-term follow-up framework for surgical innovation. METHODS: This prospective study included the first 30 consecutive patients who underwent robotic surgery with Versius by 2 surgeons without prior robotic experience between 1 April 2023 and 30 December 2023 [25 lung resections (wedge, segmentectomy and lobectomy) and 5 thymectomies]. There were no specific predetermined selection criteria for each case. The primary outcome was safe completion of the procedure without unplanned conversion. Secondary outcomes included intraoperative and postoperative complications, intraoperative device-related outcomes and pathology results. RESULTS: Twenty-eight (93.3%) cases were completed without conversion. Both conversions were to thoracoscopy, one due to a 'console alarm' and the other due to pulmonary artery bleeding. In lung resections, median console time was 103 (90-129) min. Five (20%) patients experienced postoperative complications, most frequent was persistent air leak (16%). Median length-of-stay was 3 (2-4) days. Neither readmissions nor mortality was observed. In thymectomies, no intraoperative or postoperative complications, readmissions, reinterventions or mortality were observed. Median console time was 77 (75-89) min and median length of stay was 1 (1-1) day. CONCLUSIONS: This phase 2a IDEAL-D study confirms lung resections and thymectomies are feasible with the use of Versius system, laying the foundation for larger phase 2b and 3 clinical studies within the IDEAL-D framework.

Impact of radiological follow-up frequency on resected lung cancer: a propensity score matching analysis.

Background: Despite advances in lung cancer treatment and the subsequent improvement in oncological outcomes, the optimal frequency of radiological follow-up remains unclear. Current recommendations lack consensus and do not consider individual patient characteristics and tumor factors. This study aimed to examine the impact of radiological follow-up frequency on oncological outcomes following lung cancer resection. Methods: A prospective multicenter study, involving patients who underwent anatomical lung resection in the GEVATS database between December 2016 and March 2018. The relationship between surveillance frequency and oncological outcomes was evaluated. Two groups were established based on follow-up frequency: low frequency (LF) and high frequency (HF). Subgroup analyses were performed based on tumor stage, histology, lymphadenectomy, and adjuvant therapy. Propensity score matching (PSM) was applied to balance the groups. Results: A total of 1,916 patients were included in the study, LF 444 (23.17%), HF 1,472 (76.83%). Factors associated with HF surveillance included higher stage, adjuvant chemotherapy and adjuvant radiotherapy. Subanalyses were performed after PSM for various factors, revealing significant differences between LF and HF groups in cancer-specific survival among who received adjuvant therapy {LF 53.021 months [95% confidence interval (CI): 48.622-57.421] vs. HF 58.836 months (95% CI: 55.343-62.330); HR 0.453, 95% CI: 0.242-0.849; P=0.013}, as well as overall survival for patients with squamous cell carcinoma [LF 54.394 months (95% CI: 51.424-57.364) vs. HF 61.578 months (95% CI: 59.091-64.065); HR 0.491, 95% CI: 0.299-0.806; P=0.005] and those who received adjuvant therapy LF 50.176 months [95% CI: 45.609-54.742) vs. HF 57.189 months (95% CI: 53.599-60.778); HR 0.503, 95% CI: 0.293-0.865; P=0.013]. Conclusions: Findings suggest that high-frequency surveillance only improves survival outcomes in lung cancer patients who received adjuvant treatment or had squamous cell carcinoma. Therefore, future guidelines for lung cancer follow-up should consider individualizing the frequency of radiological surveillance based on patients' risk profiles.

Impact of COVID-19 pandemic in thoracic surgery training in Spain.

In the more than 2 years since its emergence, the SARS-CoV-2 pandemic has prompted important changes in healthcare systems and their organization. The aim of this study is to determine the implications in specialized thoracic surgery training as well as the repercussions on thoracic surgery residents. With this objective, the Spanish Society of Thoracic Surgery has conducted a survey among all its trainees and those who had finished their residency during the last 3 years. It consisted of 24 multiple-answer closed questions about the impact of the pandemic on their services, their training, and their personal experience. The response rate was 42% (52 out of a target population of 120). The effect of the pandemic on thoracic surgery services was high or extreme according to 78.8% of the participants. Academic activities were completely cancelled in 42.3% of the cases, and 57.7% of the respondents were required to treat hospitalized COVID patients (25% part-time, and 32.7% full-time). More than 80% of the survey participants believed that changes during the pandemic negatively affected their training, and 36.5% would prefer to extend their training period. In sum, we observe how the pandemic has had deep negative effects on specialized training in thoracic surgery in Spain.

Postoperative morbidity after anatomical lung resections by VATS vs thoracotomy: Treatment and intention-to-treat analysis of the Spanish Video-Assisted Thoracic Surgery Group.

OBJECTIVES: In recent years, video-assisted thoracoscopic lung resections (VATS) have been associated with lower morbidity than open surgery. The aim of our study is to compare postoperative morbidity among patients from the national database of the Spanish Group of Video-Assisted Thoracic Surgery (GE-VATS) after open and video-assisted anatomic lung resections using a propensity score analysis. METHODS: From December 2016 to March 2018, a total of 3533 patients underwent anatomical lung resection at 33 centers. Pneumonectomies and extended resections were excluded. A propensity score analysis was performed to compare the morbidity of the thoracotomy group (TG) vs the VATS group (VATSG). Treatment and intention-to-treat (ITT) analyses were conducted. RESULTS: In total, 2981 patients were finally included in the study: 1092 (37%) in the TG and 1889 (63%) in the VATSG for the treatment analysis; and 816 (27.4%) in the TG and 2165 patients (72.6%) in the VATSG for the ITT analysis. After propensity score matching, in the treatment analysis, the VATSG was significantly associated with fewer overall complications than the TG OR 0.680 [95%CI 0.616, 0.750]), fewer respiratory (OR 0.571 [0.529, 0.616]) cardiovascular (OR 0.529 [0.478, 0.609]) and surgical (OR 0.875 [0.802, 0.955]) complications, lower readmission rate (OR 0.669 [0.578, 0.775]) and a reduction of hospital length of stay (-1.741 ([-2.073, -1.410]). Intention-to-treat analysis showed only statistically significant differences in overall complications (OR 0.76 [0.54-0.99]) in favor of the VATSG. CONCLUSION: In this multicenter population, VATS anatomical lung resections have been associated with lower morbidity than those performed by thoracotomy. However, when an intention-to-treat analysis was performed, the benefits of the VATS approach were less prominent.

Pulmonary vein pseudoaneurysm secondary to oesophageal stent displacement.

Oesophageal stents allow endoscopic treatment of several oesophageal disorders. Although oesophageal stents are generally safe, early and late adverse events may occur. We present a previously unpublished complication consisting of a pulmonary vein pseudoaneurysm secondary to an oesophageal stent displacement.

Preoperative radio-guided localization of lung nodules with I-125 seeds: experience with 32 patients at a single institution.

OBJECTIVES: Videothoracoscopic visualization and/or palpation of pulmonary nodules may be difficult due to their location, small size or limited solid component. The purpose of this study is to present our experience with computed tomography (CT)-guided preoperative localization of pulmonary nodules by percutaneous marking with radio-labelled iodine-125 seeds. METHODS: A total of 34 pulmonary nodules were marked under CT with the placement of 33 radio-labelled iodine-125 seeds in 32 consecutive patients. RESULTS: All patients underwent biportal video-assisted thoracic surgery (VATS) and in no case was conversion to thoracotomy necessary. A total of 88.2% of the lung nodules were successfully resected. In the remaining 11.8%, migration of the seed to the pleural cavity occurred, although these nodules were still resected during VATS. Of all the patients with pneumothorax after the marking procedure, only one required chest tube placement (3.1%). No major postoperative complications were observed. CONCLUSIONS: Preoperative marking of pulmonary nodules with I-125 seeds under CT guidance is a feasible and safe technique that allows their intraoperative identification and resection.

Impact of neoadjuvant therapy on postoperative complications in non-small-cell lung cancer patients subjected to anatomic lung resection.

OBJECTIVE: To study the impact of neoadjuvant therapies on postoperative complications and mortality among non-small-cell lung cancer (NSCLC) patients subjected to anatomic lung resection and included in the Spanish cohort of the video-assisted thoracic surgery (GE-VATS) multicenter database. METHODS: The study included a total of 3085 patients from 33 centers between December 2016 and March 2018. We performed a comparative analysis of the complications and mortality in patients who received neoadjuvant therapies (n = 263) versus those who did not (n = 2822). A propensity score-matched analysis was used to adjust for potential confounders. Association between exposure in two groups and outcomes were estimated by logistic regression weighted by inverse of probability of receiving the treatment that actually received. RESULTS: In the unadjusted analysis, the chemotherapy (CT) and chemoradiotherapy (CRT) group presented a higher frequency of ICU readmissions, reinterventions, empyema, cardiovascular complications, a greater frequency of atrial fibrillation, and an increased need for blood product transfusions. In the adjusted group, CT and CRT patients had a higher rate of cardiovascular complications (CT p = 0.002; OR 2.29; 95% CI 1.34-3.94 and CRT p = 0.001; OR 2.90; 95% CI 1.52-5-52), arrhythmias (CT p = 0.013; OR 2.23; 95% CI 1.18-4.20 and CRT p = 0.046; OR 2.22; 95% CI 1.01-4.90) and transfussions (CT p = 0.042; OR 2.95; 95% CI 1.04-8.35 and CRT p < 0.001; OR 7.74; 95% CI 3.01-19-92). CONCLUSIONS: Based on our series, neoadjuvant CT and CRT were associated with a higher rate of cardiovascular complications, arrhythmias and transfussions in patients with NSCLC subjected to anatomic lung resection.

Effect of COVID-19 on Thoracic Oncology Surgery in Spain: A Spanish Thoracic Surgery Society (SECT) Survey.

After the first wave of COVID-19, the Spanish Society of Thoracic Surgeons (SECT) surveyed its members to assess the impact of the pandemic on thoracic oncology surgery in Spain. In May 2020, all SECT members were invited to complete an online, 40-item, multiple choice questionnaire. The questionnaire was developed by the SECT Scientific Committee and sent via email. The overall response rate was 19.2%. The respondents answered at least 91.5% of the items, with only one exception (a question about residents). Most respondents (89.3%) worked in public hospitals. The reported impact of the pandemic on routine clinical activity was considered extreme or severe by 75.5% of respondents (25.5% and 50%, respectively). Multidisciplinary tumour boards were held either with fewer members attending or through electronic platforms (44.6% and 35.9%, respectively). Surgical activity decreased by 95.7%, with 41.5% of centers performing surgery only on oncological patients and 11.7% only in emergencies. Nearly 60% of respondents reported modifying standard protocols for early-stage cancer and in the preoperative workup. Most centers (≈80%) reported using full personal protective equipment when operating on COVID-19 positive patients. The COVID-19 pandemic severely affected thoracic oncology surgery in Spain. The lack of common protocols led to a variable care delivery to lung cancer patients.

Innominate Artery Dissection Caused by Video-Mediastinoscopy.

Mediastinoscopy is considered a safe technique to biopsy mediastinal lesions. Among its complications, vascular ones are the most common. We present a rare case of intimal dissection of the innominate artery during the performance of a mediastinoscopy that caused an ischemic attack from which the patient recovered completely without long-term sequelae. We analyze the possible causes and risk factors of this complication.

Spanish Video-Assisted Thoracic Surgery Group: Method, Auditing, and Initial Results From a National Prospective Cohort of Patients Receiving Anatomical Lung Resections.

INTRODUCTION: Our study sought to know the current implementation of video-assisted thoracoscopic surgery (VATS) for anatomical lung resections in Spain. We present our initial results and describe the auditing systems developed by the Spanish VATS Group (GEVATS). METHODS: We conducted a prospective multicentre cohort study that included patients receiving anatomical lung resections between 12/20/2016 and 03/20/2018. The main quality controls consisted of determining the recruitment rate of each centre and the accuracy of the perioperative data collected based on six key variables. The implications of a low recruitment rate were analysed for "90-day mortality" and "Grade IIIb-V complications". RESULTS: The series was composed of 3533 cases (1917 VATS; 54.3%) across 33 departments. The centres' median recruitment rate was 99% (25-75th:76-100%), with an overall recruitment rate of 83% and a data accuracy of 98%. We were unable to demonstrate a significant association between the recruitment rate and the risk of morbidity/mortality, but a trend was found in the unadjusted analysis for those centres with recruitment rates lower than 80% (centres with 95-100% rates as reference): grade IIIb-V OR=0.61 (p=0.081), 90-day mortality OR=0.46 (p=0.051). CONCLUSIONS: More than half of the anatomical lung resections in Spain are performed via VATS. According to our results, the centre's recruitment rate and its potential implications due to selection bias, should deserve further attention by the main voluntary multicentre studies of our speciality. The high representativeness as well as the reliability of the GEVATS data constitute a fundamental point of departure for this nationwide cohort.

Supraclavicular excision of a cervical rib for treatment of thoracic outlet syndrome.

Cervical rib resection through a supraclavicular approach is a safe and feasible treatment for patients suffering from thoracic outlet syndrome caused by the presence of a cervical rib or by an anomalous first rib. This video tutorial illustrates the technical aspects of this procedure.

Video-assisted thoracoscopic left cardiac sympathetic denervation for congenital long QT syndrome.

Left cardiac sympathetic denervation is an effective therapy for patients with congenital long QT syndrome resistant to beta-blocker therapy. In this video tutorial we describe a minimally invasive video-assisted thoracoscopic technique for performing left cardiac sympathetic denervation.