Outcomes of pulmonary resection in single-lung patients.

BACKGROUND: After pneumonectomy, the development of a new lung cancer or a recurrence in the residual lung is a challenge. Surgery often is considered contraindicated. The goal of our study is to assess the morbidity and mortality of lung resection on a single lung. METHODS: All patients who underwent lung resection after pneumonectomy from January 1996 through December 2012 were reviewed. RESULTS: There were 12 patients (10 men and 2 women). Mean age was 71 years (range, 54-81 years). Mean preoperative FEV1 was 1,470 ml (52%) and preoperative FVC 2,153 ml (61,5%). Subsequent pulmonary resection was performed after a median follow-up of 34,5 months. Wedge resection was performed in all patients. Diagnosis was pulmonary mestastatic lung cancer in 2 patients, metachronous lung cancer in 6, metastatic extrathoracic cancer in 3 and benign nodule in one. Complications occurred in 4 patients (33,4%) while operative mortality was nil. CONCLUSIONS: Lung resection on a single lung is a safe procedure associated with acceptable morbidity and mortality. Careful patient selection is very important.

Impact of Pleural Lavage Cytology Positivity on Early Recurrence After Surgery for Non-Small Cell Lung Cancer.

OBJECTIVE: The aim of this study was to elucidate the impact of pleural lavage cytology positivity on early recurrence in patients operated on non-small cell lung cancer (NSCLC). METHODS: This is a multicentre prospective cohort study of 684 patients undergoing an anatomical lung resection for NSCLC between October 2015 and October 2017 at 12 national centres. A pleural lavage was performed before and after lung resection. The association between the different predictors of early recurrence and PLC positivity was performed using univariate and multivariate logistic regression models. A propensity score analysis was performed by inverse probability weighting (IPSW) using average treatment effect (ATE) estimation to analyse the impact of PLC positivity on early recurrence. RESULTS: Overall PLC positivity was observed in 15 patients (2.2%). After two years, 193 patients (28.2%) relapsed, 182 (27.2%) with a negative PLC and 11 (73.3%) with a positive PLC (p<0.001). Factors associated to early recurrence were adenocarcinoma histology (OR=1.59, 95%CI 1.06-2.38, p=0.025), visceral pleural invasion (OR=1.59, 95%CI 1.04-2.4, p=0.03), lymph node involvement (OR=1.84, 95%CI 1.14-2.96, p=0.013), advanced pathological stage (OR=2.12, 95%CI 1.27-3.54, p=0.004) and PLC positivity (OR=4.14, 95%CI 1.25-16.36, p=0.028). After IPSW, PLC positivity was associated with an increased risk of early recurrence (OR=3.46, 95%CI 2.25-5.36, p<0.001). CONCLUSIONS: Positive pleural lavage cytology was found to be the strongest predictor of early recurrence.

Advances in robotic lung transplantation: development and validation of a new surgical technique in animal models.

The objective of this study was to describe a novel minimally invasive robotic video-assisted approach for lung transplantation, utilizing a minimally invasive technique with a subxiphoid incision, in an animal experimentation model. Two left robotic-assisted single lung transplants were performed in sheep using a robotic surgical system. A subxiphoid incision was made, and robotic ports were inserted into the thoracic cavity for dissection and anastomoses of the bronchus, artery, and pulmonary veins. The integrity of anastomoses was evaluated, and procedural details were recorded. Both animals survived the procedure, with a mean duration of 255 min and a mean console time of 201 min. Anastomoses were performed without complications, and the closed-chest approach with a subxiphoid incision proved successful in preventing gas leakage. The novel approach demonstrated improved exposure and workflow compared to existing techniques. The minimally invasive robotic video-assisted approach for lung transplantation utilizing a closed-chest technique with a subxiphoid incision appears safe and feasible in an animal experimentation model. Further studies in the clinical setting are warranted to establish its feasibility and safety in human lung transplantation. This approach has the potential to offer benefits over the traditional Clamshell incision in lung transplantation procedures.

Radicality of lymphadenectomy in lung cancer resections by thoracotomy and video-assisted thoracoscopic approach: A prospective, multicentre and propensity-score adjusted study.

OBJECTIVE: To analyse differences in intraoperative nodal assessment in patients undergoing lung cancer resection by thoracotomy and video-assisted thoracoscopy (VATS) in the Spanish Video-Assisted Thoracic Surgery Group (GEVATS). METHODS: Prospective multicentre cohort study of anatomic pulmonary resections (n = 3533) performed from December 2016 to March 2018. Main surgical, clinical and oncological variables related with lymphadenectomy were compared according to surgical approach. Corresponding tests for homogeneity were performed. Multiple logistic regression analyses were used to determine the odds ratio (OR) and 95% confidence interval (95%CI). Covariate adjustment using the propensity score (PS) was performed to reduce confounding effects. RESULTS: After exclusions, 2532 patients were analysed. Systematic nodal dissection (SND) was performed in 65%, with a median of resected/sampled lymph nodes (LN) of 7 (IQR 4-12) and pathologic (p) N2 and uncertain (u) pNu rates of 9.4% and 28.9%, respectively. At multivariate analysis, the following were associated with thoracotomy (OR; 95%CI): SND (1.4; 1.08-1.96; p = 0.014), staging mediastinoscopy (2.6; 1.59-4.25; p < 0.001), tumor > 3 cm (2.1; 1.66-2.78; p < 0.001), central tumor (2.5; 1.90-3.24; p < 0.001); pN1 (1.8; 1.25-2.67; p < 0.002), pN2 (1.8; 1.18-2.76; p = 0.006), lower FEV1 (0.9; 0.98-0.99; p < 0.001), squamous cell carcinoma (1.5; 1.16-1.98; p = 0.002) and inexperienced surgeons in VATS (compared with > 100 VATS experience) (37.6; 13.55-104.6; p < 0.001). After PS adjustment, SND maintained the OR, but in the limit of signification (1.4; 1-1.98; p = 0.05). Nodal upstaging was significantly higher in the thoracotomy group. Complication rates of SND and no SND were similar. CONCLUSIONS: Thoracotomy was associated with a more thorough lymphadenectomy in GEVATS. Therefore, intraoperative lymph node evaluation performed at VATS should be improved to have better prognostic information and more solid grounds to indicate adjuvant therapy.

Treatment and intention-to-treat propensity score analysis to evaluate the impact of video-assisted thoracic surgery on 90-day mortality after anatomical resection for lung cancer.

OBJECTIVES: The aim of this study was to know the treatment effect of video-assisted thoracic surgery (VATS) on 90-day mortality after anatomical lung resection based on a nationwide cohort. METHODS: This is a multicentre prospective cohort of 2721 anatomical resections for lung cancer from December 2016 to March 2018. Treatment and intention-to-treat (ITT) analyses were performed after inverse probability score weighting and different propensity score matching algorithms. Covariate balance was assessed by standardized mean differences. The estimators reported were the average treatment effect, the average treatment effect on the treated and odds ratios after conditional logistic models with 95% confidence intervals. The unconfoundedness assumption was evaluated by sensitivity analysis for average treatment effect (c-dependence) and average treatment effect on the treated (Γ). RESULTS: VATS was the initial approach in 1911 patients (70.2%), though 273 cases (14.3%) had to be converted to thoracotomy. Ninety-day mortality rates were: treatment analysis (VATS 1.16% vs open 3.9%, P < 0.001), ITT analysis (VATS 1.78% vs open 3.36%, P = 0.012). After inverse probability score weighting and propensity score matching, in the treatment analysis, VATS meant absolute risk reductions between 2.25% and 2.96% and relative risk reductions between 65% and 70% [OR = 0.34 (95% confidence interval 0.15-0.79), all P-values <0.004). However, all the estimators turned out to be non-significant in the ITT analyses. A high sensitivity to unobservable confounders was proved (c-dependence 0.135, Γ = 1.5). CONCLUSIONS: VATS can reduce the risk of 90-day mortality after anatomical lung resection. However, the implications of conversion to thoracotomy, comparing ITT versus treatment analysis, and the potential impact of hidden bias should deserve further attention in the future.

[SEPAR Recommendations for COVID-19 Vaccination in Patients With Respiratory Diseases]. / Recomendaciones SEPAR sobre la vacuna COVID-19 en las enfermedades respiratorias.

The Spanish Society of Pneumonology and Thoracic Surgery (SEPAR) has elaborated this document of recommendations for COVID-19 vaccination in patients with respiratory diseases aimed to help healthcare personnel make decisions about how to act in case of COVID-19 vaccination in these patients.The recommendations have been developed by a group of experts in this field after reviewing the materials published up to March 7, 2021, the information provided by different scientific societies, drug agencies and the strategies of the governmental bodies up to this date.We can conclude that COVID-19 vaccines are not only safe and effective, but also prior in vulnerable patients with chronic respiratory diseases. In addition, an active involvement of healthcare professionals, who manage these diseases, in the vaccination strategy is the key to achieve good adherence and high vaccination coverage.

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.

Executive Summary of the Consensus Statement of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Tropical Medicine and International Health (SEMTSI), the Spanish Association of Surgeons (AEC), the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), the Spanish Society of Thoracic Surgery (SECT), the Spanish Society of Vascular and Interventional Radiology (SERVEI), and the Spanish Society of Paediatric Infectious Diseases (SEIP), on the Management of Cystic Echinococcosis.

The Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Tropical Medicine and International Health (SEMTSI), the Spanish Association of Surgeons (AEC), the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), the Spanish Society of Thoracic Surgery (SECT), the Spanish Society of Vascular and Interventional Radiology (SERVEI), and the Spanish Society of Paediatric Infectious Diseases (SEIP) considered it pertinent to issue a consensus statement on the management of cystic echinococcosis (CE) to guide healthcare professionals in the care of patients with CE. Specialists from several fields (clinicians, surgeons, radiologists, microbiologists, and parasitologists) identified the most clinically relevant questions and developed this Consensus Statement, evaluating the available evidence-based data to propose a series of recommendations on the management of this disease. This Consensus Statement is accompanied by the corresponding references on which these recommendations are based. Prior to publication, the manuscript was open for comments and suggestions from the members of the SEIMC and the scientific committees and boards of the various societies involved.

[Analysis of the current situation and outlook of thoracic surgery]. / Análisis de la situación actual y previsión de futuro de la especialidad de cirugía torácica.

OBJECTIVE: The objective of this descriptive study was to analyze the current situation and forecast the future requirements for specialists in thoracic surgery, taking into account the number of doctors entering and those possibly leaving this specialty. MATERIAL AND METHODS: The data for this study were taken from the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) (n=304), Thoracic Surgeons' Club (n=122), and the Spanish Council of Medical Associations (n=225). We also took into account the current number of resident surgeons (n=84). Other specialists were included who are not recorded in these databases but who are known to be practicing (n=10). The total number of practicing specialists obtained was 211. RESULTS: There are currently 52 working thoracic surgery departments and the highest number of practicing specialists was recorded in Madrid (n=44), Catalonia (n=33), and Andalusia (n=33). The forecast number of retirements (at age 65 years) and incorporations of new specialists means that there will be a surplus of 57 thoracic surgeons in the next 5 years. CONCLUSIONS: Thoracic surgery needs to limit the intake of new trainee specialists for at least the next 5 years.

Extended uniportal video-assisted thoracic surgery for lung cancer: is it feasible?

Since the first description of uniportal video-assisted thoracic surgery (U-VATS) (or single-port) lobectomy, several centers in Asia and Europe rapidly adopted this technique as a standard approach for treatment of early stage non-small cell lung cancer (NSCLC). Despite the controversies regarding feasibility and completeness of resection, thoracic surgeons in high volume centers keep pushing the limits to perform very complex procedures also known as "extended resections" through minimally invasive surgery. Published series and case reports confirm the viability of U-VATS in highly complex surgical cases such as pneumonectomy, chest wall resection and bronchoplasty, which require experience and technical ability to be performed through a 3-6 cm single incision. In this article, the authors would like to present several clinical indications of locally advanced NSCLC and the technical aspects to accomplish an extended resection through U-VATS.

Executive summary of the SEPAR recommendations for the diagnosis and treatment of non-small cell lung cancer. / Sumario ejecutivo de las recomendaciones SEPAR de diagnóstico y tratamiento del cáncer de pulmón de células no pequeñas.

The Thoracic Surgery and Thoracic Oncology groups of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) have backed the publication of a handbook on recommendations for the diagnosis and treatment of non-small cell lung cancer. Due to the high incidence and mortality of this disease, the best scientific evidence must be constantly updated and made available for consultation by healthcare professionals. To draw up these recommendations, we called on a wide-ranging group of experts from the different specialties, who have prepared a comprehensive review, divided into 4 main sections. The first addresses disease prevention and screening, including risk factors, the role of smoking cessation, and screening programs for early diagnosis. The second section analyzes clinical presentation, imaging studies, and surgical risk, including cardiological risk and the evaluation of respiratory function. The third section addresses cytohistological confirmation and staging studies, and scrutinizes the TNM and histological classifications, non-invasive and minimally invasive sampling methods, and surgical techniques for diagnosis and staging. The fourth and final section looks at different therapeutic aspects, such as the role of surgery, chemotherapy, radiation therapy, a multidisciplinary approach according to disease stage, and other specifically targeted treatments, concluding with recommendations on the follow-up of lung cancer patients and surgical and endoscopic palliative interventions in advanced stages.

Chondroid chordoma in an atypical location.

Chondroid chordoma is an extremely rare tumour with an annual incidence of around 0.1 cases per 100,000population. Involvement of the thoracic vertebrae may be present in 2-5% of cases. Definitive diagnosis usually requires a suitable distinction between this and other mesenchymal tumours such as chondrosarcomas, so immunohistochemical analysis is virtually mandatory. In spite of its slow-growing nature, chondroid chordoma tends to relapse, and it may eventually become malignant, often jeopardising the patient's prognosis. Although surgery remains the main therapeutic approach, research into the molecular and genetic aspects of this tumour is ongoing. These new advances are likely to improve future oncology therapies by complementing surgery and radiotherapy, changing the currently poor prognosis. We report the case of a patient with a chondroid chordoma involving the thoracic vertebrae and pleural cavity, and the treatment performed.