Thoracoscopic segmentectomy for trans-fissure ground-glass opacity.

OBJECTIVES: The trans-fissure ground-glass opacity (GGO) is a special category of lesions, with a diameter always exceeding 2 cm. It is located on a fused fissure, 'seizing' 2 neighbouring lobes simultaneously. The segmentectomy for the trans-fissure GGO is never reported. METHODS: Between August 2016 and December 2022, patients operated with a trans-fissure GGO were included. The patients' backgrounds and surgical data were summarized. All procedures were performed with the help of preoperative three-dimensional computed tomography bronchography and angiography. RESULTS: A total of 84 patients were included. The selection criteria included a consolidation tumour ratio <50% and a lesion size >2 and ≤3 cm. Thirty-six patients were operated with lobectomy + wedge (the traditional method group) and 48 patients were operated with anatomical segmentectomy + function-preserving sublobectomy (the new method group). The median operative time was 87 min in the traditional group and 98 min in the new method group, and the median blood loss was 60 ml in the traditional group and 70 ml in the new method group. The median duration of hospital stays was 4 days in the traditional group and 2 days in the new method group. In the traditional method group, there was 1 case of postoperative air leakage and 5 cases of haemoptysis. In the new method group, 2 cases of postoperative air leakage were identified. The median size of the tumour in the resected segment was 2.6 cm in the traditional group and 2.5 cm in the new method group. The median margin was 2.5 cm in the traditional group and 3.3 cm in the new method group. CONCLUSIONS: The trans-fissure GGO could be safely resected en bloc by segmentectomy with a well-designed surgical procedure and appropriate preoperative planning.

Resectable non-stage IV nonsmall cell lung cancer: the surgical perspective.

Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.

Synergistic markers based on inter-covariate association estimate treatment option with lower propensity to covariates.

Background: Propensity constitutes a common problem in identifying clinical outcome prediction model whose covariates include the treatment option, which is assumed to be randomly assigned but indeed dependent of other covariates in the training data. The genuine effect of treatment option cannot be elucidated under the influence of propensity. Existing approaches, such as matched-pairs study design, still cannot solve the problem for imbalanced or small datasets. Methods: This work proposed an anti-propensity estimate of treatment option, which is generated by support vector classifier based on two synergistic markers that represent the lower and upper limits of inter-covariate association level. The algorithm for generating the synergistic markers was illustrated and the performance was evaluated on a public dataset of gene expression levels, which were obtained from surgically excised tumor samples in non-small cell lung cancer (NSCLC) patients where treatment option, i.e., adjuvant therapy or not, was known. Results: Six covariates represented by the expression levels of ZNF217, ERCC3, PMS1, PIK3CB, BARD1, and MAPK1, were selected to generate two synergistic markers and classifier for estimating the adjuvant therapy option with substantially attenuated propensity. The estimation accuracy attained an area under the receiver-operating characteristics curve, 0.78, in the test set. Conclusions: The proposed synergistic markers demonstrated a parsimonious and anti-propensity estimation of treatment option, which is ready for the further evaluation and application in the clinical outcome prediction model.

The SUPER reporting guideline suggested for reporting of surgical technique.

Background: Existing reporting guidelines pay insufficient attention to the detail and comprehensiveness reporting of surgical technique. The Surgical techniqUe rePorting chEcklist and standaRds (SUPER) aims to address this gap by defining reporting standards for surgical technique. The SUPER guideline intends to apply to articles that encompass surgical technique in any study design, surgical discipline, and stage of surgical innovation. Methods: Following the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network approach, 16 surgeons, journal editors, and methodologists reviewed existing reporting guidelines relating to surgical technique, reviewed papers from 15 top journals, and brainstormed to draft initial items for the SUPER. The initial items were revised through a three-round Delphi survey from 21 multidisciplinary Delphi panel experts from 13 countries and regions. The final SUPER items were formed after an online consensus meeting to resolve disagreements and a three-round wording refinement by all 16 SUPER working group members and five SUPER consultants. Results: The SUPER reporting guideline includes 22 items that are considered essential for good and informative surgical technique reporting. The items are divided into six sections: background, rationale, and objectives (items 1 to 5); preoperative preparations and requirements (items 6 to 9); surgical technique details (items 10 to 15); postoperative considerations and tasks (items 16 to 19); summary and prospect (items 20 and 21); and other information (item 22). Conclusions: The SUPER reporting guideline has the potential to guide detailed, comprehensive, and transparent surgical technique reporting for surgeons. It may also assist journal editors, peer reviewers, systematic reviewers, and guideline developers in the evaluation of surgical technique papers and help practitioners to better understand and reproduce surgical technique. Trial Registration: https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/#SUPER.

The SUPER reporting guideline suggested for reporting of surgical technique: explanation and elaboration.

Background: Surgical technique plays an essential role in achieving good health outcomes. However, the quality of surgical technique reporting remains heterogeneous. Reporting checklists could help authors to describe the surgical technique more transparently and effectively, as well as to assist reviewers and editors evaluate it more informatively, and promote readers to better understand the technique. We previously developed SUPER (surgical technique reporting checklist and standards) to assist authors in reporting their research that contains surgical technique more transparently. However, further explanation and elaboration of each item are needed for better understanding and reporting practice. Methods: We searched surgical literature in PubMed, Google Scholar and journal websites published up to January 2023 to find multidiscipline examples in various article types for each SUPER item. Results: We explain the 22 items of the SUPER and provide rationales item by item alongside. We provide 69 examples from 53 literature that present optimal reporting of the 22 items. Article types of examples include pure surgical technique, and case reports, observational studies and clinical trials that contain surgical technique. Examples are multidisciplinary, including general surgery, orthopaedical surgery, cardiac surgery, thoracic surgery, gastrointestinal surgery, neurological surgery, oncogenic surgery, and emergency surgery etc. Conclusions: Along with SUPER article, this explanation and elaboration file can promote deeper understanding on the SUPER items. We hope that the article could further guide surgeons and researchers in reporting, and assist editors and peer reviewers in reviewing manuscripts related to surgical technique.

Transition from multiportal video-assisted thoracic surgery to uniportal video-assisted thoracic surgery and evolution to uniportal robotic-assisted thoracic surgery?

The greatest disruptive innovation in lung cancer surgery in modern times has been the switch from open thoracotomy to video-assisted thoracic surgery (VATS). More recently, the transition from multiportal VATS (MVATS) to uniportal VATS (UVATS) has represented another mini-advance in reducing surgical access trauma. In the search for the next breakthrough in lung cancer surgery, a number of promising candidates have emerged, including screening, sublobar resections, 3D technology, enhanced peri-operative care pathways, ablative therapy and multi-modality management. However, could the way forwards be simply a further minimization of surgical access trauma, and could this be achieved by uniportal robotic surgery? Emergence of a 'winning' candidate will depend on a systematic evaluation of the evidence for the benefits and costs of each.

Reporting guidelines for surgical technique could be improved: a scoping review and a call for action.

OBJECTIVES: To identify reporting guidelines related to surgical technique and propose recommendations for areas that require improvement. STUDY DESIGN AND SETTING: A protocol-guided scoping review was conducted. A literature search of MEDLINE, the EQUATOR Network Library, Google Scholar, and Networked Digital Library of Theses and Dissertations was conducted to identify surgical technique reporting guidelines published up to December 31, 2021. RESULTS: We finally included 55 surgical technique reporting guidelines, vascular surgery (n = 18, 32.7%) was the most common among the clinical specialties covered. The included guidelines generally showed a low degree of international and multidisciplinary cooperation. Few guidelines provided a detailed development process (n = 14, 25.5%), conducted a systematic literature review (n = 13, 23.6%), used the Delphi method (n = 4, 7.3%), or described post-publication strategy (n = 6, 10.9%). The vast majority guidelines focused on the reporting of intraoperative period (n = 50, 90.9%). However, of the guidelines requiring detailed descriptions of surgical technique methodology (n = 43, 78.2%), most failed to provide guidance on what constitutes an adequate description. CONCLUSION: Our study demonstrates significant deficiencies in the development methodology and practicality of reporting guidelines for surgical technique. A standardized reporting guideline that is developed rigorously and focuses on details of surgical technique may serve as a necessary impetus for change.

Expert consensus on indocyanine green fluorescence imaging for thoracoscopic lung resection (The Version 2022).

The use of the white-light thoracoscopy is hampered by the low contrast between oncologic margins and surrounding normal parenchyma. As a result, many patients with in situ or micro-infiltrating adenocarcinoma have to undergo lobectomy due to a lack of tactile and visual feedback in the resection of solitary pulmonary nodules. Near-infrared (NIR) guided indocyanine green (ICG) fluorescence imaging technique has been widely investigated due to its unique capability in addressing the current challenges; however, there is no special consensus on the evidence and recommendations for its preoperative and intraoperative applications. This manuscript will describe the development process of a consensus on ICG fluorescence-guided thoracoscopic resection of pulmonary lesions and make recommendations that can be applied in a greater number of centers. Specifically, an expert panel of thoracic surgeons and radiographers was formed. Based on the quality of evidence and strength of recommendations, the consensus was developed in conjunction with the Chinese Guidelines on Video-assisted Thoracoscopy, and the National Comprehensive Cancer Network (NCCN) guidelines on the management of pulmonary lesions. Each of the statements was discussed and agreed upon with a unanimous consensus amongst the panel. A total of 6 consensus statements were developed. Fluorescence-guided thoracoscopy has unique advantages in the visualization of pulmonary nodules, and recognition and resection of the anterior plane of the pulmonary segment. The expert panel agrees that fluorescence-guided thoracoscopic surgery has the potential to become a routine operation for the treatment of pulmonary lesions.

Developing the surgical technique reporting checklist and standards: a study protocol.

BACKGROUND: Standardized and transparent reporting of surgical technique is the cornerstone of effective dissemination, implementation and improvement. However, current reporting of surgical techniques is inadequate. The existing guidelines potentially applied to guide surgical technique reporting are with a minimal highlight of the surgical technique, lack requirements explaining what extent and dimensions need to be described in detail, or are unlikely to extrapolate to a wide range of surgical techniques. This study aims to formulate a rigorous protocol to develop a surgical technique reporting checklist and standards (SUPER) that defines what a clear, comprehensive and detailed surgical technique report should be contained. METHODS: This protocol is designed following the classic guidance for developing reporting guidelines recommended by the EQUATOR network. RESULTS: The development team will consist of surgeons (~80%), methodologists, and journal editors. The draft checklist sources will include a scoping review of existing reporting guidelines related to surgical technique, surgical technique articles from 15 top journals published in the last year, and brainstorming by the multidisciplinary development team. The final SUPER checklist will be formed after three rounds of Delphi surveys, one round of face-to-face meeting, and a month-long pilot test. The SUPER checklist will be published as open-access and be used in combination with existing reporting guidelines related to surgical techniques (e.g., IDEAL). This protocol will steer the SUPER checklist's development, allowing us to further elaborate surgical technique reporting for all surgical specialties, and enabling a more favorable experience for surgeons, nurses, medical students, residents, editors, and reviewers. TRIAL REGISTRATION: This trial is registered at the EQUATOR network on December 18th, 2020. Available at: https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/.

Evidence on reporting guidelines for surgical technique in clinical disciplines: a scoping review protocol.

BACKGROUND: The reporting of surgical techniques is of mixed quality, with most at a very minimal level. Reporting guidelines that could be applied to guide surgical technique reporting vary in methodology for development, discipline coverage, dimension coverage and detail requested. However, a scoping review that could indicate the gaps and efforts needed in surgical technique reporting guidelines is lacking and warranted. This study aims to design a methodological rigour protocol to guide the development of a scoping review of surgical technique reporting guidelines. METHODS: This protocol is designed following the 2020 manual proposed by the Joanna Briggs Institute. To further ensure the soundness of the protocol, we also included multidisciplinary professionals (including methodologists, clinicians, and journal editors) to refine the protocol. DISCUSSION: Seven key steps for developing the scoping review are identified and presented in detail, including (I) identifying the research questions; (II) inclusion criteria; (III) search strategy; (IV) source of evidence selection; (V) data extraction; (VI) analysis of the evidence; and (VII) presentation of the results. Guided by this protocol, the subsequent scoping review will inform us the overview of surgical technique reporting guidelines and precisely guide our direction and next steps in improving surgical technique reporting guidelines. TRIAL REGISTRATION: This protocol is not registered as the PROSPERO database only accepts registration of systematic review protocols while does not accept registration of scoping review protocols.

Should sublobar resection be offered for screening-detected lung nodules?

The increasing use of low-dose CT for screening for lung cancer will inevitably identify many small, asymptomatic lung nodules and ground-glass opacities (GGOs). Current guidelines for the management of screening-detected lesions tend to advise a conservative approach based on serial imaging and intervention only if 'suspicious' features emerge. However, more recent developments in thoracic surgery and in the understanding of the screening-detected lesions themselves prompt some pertinent questions over this conservatism. Is CT surveillance sufficiently reliable to exclude malignancy? Is it really necessary to hold back on operative biopsy and resection given modern surgical safety and efficacy? Is the option for early surgical therapy a viable one-especially with the availability of sublobar resection today? Modern data suggests that the risk of inaction for some screening-detected lesions may be higher than expected, whereas the potential harm of surgical intervention may be substantially reduced by sublobar resection and the latest minimally invasive surgical techniques. A more pro-active approach towards offering surgery for screening-detected lesions should now be considered.

Implementation of a pulmonary thromboembolism prophylaxis program in Chinese lung surgery patients: compliance and effectiveness.

BACKGROUND: Most studies on prophylaxis against pulmonary embolism (PE) after lung surgery have come from the West. Whether such prophylactic programs can be successfully developed in China has not been fully studied. METHODS: A prospective observational trial included 581 Chinese patients receiving lung resection surgery between August 8 and September 12 of 2017. The Caprini score was assessed on the first postoperative day (POD1). For PE prophylaxis, patients with a low score (0-4, n=55) received early ambulation, and those with a high score (≥5, n=526) received early ambulation combined with low-molecular weight heparin (LMWH) injection. PE incidence and the compliance with this protocol was recorded. RESULTS: Three patients (0.52%) developed PE and all 3 were in the high-risk group, but LMWH was not given (non-compliance). Within the non-compliance patients (n=275), the incidence of PE was 1.09%, higher than that in the compliance patients (0%). The rate of non-compliance with the program was 47.3% (275/581) in the entire cohort. The factors associated with non-compliance were: extended lobectomy performed (9.2% vs. 1.0%, P<0.001); higher volume of postoperative chest drainages (278 vs. 239 mL, P=0.028). The non-compliance group had longer duration of ICU stay (mean of 1.3 vs. 1.1 days, P<0.001); and longer overall hospital stay (mean of 9.7 vs. 8.5 days, P<0.001). CONCLUSIONS: Developing a PE prophylaxis program for patients receiving lung surgery in China contributed to lowering the risk of PE. Failure of compliance in patients with high risk for PE after lung surgery may be linked to worse outcomes.

Video-assisted thoracoscopic surgery as the gold standard for lung cancer surgery.

Surgical resection remains the only effective means of cure in the vast majority of patients with early-stage lung cancer. It can be performed via a traditional open approach (particularly thoracotomy) or a minimally invasive approach. VATS is 'keyhole' surgery in the chest, and was first used for lung cancer resection in the early 1990s. Since then, a large volume of evolving clinical evidence has confirmed that VATS lung cancer resection offered proven safety and feasibility, better patient-reported post-operative outcomes, less surgical trauma as quantified by objective outcome measures and equivalent or better survival than open surgery. This has firmly established VATS as the surgical approach of choice for early-stage lung cancer today. Although impressive new non-surgical lung cancer therapies have emerged in recent years, VATS is also being constantly rejuvenated by the development of 'next generation' VATS techniques, the refinement of VATS sublobar resection for selected patients, the utilization of bespoke post-operative recovery programmes for VATS and the synthesis of VATS into multi-modality lung cancer therapy. There is little doubt that VATS will remain as the gold standard for lung cancer surgery for the foreseeable future.

Thoracic cancer surgery during the COVID-19 pandemic: a consensus statement from the Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery.

OBJECTIVES: Healthcare resources have been mobilized to combat the COVID-19 pandemic of 2020. The Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery reports a consensus statement on the provision of thoracic cancer surgery during this pandemic. METHODS: A Thoracic Experts Panel was convened by the Society. A consensus on the provision, safety, and setting of thoracic cancer surgery during the pandemic was obtained through a Delphi process. RESULTS: Responses were received from 26 panel members (96% response rate) from 10 regions across Asia. The Society recommended that elective thoracic cancer surgery services may need to be reduced or postponed if medical resources were needed for COVID-19 patients, especially intensive care unit beds and ventilators. However, thoracic cancer surgery should proceed as normal for all solid tumors, without restrictions based on disease stage, availability of non-surgical treatment options, or patient condition (unless there is a high likelihood of postoperative intensive care unit stay). Aerosol-forming procedures should be avoided intra- and perioperatively. The surgical approach does not make a difference in terms of safety. Services for thoracic cancer patients should be offered only in hospitals that maintain isolation wards for patients with confirmed or suspected COVID-19. CONCLUSIONS: Services for patients with thoracic cancer should be maintained during the COVID-19 pandemic. The position of the Society is that thoracic surgeons have a responsibility to perform good surgical management of thoracic cancer during the pandemic, to advocate for patients' rights to receive it, and to safeguard patients and staff from infection.

Developing training for uniportal video-assisted thoracic surgery: a commentary.

OBJECTIVES: Today, thoracic surgeons have many possible pathways to advance their training in video-assisted thoracic surgery (VATS). For uniportal VATS (uVATS) in particular, what are the training options available and does regulating training matter? METHODS: The relevant literature pertaining to uVATS training is reviewed. RESULTS: Current options for surgeons looking to train in uVATS range from videos on the internet, through 'experts' demonstrating live surgery, to symposia and hands-on wet labs being held in all regions of the world. All have merits, and the aspiring VATS surgeon can choose from a range of preceptorship and proctorship modules to suit his/her own training needs. However, issues in the formalizing training in uVATS remains unresolved. Is there an ideal pathway through uVATS training? At what point can a trainee be considered to have 'graduated' to become an expert in uVATS? Who indeed trains the trainer, and certifies the competence of a training centre? CONCLUSIONS: Although a plethora of training options exist, formulation of a robust training curriculum can further bolster the status of uVATS as a sustainable surgical approach that can be delivered with consistent quality.

General thoracic surgery services across Asia during the 2020 COVID-19 pandemic.

The COVID-19 pandemic of 2020 posed an historic challenge to healthcare systems around the world. Besides mounting a massive response to the viral outbreak, healthcare systems needed to consider provision of clinical services to other patients in need. Surgical services for patients with thoracic disease were maintained to different degrees across various regions of Asia, ranging from significant reductions to near-normal service. Key determinants of robust thoracic surgery service provision included: preexisting plans for an epidemic response, aggressive early action to "flatten the curve", ability to dedicate resources separately to COVID-19 and routine clinical services, prioritization of thoracic surgery, and the volume of COVID-19 cases in that region. The lessons learned can apply to other regions during this pandemic, and to the world, in preparation for the next one.