Early outcomes of robotic versus video-thoracoscopic anatomical segmentectomy: a propensity score-matched real-world study.

OBJECTIVES: Minimally invasive anatomic segmentectomy for the resection of pulmonary nodules has significantly increased in the last years. Nevertheless, there is limited evidence on the safety and feasibility of robotic segmentectomy compared to video-assisted thoracic surgery. This study aimed to compare the real-world early outcomes of robotic and video-thoracoscopic in anatomic segmentectomy. METHODS: Single centre cohort study including all consecutive patients undergoing segmentectomy by either robotic or video-thoracoscopic from June 2018 to November 2023. Propensity score case matching analysis generated two matched groups undergoing robotic or video-thoracoscopic segmentectomy. Short-term outcomes were analysed and compared between groups. RESULTS: 204 patients (75 robotic and 129 video-thoracoscopic patients) were included. After matching, 146 patients (73 cases in each group) were compared. One 30-day death was observed in the robotic group (P = 1). Two conversions to thoracotomy occurred in the robotic, and none in the video-thoracoscopic group (P = 0.5). Surgical time was longer in the robotic group (P = 0.091). There were no significant differences between robotic and video-thoracoscopic groups in postoperative complications (13.7% vs 15.1%, P = 1), cardiopulmonary complications (6.8% vs 6.8%, P = 1), major complications (4.1% vs 4.1%, P = 1), prolonged air leak (4.1% vs 5.5%, P = 1), arrythmia (1.4% vs 0%, P = 1) and reoperation (2.7% vs 2.7%, P = 1). Median length of stay was 3 days (IQR, 2-3 days) in the robotic group vs 3 days (IQR, 2.5-4 days) in the video-thoracoscopic group (P = 0.212). CONCLUSIONS: Robotic segmentectomy is a safe and feasible alternative to video-thoracoscopy, as no significant differences in early postoperative outcomes were found between the two techniques.

The «Weekday Effect¼ Does Not Have an Impact on the Development of Complications or Mortality After Pulmonary Resection: Retrospective Cohort Study. / El «efecto día de la semana¼ no tiene impacto en la aparición de complicaciones o mortalidad tras la resección pulmonar: estudio de cohortes histórico.

OBJECTIVE: To determine whether elective anatomic pulmonary resection surgery carried out at the end of the week is associated with a higher mortality and postoperative morbidity than surgery performed at the beginning of the week. METHOD: Historical cohort study. All patients undergoing anatomical pulmonary resection between January 2013 and November 2018 in our center were included. Patients operated at the end of the week (Thursday or Friday) were considered «not exposed¼ and patients operated at the beginning of the week (Monday, Tuesday or Wednesday) were considered «exposed¼. The likelihood of cardiorespiratory complications and operative death (30days) was compared in the two cohorts calculated using the Eurolung1 and2 risk models. 30-day mortality and the occurrence of cardiorespiratory and technical complications were studied as outcome variables. The incidence of these adverse effects was calculated for the overall series and for both cohorts, and the relative risk (RR) and its 95% confidence interval (95%CI) were determined. RESULTS: The overall mortality of the series was 0.9% (10/1172), the incidence of cardiorespiratory complications was 10.2% (120/1172) and that of technical complications was 20.6% (242/1172). The RR calculated for cardiorespiratory, technical complications and mortality in exposed and unexposed subjects was: 0.914 (95%CI: 0.804-1.039), 0.996 (95%CI: 0.895-1.107) and 0.911 (95%CI: 0.606-1.37), respectively. CONCLUSIONS: Patients operated at the end of the week do not present a higher risk of postoperative adverse effects.

Optimum web viewer application for DICOM whole slide image visualization in anatomical pathology.

BACKGROUND AND OBJECTIVE: Digital scanners are being increasingly adopt-ed in anatomical pathology, but there is still a lack of a standardized whole slide image (WSI) format. This translates into the need for interoperability and knowledge representation for shareable and computable clinical information. This work describes a robust solution, called Visilab Viewer, able to interact and work with any WSI based on the DICOM standard. METHODS: Visilab Viewer is a web platform developed and integrated alongside a proposed web architecture following the DICOM definition. To prepare the information of the pyramid structure proposed in DICOM, a specific module was defined. The same structure is used by a second module that aggregates on the cache browser the adjacent tiles or frames of the current user's viewport with the aim of achieving fast and fluid navigation over the tissue slide. This solution was tested and compared with three different web viewers, publicly available, with 10 WSIs. RESULTS: A quantitative assessment was performed based on the average load time per frame together with the number of fully loaded frames. Kruskal-Wallis and Dunn tests were used to compare each web viewer latency results and finally to rank them. Additionally, a qualitative evaluation was done by 6 pathologists based on speed and quality for zooming, panning and usability. The proposed viewer obtained the best performance in both assessments. The entire architecture proposed was tested in the 2nd worldwide DICOM Connectathon, obtaining successful results with all participant scanner vendors. CONCLUSIONS: The online tool allows users to navigate and obtain a correct visualization of the samples avoiding any restriction of format and localization. The two strategical modules allow to reduce time in displaying the slide and therefore, offer high fluidity and usability. The web platform manages not only the visualization with the developed web viewer but also includes the insertion, manipulation and generation of new DICOM elements. Visilab Viewer can successfully exchange DICOM data. Connectathons are the ultimate interoperability tests and are therefore required to guarantee that solutions as Visilab Viewer and its architecture can successfully exchange data following the DICOM standard. Accompanying demo video. (Link to Youtube video.).

SECT Clinical practice guideline on the management of patients with spontaneous pneumothorax. / Guía de práctica clínica de la SECT sobre el manejo de pacientes con neumotórax espontáneo.

This clinical practice guideline (CPG) emerges as an initiative of the scientific committee of the Spanish Society of Thoracic Surgery. We formulated PICO (patient, intervention, comparison, and outcome) questions on various aspects of spontaneous pneumothorax. For the evaluation of the quality of evidence and preparation of recommendations we followed the guidelines of the Grading of recommendations, Assessment, Development and Evaluation (GRADE) working group.

Morbidity and mortality in octogenarians with lung cancer undergoing pneumonectomy.

OBJECTIVE: Evaluate the restrictiveness of selection criteria for lung resection in lung cancer patients over 80 years of age compared to those applied in younger patients. Compare and analyze 30-day mortality and postoperative complications in both groups of patients. METHODS: Case-controlled retrospective analysis. STUDY POPULATION: Consecutive patients undergoing elective anatomical lung resection. Population was divided into octogenarians (cases) and younger patients (controls). Variables determining surgical risk (BMI, FEV1%, postoperative FEV1%, FEV1/FVC, DLCO and pneumonectomy rate) were compared using either Wilcoxon or Chi-squared tests. Thirty-day mortality and morbidity odds ratio were calculated. A logistic regression model with bootstrap resampling was constructed, including postoperative complications as dependent variable and age and post-operative FEV1% as independent variables. Data were retrieved from a prospective database. RESULTS: No statistically significant differences were found in BMI (P=.40), FEV1% (P=.41), postoperative FEV1% (P=.23), FEV1/FVC (P=.23), DLCO (P=.76) and pneumonectomy rate (P=.90). Case mortality was 1.85% and control mortality was 1.26% (OR: 1.48). Cardiorespiratory complications occurred in 12.80% of younger subjects and in 13.21% of patients aged 80 years or older. (OR: 1.03). In the logistic regression, only FEV1% was related to postoperative complications (P<.005). CONCLUSION: Selection criteria for octogenarians are similar to those applied in the rest of the population. Advanced age is not a factor for increased 30-day mortality or postoperative morbidity.

Usefulness of conventional pleural drainage systems to predict the occurrence of prolonged air leak after anatomical pulmonary resection.

OBJECTIVES: One of the reported advantages of digital pleural drainage system is the possibility of predicting the occurrence of prolonged air leak (PAL) based on the recorded pleural pressures and/or air flow through chest tubes. Nevertheless, this fact has never been well supported. The objective of this investigation is to evaluate if the occurrence of PAL can accurately be predicted using clinical data and air leak measurements 24 h after lung resection on conventional pleural drainage system (CPDS). METHODS: Prospective observational study on 100 consecutive non-complicated patients undergoing anatomical lung resection (segmentectomy, lobectomy or bilobectomy). Prior to the operation, the risk of PAL was evaluated according to the score previously published. Twenty-four hours after surgery, two independent observers measured the air flow at forced deep expiration on a CPDS with graduated analogical leak monitor. The agreement between both observers was determined and in case of discrepancy, the mean of both observations was calculated. After discharge, the occurrence of PAL (defined as persistent air leak 5 or more days after the operation) was recorded. A logistic regression model was constructed including two independent categorical variables (PAL score and air flow) and the performance of the model was assessed by non-parametric receiver operating characteristic curves. RESULTS: The series includes 81 lobectomies, 8 bilobectomies and 11 anatomical segmentectomies. Median preoperative PAL score was 1 (range 0-3.5). Any postoperative air flow was observed in 30 cases with a median value of 0 (0-3.5). The prevalence of PAL in the series was 10% (10 of 100 cases). Both independent variables entered in the multivariate model (PAL score P = 0.050, air flow: 0.016) and C-index was 0.83. CONCLUSION: The performance of this simple predictive model, without any electronic recording, warrants a larger multi-institutional study to validate its usefulness in clinical decision-making regarding the management of patients with air leak after lung resection.

Endobronchial valves in the treatment of persistent air leak, an alternative to surgery.

INTRODUCTION: Persistent air leak is frustrating for both patients and physicians, above all leaks with a high risk of surgery. Insertion of endobronchial valves could be an alternative to surgery. The aim of this study is to describe our experience in these valves and analyse their efficacy in a series of patients with persistent air leaks. MATERIAL AND METHODS: The valves are inserted by means of flexible bronchoscopy under conscious sedation and local anesthesia. A preliminary bronchoscopy identifies the air leak by bronchial occlusion using a balloon catheter. A successful outcome is defined as complete disappearance of the leak following removal of the chest drain, without the need for further surgery. RESULTS: From November 2010 to December 2013, 8 patients with persistent air leaks were treated with endobronchial valves. The number of valves used ranged from 1 to 4 (median 2), with a median duration of air leak prior to placement of 15.5 days. There were no complications and the resolution of the leak was complete in 6 of 8 patients (75%). The median duration of drainage after insertion of the valves was 13 days and the median time to removal of 52.5 days. CONCLUSIONS: Insertion of endobronchial valves is a safe and effective method for treating persistent air leaks, and a valid alternative to surgery.

Poorer Survival in Stage IB Lung Cancer Patients After Pneumonectomy.

OBJECTIVE: Pneumonectomy may be needed in exceptional cases in patients with early stage NSCLC, especially in stage IB. The aim of this study was to evaluate whether overall survival in stage IB (T2aN0M0) NSCLC patients is worse after pneumonectomy. METHODS: Retrospective study of a series of pathological IB (pIB) patients who underwent either lobectomy or pneumonectomy between 2000 and 2011. The dependent variable was all-cause death. Operative mortality was excluded. The relationship between the age, FEV1%, Charlson index and performance of pneumonectomy variables and the dependent variable were analyzed using a Cox regression. Overall survival for both groups of patients was then plotted in Kaplan-Meier graphs and compared using the log-rank test. RESULTS: A total of 407 cases were analyzed (373 lobectomies and 34 pneumonectomies). According to Cox regression, age, FEV1% and pneumonectomy were associated with poorer survival (P<.05). Age-adjusted survival and FEV1% showed diminished survival in patients who underwent pneumonectomy (log-rank, P=.0357). CONCLUSIONS: In stage pIB NSCLC patients, pneumonectomy is associated with poorer survival compared to lobectomy.

Effect of implementing the European guidelines for functional evaluation before lung resection on cardiorespiratory morbidity and 30-day mortality in lung cancer patients: a case-control study on a matched series of patients.

OBJECTIVES: We hypothesized that postoperative cardiorespiratory morbidity and/or 30-day death rates decreased after implementing the new European ERS/ESTS guidelines for functional evaluation before lung resection and tested the hypothesis by means of a case-control study. METHODS: The analysis included a series of 916 consecutive patients who underwent an anatomical pulmonary resection for non-small-cell lung cancer in our centre. Patients were divided into cases (September 2009-August 2012) and controls (December 2002-August 2009). We reviewed the records from a prospective computerized database; the final dataset included no missing data. The primary studied outcomes were the occurrence of cardiorespiratory morbidity or 30-day death after surgery. The patients were 1:1 propensity score matched according to the following variables age, ppoFEV1% and the need of pneumonectomy. RESULTS: After the matching process, 670 cases (335 cases and 335 controls) entered into the study. The rates of pneumonectomy in cases and controls were 5.7 and 13.2%, respectively, (P < 0.0001) in the whole series and 5.7 and 6.9% after matching (P = 0.52). Cardiorespiratory morbidity was 8.1% (27 of 308) in cases and 9.8% (33 of 335) in controls [odds ratio (OR): 0.8; 95% confidence interval (CI): 0.4-1.4]. Thirty-day mortality was 0.90% (3/335) in cases and 1, 2% (4 of 335) in controls (OR: 0.7; 95% CI: 0.1-4.4). CONCLUSIONS: Although we have observed a trend towards lower cardiorespiratory morbidity and 30-day mortality after implementing ERS/ESTS guidelines, the benefit of the guidelines remains unclear. Multicentric analysis including a very large number of cases is needed to demonstrate statistically the effectiveness of the guidelines to reduce operative mortality and cardiorespiratory morbidity. Maybe the effect could be easier demonstrated in series with higher operative mortality or morbidity.

The risk of bilobectomy compared with lobectomy: a retrospective analysis of a series of matched cases and controls.

OBJECTIVES: Bilobectomy is considered to be a risky procedure due to space mismatch between the pleural space and the remnant lung. The objective of this study was to evaluate if postoperative complications related or not to size mismatch are more frequent after bilobectomy compared with right lobectomy cases. METHODS: Retrospective case-control study on a series of matched non-small-cell lung cancer patients. Cases were patients who underwent right bilobectomy (upper and middle or lower and middle) and controls, patients who underwent right upper or lower lobectomy. Cases and controls were matched by propensity scoring according to site, age, ppoFEV1, type of postoperative management (intensive physiotherapy or not), cardiac comorbidity and pT status. We selected two primary outcomes for comparison: occurrence of any cardiorespiratory complication and occurrence of any complication related to space discrepancies. For the latter, all complicated case records were reviewed and two blinded observers agreed on the probability of each complication to be related to space discrepancies. Agreement was measured by the κ statistic. The overall odds ratio (OR) and 95% confidence interval (CI) for each outcome were calculated on 2 × 2 tables for the whole population and for cases with upper or lower resections. RESULTS: The study included 689 patients: 572 right lobectomy (419 upper and 153 lower) and 117 bilobectomy cases (30 upper and middle and 87 lower and middle). The overall mortality rate of the series was 2.03% (14/689), and cardiorespiratory complications were recorded in 14.4% (99/689) and space-related complications in 19.59% (135/689) cases. Both observers agreed on space-related complications in 86% of the 135 cases (κ: 0.72). After matching, 234 cases entered the study (117 with right lobectomy, including 83 lower and 34 upper, and 117 with bilobectomy, including 87 lower and 30 upper). The prevalence of cardiorespiratory complications was higher after lower and middle lobectomy compared with lower lobectomy (P = 0.0002; OR: 7.96, 95% CI: 2.19-43.16). No differences were found in death rates or in space-related complications between groups of lobectomy and bilobectomy cases. CONCLUSIONS: This study failed to demonstrate a higher space-related complication rate in bilobectomy cases but cardiorespiratory complications were statistically higher after lower and middle lobectomy compared with lower lobectomy in matched cases.

The risk of death due to cardiorespiratory causes increases with time after right pneumonectomy: a propensity score-matched analysis.

OBJECTIVES: The study aimed to compare in-hospital, 30-day and non-cancer-related 6-month death rates in a series of right and left pneumonectomy cases matched according to functional parameters. METHODS: A retrospective study was conducted on a series of 263 non-small cell lung cancer patients who underwent pneumonectomy. Left and right pneumonectomy cases were matched according to propensity scores using the following variables: age, coronary artery disease, any other cardiac comorbidity and predicted postoperative forced expiratory volume in the 1st second (ppoFEV1). After matching, 89 pairs of cases were selected. In-hospital, 30-day and 6-month crude and risk-adjusted death rates not related to cancer relapse or distant metastases were calculated for right and left pneumonectomy and compared on 2-by-2 tables using odds ratios. Death hazards were estimated by Cox regression, introducing the following independent variables in the model: age, cardiac comorbidity, ppoFEV1 and occurrence of any postoperative cardiorespiratory complication or bronchial fistula. RESULTS: Non-cancer-related in-hospital, 30-day and 6-month death rates were, respectively, 8.4 (3.4 in left and 13.5 in right cases; P = 0.015), 11.8 (7.8 in left and 15.7 in right cases; P = 0.10) and 18.5% (12.4 in left and 24.7 in right cases; P = 0.033). On Cox regression, age, right pneumonectomy and the occurrence of postoperative cardiorespiratory complications (but not bronchial fistula) were related to the risk of death at 6 months. CONCLUSIONS: The risk of death after pneumonectomy increases with time and strongly depends on the side of the operation (it is higher after right pneumonectomy) and on the occurrence of any postoperative cardiorespiratory complication. Neither hospital nor 30-day mortality should be reported as a valid outcome after pneumonectomy since they do not represent the real risk of the operation.

The values of intrapleural pressure before the removal of chest tube in non-complicated pulmonary lobectomies.

OBJECTIVES: Digitalized chest drainage systems allow for quantification of air leak and measurement of intrapleural pressure. Little is known about the value of intrapleural pressure during the postoperative phase and its role in the recovering process after pulmonary resection. The objective of this investigation was to measure the values of pleural pressure immediately before the removal of chest tube after different types of pulmonary lobectomy. METHODS: Prospective observational analysis on 203 consecutive patients submitted to pulmonary lobectomy during a 12-month period at two centres. Multiple measurements were recorded in the last hour before the removal of chest tube and averaged for the analysis. All patients were seated in bed in a 45° up-right position or in a chair, had a single chest tube and were not connected to suction during the evaluation period. Analysis of variance (ANOVA) was used to assess the differences in pleural pressure between different types of lobectomies. RESULTS: The average maximum, minimum and differential pressures were -6.1, -19.5 and 13.3 cmH(2)O, respectively. The average pressures were similar in all types of lobectomies (ANOVA, P = 0.2) and ranged from -11 to -13 cmH(2)O, with the exception of right upper bilobectomy (-20 cmH(2)O, all P-values vs. other types of lobectomies <0.05). Similar values were also recorded for maximum pressures (range -4.4 to -8.4 cmH(2)O) and minimum pressures (-31.6 cmH(2)O vs. ranged from -15.4 to -20.5 cmH(2)O, all P-values <0.01). The average pleural pressure was not associated with FEV1 (P = 0.9), DLCO (P = 0.2) or FEV1/FVC ratio (P = 0.6), when tested with linear regression. Similarly, the average pleural pressure was similar in patients with and without COPD (-12.1 vs. -13.0 cmH(2)O, P = 0.4). The ANOVA test was used to assess differences in pressures between different lobectomies. CONCLUSIONS: The so-called water seal status may actually correspond to intrapleural pressures ranging from -13 to -20 cmH(2)O. Modern electronic chest drainage devices allow a stable control of the intrapleural pressure. Thus, the values found in this study may be used as target pressures for different types of lobectomies, in order to favour lung recovery after surgery.

[Treatment of lung cancer with chest wall invasion]. / Tratamiento del cáncer de pulmón con invasión de la pared torácica.

The aim of this study was to analyze chest wall invasion, the indication and multidisciplinary nature of treatment, the methods used for parietal reconstruction and the technical problems posed by this procedure in patients with lung cancer and chest wall invasion. Chest wall invasion from adjacent malignancies affects 5% of patients with a bronchogenic carcinoma. Preoperative determination of parietal invasion aids the planning of an appropriate therapeutic approach. Positron emission tomography combined with computed tomography (PET/CT) improves the study of T-factor and metastatic nodal involvement and distant metastases. As a rule, surgical treatment should attempt complete tumoral resection: lobectomy, resection of the parietal pleura and/or of the chest wall--ensuring tumor-free margins--and hilar and mediastinal lymphadenectomy. We also analyzed the distinct prognostic factors for survival, as well as the indication for induction or adjuvant therapy. Chest wall reconstruction involves recreating the most anatomical and physiological conditions possible in the chest cavity and surrounding muscles. The ideal reconstruction would achieve adequate parietal stability and coverage to preserve functionality, with the cosmetic result being an important, but secondary, consideration. Many materials are available for reconstruction and the choice of material should be individualized in each patient. A multidisciplinary team able to plan and perform the resection and subsequent reconstruction, oversee postoperative management and treat complications early is essential.

Chest physiotherapy revisited: evaluation of its influence on the pulmonary morbidity after pulmonary resection.

OBJECTIVE: The study aimed to evaluate if perioperative chest physiotherapy modifies the risk of pulmonary morbidity after lobectomy for lung cancer. METHODS: We have reviewed a prospectively recorded database of 784 lung cancer patients treated by scheduled lobectomy (361 operated after implementing a new physiotherapy program). No other changes were introduced in the patients' perioperative management during the study period. A propensity matching score was generated for all eligible patients and two logistic models were constructed and adjusted. The first one (model A) included age of the patient, forced expiratory volume in 1s (percent) (FEV1%) and predicted postoperative forced expiratory volume in 1s (percent) (ppoFEV1%); for the second model (model B); chest physiotherapy was added to the previous ones. Using each model, patients' individual probability of postoperative complication was calculated and maintained in the database as a new variable (risk A and risk B). Individual risks calculated by both models were plotted on a time series and presented in two different graphs. RESULTS: Rates of pulmonary morbidity were 15.5% before the intensive physiotherapy program and 4.7% for patients included in the implemented program (p = 0.000). The propensity score identified 359 pairs of patients. Model A included age (p = 0.012), FEV1% (p = 0.000), and ppoFEV1% (p = 0.031) as prognostic variables. Model B included age (p = 0.012), FEV1% (p = 0.000), and physiotherapy (p = 0.000). On graphic representation, a great decrease of the estimated risk could be seen after the onset of the physiotherapy program. CONCLUSIONS: Implementing a program of perioperative intensive chest physiotherapy reduced the overall pulmonary morbidity after lobectomy for lung cancer.

A scoring system to predict the risk of prolonged air leak after lobectomy.

BACKGROUND: Prolonged air leak (PAL) remains a frequent complication after lung resection. Perioperative preventative strategies have been tested, but their efficacy is often difficult to interpret due to heterogeneous inclusion criteria. The objective of this study was to develop and validate a practical score to stratify the risk of PAL after lobectomy. METHODS: Six hundred fifty-eight consecutive patients were submitted to pulmonary lobectomy (2000 to 2008) in center A and were used to develop the risk-adjusted score predicting the incidence of PAL (> 5 days). Exclusion criteria were chest wall resection and postoperative assisted mechanical ventilation. No sealants, pleural tent, or buttressing material were used. To build the aggregate score numeric variables were categorized by receiver operating curve analysis. Variables were screened by univariate analysis and then used in stepwise logistic regression analysis (validated by bootstrap). The scoring system was developed by proportional weighing of the significant predictor estimates and was validated on patients operated on in a different center (center B). RESULTS: The incidence of PAL in the derivation set was 13% (87 of 658 cases). Predictive variables and their scores were the following: age greater than 65 years (1 point); presence of pleural adhesions (1 point); forced expiratory volume in one second less than 80% (1.5 points); and body mass index less than 25.5 kg/m(2) (2 points). Patients were grouped into 4 risk classes according to their aggregate scores, which were significantly associated with incremental risk of PAL in the validation set of 233 patients. CONCLUSIONS: The developed scoring system reliably predicts incremental risk of PAL after pulmonary lobectomy. Its use may help in identifying those high-risk patients in whom to adopt intraoperative prophylactic strategies; in developing inclusion criteria for future randomized clinical trials on new technologies aimed at reducing or preventing air leak; and for patient counseling.

Influence of major pulmonary resection on postoperative daily ambulatory activity of the patients.

To describe and compare the daily ambulatory activity of the patients before and one month after major lung resection. Daily activity was measured using a pedometer (OMROM Walking Style PRO) given preoperatively in a prospective way to a series of 21 consecutive cases scheduled for lobectomy or pneumonectomy. Analyzed variables were age, pulmonary function, mean number of total and aerobic steps per day, walked distance and mean daily time of aerobic activity. Activity variables were analyzed individually and as a new differential variable DELTA. Wilcoxon and Mann-Whitney nonparametric tests were used for comparison between groups. General series data: 19 male. Age: 63+/-10.9 years. FEV(1)%: 88.4+/-22.7. DLCO: 86.2+/-21.6. Eleven cases had COPD criteria. Type of surgery: 3 pneumonectomy/18 lobectomy. Activity data: all patients showed a global decrease of their activity one month after surgery but, patients in the pneumonectomy group are unable to keep aerobic activity meanwhile patients that undergone lobectomy showed only a 25% reduction in the measured variables. Major pulmonary resection decreases the time and the quality of the daily ambulatory activity of the patients during the first postoperative month. Despite limitations, the chosen pedometer OMRON Walking Style Pro is an efficient tool to evaluate the perioperative daily ambulatory activity of patients.

Postoperative chest tube management: measuring air leak using an electronic device decreases variability in the clinical practice.

OBJECTIVES: Since there are no data in the literature regarding variability in the management of postoperative pleural drainages, we have designed a prospective randomized study aimed at measuring inter-observer variability in deciding when to withdraw chest tubes after lung resection and to evaluate if the use of an electronic device to measure postoperative air leak decreases clinical practice variations. METHODS: Sixty-one patients undergoing pulmonary resection were randomly assigned to one of the following groups: digital group (electronic measure of pleural air leak using Millicore AB DigiVent chest drainage system) or traditional group (standard water seal pleural chamber). Chest tube withdrawal criteria were established in advance. During morning rounds, two thoracic surgeons with comparable clinical experience and blinded to the decision of their counterpart, evaluated chest tube withdrawal criteria and noted whether the tube should be withdrawn or not. Inter-observer variability kappa index and global, positive, and negative agreement rates were calculated on 2 x 2 tables. Each observation episode was considered in the calculation. RESULTS: Fifty-four observations were recorded in the traditional group. Kappa coefficient was 0.37 (overall agreement rate: 0.58; positive agreement rate: 0.72; and negative agreement rate: 0.64). In the digital group, 67 observations were recorded. Kappa coefficient was 0.88 (overall agreement rate: 0.94; positive agreement rate 0.94; and negative agreement rate 0.94). CONCLUSIONS: We have demonstrated a high rate of disagreement related to the indication to remove chest tubes after lung resection and the improvement of the agreement rate with the use of an electronic device to measure postoperative air leak and pleural pressures.