Robotic-assisted Versus Video-assisted Thoracoscopic Lobectomy: Short-term Results of a Randomized Clinical Trial (RVlob Trial).

OBJECTIVE: To determine whether RAL affects perioperative outcomes and long-term efficacy in NSCLC patients, compared with traditional VAL. SUMMARY OF BACKGROUND DATA: RAL is a promising treatment for NSCLC. However, its efficacy has not been fully evaluated. METHODS: A single-center, open-labeled prospective randomized clinical trial was launched in May 2017 to compare the efficacy of RAL and VAL. By May 2020, 320 patients were enrolled. The perioperative results of RAL and VAL were compared. RESULTS: The 320 enrolled patients were randomly assigned to the RAL group (n = 157) and the VAL group (n = 163). Perioperative outcomes were comparable between the 2 groups, including the length of hospital stay (P = 0.76) and the rate of postoperative complications (P = 0.45). No perioperative mortality occurred in either group. The total amount of chest tube drainage {830 mL [interquartile range (IQR), 550-1130 mL] vs 685 mL [IQR, 367.5-1160 mL], P = 0.007} and hospitalization costs [$12821 (IQR, $12145-$13924) vs $8009 (IQR, $7014-$9003), P < 0.001] were significantly higher in the RAL group. RAL group had a significantly higher number of LNs harvested [11 (IQR, 8-15) vs 10 (IQR, 8-13), P = 0.02], higher number of N1 LNs [6 (IQR, 4-8) vs 5 (IQR, 3-7), P = 0.005], and more LN stations examined [6 (IQR, 5-7) vs 5 (IQR, 4-6), P < 0.001]. CONCLUSIONS: Both RAL and VAL are safe and feasible for the treatment of NSCLC. RAL achieved similar perioperative outcomes, together with higher LN yield. Further follow-up investigations are required to evaluate the long-term efficacy of RAL. (ClinicalTrials.gov identifier: NCT03134534).

Italian survey on non-intubated thoracic surgery: results from INFINITY group.

BACKGROUND: Non-Intubated Thoracic Surgery (NITS) is becoming increasingly adopted all over the world. Although it is mainly used for pleural operations,, non-intubated parenchymal lung surgery has been less frequently reported. Recently, NITS utilization seems to be increased also in Italy, albeit there are no multi-center studies confirming this finding. The objective of this survey is to assess quantitatively and qualitatively the performance of NITS in Italy. METHODS: In 2018 a web-based national survey on Non-Intubated management including both thoracic surgeons and anesthesiologists was carried out. Reference centers have been asked to answer 32 questions. Replies were collected from June 26 to November 31, 2019. RESULTS: We raised feedbacks from 95% (55/58) of Italian centers. Seventy-eight percent of the respondents perform NITS but only 38% of them used this strategy for parenchymal surgery. These procedures are more frequently carried out in patients with severe comorbidities and/or with poor lung function. Several issues as obesity, previous non-invasive ventilation and/or oxygen therapy are considered contraindications to NITS. The regional anesthesia technique most used to provide intra- and postoperative analgesia was the paravertebral block (37%). Conversion to general anesthesia is not anecdotal (31% of answerers). More than half of the centers believed that NITS may reduce postoperative intensive care unit admissions. Approximately a quarter of the centers are conducting trials on NITS and, three quarters of the respondent suppose that the number of these procedures will increase in the future. CONCLUSIONS: There is a growing interest in Italy for NITS and this survey provides a clear view of the national management framework of these procedures.

Chest wall resection and reconstruction for locally recurrent breast cancer: From technical aspects to biological assessment.

INTRODUCTION: Breast cancer is the leading cause of cancer death among women in the industrialized countries. The incidence of local recurrences after mastectomy and breast-conserving therapy varies between 5% and 40% depending on risk factors and primary therapy. METHODS: From April 1999 to April 2011, 40 patients underwent chest wall resection and reconstruction for locally recurrent breast carcinoma with chest wall invasion. The main goal of surgery was local disease control to palliate clinical symptoms. RESULTS: Local radical resection was achieved in 26 patients (65%). One, 2 and 5 year overall survival rates were 94.4%, 82.0% and 68.5%; 1, 2 and 5 year disease-free survival rates were 94.4%, 73.6% and 45.5% respectively. Univariate analysis indicated age (p = 0.002) and synchronous distant metastases (p = 0.020) as factors having a negative impact on overall survival; multivariate analysis disclosed age (p = 0.052) and synchronous metastases (p = 0.059) as factors with a slight negative impact on overall survival. Older age was associated with improved overall survival. Univariate analysis indicated synchronous distant metastases (p = 0.029) and the need of post resectional additional treatments (p = 0.022) as factors adversely conditioning disease-free survival or time to progression; multivariate analysis disclosed the need of post resectional additional treatments (p = 0.036) as the only factor adversely conditioning disease-free survival or time to progression. CONCLUSIONS: Chest wall resection and reconstruction for locally recurrent breast cancer is a feasible and safe procedure providing adequate local disease control and an excellent palliation of very disabling symptoms in a selected group of patients.

Perioperative blood transfusion practices in oncologic thoracic surgery: when, why, and how.

INTRODUCTION: Available information on perioperative blood transfusion practices in oncologic thoracic surgery is scant and outdated. The purpose of this study was to investigate transfusion requirements in patients undergoing curative resection for lung cancer and to identify possible factors predictive of perioperative blood transfusion in our cohort of patients. METHODS: From 1st January 2009 to 31st December 2009, 317 patients underwent anatomic pulmonary resection. Patients who received at least 1 unit of red blood cells comprised the "transfused" group. Each case in this group was matched for surgical procedure with a control subject who did not require blood transfusion and was operated on during the same year; these patients comprised the "not transfused" group. RESULTS: A total of 75 patients (23.6%) received at least 1 unit of red blood cells during the perioperative period. Factors conditioning perioperative blood transfusion were: preoperative hemoglobin level (p < 0.0001); procedure duration (p = 0.017); body mass index (p < 0.001); induction therapies (p = 0.017); redo procedure (p = 0.021). Age, sex, histology, stage, ASA score, side, intraoperative blood loss, and fluid infusion did not affect perioperative blood transfusion practices. CONCLUSIONS: Preoperative hemoglobin level is the major risk factor for perioperative blood transfusion practices in oncologic thoracic surgery; procedure duration, body mass index, induction therapies, and redo procedure may condition transfusional needs, although they were actually not predictive on multivariate analysis.

Telemedicine for management of patients with lung cancer during COVID-19 in an Italian cancer institute: SmartDoc Project.

BACKGROUND: Telemedicine, and particularly video-consulting, has rapidly accelerated since the coronavirus disease 2019 (COVID-19) pandemic outbreak. The role of e-healthcare for the management of patients with lung diseases is evolving. We report the results of the initial experience of the SmartDoc Project, a telemedicine program activated in a cancer center (Istituto Nazionale Tumori) at the epicenter of the COVID-19 pandemic onset in Italy. METHOD: The SmartDoc project was established to guarantee continuity of healthcare services for patients with lung cancer during the COVID-19 pandemic crisis. The project was promoted within the National Health System to create a regulatory framework to authorize and reimburse telemedicine in its care delivery for all patients. At the end of the virtual meeting, patients were asked to answer an online survey. RESULTS: From June 19 to December 1, 2020, 83 patients participated in the SmartDoc project and received a teleconsultation. The majority of patients were older than 65 years. Among the 83 televisits, 14 (16.9%) were new visits, 2 (2.4%) second opinions, 4 (4.8%) 30-day postsurgery controls, and 63 (75.9%) long-term follow-up visits. A "complete satisfaction" score (5 out of 5 points) was reported in 70.59% of all the respondents; most patients (76.5%) preferred video-consulting and defined it as better than or comparable to an in-person visit. CONCLUSION: The favorable initial results of this study suggest that telemedicine should continue beyond the pandemic crisis and should be embedded in a more efficient and accessible healthcare system.

A Delphi Consensus report from the "Prolonged Air Leak: A Survey" study group on prevention and management of postoperative air leaks after minimally invasive anatomical resections.

OBJECTIVES: This study reports the results of an international expert consensus process evaluating the assessment of intraoperative air leaks (IAL) and treatment of postoperative prolonged air leaks (PAL) utilizing a Delphi process, with the aim of helping standardization and improving practice. METHODS: A panel of 45 questions was developed and submitted to an international working group of experts in minimally invasive lung cancer surgery. Modified Delphi methodology was used to review responses, including 3 rounds of voting. The consensus was defined a priori as >50% agreement among the experts. Clinical practice standards were graded as recommended or highly recommended if 50-74% or >75% of the experts reached an agreement, respectively. RESULTS: A total of 32 experts from 18 countries completed the questionnaires in all 3 rounds. Respondents agreed that PAL are defined as >5 days and that current risk models are rarely used. The consensus was reached in 33/45 issues (73.3%). IAL were classified as mild (<100 ml/min; 81%), moderate (100-400 ml/min; 71%) and severe (>400 ml/min; 74%). If mild IAL are detected, 68% do not treat; if moderate, consensus was not; if severe, 90% favoured treatment. CONCLUSIONS: This expert consensus working group reached an agreement on the majority of issues regarding the detection and management of IAL and PAL. In the absence of prospective, randomized evidence supporting most of these clinical decisions, this document may serve as a guideline to reduce practice variation.

Comparison of clinical and oncologic effectiveness between flexible 3-dimensional and bidimensional video-thoracoscopic surgery for lung cancer.

BACKGROUND: Three-dimensional (3D) vision systems are available for video-assisted thoracic surgery (VATS). It is unclear whether 3D-VATS is superior to bidimensional (2D) VATS systems. METHODS: We analyzed patients who received 3D-VATS (n = 171) or 2D-VATS (n = 228) lobectomy in a single institutional retrospective comparative study of 399 patients with resectable lung cancer conducted from June 2012 to December 2017. The operative and perioperative data were compared between the 2 groups. RESULTS: Operative time, length of hospital stay, number of dissected lymph nodes, and rate of postoperative complications were similar in both groups. In the 3D group, there was no conversion to thoracotomy for intraoperative major vascular injuries, while conversion to an open procedure for uncontrolled bleeding was recorded in 4 (1.7%) patients in the 2D group. Reoperation for hemostasis and/or aerostasis occurred in 6 (2.6%) patients of the 2D group (p = 0.04). CONCLUSION: Nonrandomized comparison of different surgical approaches is challenging. In our experience, 3D-VATS was safe and effective and offered excellent operative perception and sensitivity, enabling safer dissection of hilar structures. The 3D-VATS system helped skilled surgeons beyond the boundaries of more oncologically aggressive surgery.

Worsening Hemoptysis in a Rare Intrapulmonary Triton Tumor Mimicking Lung Cancer.

A 71-year-old male former smoker was referred for worsening hemoptysis from a hilar left tumor without radiologic or bronchoscopic identification of the bleeding source. He underwent an urgent upper lobectomy extended to the pericardium and left phrenic nerve to control active bleeding. Histologic analysis revealed a malignant triton tumor, a rare aggressive subtype of malignant peripheral nerve sheath tumors. This is a case report of unusual pulmonary involvement associated with hemoptysis. Despite radical surgery and multimodal treatment with adjuvant chemotherapy the patient died of systemic dissemination 10 months after surgery, with a disease-free survival of 3 months.

Epidemiology and management of primary spontaneous pneumothorax: a systematic review.

Primary spontaneous pneumothorax (PSP) is one of the most common thoracic diseases affecting adolescents and young adults. Despite the high incidence of PSP and the availability of several international guidelines for its diagnosis and treatment, a significant behavioural heterogeneity can be found among those management recommendations. A working group of the Italian Society of Thoracic Surgery summarized the best evidence available on PSP management with the methodological tool of a systematic review assessing the quality of previously published guidelines with the Appraisal of Guidelines for Research and Evaluation (AGREE) II. Concerning PSP physiopathology, the literature seems to be equally divided between those who support the hypothesis of a direct correlation between changes in atmospheric pressure and temperature and the incidence of PSP, so it is not currently possible to confirm or reject this theory with reasonable certainty. Regarding the choice between conservative treatment and chest drainage in the first episode, there is no evidence on whether one option is superior to the other. Video-assisted thoracic surgery represents the most common and preferred surgical approach. A primary surgical approach to patients with their first PSP seems to guarantee a lower recurrence rate than that of a primary approach consisting of a chest drainage positioning; conversely, the percentage of futile surgical interventions that would entail this aggressive attitude must be carefully evaluated. Surgical pleurodesis is recommended and frequently performed to limit recurrences; talc poudrage offers efficient pleurodesis, but a considerable number of surgeons are concerned about administering this inert material to young patients. CLINICAL TRIAL REGISTRATION NUMBER: International Prospective Register of Systematic Reviews (PROSPERO): CRD42018084247.

Extra-pleural pneumonectomy.

The extra-pleural pneumonectomy (EPP) is a standardised surgical procedure born for pleural tuberculosis and later used in pleural cancer treatment, especially in malignant pleural mesothelioma (MPM). This systematic review aimed to focus on the actual overall EPP role in surgical oncology. The literature search was performed from January 1985 to January 2018 In PubMed, Embase, and Cochrane according to PRISMA protocol. The search was restricted to publications in English with the research words "extrapleural pneumonectomy", "malignant pleural mesothelioma", "pleural malignancies". The results were then filtered focusing only on papers with series of patients treated with EPP, for mesothelioma and non-mesothelioma malignancies. The search was restricted to publications in English. We found a 5-year overall survival (OS) ranging from 0 to 78%. The peri-operative mortality and morbidity ranged from 0 to 11.8% and 0 to 82.6%, respectively. The most represented and described post-operative complications reported were ARDS, pericardial tamponade, cardiac herniation, pulmonary embolism, respiratory infections, respiratory failure, atrial arrhythmia, myocardial infarction. In referral centres and selected patients, EPP is a cytoreductive or radical surgical treatment in extended pleural malignancies. Prospective studies are needed to standardise the timing of the procedure in a multimodality treatment program, according to the oncological and functional indications, to keep an acceptable complications rate and post-operative quality of life status.

Conversion due to vascular injury during video-assisted thoracic surgery lobectomy: A multicentre retrospective analysis from the Italian video-assisted thoracic surgery group registry.

OBJECTIVES: Vascular injuries are among the most severe causes of unplanned conversion during VATS lobectomies. The study aimed to analyse the incidence of vascular injuries and their risk factors during VATS lobectomy. METHODS: The Italian VATS lobectomy Registry was used to collect data from 66 Thoracic Surgery Units. From 2013 to October 2016 (out of more than 3,700 patients enrolled) only information from Units with an enrollment >100 VATS lobectomies were retrospectively analysed. Logistic regression analysis was performed on selected variables of the univariate analysis. RESULTS: Ten institutions contributed a total of 1,679 patients. Vascular injuries leading to conversion occurred in 44 (2.6%) patients. Years of experiences were inversely related to the risk of vascular injuries. Univariate analysis showed age, gender, surgical activity, Charlson Index Score and number of resected lymph nodes like significantly associated variables. Multivariate analysis revealed that number of resected lymph nodes, VATS experience ratio (number of VATS lobectomies/total lobectomies performed in the same year at same centre), and surgical activity of the centre were significantly associated with the risk of conversion. Unplanned thoracotomy was correlated with postoperative morbidity. CONCLUSION: Vascular injuries in VATS lobectomies represented a rare complication which could directly affect the postoperative outcomes. The predictive factors for conversion were multifactorial and depended on characteristics of centres and surgeons' seniority. Minimally invasive VATS lobectomy approaches did not influence the risk of vascular damages.

Uniportal video-assisted thoracic surgery lobectomy: a consensus report from the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS).

OBJECTIVES: Our goal was to report the results of the first consensus paper among international experts in uniportal video-assisted thoracoscopic surgery (UniVATS) lobectomy obtained through a Delphi process, the objective of which was to define and standardize the main procedural steps, optimize its indications and perioperative management and identify elements to assist in future training. METHODS: The 40 members of the working group were convened and organized on a voluntary basis by the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). An e-consensus finding exercise using the Delphi method was applied to require 75% agreement for reaching consensus on each question. Repeated iterations of anonymous voting continued for 3 rounds. RESULTS: Overall, 31 international experts from 18 countries completed all 3 rounds of questionnaires. Although a technical quorum was not achieved, most of the responders agreed that the maximum size of a UniVATS incision should be ≤4 cm. Agreement was reached on many points outlining the currently accepted definition of a UniVATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions. CONCLUSIONS: The UVIG Consensus Report stated that UniVATS offers a valid alternative to standard VATS techniques. Only longer follow-up and randomized controlled studies will predict whether UniVATS represents a valid alternative approach to multiport VATS for major lung resections or whether it should be performed only in selected cases and by selected centres. The next step for the ESTS UVIG is the establishment of a UniVATS section inside the ESTS databases.

Robotic internal mammary lymphadenectomy: another possible minimally invasive approach to sampling lymph nodes in breast cancer patients.

Internal mammary lymphadenopathy may develop in breast cancer patients with silicone implants. Differential diagnosis includes malignant recurrence, infections, inflammations and granulomatous deposit. We report a case of internal mammary lymphadenopathy, in a patient with the previous history of breast cancer, requiring a tissue diagnosis. We performed a Robotic lymph nodes dissection of the left internal mammary. Final pathology diagnosis was positive for silicone granulomatous lymphadenitis secondary to silicone breast implants inserted after mastectomy for breast cancer.

Four arms robotic-assisted pulmonary resection-left upper lobectomy: how to do it.

Numerous published articles have shown the safety and efficacy of robotic anatomic pulmonary resection, including lobectomy for non-small cell lung cancer. Several techniques have been described to perform a lung lobectomy robotically. Since the beginning of our experience, we adopted a four-arm robotic approach with the da Vinci Si System. More recently we have used the newer Xi model, that offers a simplified and "quicker" set-up and docking time. This article emphases specifically on the technical aspects of how to complete the hilar dissection during four-arm robotic lobectomy.

Diaphragmatic and pericardial reconstruction after surgery for malignant pleural mesothelioma.

Extrapleural pneumonectomy (EPP) and pleurectomy-decortication (P/D) are both recognised surgical procedures for selected cases affected by malignant pleural mesothelioma (MPM). Surgical techniques have ameliorated over the last years, remaining the complete macroscopic resection of the disease the main surgical principle. EPP is defined as an en-bloc resection of the visceral pleura, parietal pleura, pericardium and diaphragm alongside the pneumonectomy. The thoracic domain of the International Association for Study of Lung Cancer (IASLC) recently clarified the, previously confused, surgical terminology. "Extended P/D" is considered as parietal and visceral pleurectomy, diaphragmatic and pericardial resection with the purpose to remove all macroscopic disease. The term "radical" was replaced by "extended" to underline that this procedure does not have oncologic radicality aims. Both operations above are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. The technical aspects of resection and reconstruction are described and the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.

Four arms robotic-assisted pulmonary resection-right lower/middle lobectomy: how to do it.

In the last few years, robotic approach for anatomic lung resection has brought an innovative development in minimally invasive thoracic surgery. This study analyzes the technical aspects of performing the hilar dissection for a lobectomy via robotic approach. With a detailed step-by-step description and essential tips and videos, in this paper, we report the procedure to carry out a four-arm robotic middle and lower lobectomy.

Surgical approaches in patients with oligometastatic non-small cell lung cancer.

In recent years, retrospective analyses have suggested that an oligometastatic state could exist, but the best evidence to date that a temporary oligometastatic disease exists for lung cancer mainly derives from the survival data on retrospective patients underwent surgical resection of a single M1 site and all intrathoracic disease. The critical determinates of long-term survival include definitive treatment of the primary non-small cell lung cancer (NSCLC), a single organ site of synchronous or metachronous disease, a long disease-free interval between treatment of the primary NSCLC and development of metastases, and the absence of intrathoracic lymph node (N0) disease. The ongoing development of innovative approaches to local therapy and treatment directed to the oligometastatic sites should be defined in future studies.

Bronchopleural Fistula After Pneumonectomy: Risk Factors and Management, Focusing on Open-Window Thoracostomy.

We evaluated principal risk factors and different therapeutic approaches for post-pneumonectomy bronchopleural fistula (BPF), focusing on open-window thoracostomy (OWT). We retrospectively reviewed all patients treated by pneumonectomy for lung cancer from 1999 to 2014; we evaluated preoperative, operative, and postoperative data; time between operation; and fistula formation, size, treatment, and predicting factors of BPF. Cumulative incidence curves for the development of BPF were drawn according to the Kaplan-Meier method. Differences between groups were assessed with the log rank test. Multivariable Cox proportional hazards regression analysis was used to assess the independent risk factors for BPF. P values <0.05 were considered significant. BPF occurred in 60 of 733 patients (8.2%). Bronchial suture with Stapler (EndoGia) (P = 0.02), right side (P = 0.003), and low preoperative albumin levels (< 3.5 g/dL) (P = 0.02) were independent predicting factors of fistula. Early BPF was treated by thoracotomic (12) or thoracoscopic (2) debridement of necrotic tissue and BPF surgical repair. Late BPF was treated by bronchoscopic application of fibrin glue (3) or endobronchial stent (1), chest tube and cavity irrigation by povidone-iodine (15). OWT was performed in 27 patients, followed by muscle flap interposition in 7 of these 27. The survival time of patients after the treatment of BPF was 29.0 months. The overall survival of patients treated by OWT was 50% at 2 years and 27 (8%) at 4 years. Correct management of BPF depends on several factors. In case of failure of different initial therapeutic approaches, we could consider OWT, followed by myoplasty.

Outcomes from the Delphi process of the Thoracic Robotic Curriculum Development Committee.

OBJECTIVES: As the adoption of robotic procedures becomes more widespread, additional risk related to the learning curve can be expected. This article reports the results of a Delphi process to define procedures to optimize robotic training of thoracic surgeons and to promote safe performance of established robotic interventions as, for example, lung cancer and thymoma surgery. METHODS: In June 2016, a working panel was spontaneously created by members of the European Society of Thoracic Surgeons (ESTS) and European Association for Cardio-Thoracic Surgery (EACTS) with a specialist interest in robotic thoracic surgery and/or surgical training. An e-consensus-finding exercise using the Delphi methodology was applied requiring 80% agreement to reach consensus on each question. Repeated iterations of anonymous voting continued over 3 rounds. RESULTS: Agreement was reached on many points: a standardized robotic training curriculum for robotic thoracic surgery should be divided into clearly defined sections as a staged learning pathway; the basic robotic curriculum should include a baseline evaluation, an e-learning module, a simulation-based training (including virtual reality simulation, Dry lab and Wet lab) and a robotic theatre (bedside) observation. Advanced robotic training should include e-learning on index procedures (right upper lobe) with video demonstration, access to video library of robotic procedures, simulation training, modular console training to index procedure, transition to full-procedure training with a proctor and final evaluation of the submitted video to certified independent examiners. CONCLUSIONS: Agreement was reached on a large number of questions to optimize and standardize training and education of thoracic surgeons in robotic activity. The production of the content of the learning material is ongoing.

Tips and tricks of the propensity score methods in the thoracic surgery research.

Without randomization, the differences in the distribution of baseline covariates can confound the evaluation of outcomes between the groups. To estimate the causal effects of treatment on the results randomized clinical trials (RCT) are routinely used. When RCT are not feasible for cost, time, and ethical issues, the effect of treatment on an inevitable outcome could be investigated by using a non-experimental study design. The propensity score (PS) refers to the individual probability, for a subject involved in a study, of receiving a new treatment rather than the control treatment. PS matching is a valuable and increasingly popular tool for dealing with observational data and non-random treatment assignment. Nevertheless, surgeons need to proceed with caution and apply PS methods appropriately.