Preoperative CHA2DS2-VASc Score Predicts Postoperative Atrial Fibrillation after Lobectomy.

BACKGROUND: Postoperative atrial fibrillation (POAF) affects 10 to 20% of noncardiac thoracic surgeries and increases patient morbidity and costs. The purpose of this study is to determine if preoperative CHA2DS2-VASc score can predict POAF after pulmonary lobectomy for nonsmall cell lung cancer. METHODS: Patients with complete CHA2DS2-VASc data who underwent lobectomies from January 2007 to January 2016 at a single institution were analyzed in a retrospective case-control study using a prospective database. An independent samples t-test was used to compare the mean CHA2DS2-VASc scores of POAF and non-POAF groups. A multivariable logistic regression analysis (MVA) evaluated the independent contribution of variables of the CHA2DS2-VASc score in predicting POAF. Chi-square test with univariate odds ratios (ORs) was used to determine a statistically significant cutoff score for predicting POAF. RESULTS: Of 525 total patients, 82 (15.6%) developed POAF (mean CHA2DS2-VASc score: 2.7) and 443 (84.4%) did not develop POAF (mean score: 2.3). Mean difference between these groups was significant at 0.43 (p = 0.01; 95% confidence interval [CI]: 0.09-0.76). In the MVA, significant predictors of POAF were age 65 to 74 years (adjusted OR [aOR] = 2.45; 95% CI: 1.31-4.70; p = 0.006) and age ≥75 years (aOR = 3.11; 95% CI: 1.62-5.95; p = 0.0006). Patients with CHA2DS2-VASc scores ≥5 had significantly increased OR for POAF (OR = 2.59; 95% CI: 1.22-5.50). CONCLUSIONS: Preoperatively calculated CHA2DS2-VASc score can predict POAF in patients undergoing pulmonary lobectomy. Age is the most statistically significant independent predictor, and patients with scores ≥5 have significantly increased risk. Trials for POAF prophylaxis should target this population.

Racial and Ethnic Differences in Lung Cancer Surgical Stage: An STS Database Study.

BACKGROUND: Racial and ethnic differences in lung cancer care have been previously documented. These differences may be related to access to care, cultural differences, or fewer patients presenting with operable lung cancer. The relationship between race and pathologic stage of patients who undergo lung cancer resection has not been defined. This study estimates racial disparities in lung cancer stage among patients who undergo surgical resection. METHODS: The Society of Thoracic Surgeons (STS) database was queried for patients who underwent resection of non-small cell lung cancer and had complete pathologic staging and racial identification. Univariate and multivariate analyses were performed. Study end point was the pathologic stage and we evaluated its association with the racial and ethnic origins of the patients. RESULTS: Of 19,173 eligible patients with non-small cell lung cancer of known pathological stage who underwent surgery between 2002 and 2008, the majority were Caucasian (17,148, 89.4%), 1,502 (7.8%) were African-American, 273 (1.4%) were Asian, and 250 (1.3%) were Hispanic. In univariate analysis, significantly more Caucasian and African-American patients underwent resection of stage I/II lung cancer (13,929, 81.2% and 1,217, 81%, respectively) as compared with the Asian (207, 75.2%) and Hispanic (188, 75.8%) patients (p = 0.007). Stage at operation did not differ between Caucasians and African-Americans. Multivariate analysis confirmed these findings (p = 0.03) after adjustment for age, gender, tobacco use, diabetes, and year of surgery. CONCLUSION: Within the STS database, patients identified as Asian or Hispanic had a significantly higher pathologic stage at the time of resection than Caucasian or African-American patients. The causes of these differences in the treatment of potentially curable lung cancer are unknown and require further investigation.

The STS 2024 Risk Models for Lung Cancer Resection: Continued Refinement and Improved Outcomes.

BACKGROUND: The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) has been used to develop risk models for patients undergoing pulmonary resection for cancer. Leveraging a contemporary and more inclusive cohort, we sought to refine these models. METHODS: The study population consisted of adult patients in the STS GTSD who underwent pulmonary resection for cancer between 2015 and 2022. Unlike previous models, non-elective operations were included. Separate risk models were derived for operative mortality, major morbidity, and composite morbidity or mortality. Logistic regression with backward selection was used with predictors retained in models if p<0.10. All derived models were validated using 9-fold cross validation. Model discrimination and calibration were assessed for the overall cohort and for surgical procedure, demographic, and risk factor subgroups. RESULTS: Data from 140,927 patients at 337 participating centers were included in the study. Overall operative mortality rate was 1.1%, major morbidity 7.3%, and composite morbidity or mortality 7.6%. Novel predictors of short-term outcomes included interstitial lung disease, DLCO, and payor status. Overall discrimination was superior to previous STS pulmonary resection models for operative mortality [C-statistic = 0.80] and for composite morbidity or mortality [C-statistic = 0.70]. Model discrimination was comparable and model calibration was excellent across all procedure- and demographic-specific sub-cohorts. CONCLUSIONS: Among STS GTSD participants, major morbidity and operative mortality rates remain low following pulmonary resection. The newly derived pulmonary resection risk models demonstrate superior performance compared to previous models, with broader real-life applicability and clinical face validity.

Impact of Liposomal Bupivacaine on Enhanced Recovery After Surgery Protocol for Lung Resection.

BACKGROUND: There is limited data showing the benefit of liposomal bupivacaine as part of an Enhanced Recovery After Surgery (ERAS) protocol in reducing opioid use in minimally invasive lobectomies. METHODS: A retrospective observational study compared three cohorts of patients undergoing lobectomies between January 2015 and December 2021. The control group neither received liposomal bupivacaine intraoperatively nor underwent an ERAS protocol. The liposomal bupivacaine cohort only received a nerve block, whereas the ERAS cohort received a nerve block intraoperatively and underwent an ERAS protocol. Primary outcome was post-operative opioid consumption. RESULTS: There were 433 patients in this study (n=87 for controls, n=138 for liposomal bupivacaine alone, and n=208 for ERAS/liposomal bupivacaine). There was a statistically significant difference in the amount of opioids used between the control (43 OME) and liposomal bupivacaine alone cohort (30.5 OME) (p<.001); between control vs. ERAS/liposomal bupivacaine cohort (17 OME) (p<.001); and between liposomal bupivacaine alone and ERAS/liposomal bupivacaine cohorts (p<.001). Hospital stay was not statistically different between the two groups of interest (3 days); however, hospital stay differed from the control (4 days). 30-day readmission was not significantly different between the 3 groups (p=.43). CONCLUSIONS: Liposomal bupivacaine alone as part of a larger ERAS protocol significantly reduced opioid use and hospitalization duration; however, the reduction in opioid use was much greater with incorporation of liposomal bupivacaine into an ERAS protocol rather than in isolation. Prospective studies are needed to determine reproducibility and applicability of liposomal bupivacaine for opioid use reduction in other US hospital systems.

Conversion to Thoracotomy During Thoracoscopic vs Robotic Lobectomy: Predictors and Outcomes.

BACKGROUND: Conversion to thoracotomy during minimally invasive lobectomy for lung cancer is occasionally necessary. Differences between video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) lobectomy conversion have not been described. METHODS: We queried The Society of Thoracic Surgeons General Thoracic Surgery Database from January 1, 2015 to December 31, 2018. Patients with prior thoracic operations and metastatic disease were excluded. Univariable comparisons with χ2 and Kruskal-Wallis tests and multivariable logistic regression modeling were performed. RESULTS: There were 27,695 minimally invasive lobectomies from 269 centers. Conversion to thoracotomy occurred in 11.0% of VATS and 6.0% of RATS (P < .001). Conversion was associated with increased mortality (P < .001), major complications (P < .001), and intraoperative (P < .001) and postoperative (P < .001) blood transfusions. Conversion from RATS occurred emergently (P < .001) and for vascular injury (P < .001) more frequently than from VATS, but there was no difference in overall major complications or mortality. Mortality after conversion was 3.1% for RATS and 2.2% for VATS (P = .24). Clinical cancer stage II or III (P < .001), preoperative chemotherapy (P = .003), forced expiratory volume in 1 second (P = .006), body mass index (P < .001), and left-sided resection (P = .0002) independently predicted VATS conversion. For RATS clinical stage III (P = .037), left-sided resection (P = .041), and forced expiratory volume in 1 second (P = .002) predicted conversion. Lower volume centers had increased rates of conversion (P < .001) in both groups. CONCLUSIONS: Conversion from minimally invasive to open lobectomy is associated with increased morbidity and mortality. Conversion occurs more frequently during VATS compared with RATS, albeit less often emergently, and with similar rates of overall mortality and major complications. Predictors, urgency, and reasons for conversion differ between RATS and VATS lobectomy and may assist in patient selection.

Incorporating research into thoracic surgery practice.

The incorporation of research into a career in thoracic surgery is a complex process. Ideally, the preparation for a career in academic thoracic surgery begins with a research fellowship during training. In the academic setting, a research portfolio might include clinical research, translational research, or basic research. Using strategies for developing collaboration, thoracic surgeons in community-based programs may also be successful clinical investigators. In addition to the rigors of conducting research, strategies for reserving protected time and obtaining grant support must be considered to be successful in academic surgery.

Diltiazem Does Not Prevent Postoperative Atrial Fibrillation After Thoracoscopic Lobectomy.

OBJECTIVE: Thoracoscopic lobectomy is associated with lower rates of adverse events compared to thoracotomy. Despite this, postoperative atrial fibrillation (POAF) occurs in at least 10% of patients. Our objective is to determine if prophylaxis with diltiazem significantly reduced POAF events. METHODS: Patients without prior history of atrial fibrillation who underwent thoracoscopic lobectomy from 2007 to 2016 at one institution were analyzed in a retrospective cohort study utilizing a prospective database. Patients treated from 2007 to 2012 received no prophylaxis. Patients treated after 2012 received diltiazem postoperatively. All patients were monitored with continuous telemetry postoperatively. Multivariate direct logistic regression was performed to determine independent predictors of POAF. We report adjusted odds ratios and accompanying 95% confidence intervals, with P < 0.05 denoting statistical significance. RESULTS: The final regression model included 416 patients (52 with POAF, 364 without). In univariate analysis, the variables of body mass index and history of congestive heart failure, diabetes, or hypertension, and prophylaxis status did not meet inclusion criteria. Age, gender, history of stroke or transient ischemic attack, and vascular disease were included. Only ages 65 to 74 (P = 0.03) and ≥75 (P = 0.02), compared to <65, were statistically significant predictors of POAF. Adjusted odds ratios of ages 65 to 74 and ≥75 were 2.88 and 2.62, respectively. CONCLUSIONS: Diltiazem prophylaxis did not significantly reduce POAF incidence following thoracoscopic lobectomy. Further study is warranted since POAF remains an unwanted source of morbidity and cost for lobectomy patients.

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2021 Update on Outcomes and Research.

The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) remains the largest and most robust thoracic surgical database in the world. Participating sites receive risk-adjusted performance reports for benchmarking and quality improvement initiatives. The GTSD also provides several mechanisms for high-quality clinical research using data from 271 participant sites and nearly 720,000 procedures since its inception in 2002. Participant sites are audited at random annually for completeness and accuracy. During the last year and a half, the GTSD Task Force continued to refine the data collection form, ensuring high-quality data while minimizing data entry burden. In addition, the STS Workforce on National Databases has supported robust GTSD-based research program, which led to 10 scholarly publications in 2020. This report provides an update on outcomes, volume trends, and database improvements as well as a summary of research productivity resulting from the GTSD over the preceding year.

The impact of comprehensive air purification on patient duration of stay, discharge outcomes, and health care economics: A retrospective cohort study.

BACKGROUND: Infectious airborne and surface pathogens constitute a substantial and poorly explored source of patient subclinical illness and infections. With that in mind, a system of advanced air purification technology was designed to destroy the DNA and RNA of all bacteria, fungi, and viruses. This study compares the effects of advanced air purification technology versus high efficiency particulate air filtration with respect to certain metrics of health care economics and resource utilization at a large, community-based, urban hospital. Our hypothesis was that the use of the advanced air purification technology would decrease health care durations of stay, lead to fewer nonhome discharges, and decrease hospital charges. METHODS: After the installation of advanced air purification technology, 3 resultant air purification "zones" were established: zone C, a control floor with high efficiency particulate air filtration; zone B, a mixed high efficiency particulate air and advanced air purification technology floor; and zone A, a comprehensive advanced air purification technology remediation. This study included nonbariatric surgical patients admitted to any zone between December 2017 and December 2018, with reported case mix index on discharge. We analyzed hospital duration of stays, discharge destination, and hospital charges with adjustment for severity of illness using the case mix index. The likelihood of mortality, health care-associated infection, and readmission for each study zone was examined using logistic regression adjusting for case mix index, age, sex, and source of admission. RESULTS: The study included 1,002 patients across the 3 zones, with mean age of 55.8 years (53.7% female), average case mix index of 1.98, and mortality of 1.7%. Compared with zone C, patients in zones A and B demonstrated decreased hospital stays, a greater percentage of home discharges (86.5-87.8% vs 64.7%), and less hospital charges. In addition, logistic regression modeling performed on 999 study patients showed that the likelihood of mortality, hospital-acquired infections, and readmissions did not differ among the 3 zones. A trend toward a lesser incidence of hospital-acquired infections was noted in zones A and B (0.40% and 0.48%, respectively) when compared with zone C (0.63%). CONCLUSION: Patients in the advanced air purification technology zones demonstrated statistically significant improvements in durations of stay, discharge to home, and costs after adjusting for case mix index. In addition, a trend toward fewer hospital-acquired infections in advanced air purification technology zones was noted. These findings suggest that environmental factors may affect key clinical and economic outcomes, supporting further research in this important and largely unexplored area.

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2020 Update on Outcomes and Research.

The Society of Thoracic Surgeons General Thoracic Surgery Database (GTSD) remains the largest and most robust thoracic surgical database in the world. The GTSD provides participant sites with risk-adjusted performance reports for benchmarking and facilitates quality improvement initiatives. In addition the GTSD provides several mechanisms for high-quality research using data from over 283 participant sites and nearly 620,000 procedures since its inception in 2002. Participant sites are audited at random annually to ensure continued completeness and accuracy of the GTSD. In 2020 the GTSD migrated to a cloud-based interactive data platform, and the Task Force continues to refine the data collection form to decrease data entry burden while maintaining data quality, granularity, and relevance. This report provides an update on outcomes, volume trends, and database improvements as well as a summary of research productivity resulting from the GTSD over the preceding year.

The Society of Thoracic Surgeons General Thoracic Surgery Database 2019 Update on Outcomes and Quality.

The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) remains the most robust thoracic surgical database in the world, providing participating institutions semiannual risk-adjusted performance reports and facilitating multiple quality improvement initiatives each year. In 2018, the STS GTSD Data Collection Form was substantially revised to acquire the most important variables with the least data manager burden. In addition, a composite quality measure for all pulmonary resections for cancer was developed, and the impact that minimally invasive approaches have on the model was assessed. The 2018 database audit found that the accuracy of the database remains high, ranging from 92.5% to 98.4%. In 2019, the STS GTSD Task Force plans to focus on increasing generalizability of the database, initiating esophagectomy outcome public reporting, and creating customizable real-time dashboards. This review summarizes all national aggregate outcome, quality measurement, and improvement initiatives from the STS GTSD over the past 12 months.

Defining Proficiency for The Society of Thoracic Surgeons Participants Performing Thoracoscopic Lobectomy.

BACKGROUND: Parameters defining attainment and maintenance of proficiency in thoracoscopic video-assisted thoracic surgery (VATS) lobectomy remain unknown. To address this knowledge gap, this study investigated the institutional performance curve for VATS lobectomy by using risk-adjusted cumulative sum (Cusum) analysis. METHODS: Using The Society of Thoracic Surgeons General Thoracic Surgery Database, the study investigators identified centers that had performed a total of 30 or more VATS lobectomies. Major morbidity, mortality, and blood transfusion were deemed primary outcomes, with expected incidence derived from risk-adjusted regression models. Acceptable and unacceptable failure rates for outcomes were set a priori according to clinical relevance and informed by regression model output. RESULTS: Between 2001 and 2016, 24,196 patients underwent VATS lobectomy at 159 centers with a median volume of 103 (range, 30 to 760). Overall rates of operative mortality, major morbidity, and transfusion were 1% (244 of 24,189), 17.1% (4,145 of 24,196), and 4% (975 of 24,196), respectively. Of the highest-volume centers (≥100 cases), 84% (65 of 77) and 82 % (63 of 77) (p = 0.48) were proficient by major morbidity standards by their 50th and 100th cases, respectively. Similarly, 92% (71 of 77) and 90% (69 of 77) (p = 0.41) of centers showed proficiency by transfusion standards by their 50th and 100th cases, respectively. Three performance patterns were observed: (1) initial and sustained proficiency, (2) crossing unacceptability thresholds with subsequent improved performance; and (3) crossing unacceptability thresholds without subsequent improved performance. CONCLUSIONS: VATS lobectomy outcomes have improved with lower mortality and transfusion rates. The majority of high-volume centers demonstrated proficiency after 50 cases; however, maintenance of proficiency is not ensured. Cusum provides a simple yet powerful tool that can trigger internal audits and performance improvement initiatives.

Oncologic Equivalence of Minimally Invasive Lobectomy: The Scientific and Practical Arguments.

BACKGROUND: Despite the slow adoption of minimally invasive lobectomy (MIL), it is now a preferred approach for early lung cancer. Nevertheless, ongoing concerns about MIL oncologic effectiveness has led to calls for prospective, randomized trials. METHODS: Retrospective analysis of on-line databases, collected readings, and other scholarly experiences of the experienced authors were used to construct this review. All available reports that contained long-term survival comparisons for open versus MIL were tabulated. RESULTS: The preponderance of limited randomized and numerous large propensity-matched database analyses indicate equivalent or improved long-term MIL survival for early-stage disease. MIL lymph node dissection quality has been challenged; however, this was attributed to MIL avoidance of central tumors in early reports. Although technical inadequacies for MIL should be amplified for advanced cancer resections, early reports show no such concern. In fact, for special populations such as older, frail patients, evidence is much stronger that MIL confers a survival advantage. CONCLUSIONS: MIL is an oncologically equivalent operation with substantially less morbidity, especially in frail populations. It is reasonable to suggest that MIL should be the technique of choice, even a quality indicator, for lobectomy.

Non-invasive early detection of malignant pulmonary nodules by FISH-based sputum test.

BACKGROUND: Early detection decreases lung cancer mortality. The Target-FISH Lung Cancer Detection (LCD) Test is a non-invasive test designed to detect chromosomal changes (deletion or amplification) via Fluorescence in situ Hybridization (FISH) in sputum specimens from persons suspected of having lung cancer. We evaluated the performance of the LCD test in patients with highly suspicious pulmonary nodules who were scheduled for a biopsy procedure. METHODS: Induced sputum was collected from patients who were scheduled for biopsy of a solitary pulmonary nodule (0.8-3 cm) in one of 6 tertiary medical centers in the US and Israel. The lung cancer detection (LCD) Test combined sputum cytology and Target-FISH analysis on the same target cells and the results were compared to the pathology. Participants with non-surgical negative biopsy results were followed for 2 years to determine their final diagnosis. RESULTS: Of the 173 participants who were evaluated, 112 were available for analysis. Overall, the LCD test had a sensitivity of 85.5% (95% CI, 76.1-92.3), specificity of 69% (95% CI, 49.2-84.7) and an accuracy of 81.3% (95% CI, 72.8-88). The positive and negative predictive values (PPV, NPV) were 88.8% and 62.5%, respectively. The LCD test was positive in 9 of 11 lung cancer patients who had an initial negative biopsy. CONCLUSIONS: In a cohort of patients with highly suspicious lung nodules, the LCD test is a non-invasive option with good sensitivity and a high positive predictive value. A positive LCD test reinforces the need to aggressively pursue a definitive diagnosis of suspicious nodules.

National Quality Forum Metrics for Thoracic Surgery.

The National Quality Forum (NQF) is a multistakeholder, nonprofit, membership-based organization improving health care through preferential use of valid performance measures. NQF-endorsed measures are considered the gold standard for health care measurement in the United States. The Society of Thoracic Surgeons is the steward of the only six NQF-endorsed general thoracic surgery measures. These measures include one structure measure (participation in a national general thoracic surgery database), two process measures (recording of clinical stage and recording performance status before lung and esophageal resections), and three outcome measures (risk-adjusted morbidity and mortality after lung and esophageal resections and risk-adjusted length of stay greater than 14 days after lobectomy).

Mortality and Respiratory Failure After Thoracoscopic Lung Biopsy for Interstitial Lung Disease.

BACKGROUND: Surgical lung biopsy contributes to establishing a specific diagnosis among many patients with interstitial lung disease (ILD). The risks of death and respiratory failure associated with elective thoracoscopic surgical lung biopsy, and patient characteristics associated with these outcomes, are not well understood. METHODS: This is a retrospective cohort study of patients who underwent elective thoracoscopic lung biopsy for ILD between 2008 and 2014, according to The Society of Thoracic Surgeons database. The study determined the incidence of operative mortality and of postoperative respiratory failure. Multivariable models were used to identify risk factors for these adverse outcomes. RESULTS: Among 3,085 patients, 46 (1.5%) died before hospital discharge or within 30 days of thoracoscopic lung biopsy. Postoperative respiratory failure occurred in 90 (2.9%) patients. Significant risk factors for operative mortality among patients with ILD included a diagnosis of pulmonary hypertension, preoperative corticosteroid treatment, and low diffusion capacity. CONCLUSIONS: Elective thoracoscopic lung biopsy among patients with ILD is associated with a low risk of operative mortality and postoperative respiratory failure. Attention to the presence of pulmonary hypertension, preoperative corticosteroid treatment, and diffusion capacity may help inform risk stratification for thoracoscopic lung biopsy among patients with ILD.

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2017 Update on Research.

The outcomes research efforts based on The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database include two established research programs with dedicated task forces and with data analyses conducted at the STS data analytic center: (1) The STS-sponsored research by the Access and Publications program, and (2) grant and institutionally funded research by the Longitudinal Follow-Up and Linked Registries Task Force. Also, the STS recently introduced the research program enabling investigative teams to apply for access to deidentified patient-level General Thoracic Surgery Database data sets and conduct related analyses at their own institution. Last year's General Thoracic Surgery Database-based research publications and the new Participant User File research program are reviewed.

Comparison of Video-Assisted Thoracoscopic Surgery and Robotic Approaches for Clinical Stage I and Stage II Non-Small Cell Lung Cancer Using The Society of Thoracic Surgeons Database.

BACKGROUND: Data from selected centers show that robotic lobectomy is safe and effective and has 30-day mortality comparable to that of video-assisted thoracoscopic surgery (VATS). However, widespread adoption of robotic lobectomy is controversial. We used The Society of Thoracic Surgeons General Thoracic Surgery (STS-GTS) Database to evaluate quality metrics for these 2 minimally invasive lobectomy techniques. METHODS: A database query for primary clinical stage I or stage II non-small cell lung cancer (NSCLC) at high-volume centers from 2009 to 2013 identified 1,220 robotic lobectomies and 12,378 VATS procedures. Quality metrics evaluated included operative morbidity, 30-day mortality, and nodal upstaging, defined as cN0 to pN1. Multivariable logistic regression was used to evaluate nodal upstaging. RESULTS: Patients undergoing robotic lobectomy were older, less active, and less likely to be an ever smoker and had higher body mass index (BMI) (all p < 0.05). They were also more likely to have coronary heart disease or hypertension (all p < 0.001) and to have had preoperative mediastinal staging (p < 0.0001). Robotic lobectomy operative times were longer (median 186 versus 173 minutes; p < 0.001); all other operative measurements were similar. All postoperative outcomes were similar, including complications and 30-day mortality (robotic lobectomy, 0.6% versus VATS, 0.8%; p = 0.4). Median length of stay was 4 days for both, but a higher proportion of patients undergoing robotic lobectomy had hospital stays less than 4 days (48% versus 39%; p < 0.001). Nodal upstaging overall was similar (p = 0.6) but with trends favoring VATS in the cT1b group and robotic lobectomy in the cT2a group. CONCLUSIONS: Patients undergoing robotic lobectomy had more comorbidities and robotic lobectomy operative times were longer, but quality outcome measures, including complications, hospital stay, 30-day mortality, and nodal upstaging, suggest that robotic lobectomy and VATS are equivalent.