Update in the Treatment of Pleural Tumors: Robotic Surgery Combined with Hyperthermic Intrathoracic Chemotherapy.

(1) Background. Intracavitary hyperthermic chemotherapy (HITHOC) remains part of the complex mosaic that is the multimodal approach for advanced stage thymoma and pleural malignancies. However, robotic pleurectomy/removal of pleural lesions in combination with intrathoracic chemotherapy is not currently being investigated. The aim of this study is to evaluate the safety of robotic pleurectomy/removal of relapses and HITHOC in patients with pleural recurrence of thymoma or MPM. (2) Methods: The data of nine consecutive patients affected by thymoma relapses or MPM who underwent robotic surgery in combination with HITHOC from February 2017 to November 2022 were collected and analyzed. Surgery performed prior to intrathoracic infusion of high-temperature chemotherapy consisted of removal of recurrences (three patients) or pleurectomy (six patients). All surgeries were performed with a four-port, fully robotic technique. (3) Results: No intraoperative complications occurred. No renal complications related to infusion were recorded. One patient, who underwent pleurectomy for MPM, had a grade II Clavien-Dindo postoperative complication. Oncological follow-up showed results in line with the literature. (4) Conclusions: With the limitation of the small number of patients, robotic surgery in combination with HITHOC seems to be safe in patients with pleural relapses of thymoma and early-stage MPM.

Sentinel Lymph Node Mapping in Lung Cancer: A Pilot Study for the Detection of Micrometastases in Stage I Non-Small Cell Lung Cancer.

Lymphadenectomy represents a fundamental step in the staging and treatment of non-small cell lung cancer (NSCLC). To date, the extension of lymphadenectomy in early-stage NSCLC is a debated topic due to its possible complications. The detection of sentinel lymph nodes (SLNs) is a strategy that can improve the selection of patients in which a more extended lymphadenectomy is necessary. This pilot study aimed to refine lymph nodal staging in early-stage NSCLC patients who underwent robotic lung resection through the application of innovative intraoperative sentinel lymph node (SLN) identification and the pathological evaluation using one-step nucleic acid amplification (OSNA). Clinical N0 NSCLC patients planning to undergo robotic lung resection were selected. The day before surgery, all patients underwent radionuclide computed tomography (CT)-guided marking of the primary lung lesion and subsequently Single Photon Emission Computed Tomography (SPECT) to identify tracer migration and, consequently, the area with higher radioactivity. On the day of surgery, the lymph nodal radioactivity was detected intraoperatively using a gamma camera. SLN was defined as the lymph node with the highest numerical value of radioactivity. The OSNA amplification, detecting the mRNA of CK19, was used for the detection of nodal metastases in the lymph nodes, including SLN. From March to July 2021, a total of 8 patients (3 female; 5 male), with a mean age of 66 years (range 48-77), were enrolled in the study. No complications relating to the CT-guided marking or preoperative SPECT were found. An average of 5.3 lymph nodal stations were examined (range 2-8). N2 positivity was found in 3 out of 8 patients (37.5%). Consequently, pathological examination of lymph nodes with OSNA resulted in three upstages from the clinical IB stage to pathological IIIA stage. Moreover, in 1 patient (18%) with nodal upstaging, a positive node was intraoperatively identified as SLN. Comparing this protocol to the usual practice, no difference was found in terms of the operating time, conversion rate, and complication rate. Our preliminary experience suggests that sentinel lymph node detection, in association with the accurate pathological staging of cN0 patients achieved using OSNA, is safe and effective in the identification of metastasis, which is usually undetected by standard diagnostic methods.

National Multicenter Study on the Comparison of Robotic and Open Thymectomy for Thymic Neoplasms in Myasthenic Patients: Surgical, Neurological and Oncological Outcomes.

Thymectomy is the gold standard in the treatment of thymic neoplasm and plays a key role in the therapeutic path of myasthenia gravis. For years, sternotomy has been the traditional approach for removing anterior mediastinal lesions, although the robotic thymectomy is now widely performed. The literature is still lacking in papers comparing the two approaches and evaluating long-term oncological and neurological outcomes. This study aims to analyze the postoperative results of open and robotic thymectomy for thymic neoplasms in myasthenic patients. Surgical, oncological and neurological data of myasthenic patients affected by thymic neoplasms and surgically treated with extended thymectomy, both with the open and the robotic approach, in six Italian Thoracic Centers between 2011 and 2021 were evaluated. A total of 213 patients were enrolled in the study: 110 (51.6%) were treated with the open approach, and 103 (48.4%) were treated with robotic surgery. The open surgery, compared with the robotic, presented a shorter operating time (p < 0.001), a higher number of postoperative complications (p = 0.038) and longer postoperative hospitalization (p = 0.006). No other differences were observed in terms of surgical, oncological or neurological outcomes. The robotic approach can be considered safe and feasible, comparable to the open technique, in terms of surgical, oncological and neurological outcomes.

Robotic versus Open Surgery in Locally Advanced Non-Small Cell Lung Cancer: Evaluation of Surgical and Oncological Outcomes.

Locally advanced non-small cell lung cancer (NSCLC) consists of a heterogeneous group, with different pulmonary extension and lymph nodal involvement. Robotic surgery can play a key role in these tumours thanks to its technological features, although open surgery is still considered the gold-standard approach. Our study aims to evaluate the surgical and oncological outcomes of locally advanced NSCLC patients who underwent robotic surgery in a high-volume centre. Data from consecutive patients with locally advanced NSCLC who underwent robotic lobectomy were retrospectively analysed and compared with patients treated with open surgery. Clinical characteristics and surgical and oncological information were evaluated. From 2010 to 2020, 131 patients underwent anatomical lung resection for locally advanced NSCLC. A total of 61 patients were treated with robotic surgery (46.6%); the median hospitalization time was 5.9 days (range 2-27) and the postoperative complication rate was 18%. Open surgery was performed in 70 patients (53.4%); the median length of stay was 9 days (range 4-48) and the postoperative complication rate was 22.9%. The median follow-up time was 70 months. The 5-year overall survival was 34% in the robotic group and 31% in the thoracotomy group. Robotic surgery can be considered safe and feasible not only for early stages but also for the treatment of locally advanced NSCLC.

The Role of Lymphadenectomy in Early-Stage NSCLC.

Lung cancer remains the leading cause of cancer-related death worldwide. The involvement of lymph nodes by the tumor has a strong impact on survival of patients. For this reason, lymphadenectomy plays a crucial role in the staging and prognosis of NSCLC, to define the most appropriate therapeutic strategies concerning the stage of the disease. To date, the benefit, in terms of survival, of the different extents of lymphadenectomy remains controversial in the scientific community. It is recognized that metastatic involvement of mediastinal lymph nodes in lung cancer is one of the most significant prognostic factors, in terms of survival, and it is therefore mandatory to identify patients with lymph node metastases who may benefit from adjuvant therapies, to prevent distant disease and local recurrences. The purpose of this review is to evaluate the role of lymphadenectomy in early-stage NSCLC in terms of efficacy and accuracy, comparing systematic, sampling, and lobe-specific lymph node dissection and analyzing the existing critical issue, through a search of the most relevant articles published in the last decades.

Different pathological response and histological features following neoadjuvant chemotherapy or chemo-immunotherapy in resected non-small cell lung cancer.

Introduction: Non-small cell lung cancer (NSCLC) is the leading cause of cancer incidence and mortality worldwide. Neoadjuvant chemo-immunotherapy has led to clinical benefits in resectable NSCLC in comparison to chemo-therapy alone. Major pathological response (MPR) and pathological complete response (pCR) have been used as surrogates of neoadjuvant therapy response and clinical outcomes. However, the factors affecting the pathological response are still controversial. Therefore, in this study we retrospectively examined MPR and pCR in two different cohorts of NSCLC patients, 14 treated by chemotherapy and 12 by chemo-immunotherapy in the neoadjuvant setting. Methods: In resected tumor specimens, different histological characteristics were evaluated: necrosis, fibrosis, inflammation, presence of organizing pneumonia, granuloma, cholesterol cleft, and reactive epithelial alterations. In addition, we evaluated how MPR impacts on event-free survival (EFS) and overall survival (OS). In a small group of patients treated by chemo-immunotherapy, a gene expression analysis of the Hippo pathway was performed both in preoperative biopsies and matched post-surgical specimens. Results: We observed a better pathological response in the chemo-immunotherapy treated cohort: 6/12 patients (50.0%) achieved a MPR ≤10% and 1/12 (8.3%) achieved pCR both on primary tumor and on lymph nodes. On the contrary, no patient treated with chemotherapy alone achieved pCR or MPR ≤10%. A higher amount of stroma in the neoplastic bed was observed in patients treated with immuno-chemotherapy. Moreover, patients achieving better MPR (including pCR) had significantly improved overall survival (OS) and event-free survival (EFS). After neoadjuvant chemo-immunotherapy, residual tumors showed a remarkable upregulation of genes consistent with the activation of YAP/TAZ. Also, alternative checkpoint, such as CTLA-4, were enhanced. Discussion: Our findings showed that neoadjuvant chemo-immunotherapy treatment improves MPR and pCR thus resulting in better EFS and OS. Moreover, a combined treatment could induce different morphological and molecular changes in comparison to chemotherapy alone, thus giving new insights in the assessment of pathological response.

Intraoperative Catastrophes during Robotic Lung Resection: A Single-Center Experience and Review of the Literature.

BACKGROUND: Robotic surgery is increasingly used in the treatment of lung disease. Intraoperative catastrophes, despite their low incidence, are currently a critical aspect of this approach. This study aims to identify the incidence and management of catastrophic events in patients who underwent robotic anatomical pulmonary resection; (2) Methods: Data from all patients who underwent robotic anatomical pulmonary resection from 2014 to 2021 for lung disease were collected and analyzed. Catastrophic intraoperative events are defined as events that demanded emergency management for life-threatening bleeding, with or without undocking and thoracotomy; (3) Results: Catastrophic events occurred in seven (1.4%) procedures; all of them consisted of vascular damage during lobectomy. Most of the catastrophic events occurred during left upper lobectomies (57%). Patients in this group had a higher ASA class and a higher pathological stage compared to the control group; (4) Conclusions: Intraoperative catastrophes are unpredictable events which also occur in experienced surgical teams. Given the widespread use of robotic surgery, it is essential to develop well-defined crisis management strategies to better manage catastrophic events in robotic thoracic surgery and improve clinical outcomes.

Comparison of Robotic and Open Lobectomy for Lung Cancer in Marginal Pulmonary Function Patients: A Single-Centre Retrospective Study.

BACKGROUND: The treatment of non-small-cell lung cancer (NSCLC) patients with reduced respiratory function represents a challenge for thoracic surgeons. Minimally invasive surgery seems to be beneficial for these patients because it reduces tissue trauma and its impact on respiratory mechanics. Application of the robotic technique, the use of CO2 insufflation and longer surgical time are factors that could influence the outcomes of marginal pulmonary function patients. The objective of this study was to evaluate the impact of the robotic technique on the postoperative outcomes of patients with poor lung function. METHODS: We retrospectively collected and analyzed data from consecutive marginal respiratory function patients who underwent robotic or open lobectomy for NSCLC. Data regarding clinical, operative and postoperative details were compared between the open and robotic approaches. RESULTS: The outcomes of 100 patients with reduced respiratory function were evaluated, of whom 59 underwent open lobectomies and 41 underwent robotic lobectomies. Robotic lobectomy was characterized by a longer operative time, a reduced hospital stay and a lower incidence of postoperative complications (22% vs. 33.9%), when compared to the open approach. CONCLUSION: Robotic lobectomy is a safe and feasible procedure for patients with marginal pulmonary function.

Machine Learning and Regression Analysis to Model the Length of Hospital Stay in Patients with Femur Fracture.

Fractures of the femur are a frequent problem in elderly people, and it has been demonstrated that treating them with a diagnostic-therapeutic-assistance path within 48 h of admission to the hospital reduces complications and shortens the length of the hospital stay (LOS). In this paper, the preoperative data of 1082 patients were used to further extend the previous research and to generate several models that are capable of predicting the overall LOS: First, the LOS, measured in days, was predicted through a regression analysis; then, it was grouped by weeks and was predicted with a classification analysis. The KNIME analytics platform was applied to divide the dataset for a hold-out cross-validation, perform a multiple linear regression and implement machine learning algorithms. The best coefficient of determination (R2) was achieved by the support vector machine (R2 = 0.617), while the mean absolute error was similar for all the algorithms, ranging between 2.00 and 2.11 days. With regard to the classification analysis, all the algorithms surpassed 80% accuracy, and the most accurate algorithm was the radial basis function network, at 83.5%. The use of these techniques could be a valuable support tool for doctors to better manage orthopaedic departments and all their resources, which would reduce both waste and costs in the context of healthcare.

Preoperative Assessment and Management of Cardiovascular Risk in Patients Undergoing Non-Cardiac Surgery: Implementing a Systematic Stepwise Approach during the COVID-19 Pandemic Era.

Major adverse cardiac events, defined as death or myocardial infarction, are common causes of perioperative mortality and major morbidity in patients undergoing non-cardiac surgery. Reduction of perioperative cardiovascular risk in relation to non-cardiac surgery requires a stepwise patient evaluation that integrates clinical risk factors, functional status and the estimated stress of the planned surgical procedure. Major guidelines on preoperative cardiovascular risk assessment recommend to establish, firstly, the risk of surgery per se (low, moderate, high) and the related timing (elective vs. urgent/emergent), evaluate the presence of unstable cardiac conditions or a recent coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting), assess the functional capacity of the patient (usually expressed in metabolic equivalents), determine the value of non-invasive and/or invasive cardiovascular testing and then combine these data in estimating perioperative risk for major cardiac adverse events using validated scores (Revised Cardiac Risk Index (RCRI) or National Surgical Quality Improvement Program (NSQIP)). This stepwise approach has the potential to guide clinicians in determining which patients could benefit from cardiovascular therapy and/or coronary artery revascularization before non-cardiac surgery towards decreasing the incidence of perioperative morbidity and mortality. Finally, it should be highlighted that there is a need to implement specific strategies in the 2019 Coronavirus disease (COVID-19) pandemic to minimize the risk of transmission of COVID-19 infection during the preoperative risk assessment process.

Robotic thymectomy: A surgical point of view.

Robotic thymectomy is the most innovative surgical approach for treating disease of the anterior mediastinum. Robotic surgery offers low postoperative morbidity, faster recovery, shorter hospital stay, and better cosmetic results, without compromising surgical radicality. During the operation, the patient is placed in a supine position at the left edge of the operating table with the left hemithorax upward; the position is maintained with sandbags. The target area for the autodocking should be toward the jugulum. The first surgical step is to isolate the inferior thymic horns via the dissection that starts from the inferior portion of the mediastinal tissue and proceeds toward the right side, following the contralateral pleural reflection. Afterward, it is necessary to move toward the superior horns, following the phrenic nerve, the first landmark, to the innominate vein, our second landmark. Finally, we dissect the superior horns while searching for the thymic veins, which could appear atrophic, and clip the vessels to safely isolate the innominate vein. During this step, it is useful to use a retraction movement to progressively dissect the horns from the jugulum. The thymus gland is removed en bloc with the perithymus fat using an endoscopic bag inserted through the right port incision.

Robotic Surgery for Non-Small Cell Lung Cancer Treatment in High-Risk Patients.

Robotic-assisted pulmonary resection has greatly increased over the last few years, yet data on the application of robotic surgery in high-risk patients are still lacking. The objective of this study is to evaluate the perioperative outcomes in ASA III-IV patients who underwent robotic-assisted lung resection for NSCLC. Between January 2010 and December 2017, we retrospectively collected the data of 148 high-risk patients who underwent lung resection for NSCLC via a robotic approach at our institution. For this study, the prediction of operative risk was based on the ASA-PS score, considering patients in ASA III and IV classes as high-risk patients: of the 148 high-risk patients identified, 146 patients were classified as ASA III (44.8%) and two as ASA IV (0.2%). Possible prognostic factors were also analysed. The average hospital stay was 6 days (8-30). Post-operative complications were observed in 87 (58.8%) patients. Patients with moderate/severe COPD developed in 33 (80.5%) cases post-operative complications, while elderly patients in 25 (55%) cases, with a greater incidence of high-grade complications. No difference was observed when comparing the data of obese and non-obese patients. Robotic surgery appears to be associated with satisfying post-operative results in ASA III-IV patients. Both marginal respiratory function and advanced age represent negative prognostic factors. Due to its safety and efficacy, robotic surgery can be considered the treatment of choice in high-risk patients.

Robotic thymectomy for thymoma in patients with myasthenia gravis: neurological and oncological outcomes.

OBJECTIVES: The goal of this study was to analyse the outcomes in 53 patients with thymoma, 34 of whom had myasthenia gravis (MG), who were treated with robotic surgery. The oncological outcomes of the whole series of patients were analysed. Furthermore, because consistent data are not yet available in the literature, the main focus was the analysis of the neurological results of the patients affected by MG and thymoma. METHODS: The clinical outcomes of 53 patients with a diagnosis of thymoma who underwent robotic thymectomy between January 2014 and December 2019 in our institution were collected and evaluated; 34 of these patients had a concomitant diagnosis of MG. The neurological status of the patients was determined from a clinical evaluation according to the Osserman classification and on pre- and post-surgery Myasthenia Gravis Composite scores, whereas neurological clinical outcomes were assessed using the Myasthenia Gravis Foundation of America Post-Intervention Score. Reduction of steroid therapy was also considered. The recurrence rate, adjuvant radiotherapy and overall survival of the patients with a thymoma were evaluated. RESULTS: Neurological outcomes: improvement of the clinical conditions was obtained in 26 patients (76.5%) following the operation: complete stable remission was observed in 5 patients (14.7%), pharmacological remission in 10 (29.4%) and minimal manifestation in 11 (32.3%). Four patients (11.8%) exhibited no substantial change from the pretreatment clinical manifestations or reduction in MG medication and 4 (11.8%) patients experienced worsening of clinical conditions. In 21 patients (61.7%) a reduction of the dosage of steroid therapy was obtained. Oncological outcomes: at an average follow-up of 36 months, the overall survival was 96%, 4 patients (7.5%) had pleural relapses and 12 patients (22.6%) underwent postoperative radiotherapy, according to their stage. In accordance with Masaoka staging, 34% were in stage I, 56.6% in stage II and 9.4% in stage III. CONCLUSIONS: Our results suggest that robotic surgical treatment of patients with thymoma and concomitant MG is effective in improving the neurological outcomes. Moreover, the oncological results obtained in this series confirm the efficacy of robotic surgery for the treatment of thymic malignancies, with results in line with those of open surgery. However, due to the indolent growth of thymomas, further observations with longer follow-up are necessary.

Radioguided Surgery, a Cost-Effective Strategy for Treating Solitary Pulmonary Nodules: 20-Year Experience of a Single Center.

INTRODUCTION: Surgical resection with minimally invasive approach is the gold standard for both definitive diagnosis and treatment of solitary pulmonary nodules (SPNs); however, it can be difficult to pinpoint small, deep, or subsolid nodes without palpating lung parenchyma. The primary endpoint of this study is showing that radioguided surgery is a cost-effective strategy to improve the effectiveness of video-thoracoscopic localization/resection of SPNs/ground-glass opacities (GGOs). Secondary endpoints are analyzing the morbidity of this technique and tips and tricks to better manage this method. METHODS: SPN smaller than 20 mm and/or with a distance from the visceral pleura ≥5 mm underwent minimally invasive resection after computed tomography-guided injection of a solution composed of 0.1/0.2 mL of 99Tc-labeled human serum albumin microspheres and 0.1 mL of nonionic contrast. In the operating theater, a collimated probe connected to a gamma ray detector allowed localization of the target area. RESULTS: Between 1997 and 2018, a total of 451 patients with SPN/GGO underwent minimally invasive surgery with a radioguided technique at our hospital. The mean SPN diameter was 13 mm (range, 5-20 mm), and the mean distance from the visceral pleura was 15 mm (range, 6-29 mm). The mean time to a localizing nodule was 3 minutes (range, 1-5 minutes). No significant injection-related complications were reported; only 3.3% of patients (15 of 451) developed pneumothorax. Both 30- to 60-day and 90-day mortality were 0%. The rate of postoperative complications was 2.53% (prolonged air leak). The conversion rate to thoracotomy was 1.55% (7 of 451). CONCLUSIONS: Our 20-year experience shows that radioguided thoracoscopic surgery is a safe and feasible strategy to treat suspicious SPN/GGO, with a success rate of 98%.

Thoracic redo-robotic surgery (TRRS): a case series of a single centre.

BACKGROUND: Robotic-assisted thoracic surgery has been shown as a safe and feasible surgical procedure to treat a broad range of thoracic malignancies with a shorten hospital stay, a quicker return to normal daily activities and superior quality of life compared to open approach. Nonetheless, its utilization has predominantly been restricted to the average surgical intervention. In the latest years, given the technological improvements and the advanced skills of the "robotic" surgeons, this approach has been applied to more complex and challenging procedures (e.g., advanced stages/ after neoadjuvant therapies). The aim of this study is to show the results and the advantages of redo thoracic procedures performed with a robot-assisted approach. METHODS: Retrospective analysis of a prospectively collected database (2017-2019). We analysed the first case series undergoing robotic approach (totally endoscopic) in patients who underwent previous surgery and/or radiotherapy for thoracic malignancies. RESULTS: Nine patients (M/F =5/4) with a median age of 73 years underwent robotic procedures after previous radical surgery (n=6) or radiation therapy treatment (n=3). The mean time interval between the two interventions was 96.12 months (range, 7-444 months). The conversion rate was 0%. No postoperative death occurred. Only one complication arose (air leaking) treated conservatively. The median length of stay and chest tube duration were 5 days (range, 4-10 days) and 2 days (range, 2-5 days). The 30-, 60- and 90-day mortality was 0%. With a median follow-up of 10 months (range, 2-12 months), all patients are currently alive, disease free, and with an overall survival and a disease-free survival of 10 months. CONCLUSIONS: The robotic surgery is a safe and feasible approach in case of redo-robotic surgery, showing good outcomes, permitting a fast return to full daily activity, and enabling the patients to rapidly undergo adjuvant treatments, when required.

Impact of pulmonary function on pulmonary complications after robotic-assisted thoracoscopic lobectomy.

OBJECTIVES: Percentage-predicted forced expiratory volume in 1 s (FEV1) and diffusing capacity for carbon monoxide (DLCO), and their predicted postoperative (ppo) values are established prognostic factors for postoperative pulmonary complications after thoracotomy. However, their predictive value for minimally invasive pulmonary resections remains controversial. This study assessed the incidence of pulmonary complications after robotic lobectomy for primary lung cancer and analysed the predictive significance of FEV1 and DLCO. METHODS: This was a retrospective analysis of patients who underwent robotic lobectomy from 4 institutions. Descriptive and comparative analyses were performed for patients who experienced pulmonary complications versus patients who did not, in relation to FEV1 and DLCO values. To identify thresholds for increased complications, patients were categorized into groups of 10% incremental increases in FEV1 and DLCO, and their ppo values. RESULTS: From November 2002 to April 2018, 1088 patients underwent robotic lobectomy. Overall, 169 postoperative pulmonary complications occurred in 141 patients. Male gender and Eastern Cooperative Oncology Group grade ≥1 were associated with increased pulmonary complications on univariable analysis. Patients who experienced pulmonary complications had increased mortality (2.1% vs 0.2%, P = 0.017) and longer hospitalizations (9 vs 4 days, P < 0.001). Pulmonary complications were associated when FEV1 ≤60% and DLCO ≤50%, and when ppo FEV1 or DLCO was ≤50%; ppo FEV1 ≤50% (P < 0.001) and ppo DLCO ≤50% (P = 0.031) remained statistically significant on multivariable analysis. CONCLUSIONS: Both FEV1 and DLCO were shown to be significant predictors of pulmonary complications. Furthermore, thresholds of percentage-predicted and ppo FEV1 and DLCO values were identified, below which pulmonary complications occurred significantly more frequently, suggesting their predictive values are particularly useful in patients with poorer pulmonary function.

Implementing successful systematic Patient Reported Outcome and Experience Measures (PROMs and PREMs) in robotic oncological surgery-The role of physicians.

Patient Reported Outcome and Experience Measures (PROMs and PREMs) play an increasingly important role in monitoring the quality of the oncological pathway. The aim of this study is to describe the case of five hospitals a year after the adoption of PROMs and PREMs for robotic oncological colorectal surgery in Tuscany and to investigate how the clinicians can impact the process of implementation and the efficacy of such measures. We used 14 months of data from the five robotic centers in Tuscany. Above all, the physician's personal motivation to improve the treatment of patients, the teamwork, and the possibility to use data for research purposes proved to be the essential factors for their engagement and the successful implementation of patient reported measures. Physicians play a key role in the adoption of systematic PROMs and PREMs. The higher their level of engagement, the higher the collection success, both in terms of number of patients enrolled and response rates. Moreover, the collection of patient reported measures may become part of physicians' daily practice and may lead to a change in their relationship and communication with patients, as clinicians accept to have their job reviewed and are not afraid to be evaluated by their patients.

Correction to: Lung metastasectomy after colorectal cancer: prognostic impact of resection margin on long term survival, a retrospective cohort study.

The original version of this article, unfortunately, contained an error. In Fig. 2 - panel d, incorrect image was published and this is now presented correctly in this article.

Outcomes of major complications after robotic anatomic pulmonary resection.

BACKGROUND: There is a paucity of robust clinical data on major postoperative complications following robotic-assisted resection for primary lung cancer. This study assessed the incidence and outcomes of patients who experienced major complications after robotic anatomic pulmonary resection. METHODS: This was a multicenter, retrospective review of patients who underwent robotic anatomic pulmonary resection between 2002 and 2018. Major complications were defined as grade III or higher complications according to the Clavien-Dindo classification. Statistical analysis was performed based on patient-, surgeon-, and treatment-related factors. RESULTS: During the study period, 1264 patients underwent robotic anatomic pulmonary resections, and 64 major complications occurred in 54 patients (4.3%). Univariate analysis identified male sex, forced expiratory volume in 1 second, diffusion capacity of the lung for carbon monoxide, neoadjuvant therapy, and extent of resection as associated with increased likelihood of a major postoperative complication. Patient age, performance status, body mass index, reoperation status, and surgeon experience did not have a significant impact on major complications. Patients who experienced at least 1 major complication were at higher risk for an intensive care unit stay of >24 hours (17.0% vs 1.4%; P < .001) and prolonged hospitalization (8.5 days vs 4 days; P < .001). Patients who experienced a major postoperative complication had a 14.8% risk of postoperative death. CONCLUSIONS: In this series, the major complication rate during the postoperative period was 4.3%. A number of identified patient- and treatment-related factors were associated with an increased risk of major complications. Major complications had a significant impact on mortality and duration of stay.

Lung metastasectomy after colorectal cancer: prognostic impact of resection margin on long term survival, a retrospective cohort study.

BACKGROUND: Pulmonary metastasectomy is considered a potentially curative treatment for selected patients with metastatic colorectal cancer (CRC). Several prognostic factors have been analysed, but to date, it is still not well defined which is the optimal resection margin during lung metastasectomy (LM). This study analyses the long-term results and prognostic factors after LM in CRC patients with particular attention to the resection margins. Primary endpoint of this study is to assess the correlation between resection margins and long-term outcomes. METHODS: Observational cohort study on all proven cases of CRC lung metastases (2000-2016) resected with curative intent in a single centre. RESULTS: The series included 210 consecutive patients (M/F 133/77) with a mean age of 65.4 (± 9.96) years, 75% (159/210) of them with a solitary metastasis. Mean size of metastasis was 2.57 cm (± 1.45). One hundred sixty-eight patients underwent wedge resections (80%) and lymphadenectomy was carried out in 90 cases (42.9%). With a mean follow-up of 56 months (range 5-192), we observed a 1-, 3- and 5-year overall survival (OS) of 95%, 74% and 54%, respectively. The patients were divided into three groups according to the resection margin distance from the tumour: (a) ≥ 2 cm (145 cases); (b) < 2, ≥ 1 cm (37 cases); and (c) < 1 cm (12 cases). The OS was significantly different between the three groups (p = 0,020); univariate and multivariate analyses showed that a narrow resection margin was an independent prognostic factor of worse survival (p = 0.006 and HR 3.4 p = 0.009). CONCLUSIONS: Long-term survival of patients after LM is strongly associated with a greater distance between the lesion and the resection margin.