Impacto de la pandemia por COVID-19 en la formación de los cirujanos torácicos en España / Impact of the COVID-19 pandemic on thoracic surgery training in Spain

Tras más de dos años desde su aparición, la pandemia por SARS-CoV-2 ha generado importantes cambios en la sanidad y su organización. El presente trabajo trata de dilucidar las implicaciones de estos en la formación especializada de la cirugía torácica y sus repercusiones en los profesionales. Para ello, desde la Sociedad Española de Cirugía Torácica (SECT) se distribuye una encuesta entre los residentes en activo y aquellos que han terminado su formación en los últimos tres años. Esta consta de 24 preguntas cerradas de respuesta múltiple sobre el impacto de la pandemia en sus servicios, su formación y su vivencia. La tasa de respuesta (TR) de la encuesta fue de 42% (52 de una población objetivo de 120). El efecto de la pandemia en el funcionamiento de los servicios de cirugía torácica fue considerado alto o extremo según 78,8% de los participantes. Las actividades académicas fueron completamente suspendidas en 42,3% de los casos, mientras que 57,7% de los participantes tuvieron que prestar atención asistencial a pacientes ingresados por COVID, de los cuales 25% fue a tiempo parcial y 32,7% a tiempo completo. De los encuestados, 80% consideró que los cambios sufridos durante la pandemia afectaron su formación como residente y 36,5% opinó que debería ofrecerse una prolongación del periodo de formación para quienes se hayan visto afectados. Así pues, observamos cómo la pandemia ha afectado profundamente de forma negativa la formación especializada en cirugía torácica en España. (AU)

In the more than 2 years since its emergence, the SARS-CoV-2 pandemic has prompted important changes in healthcare systems and their organization. The aim of this study is to determine the implications in specialized thoracic surgery training as well as the repercussions on thoracic surgery residents. With this objective, the Spanish Society of Thoracic Surgery has conducted a survey among all its trainees and those who had finished their residency during the last 3 years. It consisted of 24 multiple-answer closed questions about the impact of the pandemic on their services, their training, and their personal experience. The response rate was 42% (52 out of a target population of 120). The effect of the pandemic on thoracic surgery services was high or extreme according to 78.8% of the participants. Academic activities were completely cancelled in 42.3% of the cases, and 57.7% of the respondents were required to treat hospitalized COVID patients (25% part-time, and 32.7% full-time). More than 80% of the survey participants believed that changes during the pandemic negatively affected their training, and 36.5% would prefer to extend their training period. In sum, we observe how the pandemic has had deep negative effects on specialized training in thoracic surgery in Spain. (AU)

Postoperative morbidity after anatomical lung resections by VATS vs thoracotomy: Treatment and intention-to-treat analysis of the Spanish Video-Assisted Thoracic Surgery Group / Morbilidad postoperatoria después de una resección pulmonar anatómica mediante cirugía toracoscópica frente a cirugía abierta: análisis por tratamiento y por intención de tratar del Grupo Español de Cirugía Torácica Videoasistida

Objectives In recent years, video-assisted thoracoscopic lung resections (VATS) have been associated with lower morbidity than open surgery. The aim of our study is to compare postoperative morbidity among patients from the national database of the Spanish Group of Video-Assisted Thoracic Surgery (GE-VATS) after open and video-assisted anatomic lung resections using a propensity score analysis.MethodsFrom December 2016 to March 2018, a total of 3533 patients underwent anatomical lung resection at 33 centers. Pneumonectomies and extended resections were excluded. A propensity score analysis was performed to compare the morbidity of the thoracotomy group (TG) vs the VATS group (VATSG). Treatment and intention-to-treat (ITT) analyses were conducted.ResultsIn total, 2981 patients were finally included in the study: 1092 (37%) in the TG and 1889 (63%) in the VATSG for the treatment analysis; and 816 (27.4%) in the TG and 2165 patients (72.6%) in the VATSG for the ITT analysis. After propensity score matching, in the treatment analysis, the VATSG was significantly associated with fewer overall complications than the TG OR 0.680 [95%CI 0.616, 0.750]), fewer respiratory (OR 0.571 [0.529, 0.616]) cardiovascular (OR 0.529 [0.478, 0.609]) and surgical (OR 0.875 [0.802, 0.955]) complications, lower readmission rate (OR 0.669 [0.578, 0.775]) and a reduction of hospital length of stay (−1.741 ([−2.073, −1.410]). Intention-to-treat analysis showed only statistically significant differences in overall complications (OR 0.76 [0.54–0.99]) in favor of the VATSG.ConclusionIn this multicenter population, VATS anatomical lung resections have been associated with lower morbidity than those performed by thoracotomy. However, when an intention-to-treat analysis was performed, the benefits of the VATS approach were less prominent. (AU)

Introducción El objetivo de nuestro estudio es comparar la morbilidad postoperatoria entre los pacientes de la base de datos nacional del Grupo Español de Cirugia Torácica Videoasistida (GE-VATS) después de resecciones pulmonares anatómicas abiertas y videoasistidas mediante un análisis de emparejamiento por índice de propensión.MétodosDesde Diciembre de 2016 hasta Marzo de 2018, un total 3533 pacientes fueron intervenidos de resección pulmonar anatómica en 33 centros. Se excluyeron las neumonectomías y las resecciones extendidas. Se realizó un análisis de índice de propensión para comparar la morbilidad de cirugía abierta (TG) frente a VATS (VATSG). Se realizó un análisis por tratamiento y por intención de tratar (ITT).ResultadosEn el estudio se incluyeron finalmente 2981 pacientes: 1092 (37%) en TG y 1889 (63%) en VATSG. En el análisis por tratamiento, la VATS se asoció significativamente con menor tasa de complicaciones que la cirugía abierta (OR 0.680 [95%CI 0.616, 0.750]), de complicaciones respiratorias (OR 0.571 [0.529, 0.616]), cardiovasculares (OR 0.529 [0.478, 0.609]) y quirúrgicas (OR 0.875 [0.802, 0.955]), menor tasa de reingresos (OR 0.669 [0.578, 0.775]) y menor estancia (−1.741 ([−2.073, −1.410]). En el de intención de tratar, se observaron diferencias estadísticamente significativas a favor de la VATS solo en las complicaciones en general (OR 0.76 [0.54–0.99]).ConclusionesEn esta población multicéntrica, las lobectomías y segmentectomias anatómicas por VATS se han asociado con menor tasa de complicaciones que las realizadas por toracotomía. Sin embargo, en el análisis por intención de tratar, los beneficios de la VATS no fueron tan evidentes. (AU)

Postoperative morbidity after anatomical lung resections by VATS vs thoracotomy: Treatment and intention-to-treat analysis of the Spanish Video-Assisted Thoracic Surgery Group.

OBJECTIVES: In recent years, video-assisted thoracoscopic lung resections (VATS) have been associated with lower morbidity than open surgery. The aim of our study is to compare postoperative morbidity among patients from the national database of the Spanish Group of Video-Assisted Thoracic Surgery (GE-VATS) after open and video-assisted anatomic lung resections using a propensity score analysis. METHODS: From December 2016 to March 2018, a total of 3533 patients underwent anatomical lung resection at 33 centers. Pneumonectomies and extended resections were excluded. A propensity score analysis was performed to compare the morbidity of the thoracotomy group (TG) vs the VATS group (VATSG). Treatment and intention-to-treat (ITT) analyses were conducted. RESULTS: In total, 2981 patients were finally included in the study: 1092 (37%) in the TG and 1889 (63%) in the VATSG for the treatment analysis; and 816 (27.4%) in the TG and 2165 patients (72.6%) in the VATSG for the ITT analysis. After propensity score matching, in the treatment analysis, the VATSG was significantly associated with fewer overall complications than the TG OR 0.680 [95%CI 0.616, 0.750]), fewer respiratory (OR 0.571 [0.529, 0.616]) cardiovascular (OR 0.529 [0.478, 0.609]) and surgical (OR 0.875 [0.802, 0.955]) complications, lower readmission rate (OR 0.669 [0.578, 0.775]) and a reduction of hospital length of stay (-1.741 ([-2.073, -1.410]). Intention-to-treat analysis showed only statistically significant differences in overall complications (OR 0.76 [0.54-0.99]) in favor of the VATSG. CONCLUSION: In this multicenter population, VATS anatomical lung resections have been associated with lower morbidity than those performed by thoracotomy. However, when an intention-to-treat analysis was performed, the benefits of the VATS approach were less prominent.

Impact of COVID-19 pandemic in thoracic surgery training in Spain.

In the more than 2 years since its emergence, the SARS-CoV-2 pandemic has prompted important changes in healthcare systems and their organization. The aim of this study is to determine the implications in specialized thoracic surgery training as well as the repercussions on thoracic surgery residents. With this objective, the Spanish Society of Thoracic Surgery has conducted a survey among all its trainees and those who had finished their residency during the last 3 years. It consisted of 24 multiple-answer closed questions about the impact of the pandemic on their services, their training, and their personal experience. The response rate was 42% (52 out of a target population of 120). The effect of the pandemic on thoracic surgery services was high or extreme according to 78.8% of the participants. Academic activities were completely cancelled in 42.3% of the cases, and 57.7% of the respondents were required to treat hospitalized COVID patients (25% part-time, and 32.7% full-time). More than 80% of the survey participants believed that changes during the pandemic negatively affected their training, and 36.5% would prefer to extend their training period. In sum, we observe how the pandemic has had deep negative effects on specialized training in thoracic surgery in Spain.

Low-Dose Gamma Radiation Sterilization for Decellularized Tracheal Grafts.

One of the main key aspects in ensuring that a transplant evolves correctly is the sterility of the medium. Decellularized tracheal transplantation involves implanting an organ that was originally in contact with the environment, thus not being sterile from the outset. While the decellularization protocol (through detergent exposition [2% sodium dodecyl sulfate], continuous stirring, and osmotic shocks) is conducted in line with aseptic measures, it does not provide sterilization. Therefore, one of the main challenges is ensuring sterility prior to in vivo implantation. Although there are established gamma radiation sterilization protocols for inorganic materials, there are no such measures for organic materials. Additionally, the protocols in place for inorganic materials cannot be applied to organic materials, as the established radiation dose (25 kGy) would completely destroy the implant. This paper studies the effect of an escalated radiation dose in a decellularized rabbit trachea. We maintained the dose range (kGy) and tested escalated doses until finding the minimal dose at which sterilization is achieved. After determining the dose, we studied effects of it on the organ, both histologically and biomechanically. We determined that while 0.5 kGy did not achieve sterility, doses of both 1 kGy and 2 kGy did, with 1 kGy, therefore, being the minimal dose necessary to achieve sterilization. Microscopic studies showed no relevant changes compared to non-sterilized organs. Axial biomechanical characteristics were not altered at all, and only a slight reduction in the force per unit of length that the organ can radially tolerate was observed. We can therefore conclude that 1 kGy achieves complete sterilization of decellularized rabbit trachea with a minimal, if any, effects on the organ.

[Impact of the COVID-19 pandemic on thoracic surgery training in Spain]. / Impacto de la pandemia por COVID-19 en la formación de los cirujanos torácicos en España.

In the more than 2 years since its emergence, the SARS-CoV-2 pandemic has prompted important changes in healthcare systems and their organization. The aim of this study is to determine the implications in specialized thoracic surgery training as well as the repercussions on thoracic surgery residents. With this objective, the Spanish Society of Thoracic Surgery has conducted a survey among all its trainees and those who had finished their residency during the last 3 years. It consisted of 24 multiple-answer closed questions about the impact of the pandemic on their services, their training, and their personal experience. The response rate was 42% (52 out of a target population of 120). The effect of the pandemic on thoracic surgery services was high or extreme according to 78.8% of the participants. Academic activities were completely cancelled in 42.3% of the cases, and 57.7% of the respondents were required to treat hospitalized COVID patients (25% part-time, and 32.7% full-time). More than 80% of the survey participants believed that changes during the pandemic negatively affected their training, and 36.5% would prefer to extend their training period. In sum, we observe how the pandemic has had deep negative effects on specialized training in thoracic surgery in Spain.

Spanish Society of Thoracic Surgery (SECT) consensus document. Long-term follow-up for operated patients with lung cancer.

The most effective treatment for lung cancer is complete lung resection, although recurrences reach up to 10% and the appearance of second neoplasms, up to 6%. Therefore, the follow-up of these patients will be essential for the early detection and treatment of these events; however there is no definition of the form, time and cadence of these follow-ups. In this consensus document, we try to define them based on the available scientific evidence. A critical review of the literature is carried out (meta-analysis, systematic reviews, reviews, consensus recommendations of scientific societies, randomized controlled studies, non-randomized controlled studies, observational studies and case series studies) and communications to the main congresses on oncology and thoracic surgery in Spanish, English and French. The evidences found are classified following the GRADE system. It is defined according to the existing evidence that the patient resected for lung cancer should be followed up, as well as that this follow-up should be close during the first years and with CT (not being necessary to follow up with PET-CT, biomarkers or bronchoscopy). Cessation of smoking is also recommended in this follow-up.

Surgical Risk Following Anatomic Lung Resection in Thoracic Surgery: A Prediction Model Derived from a Spanish Multicenter Database. / Riesgo quirúrgico tras resección pulmonar anatómica en cirugía torácica. Modelo predictivo a partir de una base de datos nacional multicéntrica.

INTRODUCTION: The aim of this study was to develop a surgical risk prediction model in patients undergoing anatomic lung resections from the registry of the Spanish Video-Assisted Thoracic Surgery Group (GEVATS). METHODS: Data were collected from 3,533 patients undergoing anatomic lung resection for any diagnosis between December 20, 2016 and March 20, 2018. We defined a combined outcome variable: death or Clavien Dindo grade IV complication at 90 days after surgery. Univariate and multivariate analyses were performed by logistic regression. Internal validation of the model was performed using resampling techniques. RESULTS: The incidence of the outcome variable was 4.29% (95% CI 3.6-4.9). The variables remaining in the final logistic model were: age, sex, previous lung cancer resection, dyspnea (mMRC), right pneumonectomy, and ppo DLCO. The performance parameters of the model adjusted by resampling were: C-statistic 0.712 (95% CI 0.648-0.750), Brier score 0.042 and bootstrap shrinkage 0.854. CONCLUSIONS: The risk prediction model obtained from the GEVATS database is a simple, valid, and reliable model that is a useful tool for establishing the risk of a patient undergoing anatomic lung resection.

A Standardised Approach to the Biomechanical Evaluation of Tracheal Grafts.

The ideal tracheal substitute must have biomechanical properties comparable to the native trachea, but currently there is no standardised approach to evaluating these properties. Here we propose a novel method for evaluating and comparing the properties of tracheal substitutes, thus systematising both measurement and data curation. This system was tested by comparing native rabbit tracheas to frozen and decellularised specimens and determining the histological characteristics of those specimens. We performed radial compression tests on the anteroposterior tracheal axis and longitudinal axial tensile tests with the specimens anastomosed to the jaw connected to a measuring system. All calculations and results were adjusted according to tracheal size, always using variables relative to the tracheal dimensions, thus permitting comparison of different sized organs. The biomechanical properties of the decellularised specimens were only slightly reduced compared to controls and significant in regard to the maximum stress withstood in the longitudinal axis (-0.246 MPa CI [-0.248, -0.145] MPa) and the energy stored per volume unit (-0.124 mJ·mm-3 CI [-0.195, -0.055] mJ·mm-3). The proposed method is suitable for the systematic characterisation of the biomechanical properties of different tracheal substitutes, regardless of the size or nature of the substitute, thus allowing for direct comparisons.

Spanish Society of Thoracic Surgery (SECT) consensus document. Long-term follow-up for operated patients with lung cancer. / Documento de consenso de la Sociedad Española de Cirugía Torácica (SECT). Seguimiento a largo plazo de los pacientes operados de cáncer de pulmón.

The most effective treatment for lung cancer is complete lung resection, although recurrences reach up to 10% and the appearance of second neoplasms, up to 6%. Therefore, the follow-up of these patients will be essential for the early detection and treatment of these events; however, there is no definition of the form, time and cadence of these follow-ups. In this consensus document, we try to define them based on the available scientific evidence. A critical review of the literature is carried out (meta-analysis, systematic reviews, reviews, consensus recommendations of scientific societies, randomized controlled studies, non-randomized controlled studies, observational studies and case series studies) and communications to the main congresses on oncology and thoracic surgery in Spanish, English and French. The evidences found are classified following the GRADE system. It is defined according to the existing evidence that the patient resected for lung cancer should be followed up, as well as that this follow-up should be close during the first years and with CT (not being necessary to follow up with PET-CT, biomarkers or bronchoscopy). Cessation of smoking is also recommended in this follow-up.

Effect of COVID-19 on Thoracic Oncology Surgery in Spain: A Spanish Thoracic Surgery Society (SECT) Survey.

After the first wave of COVID-19, the Spanish Society of Thoracic Surgeons (SECT) surveyed its members to assess the impact of the pandemic on thoracic oncology surgery in Spain. In May 2020, all SECT members were invited to complete an online, 40-item, multiple choice questionnaire. The questionnaire was developed by the SECT Scientific Committee and sent via email. The overall response rate was 19.2%. The respondents answered at least 91.5% of the items, with only one exception (a question about residents). Most respondents (89.3%) worked in public hospitals. The reported impact of the pandemic on routine clinical activity was considered extreme or severe by 75.5% of respondents (25.5% and 50%, respectively). Multidisciplinary tumour boards were held either with fewer members attending or through electronic platforms (44.6% and 35.9%, respectively). Surgical activity decreased by 95.7%, with 41.5% of centers performing surgery only on oncological patients and 11.7% only in emergencies. Nearly 60% of respondents reported modifying standard protocols for early-stage cancer and in the preoperative workup. Most centers (≈80%) reported using full personal protective equipment when operating on COVID-19 positive patients. The COVID-19 pandemic severely affected thoracic oncology surgery in Spain. The lack of common protocols led to a variable care delivery to lung cancer patients.

Decellularized tracheal prelamination implant: A proposed bilateral double organ technique.

In tracheal replacement transplantation, prelamination is a critical stage. Nowadays, the most widely used prelamination technique is the prethoracic fascia flap with lateral thoracic artery. We propose a flap based on the internal thoracic artery, which allows a relatively non-aggressive double organ implant, and we have tested its efficacy in decellularized tracheas. Tracheas of albino New Zealand rabbits were decellularized following a protocol that uses detergents and cryogenization, sterilized with 1kGy gamma radiation, and tutorized with a stent. Bilateral pedicled flaps made of pectoral fascia and a muscular component were harvested through a longitudinal 3-cm central thoracic incision, wrapping the tracheas with them in 16 rabbits, remaining them implanted for 2, 4, 8, and 12 weeks. The tracheas were then studied histologically using standard stainings plus immunohistochemistry (CD31). The models were adjusted with Bayesian statistics using ordinal regression; results as odds ratios and credibility intervals. All analysis were performed using R software. Acute inflammatory cell invasion was observed at 2 weeks, which almost disappeared at week 8 after implant. Only macrophages and giant cells increased between Weeks 8 and 12 (OR 10.487, CI [1.603-97.327]). The cartilage maintained its structure, with slight signs of ischemia in a few cases. New CD31-positive vessels were observed from Week 2 and increasing thereafter, reaching a maximum peak at Week 8. We propose a bilateral implant technique that is viable and effective as a prelamination option for two concurrent tracheas, achieving perfect vascularization and integration of the organ with hardly any inflammatory response in the medium or long term.

How do we classify a central tumor? Results of a multidisciplinary survey from the SEPAR Thoracic Oncology area / ¿Cómo clasificamos un tumor central? Resultados de una encuesta multidisciplinaria propuesta desde el área de Oncología Torácica de SEPAR

Introduction: In patients with non-small cell lung cancer (NSCLC) and normal mediastinal imaging tests, centrally located tumors have greater occult mediastinal involvement. Clinical guidelines, therefore, recommend invasive mediastinal staging in this situation. However, definitions of centrality in the different guidelines are inconsistent. The SEPAR Thoracic Oncology area aimed to evaluate the degree of familiarity with various concepts related to tumor site among professionals who see patients with NSCLC in Spain.Methods: A questionnaire was distributed to members of Spanish medical societies involved in the management of NSCLC, structured according to the 3 aspects to be evaluated: 1) uniformity in the definition of central tumor location; 2) uniformity in the classification of lesions that extend beyond dividing lines; and 3) ability to delineate lesions in the absence of dividing lines.Results: A total of 430 participants responded. The most voted definition of centrality was «lesions in contact with hilar structures» (49.7%). The lines most often chosen to delimit the hemithorax were concentric hilar lines (89%). Most respondents (92.8%) classified tumors according to the side of the dividing line that contained most of their volume. Overall, 78.6% were able to correctly classify a central lesion in the absence of dividing lines.Conclusions: In our survey, the most widely accepted definition of centrality is not one of the proposals specified in the clinical guidelines. The results reflect wide variability in the classification of tumor lesions. (AU)

Introducción: En pacientes con cáncer de pulmón de célula no pequeña (CPCNP) y mediastino normal, en pruebas de imagen, los tumores de localización central presentan mayor afectación mediastínica oculta. Por ello las guías clínicas recomiendan estadificación mediastínica invasiva en esta situación. No obstante, las definiciones de centralidad son poco uniformes entre guías. Desde el área de oncología torácica de la SEPAR se propuso evaluar el grado de familiaridad con varios conceptos relacionados con la localización tumoral entre profesionales que atienden pacientes con CPCNP en nuestro territorio.Métodos: Se envió una encuesta a miembros de sociedades médicas nacionales implicadas en el manejo del CPCNP. La encuesta se estructuró en tres aspectos a evaluar: 1) uniformidad en la definición de localización tumoral central; 2) uniformidad en la clasificación de lesiones que sobrepasan líneas divisorias y 3) capacidad para delimitar lesiones en ausencia de líneas divisorias.Resultados: 430 participantes respondieron. La definición de centralidad más votada fue «lesiones en contacto con las estructuras hiliares» (49,7%). Las líneas más escogidas para delimitar el hemitórax fueron líneas concéntricas al hilio (89%). La mayoría (92,8%) consideró los tumores según en qué lado de la línea divisoria se encontrase la mayor parte de su volumen. Un 78,6% fue capaz de catalogar correctamente una lesión central en ausencia de líneas divisorias.Conclusiones: En nuestra encuesta, la definición de centralidad más aceptada no es ninguna de las propuestas en las guías clínicas. Los resultados reflejan amplia variabilidad para clasificar lesiones tumorales. (AU)

Optimization of a decellularization protocol of porcine tracheas. Long-term effects of cryopreservation. A histological study.

OBJECTIVE: The aim of this study was to optimize a decellularization protocol in the trachea of Sus scrofa domestica (pig) as well as to study the effects of long-term cryopreservation on the extracellular matrix of decellularized tracheas. METHODS: Porcine tracheas were decellularized using Triton X-100, SDC, and SDS alone or in combination. The effect of these detergents on the extracellular matrix characteristics of decellularized porcine tracheas was evaluated at the histological, biomechanical, and biocompatibility level. Morphometric approaches were used to estimate the effect of detergents on the collagen and elastic fibers content as well as on the removal of chondrocytes from decellularized organs. Moreover, the long-term structural, ultrastructural, and biomechanical effect of cryopreservation of decellularized tracheas were also estimated. RESULTS: Two percent SDS was the most effective detergent tested concerning cell removal and preservation of the histological and biomechanical properties of the tracheal wall. However, long-term cryopreservation had no an appreciable effect on the structure, ultrastructure, and biomechanics of decellularized tracheal rings. CONCLUSION: The results presented here reinforce the use of SDS as a valuable decellularizing agent for porcine tracheas. Furthermore, a cryogenic preservation protocol is described, which has minimal impact on the histological and biomechanical properties of decellularized porcine tracheas.

How do we Classify a Central Tumor? Results of a Multidisciplinary Survey from the SEPAR Thoracic Oncology Area. / ¿Cómo clasificamos un tumor central? Resultados de una encuesta multidisciplinaria propuesta desde el área de Oncología Torácica de SEPAR.

INTRODUCTION: In patients with non-small cell lung cancer (NSCLC) and normal mediastinal imaging tests, centrally located tumors have greater occult mediastinal involvement. Clinical guidelines, therefore, recommend invasive mediastinal staging in this situation. However, definitions of centrality in the different guidelines are inconsistent. The SEPAR Thoracic Oncology area aimed to evaluate the degree of familiarity with various concepts related to tumor site among professionals who see patients with NSCLC in Spain. METHODS: A questionnaire was distributed to members of Spanish medical societies involved in the management of NSCLC, structured according to the 3 aspects to be evaluated: 1) uniformity in the definition of central tumor location; 2) uniformity in the classification of lesions that extend beyond dividing lines; and 3) ability to delineate lesions in the absence of dividing lines. RESULTS: A total of 430 participants responded. The most voted definition of centrality was «lesions in contact with hilar structures¼ (49.7%). The lines most often chosen to delimit the hemitorax were concentric hilar lines (89%). Most participants (92.8%) classified tumors according to the side of the dividing line that contained most of their volume. Overall, 78.6% were able to correctly classify a central lesion in the absence of dividing lines. CONCLUSIONS: In our survey, the most widely accepted definition of centrality is not one of the proposals specified in the clinical guidelines. The results reflect wide variability in the classification of tumor lesions.

Spanish Video-Assisted Thoracic Surgery Group: Method, Auditing, and Initial Results From a National Prospective Cohort of Patients Receiving Anatomical Lung Resections / Grupo Español de Cirugía Torácica Videoasistida: Método, Auditoría y Resultados Iniciales de una Cohorte Nacional Prospectiva de Pacientes Tratados con Resección Pulmonar Anatómica

INTRODUCTION: Our study sought to know the current implementation of video-assisted thoracoscopic surgery (VATS) for anatomical lung resections in Spain. We present our initial results and describe the auditing systems developed by the Spanish VATS Group (GEVATS). METHODS: We conducted a prospective multicentre cohort study that included patients receiving anatomical lung resections between 12/20/2016 and 03/20/2018. The main quality controls consisted of determining the recruitment rate of each centre and the accuracy of the perioperative data collected based on six key variables. The implications of a low recruitment rate were analysed for "90-day mortality" and "Grade IIIb-V complications". RESULTS: The series was composed of 3533 cases (1917 VATS; 54.3%) across 33 departments. The centres' median recruitment rate was 99% (25-75th:76-100%), with an overall recruitment rate of 83% and a data accuracy of 98%. We were unable to demonstrate a significant association between the recruitment rate and the risk of morbidity/mortality, but a trend was found in the unadjusted analysis for those centres with recruitment rates lower than 80% (centres with 95-100% rates as reference): grade IIIb-V OR = 0.61 (p = 0.081), 90-day mortality OR = 0.46 (p = 0.051). CONCLUSIONS: More than half of the anatomical lung resections in Spain are performed via VATS. According to our results, the centre's recruitment rate and its potential implications due to selection bias, should deserve further attention by the main voluntary multicentre studies of our speciality. The high representativeness as well as the reliability of the GEVATS data constitute a fundamental point of departure for this nationwide cohort

INTRODUCCIÓN: Nuestro estudio buscó conocer el grado de implementación actual de la cirugía toracoscópica asistida por video (VATS, por sus siglas en inglés) para las resecciones pulmonares anatómicas en España. Presentamos nuestros resultados iniciales y describimos los sistemas de auditoría desarrollados por el grupo español de VATS (GEVATS). MÉTODOS: Realizamos un estudio de cohortes prospectivo multicéntrico que incluyó pacientes que fueron tratados con resecciones pulmonares anatómicas entre el 20/12/2016 y el 20/03/2018. Los controles de calidad principales consistieron en determinar la tasa de reclutamiento de cada centro y la precisión de los datos perioperatorios recolectados en base a seis variables clave. Se analizaron las implicaciones de una baja tasa de reclutamiento para "mortalidad a los 90 días" y "complicaciones de grado IIIb-V". RESULTADOS: La serie estaba compuesta por 3533 casos (1917 VATS; 54,3%) en 33 servicios. La mediana de la tasa de reclutamiento de los centros fue del 99% (p25-p75: 76-100%), con una tasa de reclutamiento global del 83% y una precisión de los datos del 98%. No pudimos demostrar una asociación significativa entre la tasa de reclutamiento y el riesgo de morbi-mortalidad, pero se encontró una tendencia en el análisis no ajustado para aquellos centros con tasas de reclutamiento inferiores al 80% (usando los centros con tasas de 95-100% como referencia): OR = 0,61 para el grado IIIb-V (p = 0,081), OR = 0,46 para la mortalidad a los 90 días (p = 0,051). CONCLUSIONES: Más de la mitad de las resecciones pulmonares anatómicas en España se realizan a través de VATS. Según nuestros resultados, la tasa de reclutamiento del centro y sus posibles implicaciones debido al sesgo de selección, deberían recibir más atención por parte de los principales estudios multicéntricos voluntarios de nuestra especialidad. La alta representatividad y la confiabilidad de los datos de GEVATS constituyen un punto de partida fundamental para esta cohorte nacional

Spanish Video-Assisted Thoracic Surgery Group: Method, Auditing, and Initial Results From a National Prospective Cohort of Patients Receiving Anatomical Lung Resections.

INTRODUCTION: Our study sought to know the current implementation of video-assisted thoracoscopic surgery (VATS) for anatomical lung resections in Spain. We present our initial results and describe the auditing systems developed by the Spanish VATS Group (GEVATS). METHODS: We conducted a prospective multicentre cohort study that included patients receiving anatomical lung resections between 12/20/2016 and 03/20/2018. The main quality controls consisted of determining the recruitment rate of each centre and the accuracy of the perioperative data collected based on six key variables. The implications of a low recruitment rate were analysed for "90-day mortality" and "Grade IIIb-V complications". RESULTS: The series was composed of 3533 cases (1917 VATS; 54.3%) across 33 departments. The centres' median recruitment rate was 99% (25-75th:76-100%), with an overall recruitment rate of 83% and a data accuracy of 98%. We were unable to demonstrate a significant association between the recruitment rate and the risk of morbidity/mortality, but a trend was found in the unadjusted analysis for those centres with recruitment rates lower than 80% (centres with 95-100% rates as reference): grade IIIb-V OR=0.61 (p=0.081), 90-day mortality OR=0.46 (p=0.051). CONCLUSIONS: More than half of the anatomical lung resections in Spain are performed via VATS. According to our results, the centre's recruitment rate and its potential implications due to selection bias, should deserve further attention by the main voluntary multicentre studies of our speciality. The high representativeness as well as the reliability of the GEVATS data constitute a fundamental point of departure for this nationwide cohort.

Video-Assisted Thoracic Surgical Repair of the Airway.

We communicate the first reported application of video-assisted thoracic surgery for early repair of a postintubation tracheal laceration. The patient was a 60-year-old man. After an initial unsuccessful approach with conservative measures, surgical repair was indicated. The patient underwent 2-port video-assisted thoracic surgery for direct tracheal repair using a 3-0 resorbable monofilament running suture and two reinforcing X-stitches. Bronchoscopic control after 2 and 4 weeks showed complete restoration of the airway, with no complication.

Clinical Significance of Molecular Micrometastasis in the Sentinel Lymph Node of Early-stage Non-Small Cell Lung Cancer Patients.

OBJECTIVES: Metastatic affectation of lymph node is the main prognostic factor in localized lung cancer. A pathologic study of the obtained samples, even after adequate lymphadenectomy, showed tumor relapses for 20% of stage I patients after oncological curative surgery. We evaluated the prognostic value of molecular micrometastasis in the sentinel lymph node of patients with early-stage lung cancer. PATIENTS AND METHODS: The sentinel node was marked immediately after performing thoracotomy by peritumorally injecting 0.25 mCi of nanocoloid of albumin (Nanocol1) labeled with Tc-99m in 0.3 mL. Guided by a Navigator1 gammagraphic sensor, we proceeded to its resection. The RNA of the tissue was extracted, and the presence of genes CEACAM5, BPIFA1, and CK7 in mRNA was studied. The significant association between the presence of micrometastasis, clinicopathologic characteristics, and patients' outcome was assessed. RESULTS: Eighty-nine stage I-II non-small cell lung cancer patients were included in the study. Of the 89 analyzed sentinel lymph nodes, 44 (49.4%) were positive for CK7, 24 (26.9%) for CEACAM5, and 17 (19.1%) for BPIFA1, whereas 10 (11.2%) were positive for the 3 analyzed genes. A survival analysis showed no significant relation between the presence of molecular micrometastasis in the sentinel node and patients' progression. CONCLUSIONS: The molecular analysis of the sentinel node in patients with early-stage lung cancer shows node affectation in cases staged as stage I/II by hematoxylin-eosin or an immunohistochemical analysis. However, this nodal affectation was not apparently related to patients' outcome.