Operative outcomes and middle-term survival of robotic-assisted lung resection for clinical stage IA lung cancer compared with video-assisted thoracoscopic surgery / Resultados postoperatorios y de supervivencia a medio plazo de las resecciones pulmonares asistidas por robot en el cáncer de pulmón en estadio clínico IA en comparación con la cirugía toracoscópica videoasistida

Background: Despite limited published evidence, robotic-assisted thoracoscopic surgery (RATS) for anatomic lung resection in early-stage lung cancer continues growing. The aim of this study is to evaluate its safety and oncologic efficacy compared to video-assisted thoracoscopic surgery (VATS). Methods: Single-centre retrospective study of all patients with resected clinical stage IA NSCLC who underwent RATS or VATS anatomic lung resection from June 2018 to January 2022. RATS and VATS cases were matched by propensity scoring (PSM) according to age, sex, histology, and type of resection. Short-term outcomes were compared, and the Kaplan-Meier method and log-rank test were used to evaluate the overall survival (OS) and disease-free survival (DFS). Results: 321 patients (94 RATS and 227 VATS cases) were included. After PSM, 94 VATS and 94 RATS cases were compared. Demographics, pulmonary function, and comorbidity were similar in both groups. Overall postoperative morbidity was comparable for RATS and VATS cases (20.2% vs 25.5%, P = 0.385, respectively). Pathological nodal upstaging was similar in both groups (10.6% in RATS and 12.8% in VATS). During the 3.5-year follow-up period (median: 29 months; IQR: 18–39), recurrence rate was 6.4% in RATS group and 18.1% in the VATS group (P = 0.014). OS and DFS were similar in RATS and VATS groups (log rank P = 0.848 and P = 0.117, respectively). Conclusion: RATS can be performed safely in patients with early-stage NSCLC. For clinical stage IA disease, robotic anatomic lung resection offers better oncologic outcomes in terms of recurrence, although there are no differences in OS and DFS compared with VATS.(AU)

Introducción: A pesar de la limitada evidencia disponible, el uso de la RATS en resecciones pulmonares anatómicas por cáncer continúa creciendo. El objetivo de este estudio es evaluar su seguridad y eficacia oncológica en comparación con la VATS. Métodos: Estudio retrospectivo unicéntrico en el que se incluyeron todos los pacientes con CPNM en estadio cIA sometidos a resección pulmonar anatómica RATS o VATS entre junio de 2018 y enero de 2022. Los casos se emparejaron mediante puntuación de propensión (PSM) según edad, sexo, histología y tipo de resección. Se compararon los resultados a corto plazo y la supervivencia global (OS) y libre de enfermedad (DFS) mediante el método de Kaplan-Meier y la prueba de rangos logarítmicos. Resultados: Se incluyeron 321 pacientes (94 RATS y 227 VATS). Tras el PSM, se compararon 94 VATS y 94 RATS. La morbilidad global fue comparable en ambos grupos (20.2 % en RATS vs 25.5 % en VATS, P = 0.385). El upstaging ganglionar fue similar en ambos abordajes (10.6% en RATS y 12.8% en VATS). Durante los 3.5 años de seguimiento, la tasa de recurrencia fue del 6.4 % en RATS y del 18.1 % en VATS (P = 0.014). OS y DFS fueron similares en los dos grupos (rango logarítmico P = 0.848 y P = 0.117, respectivamente). Conclusión: La RATS se puede realizar de forma segura en pacientes con CPNM en estadio inicial. Para la enfermedad en estadio cIA, el abordaje robótico ofrece mejores resultados en términos de recurrencia, aunque no hay diferencias en la OS y la DFS en comparación con la VATS.(AU)

RNA interference of NADPHcytochrome P450 increased deltamethrin susceptibility in a resistant strain of the Chagas disease vector Triatoma infestans.

The enzyme NADPH-cytochrome P450 reductase (CPR) plays a central role in cytochromes P450 activity. Gene expression analysis of cytochromes P450 and CPR in deltamethrin-resistant and susceptible populations revealed that P450s genes are involved in the development of insecticide resistance in Triatoma infestans. To clarify the role of cytochromes P450 in insecticide resistance, it was proposed to investigate the effect of CPR gene silencing by RNA interference (RNAi) in a pyrethroid resistant population of T. infestans. Silencing of the CPR gene showed a significant increase in susceptibility to deltamethrin in the population analysed. This result support the hypothesis that the metabolic process of detoxification mediated by cytochromes P450 contributes to the decreased deltamethrin susceptibility observed in the resistant strain of T. infestans.

Operative outcomes and middle-term survival of robotic-assisted lung resection for clinical stage IA lung cancer compared with video-assisted thoracoscopic surgery.

BACKGROUND: Despite limited published evidence, robotic-assisted thoracoscopic surgery (RATS) for anatomic lung resection in early-stage lung cancer continues growing. The aim of this study is to evaluate its safety and oncologic efficacy compared to video-assisted thoracoscopic surgery (VATS). METHODS: Single-centre retrospective study of all patients with resected clinical stage IA NSCLC who underwent RATS or VATS anatomic lung resection from June 2018 to January 2022. RATS and VATS cases were matched by propensity scoring (PSM) according to age, sex, histology, and type of resection. Short-term outcomes were compared, and the Kaplan-Meier method and log-rank test were used to evaluate the overall survival (OS) and disease-free survival (DFS). RESULTS: 321 patients (94 RATS and 227 VATS cases) were included. After PSM, 94 VATS and 94 RATS cases were compared. Demographics, pulmonary function, and comorbidity were similar in both groups. Overall postoperative morbidity was comparable for RATS and VATS cases (20.2% vs 25.5%, P = 0.385, respectively). Pathological nodal upstaging was similar in both groups (10.6% in RATS and 12.8% in VATS). During the 3.5-year follow-up period (median: 29 months; IQR: 18-39), recurrence rate was 6.4% in RATS group and 18.1% in the VATS group (P = 0.014). OS and DFS were similar in RATS and VATS groups (log rank P = 0.848 and P = 0.117, respectively). CONCLUSION: RATS can be performed safely in patients with early-stage NSCLC. For clinical stage IA disease, robotic anatomic lung resection offers better oncologic outcomes in terms of recurrence, although there are no differences in OS and DFS compared with VATS.

Operating time: an independent and modifiable risk factor for short-term complications after video-thoracoscopic pulmonary lobectomy.

OBJECTIVES: The relationship between operating time and postoperative morbidity has not been fully characterized in lung resection surgery. We aimed to determine the variables associated with prolonged operative times and their influence on postoperative complications after video-thoracoscopic lobectomy. METHODS: Patients undergoing thoracoscopic lobectomy for lung cancer from December 2016 to March 2018, within the prospective registry of the Spanish Video-Assisted Thoracic Surgery Group were identified. Operating time was stratified by quartiles and complication rates analysed using chi-squared test. Primary outcomes included 30-day overall, pulmonary and cardiovascular complications and wound infection. Multivariable logistic regression analyses were performed to identify variables independently associated with operating time and their influence on the occurrence of postoperative complications. RESULTS: Data of 1518 cases were examined. The median operating time was 174 min (interquartile range: 130-210 min). Overall morbidity rates significantly increased with surgical duration (20.5% vs 34.4% in the 1st and 4th quartiles, respectively, P < 0.05) and so did pulmonary complications (14.6% vs 26.4% in the 1st and 4th quartiles, respectively, P < 0.05). Differences were not found regarding cardiovascular and wound complications. After multivariable logistic regression analysis, operating time remained as an independent risk factor for overall (odds ratios, 2.05) and pulmonary complications (odds ratios, 2.01). Male sex, predicted postoperative diffusing capacity of the lung for carbon monoxide, number of lymphatic stations harvested, pleural adhesions, fissures completeness, lobectomy site, surgeon seniority, individual video-thoracoscopic surgeon experience and fissureless technique were identified as predictive factors for long operative time. CONCLUSIONS: Prolonged operating time is associated with increased odds of postoperative complications. Modifiable factors contributing to prolonged operating time may serve as a target for quality improvement.

Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis.

INTRODUCTION: Outcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections. METHODS: Retrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients' age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann-Whitney U test for continuous variables. RESULTS: A total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p=0.369), major complications (RATS: 9% vs VATS: 9.2%; p=0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p=1; pneumonia RATS:0%, VATS:4.6%, p=0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p=0.718) and reoperation (RATS: 3%, VATS: 1.5%, p=1) were comparable between both groups. The median length of stay was 3 days in both groups (p=0.101). CONCLUSIONS: A RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.

"Obesity paradox" has not an impact on minimally invasive anatomical lung resection.

INTRODUCTION: The paradoxical benefit of obesity, the 'obesity paradox', has been analyzed in lung surgical populations with contradictory results. Our goal was assessing the relationship of body mass index (BMI) to acute outcomes after minimally invasive major pulmonary resections. METHODS: Retrospective review of consecutive patients who underwent pulmonary anatomical resection through a minimally invasive approach for the period 2014-2019. Patients were grouped as underweight, normal, overweight and obese type I, II and III. Adjusted odds ratios regarding postoperative complications (overall, respiratory, cardiovascular and surgical morbidity) were produced with their exact 95% confidence intervals. All tests were considered statistically significant at p<0.05. RESULTS: Among 722 patients included in the study, 37.7% had a normal BMI and 61.8% were overweight or obese patients. When compared with that of normal BMI patients, adjusted pulmonary complications were significantly higher in obese type I patients (2.6% vs 10.6%, OR: 4.53 [95%CI: 1.86-12.11]) and obese type II-III (2.6% vs 10%, OR: 6.09 [95%CI: 1.38-26.89]). No significant differences were found regarding overall, cardiovascular or surgical complications among groups. CONCLUSIONS: Obesity has not favourable effects on early outcomes in patients undergoing minimally invasive anatomical lung resections, since the risk of respiratory complications in patients with BMI≥30kg/m2 and BMI≥35kg/m2 is 4.5 and 6 times higher than that of patients with normal BMI.

“Obesity paradox” has not an impact on minimally invasive anatomical lung resection

IntroductionThe paradoxical benefit of obesity, the ‘obesity paradox’, has been analyzed in lung surgical populations with contradictory results. Our goal was assessing the relationship of body mass index (BMI) to acute outcomes after minimally invasive major pulmonary resections.MethodsRetrospective review of consecutive patients who underwent pulmonary anatomical resection through a minimally invasive approach for the period 2014–2019. Patients were grouped as underweight, normal, overweight and obese type I, II and III. Adjusted odds ratios regarding postoperative complications (overall, respiratory, cardiovascular and surgical morbidity) were produced with their exact 95% confidence intervals. All tests were considered statistically significant at p<0.05.ResultsAmong 722 patients included in the study, 37.7% had a normal BMI and 61.8% were overweight or obese patients. When compared with that of normal BMI patients, adjusted pulmonary complications were significantly higher in obese type I patients (2.6% vs 10.6%, OR: 4.53 [95%CI: 1.86–12.11]) and obese type II–III (2.6% vs 10%, OR: 6.09 [95%CI: 1.38–26.89]). No significant differences were found regarding overall, cardiovascular or surgical complications among groups.ConclusionsObesity has not favourable effects on early outcomes in patients undergoing minimally invasive anatomical lung resections, since the risk of respiratory complications in patients with BMI≥30kg/m2 and BMI≥35kg/m2 is 4.5 and 6 times higher than that of patients with normal BMI (AU)

IntroducciónEl beneficio paradójico de la obesidad, la «paradoja de la obesidad», ha sido analizado en distintas series de cirugía de resección pulmonar con conclusiones contradictorias. El objetivo del estudio es evaluar la influencia del índice de masa corporal (IMC) en los resultados postoperatorios de resecciones pulmonares anatómicas por vía mínimamente invasiva.MétodosRevisión retrospectiva de pacientes consecutivos sometidos a resección pulmonar anatómica a través de un abordaje mínimamente invasivo durante el período comprendido entre 2014 y 2019. Los pacientes se agruparon en: bajo peso, normopeso, sobrepeso y obesidad tipo I, II y III. Se calcularon las odds ratio ajustadas con respecto a las distintas complicaciones (globales, respiratorias, cardiovasculares y quirúrgicas) con sus intervalos de confianza al 95% (IC 95%). Todas las pruebas se consideraron estadísticamente significativas con p<0,05.ResultadosEntre 722 pacientes incluidos en el estudio, el 37,7% tenían un IMC normal y el 61,8% eran pacientes con sobrepeso u obesidad. En comparación con los pacientes con IMC normal, las complicaciones pulmonares ajustadas fueron significativamente mayores en los pacientes obesos tipo I (2,6 vs. 10,6%; OR: 4,53 [IC 95%: 1,72-11,92]) y obesos tipo II-III (2,6 vs. 10%; OR: 6,09 [IC 95%: 1,38-26,89]). No se encontraron diferencias significativas con respecto a las complicaciones globales, cardiovasculares o quirúrgicas entre los distintos grupos.ConclusionesLa obesidad no tiene efectos favorables en los resultados postoperatorios en pacientes sometidos a resecciones pulmonares anatómicas mínimamente invasivas. El riesgo de complicaciones respiratorias en pacientes con IMC≥30kg/m2 e IMC≥35kg/m2 es 4,5 y 6 veces mayor que el de pacientes con IMC normal (AU)

Thoracic surgery in Spain.

In this manuscript, we briefly report on the Spanish health care system and the current situation of Thoracic Surgery in the country. Our surgical speciality is approached in terms of national spread of thoracic units, education, technological development, and other relevant aspects. Thoracic Surgery national workforce is also reviewed and compared to sister specialities. Prospects and authors' recommendations for development are included. Total cost of public health care expenditure in Spain represents 9% of the gross domestic product (GDP) and the National Health System is included in the top ten more efficient systems in the World. Thoracic Surgery in Spain is an independent medical speciality. The access to training in accredited hospitals is uniformly regulated all around the country and represents the official and only route to certified medical specialization. 0.5 certified specialists in Thoracic Surgery per 100,000 habitants are working in the country, half of them being female in the age subset of 30-39. Currently, more than half of all anatomical resection in the country are performed via VATS. Seven centres are currently accredited by the Ministry of Health for lung transplantation, and the current rate of lung transplants is 7.1 per million of population. To note is the success of the non-heart-beating donors program developed in recent years. Three national professional and scientific societies are gathering most Spanish thoracic surgeons and promoting cooperative multidisciplinary studies on lung cancer and surgical techniques such are video-assisted and robotic lung resection. Implementing a national database of thoracic surgical procedures would be advisable to promote continuous clinical quality improvements.

The robotic surgery learning curve of a surgeon experienced in video-assisted thoracoscopic surgery compared with his own video-assisted thoracoscopic surgery learning curve for anatomical lung resections.

OBJECTIVES: Robotic surgery, although it shares some technical features with video-assisted thoracoscopic surgery (VATS), offers some advantages, such as ergonomic design and a 3-dimensional view. Thus, the learning curve for robotic lung resection could be expected to be shorter than that of VATS for surgeons who are proficient in VATS. The goal of this study was to analyse the robotic learning curve of a VATS experienced surgeon and to compare it to his own VATS learning curve for anatomical lung resections. METHODS: We conducted a retrospective observational study based on the prospectively recorded data of the first 150 anatomical lung resections performed with VATS (75 cases) and with the robotic (75 cases) approach by the same surgeon in our centre. Learning curves were analysed using the cumulative sum method to assess the trends for total operating time and surgical failure (intraoperative complications, conversion, technical postoperative complications and reintervention) across case sequences. Subsequently, using adequate statistical tests, we compared the postoperative outcomes in both groups. RESULTS: The median operating time was similar for both approaches (P = 0.401). Surgical failure rate was higher for the robotic cases (21.3% vs 12%; P = 0.125). Based on cumulative sum analyses, operating time decreased starting with case 34 in the VATS group and with case 32 in the robotic cohort. Surgical failure tended to decline starting with case 28 in the VATS group and with case 32 in the robotic group. Perioperative results were similar in both groups. CONCLUSIONS: When we compared robotic and VATS learning curves for anatomical lung resection, we did not find any differences. Postoperative outcomes were also similar with both approaches.

Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis.

INTRODUCTION: Outcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections. METHODS: Retrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients' age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann-Whitney U test for continuous variables. RESULTS: A total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p=0.369), major complications (RATS: 9% vs VATS: 9.2%; p=0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p=1; pneumonia RATS:0%, VATS:4.6%, p=0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p=0.718) and reoperation (RATS: 3%, VATS: 1.5%, p=1) were comparable between both groups. The median length of stay was 3 days in both groups (p=0.101). CONCLUSIONS: A RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.

Quality Control in Anatomical Lung Resection. Major Postoperative Complications vs Failure to Rescue / Control de calidad en la resección pulmonar anatómica. Complicaciones postoperatorias graves vs. fallo en el rescate

Objectives: Failure to rescue (FTR) is defined by the number of deaths among patients experiencing major complications after surgery. In this report we analyze FTR and apply a cumulative sum control chart (CUSUM) methodology for monitoring performance in a large series of operated lung carcinoma patients.Methods: Prospectively stored records of cases undergoing anatomical lung resection in one center were reviewed. Postoperative adverse events were coded and included as a binary variable (major, or minor complications). The occurrence of 30-day mortality was also recorded. Patients dying after suffering major complications were considered as FTR. Risk-adjusted CUSUM graphs using EuroLung1 and 2 variables were constructed for major complications and FTR. Points of plateauing or trend inversion were checked to detect intentional or non-adverted changes in the process of care.Results: 2237 cases included. 9.1% cases suffered major complications. The number of cases considered as failures to rescuing was 46 (2.1% of the total series and 22.5% of cases having major complications). The predictive performance of EuroLung1 and 2 models was as follows: EuroLung1 (major morbidity) C-index 0.70 (95%CI: 0.66–0.73); EuroLung2 (applied to FTR) C-index 0.81 (95%CI: 0.750.87). CUSUM graphs depicted improvement in rescuing complicated patients after case 330 but no improvement in the rate of non-complicated cases until case 720. (AU)

Objetivos: El fallo en el rescate (FTR, por sus siglas en inglés) se define por el número de muertes entre los pacientes que experimentan complicaciones graves tras la cirugía. En este informe analizamos el FTR y realizamos gráficos de control de suma acumulada (CUSUM, por sus siglas en inglés) para monitorizar los resultados en una serie de gran tamaño de pacientes operados de carcinoma de pulmón.Métodos: Se revisaron los datos almacenados prospectivamente de los casos de resección pulmonar anatómica en un centro. Se codificaron los eventos adversos postoperatorios y se incluyeron como una variable binaria (complicaciones graves o menores). También se registró la mortalidad a los 30 días. Los pacientes que murieron después de sufrir complicaciones mayores se consideraron FTR. Se elaboraron gráficos CUSUM ajustados al riesgo, utilizando las variables EuroLung1 y 2, para el análisis de las complicaciones graves y el FTR. Se analizaron los puntos de estancamiento o inversión de la tendencia para detectar los posibles cambios voluntarios o inadvertidos en el plan de cuidados.Resultados: Se incluyeron 2.237 casos. El 9,1% sufrieron complicaciones graves. El número de casos que se consideraron como fallos en el rescate fue de 46 (2,1% del total de la serie y 22,5% de los casos con complicaciones graves). El rendimiento predictivo de los modelos EuroLung1 y 2 fue el siguiente: EuroLung1 (morbilidad grave) índice C: 0,70 (IC 95%: 0,66-0,73); EuroLung2 (aplicado al FTR) índice C: 0,81 (IC 95%: 0,75-0,87). Los gráficos de CUSUM mostraron una mejora en el rescate de pacientes con complicaciones después del caso 330, pero ninguna mejora en la tasa de casos sin complicaciones hasta el caso 720. (AU)

"Obesity paradox" has not an impact on minimally invasive anatomical lung resection.

INTRODUCTION: The paradoxical benefit of obesity, the 'obesity paradox', has been analyzed in lung surgical populations with contradictory results. Our goal was assessing the relationship of body mass index (BMI) to acute outcomes after minimally invasive major pulmonary resections. METHODS: Retrospective review of consecutive patients who underwent pulmonary anatomical resection through a minimally invasive approach for the period 2014-2019. Patients were grouped as underweight, normal, overweight and obese type I, II and III. Adjusted odds ratios regarding postoperative complications (overall, respiratory, cardiovascular and surgical morbidity) were produced with their exact 95% confidence intervals. All tests were considered statistically significant at p<0.05. RESULTS: Among 722 patients included in the study, 37.7% had a normal BMI and 61.8% were overweight or obese patients. When compared with that of normal BMI patients, adjusted pulmonary complications were significantly higher in obese type I patients (2.6% vs 10.6%, OR: 4.53 [95%CI: 1.86-12.11]) and obese type II-III (2.6% vs 10%, OR: 6.09 [95%CI: 1.38-26.89]). No significant differences were found regarding overall, cardiovascular or surgical complications among groups. CONCLUSIONS: Obesity has not favourable effects on early outcomes in patients undergoing minimally invasive anatomical lung resections, since the risk of respiratory complications in patients with BMI≥30kg/m2 and BMI≥35kg/m2 is 4.5 and 6 times higher than that of patients with normal BMI.

Quality Control in Anatomical Lung Resection. Major Postoperative Complications vs Failure to Rescue.

OBJECTIVES: Failure to rescue (FTR) is defined by the number of deaths among patients experiencing major complications after surgery. In this report we analyze FTR and apply a cumulative sum control chart (CUSUM) methodology for monitoring performance in a large series of operated lung carcinoma patients. METHODS: Prospectively stored records of cases undergoing anatomical lung resection in one center were reviewed. Postoperative adverse events were coded and included as a binary variable (major, or minor complications). The occurrence of 30-day mortality was also recorded. Patients dying after suffering major complications were considered as FTR. Risk-adjusted CUSUM graphs using EuroLung1 and 2 variables were constructed for major complications and FTR. Points of plateauing or trend inversion were checked to detect intentional or non-adverted changes in the process of care. RESULTS: 2237 cases included. 9.1% cases suffered major complications. The number of cases considered as failures to rescuing was 46 (2.1% of the total series and 22.5% of cases having major complications). The predictive performance of EuroLung1 and 2 models was as follows: EuroLung1 (major morbidity) C-index 0.70 (95%CI: 0.66-0.73); EuroLung2 (applied to FTR) C-index 0.81 (95%CI: 0.750.87). CUSUM graphs depicted improvement in rescuing complicated patients after case 330 but no improvement in the rate of non-complicated cases until case 720. CONCLUSIONS: FTR offers a complementary view to classical outcomes for quality assessment in Thoracic Surgery. Our study also shows how the analysis of FTR on time series can be applied to evaluate changes in team performance along time.