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

Volume Pledge is Not Associated with Better Short-Term Outcomes After Lung Cancer Resection.

PURPOSE: We examined the relationship between short-term outcomes and hospitals and surgeons who met minimum volume thresholds for lung cancer resection based on definitions provided by the Volume Pledge. A secondary aim was to evaluate the volume-outcome relationship to determine alternative thresholds in the event the Volume Pledge was not associated with outcomes. PATIENTS AND METHODS: We conducted a retrospective study (2015-2017) using the Society of Thoracic Surgeons General Thoracic Surgery Database. We used generalized estimating equations that accounted for confounding and clustering to compare outcomes across hospitals and surgeons who did and did not meet the Volume Pledge criteria: ≥ 40 patients per year for hospitals and ≥ 20 patients per year for surgeons. Our secondary aim was to model volume by using restricted cubic splines to determine the association between volume and short-term outcomes. RESULTS: Among 32,183 patients, 465 surgeons, and 209 hospitals, 16,630 patients (52%) received care from both a hospital and surgeon meeting the Volume Pledge criteria. After adjustment, there was no relationship with operative mortality, complications, major morbidity, a major morbidity-mortality composite end point, or failure to rescue. The Volume Pledge group had a 0.5 day (95% CI, 0.2 to 0.7 day) shorter length of stay. Our secondary aim revealed a nonlinear relationship between hospital volume and complications in which intermediate-volume hospitals had the highest risk of complications. Surgeon volume was associated with major morbidity, a major morbidity-mortality composite end point, and length of stay in an inverse linear fashion. Only 8% of surgeons had volumes associated with better outcomes. CONCLUSION: The Volume Pledge was not associated with better outcomes except for a marginally shorter length of stay. A re-examination of volume-outcome relationships for hospitals and surgeons yielded mixed results that did not reveal a practical alternative for volume-based quality improvement efforts.

Minimizing the Risk of Aerosol Contamination During Elective Lung Resection Surgery.

BACKGROUND: In the setting of the COVID-19 pandemic, the conduct of elective cancer surgery has become an issue because of the need to balance the requirement to treat patients with the possibility of transmission of the virus by asymptomatic carriers. A particular concern is the potential for viral transmission by way of aerosol which may be generated during perioperative care. There are currently no guidelines for the conduct of elective lung resection surgery in this context. METHODS: A working group composed of 1 thoracic surgeon, 2 anesthesiologists and 1 critical care specialist assessed the risk for aerosol during lung resection surgery and proposed steps for mitigation. After external review, a final draft was approved by the Committee for the Governance of Perioperative and Surgical Activities of the Hôpital Maisonneuve-Rosemont, in Montreal, Canada. RESULTS: The working group divided the risk for aerosol into 6 time-points: (1) intubation and extubation; (2) Lung isolation and patient positioning; (3) access to the chest; (4) conduct of the surgical procedure; (5) procedure termination and lung re-expansion; (6) chest drainage. Mitigating strategies were proposed for each time-point. CONCLUSIONS: The situation with COVID-19 is an opportunity to re-evaluate operating room protocols both for the purposes of this pandemic and similar situations in the future. In the context of lung resection surgery, specific time points during the procedure seem to pose specific risks for the genesis of aerosol and thus should be the focus of attention.

Left lower lobectomy and partial preservation of segmental arteries of left upper lobe: A strategy to avoid pneumonectomy in selected cases.

In this article we report two cases of left lower lobe lung cancer undergoing a surgical procedure that allowed the preservation of lung parenchyma and avoided pneumonectomy. The first case concerned a left lower lobe non-small cell lung cancer with extracapsular spread in a metastatic interlobar lymph node and the second a left lower lobe lung cancer with invasion of the pulmonary artery at the origin of lobar branches to the lower lobe. In both cases, a lung-sparing surgical treatment was preferred and a left lower lobectomy was performed with division of lingular arteries and the interlobar artery, preserving the remaining arterial branches to the upper lobe.

BET1: Pre-hospital finger thoracostomy in patients with traumatic cardiac arrest.

A short cut review was carried out to see if 'finger' thoracostomy was a safe and effective procedure to use in the pre-hospital setting in patients with traumatic cardiac arrest. Three relevant papers were found describing the use of this technique in the pre-hospital setting. The author, date and country of publication, patient group studied, study type, relevant outcomes, results study weaknesses of these papers are tabulated. Finger thoracostomy appears to be an acceptable and effective technique for trained physicians in the pre-hospital setting.

Attributes contributing to superior outcomes in the surgical management of early-stage lung cancer and examples of implementing improvement.

Attributes contributing to superior clinical outcomes include high clinical volumes, specialized care, and multidisciplinary care. Using a quality template as the framework for review, the literature surrounding these relative to lung cancer surgery and operative mortality and morbidity is examined. Costs of lung cancer surgery operative mortality or complications are discussed. Finally, examples of quantifying and implementing high-quality medical care, especially regarding lung cancer, are reviewed.

[Standardization of lung cancer surgery].

A lobectomy with systematic nodal dissection is accepted as the standard radical operation for early-stage lung cancer. When this was established as the standard operation, there was little evidence to confirm that the results after a lobectomy with systematic nodal dissection were superior to those after other procedures. Most thoracic surgeons accepted lobectomy with systematic nodal dissection as the gold standard for lung cancer surgery. Therefore, no randomized, controlled study was conducted to confirm the justification for that procedure. However, numerous reports of nonrandomized trials or practices were published to justify its acceptance as the standard radical operation for stage IA lung cancers. On the other hand, advances in diagnostic equipment including helical computed tomography (CT), magnetic resonance imaging, and position-emission tomography rapidly changed the concept of early-stage lung cancers. Detection of ground glass attenuation by CT and the introduction of the new pathological concept of localized bronchioloalveolar cell carcinoma as an extremely early-stage lung cancer encouraged surgeons to start clinical trials to obtain evidence. Those efforts will create a new standard for lung cancer surgery. Finally, patients will choose a procedure after consideration of his or her own personal situation excluding medical condition. The procedure selected by most patients will become the gold standard. The gold standard will change with changes in society.

Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries.

BACKGROUND: Pulmonary tractotomy was introduced in 1994 as a novel concept for lung salvage after penetrating wounds. Recently, tractotomy has been suggested to increase morbidity and, thus, its practice has been challenged. The purpose of this study was to compare the morbidity and mortality associated with nonanatomic and anatomic lung resection in the management of severe pulmonary injuries. METHODS: Using our trauma registry, patients admitted to an urban Level I trauma center during an 11-year period with thoracic injuries requiring thoracotomy and pulmonary operation were identified. A chart review was performed with attention to patient demographics, operative treatment, and outcome. Pulmonary operations performed were classified as either nonanatomic (wedge resection and tractotomy) or anatomic resection (lobectomy and pneumonectomy). Statistical analysis was performed using Student's test, Fisher's exact test, and logistic regression as appropriate. RESULTS: There were 34 men and 2 women, with a mean age of 29 +/- 2 years. Mechanism of injury was predominantly penetrating, with 26 (72%) gunshot wounds and 8 (22%) stab wounds. Intraoperative blood loss and early red blood cell transfusion requirement were lower in patients undergoing nonanatomic resection (3.85 L vs. 11.90 L and 17.4 U vs. 27.9 U, respectively; p < 0.05). Mortality was 4% in the nonanatomic resection group versus 77% in the anatomic resection group. CONCLUSION: Nonanatomic resection is associated with an improved morbidity and mortality compared with anatomic resection in the management of severe lung injuries. Although not a randomized study, these findings encourage the continued application of lung-sparing procedures when feasible.