Publications by authors named "Alessandro Brunelli"

266 Publications

Commentary-Aerosolization from chest drainage systems in patients with air leak: risk of viral spreading in the hospital and community.

Semin Thorac Cardiovasc Surg 2021 Feb 15. Epub 2021 Feb 15.

Department of Thoracic Surgery; St. James's University Hospital; Bexley Wing, Beckett Street, Leeds, LS9 7TF, UK. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2020.12.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883707PMC
February 2021

Shared decision-making in early stage non-small cell lung cancer: A systematic review.

Ann Thorac Surg 2021 Feb 10. Epub 2021 Feb 10.

Section of Patient Centred Outcomes Research, Leeds Institute for Medical Research at St James's, University of Leeds. Beckett Street, Leeds, LS9 7TF, United Kingdom; Department of Thoracic Surgery, Leeds Teaching Hospital, Leeds, United Kingdom. Electronic address:

Background: The United Kingdom National Institute for Health and Care Excellence guidelines recommend that patients and professionals make shared decisions between surgery and stereotactic ablative radiotherapy (SABR) when treating early stage non-small cell lung cancer (NSCLC). Variation by centre suggests treatment decisions may be disproportionately influenced by clinician judgment and treatment availability rather than patient preference. This systematic review critically evaluates studies of patient and clinician preferences for treatment of early stage NSCLC.

Methods: Primary empirical research up to 30 April 2020 was identified from searches of MEDLINE, EMBASE, PsycInfo and Web of Science databases. Data extracted included: study characteristics and methods, preferences for NSCLC treatment and involvement in decision-making and risk of bias using the Mixed Methods Appraisal Tool. Findings were synthesized using descriptive data and narrative synthesis.

Results: 23 studies were included in the review; 18 measured patient preferences, 4 clinician preferences and 1 both clinician and patient preferences. Patients and clinicians were both most likely to prefer a collaborative role in treatment decisions. Most patients did not recall there being a choice between surgery or SABR options, and thus experienced minimal decisional conflict.

Conclusions: For professionals to support patients in making informed, value based decisions about NSCLC treatments, better quality evidence is needed of the clinical and quality of life trade offs for both surgery and SABR.
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http://dx.doi.org/10.1016/j.athoracsur.2021.01.046DOI Listing
February 2021

Commentary: Ground glass opacity: Is it the Holy Grail?

J Thorac Cardiovasc Surg 2021 Jan 10. Epub 2021 Jan 10.

Department of Thoracic Surgery, St James's University Hospital, Leeds, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.12.120DOI Listing
January 2021

Exploring consensus for the optimal sealant use to prevent air leak following lung surgery: a modified Delphi survey from The European Society of Thoracic Surgeons.

Eur J Cardiothorac Surg 2020 Dec 2. Epub 2020 Dec 2.

Triducive Partners Limited, Kent, UK.

Objectives: The use of sealants is one of the methods available to reduce the occurrence of intraoperative air leaks. The objective of this modified Delphi survey among ESTS members is to understand the attitudes of clinicians to the optimal use of sealants in air leak management.

Methods: To understand the attitudes of a wider sample of clinicians, a questionnaire was developed highlighting key issues through 37 statements. Respondents were invited to score their level of agreement with each. A modified Delphi methodology was used to review responses with a threshold of agreement for consensus of 75%.

Results: A total of 258 responses were received (response rate 17%). Respondents agreed that prolonged air leaks are a common complication in thoracic surgery presenting a burden to the patient and increasing the costs of care. There is clear support for the use of sealants to reduce costs and improve the efficiency of healthcare provision and duration of chest tube use in selected high-risk patients with intraoperative air leak at the end of the lung surgery. Respondents also agreed that, due to often complex nature of thoracic surgery, sealants should be developed specifically for this application.

Conclusion: There is a clear role for sealants in the management of air leaks and certain surgical procedures demand their use (i.e. lung volume reduction surgery, decortication). This opinion-based consensus review helps to raise the debate about the burden of air leaks in thoracic surgery in order that this issue is recognized in practice and informs the optimal use of sealants in lung surgery.
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http://dx.doi.org/10.1093/ejcts/ezaa428DOI Listing
December 2020

Report from the European Society of Thoracic Surgeons database 2019: current surgical practice and perioperative outcomes of pulmonary metastasectomy.

Eur J Cardiothorac Surg 2020 Nov 24. Epub 2020 Nov 24.

Department of Thoracic Surgery, Strasbourg University Hospital, Strasbourg, France.

Objectives: We report an overview of surgical practices and outcomes in patients undergoing pulmonary metastasectomy based on data from the European Society of Thoracic Surgeons database.

Methods: We retrieved data on resections performed for pulmonary metastases between July 2007 and July 2019. We evaluated baseline characteristics, surgical management and postoperative outcomes. Open and video-assisted thoracic surgery (VATS) procedures were compared in terms of surgical management, morbidity and mortality.

Results: We selected 8868 patients [male/female 5031/3837; median age: 64 years (interquartile range 55-71)] who underwent pulmonary metastasectomy. Surgical approach consisted of open thoracotomy in 63.5% of cases (n = 5627) and VATS in 36.5% (n = 3241), with a conversion rate of 2.1% (n = 69). Surgical resection was managed by wedge or local excision in 61% (n = 5425) of cases and anatomical resection in 39% (n = 3443); lobectomy: 26% (n = 2307); segmentectomy: 11% (n = 949); bilobectomy: 1% (n = 95); pneumonectomy: 1% (n = 92)). Lymph node assessment was realized in 58% (n = 5097) [sampling: 21% (n = 1832); complete dissection: 37% (n = 3265)]. Overall morbidity and mortality rates were 15% (n = 1308) and 0.8% (n = 69), respectively. Median duration of stay was 6 days (interquartile range 4-8). The rate of VATS procedures increased from 15% in 2007 to 58% in 2018. When comparing VATS and Open surgery, there were significantly (P < 0.001) fewer anatomical resections by VATS (24% vs 49%), lymph node assessments (36% vs 70%), less morbidity (9% vs 18%) and shorter durations of stay (median: 4 vs 7 days).

Conclusions: We report a good overview of current surgical practices in terms of resection extent and postoperative outcomes with a gradual acceptance of VATS.
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http://dx.doi.org/10.1093/ejcts/ezaa405DOI Listing
November 2020

Commentary-Chemotherapy Before or After Surgery in Patients With Single Station N2 Non-Small Cell Lung Cancer: One Size Does Not Fit All.

Semin Thorac Cardiovasc Surg 2020 Nov 9. Epub 2020 Nov 9.

Department of Thoracic Surgery; St. James's University Hospital; Leeds, UK. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2020.10.024DOI Listing
November 2020

Poor preoperative quality of life predicts prolonged hospital stay after VATS lobectomy for lung cancer.

Eur J Cardiothorac Surg 2021 Jan;59(1):116-121

Department of Thoracic Surgery, Leeds Teaching Hospital Trust, Leeds, UK.

Objectives: The aim of this study was to assess whether quality of life (QoL) scales are associated with postoperative length of stay (LoS) following video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer.

Methods: This is a single-centre retrospective analysis on 250 consecutive patients submitted to VATS lobectomies (233) or segmentectomies (17) over a period of 3 years. QoL was assessed in all patients by the self-administration of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 questionnaire. The individual QoL scales were tested for possible association with LoS along with other objective baseline and surgical parameters using univariable and multivariable analyses.

Results: Thirty-day cardiopulmonary and mortality rates were 22% and 2.4%. The median LoS was 4 days [interquartile range (IQR) 3-7]. Fifty-one (20%) patients remained in hospital longer than 7 days after surgery (upper quartile). General health [global health score (GHS)] (P = 0.019), physical function (P = 0.014) and role functioning (P = 0.016) scales were significantly worse in patients with prolonged stay. They were highly correlated between each other and tested separately in different logistic regression analyses. The best model resulted the one containing GHS (P = 0.032) along with age, low force expiratory volume in 1 s and carbon monoxide lung diffusion capacity and history of cerebrovascular disease. Fifty-nine patients had GHS <58 (lower interquartile value). Thirty-one percent of them experienced prolonged hospital stay (vs 17% of those with higher GHS, P = 0.027).

Conclusions: Preoperative patient-reported QoL was associated with prolonged postoperative hospital stay. Baseline QoL status should be taken into consideration to implement psychosocial supportive programmes in the context of enhanced recovery after surgery.
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http://dx.doi.org/10.1093/ejcts/ezaa245DOI Listing
January 2021

Eurolung risk score is associated with long-term survival after curative resection for lung cancer.

J Thorac Cardiovasc Surg 2021 Mar 24;161(3):776-786. Epub 2020 Aug 24.

Department of Thoracic Surgery, St James's University Hospital Bexley Wing, Leeds, United Kingdom.

Objective: The study objective was to verify whether the Eurolung score was associated with long-term prognosis after lung cancer resection.

Methods: A total of 1359 consecutive patients undergoing anatomic lung resection (1136 lobectomies, 103 pneumonectomies, 120 segmentectomies) (2014-2018) were analyzed. The parsimonious aggregate Eurolung2 score was calculated for each patient. Median follow-up was 802 days. Survival distribution was estimated by the Kaplan-Meier method. Cox proportional hazard regression and competing risk regression analyses were used to assess the independent association of Eurolung with overall and disease-specific survival.

Results: Patients were grouped into 4 classes according to their Eurolung scores (A 0-2.5, B 3-5, C 5.5-6.5, D 7-11.5). Most patients were in class A (52%) and B (33%), 8% were in class C, and 7% were in class D. Five-year overall survival decreased across the categories (A: 75%; B: 52%; C: 29%; D: 27%, log rank P < .0001). The score stratified the 3-year overall survival in patients with pT1 (P < .0001) or pT>1 (P < .0001). In addition, the different classes were associated with incremental risk of long-term overall mortality in patients with pN0 (P < .0001) and positive nodes (P = .0005). Cox proportional hazard regression and competing regression analyses showed that Eurolung aggregate score remained significantly associated with overall (hazard ratio, 1.19; P < .0001) and disease-specific survival after adjusting for pT and pN stage (hazard ratio, 1.09; P = .005).

Conclusions: Eurolung aggregate score was associated with long-term survival after curative resection for cancer. This information may be valuable to inform the shared decision-making process and the multidisciplinary team discussion assisting in the selection of the most appropriate curative treatment in high-risk patients.
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http://dx.doi.org/10.1016/j.jtcvs.2020.06.151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444606PMC
March 2021

Perioperative outcomes of segmentectomies versus lobectomies in high-risk patients: an ESTS database analysis.

Eur J Cardiothorac Surg 2020 Sep 15. Epub 2020 Sep 15.

Department of Thoracic Surgery, University Hospital Strasbourg, Strasbourg, France.

Objectives: We queried the European Society of Thoracic Surgeons (ESTS) database with the aim to assess cardiopulmonary morbidity and 30-day mortality of segmentectomies and lobectomies in patients with a Eurolung-predicted mortality above the upper interquartile and classified as high risk.

Methods: A total of 61 492 patients registered in the ESTS database (2007-2018) and submitted to lobectomy (55 353) or segmentectomy (6139) were divided into high risk or low risk according to a Eurolung-predicted mortality cut-off of 2.5% (corresponding in our population to the upper interquartile). Predicted versus observed mortalities were compared within each type of operation by using binomial test of proportion. Observed morbidity and mortality rates were compared between the 2 procedures using the χ2 test.

Results: A total of 14 007 lobectomies and 1251 segmentectomies were classified as high risk. In the high-risk group, the cardiopulmonary morbidity and 30-day mortality rates observed in segmentectomies were lower than in lobectomies (morbidity: 12% vs 17%, P < 0.0001; mortality: 2.4% vs 3.7%, P = 0.018). In segmentectomy patients, the observed mortality rate was lower than the Eurolung-predicted one (2.4% vs 3.8%, P = 0.009), while in the lobectomy patients, there was no difference between observed and predicted mortality (3.7% vs 3.8%, P = 0.9). In the low-risk group, the cardiopulmonary morbidity and 30-day mortality rates observed in segmentectomies were lower than in lobectomies (morbidity: 4.5% vs 7.8%, P < 0.0001; mortality: 0.6% vs 1.0%, P = 0.01). In segmentectomy patients, the observed mortality rate was lower than the Eurolung-predicted one (0.6% vs 1.0%, P = 0.0003), while in the lobectomy patients, there was no difference between observed and predicted mortality (1.0% vs 1.1%, P = 0.06).

Conclusions: Segmentectomy was found associated with a 0.65 relative risk of mortality rate compared to lobectomy in patients deemed at higher surgical risk.
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http://dx.doi.org/10.1093/ejcts/ezaa308DOI Listing
September 2020

Evaluation of Risk for Thoracic Surgery.

Surg Oncol Clin N Am 2020 Oct 21;29(4):497-508. Epub 2020 Jul 21.

Cardiothoracic Surgery, Department of Thoracic Surgery, St. James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK.

Modern surgical practice places increased emphasis on treatment outcomes. There has been a paradigm shift from paternalistic ways of practicing medicine to patients having a major involvement in decision making and treatment planning. The combination of these two factors undoubtedly leaves the surgeon open to greater scrutiny in respect of results and outcomes. In dealing with this it is important that the surgeon, wider multidisciplinary team, and patient appreciate the idea of surgical risk. This article reviews the latest evidence relating to risk assessment in thoracic surgery and suggests how this should be incorporated into clinical practice.
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http://dx.doi.org/10.1016/j.soc.2020.06.001DOI Listing
October 2020

Ninety-day hospital costs associated with prolonged air leak following lung resection.

Interact Cardiovasc Thorac Surg 2020 10;31(4):507-512

Costing Team, Finance Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK.

Objectives: Our goal was to assess the postoperative 90-day hospital costs of patients with prolonged air leak (PAL) including costs incurred after discharge from the initial index hospitalization.

Methods: We performed a retrospective analysis of 982 patients undergoing lobectomy (898) or segmentectomy (78) (April 2014-August 2018). A total of 167 operations were open, 780 were video-assisted thoracoscopic surgery and 28 were robotic. A PAL was defined as an air leak >5 days. The 90-day postoperative costs included all fixed and variable costs incurred during the 90 days following surgery. The postoperative costs of patients with and without PAL were compared. The independent association of PAL with postoperative 90-day costs was tested after adjustment for patient-related factors and other complications by a multivariable regression analysis.

Results: PAL occurred in 261 patients (27%). Their postoperative stay was 4 days longer than that of those without PAL (9.6 vs 5.7; P < 0.0001). Compared to patients without PAL, those with PAL had 27% higher index postoperative costs [7354€, standard deviation (SD) 7646 vs 5759€, SD 7183, P < 0.0001] and 40% higher 90-day postoperative costs (18 340€, SD 23 312 vs 13 102€, SD 10 264; P < 0.0001). The relative postoperative costs (the difference between 90-day and index postoperative costs) were 50% higher in PAL patients compared to non-PAL patients (P < 0.0001) and accounted for 60% of the total 90-day costs. Multivariable regression analysis showed that PAL remained an independent factor associated with 90-day costs (P < 0.0001) along with the occurrence of other cardiopulmonary complications (P < 0.0001), male gender (P = 0.018), low carbon monoxide lung diffusion capacity (P = 0.043) and thoracotomy approach (P = 0.022).

Conclusions: PAL is associated not only with increased index hospitalization costs but also with increased costs after discharge. Evaluation of the cost-effectiveness of measures to prevent air leaks should also include post-discharge costs.
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http://dx.doi.org/10.1093/icvts/ivaa140DOI Listing
October 2020

The impact of coronavirus disease 2019 on the practice of thoracic oncology surgery: a survey of members of the European Society of Thoracic Surgeons (ESTS).

Eur J Cardiothorac Surg 2020 Oct;58(4):752-762

Department of Thoracic Surgery, St. James's University Hospital, Leeds, UK.

Objectives: There is widespread acknowledgement that coronavirus disease 2019 (COVID-19) has disrupted surgical services. The European Society of Thoracic Surgeons (ESTS) sent out a survey to assess what impact the COVID-19 pandemic has had on the practice of thoracic oncology surgery.

Methods: All ESTS members were invited (13-20 April 2020) to complete an online questionnaire of 26 questions, designed by the ESTS learning affairs committee.

Results: The response rate was 23.0% and the completeness rate was 91.2%. The number of treated COVID-positive cases per hospital varied from fewer than 20 cases (30.6%) to more than 200 cases (22.7%) per hospital. Most hospitals (89.1%) postponed surgical procedures. All hospitals performed patient screening with a nasopharyngeal swab, but only 6.7% routinely tested health care workers. A total of 20% of respondents reported that multidisciplinary meetings were completely cancelled and 66%, that multidisciplinary decisions were not different from normal practice. Trends were recognized in prioritizing surgical patients based on age (younger than 70), type of surgery (lobectomy or less), size of tumour (T1-2) and lymph node involvement (N1). Sixty-three percent of respondents reported that surgeons were involved in daily care of COVID-19-positive patients. Fifty-three percent mentioned that full personal protective equipment was available to them when treating a COVID-19-positive patient.

Conclusions: The COVID-19 pandemic has created issues for the safety of health care workers, and surgeons have been forced to change their routine practice. However, there was no consensus about surgical priorities in lung cancer patients, demonstrating the need for the production of specific guidelines.
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http://dx.doi.org/10.1093/ejcts/ezaa284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7499623PMC
October 2020

Fibrin sealant for esophageal anastomosis: A phase II study.

World J Gastrointest Oncol 2020 Jun;12(6):651-662

Department of Thoracic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Esophageal Cancer Institute, Sun Yat-sen University Cancer Center, Guangzhou 510060, Guangdong Province, China.

Background: Esophagectomy is a pivotal curative modality for localized esophageal or esophagogastric junction cancer (EC or EJC). Postoperative anastomotic leakage (AL) remains problematic. The use of fibrin sealant (FS) may improve the strength of esophageal anastomosis and reduce the incidence of AL.

Aim: To assess the efficacy and safety of applying FS to prevent AL in patients with EC or EJC.

Methods: In this single-arm, phase II trial (Clinicaltrial.gov identifier: NCT03529266), we recruited patients aged 18-80 years with resectable EC or EJC clinically staged as T1-4aN0-3M0. An open or minimally invasive McKeown esophagectomy was performed with a circular stapled anastomosis. After performing the anastomosis, 2.5 mL of porcine FS was applied circumferentially. The primary endpoint was the proportion of patients with AL within 3 mo.

Results: From June 4, 2018, to December 29, 2018, 57 patients were enrolled. At the data cutoff date (June 30, 2019), three (5.3%) of the 57 patients had developed AL, including two (3.5%) with esophagogastric AL and one (1.8%) with gastric fistula. The incidence of anastomotic stricture and other major postoperative complications was 1.8% and 17.5%, respectively. The median time needed to resume oral feeding after operation was 8 d (Interquartile range: 7.0-9.0 d). No adverse events related to FS were recorded. No deaths occurred within 90 d after surgery.

Conclusion: Perioperative sealing with porcine FS appears safe and may prevent AL after esophagectomy in patients with resectable EC or EJC. Further phase III studies are warranted.
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http://dx.doi.org/10.4251/wjgo.v12.i6.651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340992PMC
June 2020

Prognostic relevance of programmed cell death protein 1/programmed death-ligand 1 pathway in thymic malignancies with combined immunohistochemical and biomolecular approach.

Expert Opin Ther Targets 2020 09 23;24(9):937-943. Epub 2020 Jul 23.

Medical Oncology, Università Politecnica delle Marche, Ospedali Riuniti Umberto I-GM Lancisi-G Salesi , Ancona, Italy.

Background: The aim of the study was to investigate Programmed cell Death protein 1 (PD-1) and Programmed Death-Ligand 1 (PD-L1) and their mRNA expression in thymic epithelial tumors (TETs).

Research Design And Methods: We analyzed 68 samples of formalin-fixed paraffin-embedded tissue (63 thymomas and 5 thymic carcinomas). PD-1 and PD-L1 protein expression were evaluated by immunohistochemistry, and mRNA expression was evaluated by real-time PCR.

Results: M/F ratio was 33/35, and median age was 60.5 years. Twenty patients had Myasthenia Gravis (MG). In the subgroup with large tumors (>5 cm), PD-L1 mRNA overexpression was significantly associated with worse prognosis vs. patients with no mRNA overexpression (p = 0.0083) and simultaneous PD-L1 immunostaining (>1%); PD-L1 mRNA overexpression was significantly associated with worse prognosis, respect to patient with PD-L1 negative immunostaining, and no PD-L1 mRNA overexpression (p = 0.0178). The elderly patients (>60 years) with large tumors showed worse prognosis (p = 0.0395). PD-L1 immunostaining (>50%) resulted to be significantly associated with MG.

Conclusions: Our data suggest the potential involvement of the PD-1 and PD-L1 pathway in TETs' progression. According to our results, it may be helpful to design future trials with anti-PD-1 drugs to establish high-risk patients after surgery.
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http://dx.doi.org/10.1080/14728222.2020.1790529DOI Listing
September 2020

General patient satisfaction after elective and acute thoracic surgery is associated with postoperative complications.

J Thorac Dis 2020 May;12(5):2088-2095

Section of Patient Centred Outcomes Research, Leeds Institute for Medical Research at St James's, University of Leeds, Leeds, UK.

Background: Patient's satisfaction has been regarded as a subjective reflection of the quality of care received by patients during their hospital stay. However, which factors may influence patient satisfaction in different healthcare settings needs to be determined.

Methods: Cross-sectional investigation of satisfaction at the time of discharge in 52 consecutive patients admitted in a UK Referral Centre for Thoracic Surgery for either elective (41 patients) or acute (11 patients) procedures. We evaluated patients' satisfaction with the inpatient service through the European Organisation for the Research and Treatment of Cancer IN-PATSAT32 standardised questionnaire. Major cardiopulmonary complications were defined according to the definition of the European Society of Thoracic Surgeons database. We focused on the General Patient Satisfaction Scale of the questionnaire to explore its relationship with several demographic and clinical factors. Relationships were tested using univariate regression analyses.

Results: General inpatient satisfaction was lower in patients with complications rather than those without (P=0.006) and in males rather than females (P=0.04). Living area, sex, and complications explained 22% of the variation in general inpatient satisfaction (P=0.006).

Conclusions: Regardless of the diagnosis, post-operative complications were associated with a lower patient satisfaction following thoracic surgery in our group of patients. This was particularly so for males and patients from rural areas. Research should focus on different clinical groups in our speciality to determine the specific strategies warranted to improve their quality of care and hence increase their satisfaction with inpatient services.
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http://dx.doi.org/10.21037/jtd-19-3345bDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330326PMC
May 2020

Cardio-Pulmonary Exercise Testing Prior to Major Surgery.

Ann Surg Oncol 2020 Oct 23;27(10):3583-3584. Epub 2020 May 23.

Department of Thoracic Surgery, St. James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK.

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http://dx.doi.org/10.1245/s10434-020-08642-zDOI Listing
October 2020

International expert consensus on the management of bleeding during VATS lung surgery.

Ann Transl Med 2019 Dec;7(23):712

Division of Thoracic Surgery, Sun Yat-Sen Cancer Center, Taipei, Taiwan, China.

Intraoperative bleeding is the most crucial safety concern of video-assisted thoracic surgery (VATS) for a major pulmonary resection. Despite the advances in surgical techniques and devices, intraoperative bleeding is still not rare and remains the most common and potentially fatal cause of conversion from VATS to open thoracotomy. Therefore, to guide the clinical practice of VATS lung surgery, we proposed the International Interest Group on Bleeding during VATS Lung Surgery with 65 experts from 10 countries in the field to develop this consensus document. The consensus was developed based on the literature reports and expert experience from different countries. The causes and incidence of intraoperative bleeding were summarised first. Seven situations of intraoperative bleeding were collected based on clinical practice, including the bleeding from massive vessel injuries, bronchial arteries, vessel stumps, and bronchial stumps, lung parenchyma, lymph nodes, incisions, and the chest wall. The technical consensus for the management of intraoperative bleeding was achieved on these seven surgical situations by six rounds of repeated revision. Following expert consensus statements were achieved: (I) Bleeding from major vascular injuries: direct compression with suction, retracted lung, or rolled gauze is useful for bleeding control. The size and location of the vascular laceration are evaluated to decide whether the bleeding can be stopped by direct compression or by ligation. If suturing is needed, the suction-compressing angiorrhaphy technique (SCAT) is recommended. Timely conversion to thoracotomy with direct compression is required if the operator lacks experience in thoracoscopic angiorrhaphy. (II) Bronchial artery bleeding: pre-emptive clipping of bronchial artery before bronchial dissection or lymph node dissection can reduce the incidence of bleeding. Bronchial artery bleeding can be stopped by compression with the suction tip, followed by the handling of the vascular stump with energy devices or clips. (III) Bleeding from large vessel stumps and bronchial stumps: bronchial stump bleeding mostly comes from accompanying bronchial artery, which can be clipped for hemostasis. Compression for hemostasis is usually effective for bleeding at the vascular stump. Otherwise, additional use of hemostatic materials, re-staple or a suture may be necessary. (IV) Bleeding from the lung parenchyma: coagulation hemostasis is the first choice. For wounds with visible air leakage or an insufficient hemostatic effect of coagulation, suturing may be necessary. (V) Bleeding during lymph node dissection: non-grasping en-bloc lymph node dissection is recommended for the nourishing vessels of the lymph node are addressed first with this technique. If bleeding occurs at the site of lymph node dissection, energy devices can be used for hemostasis, sometimes in combination with hemostatic materials. (VI) Bleeding from chest wall incisions: the chest wall incision(s) should always be made along the upper edge of the rib(s), with good hemostasis layer by layer. Recheck the incision for hemostasis before closing the chest is recommended. (VII) Internal chest wall bleeding: it can usually be managed with electrocoagulation. For diffuse capillary bleeding with the undefined bleeding site, compression of the wound with gauze may be helpful.
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http://dx.doi.org/10.21037/atm.2019.11.142DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989967PMC
December 2019

Training curriculum for European thoracic surgeons: a joint initiative of the European Society of Thoracic Surgeons and the European Respiratory Society.

Eur J Cardiothorac Surg 2020 03;57(3):418-421

Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.

Because of the differing definitions of the margins of thoracic surgery as a specialty and the variability in the training curricula among European countries, the European Society of Thoracic Surgeons formed a task force to elaborate a consensual proposal. The first step comprised creating a harmonized syllabus that was completed and published in 2018. This publication presents a proposal for a curriculum upon which the task force and the external expert reviewers have agreed. The curriculum was developed by the task force: each module and item describe the expected level of knowledge, skills and attitudes to be attained by the participants; learning opportunities, assessment tools and minimal clinical exposures have been defined as well. Competence in terms of non-technical skills has been defined for each module according to the CanMEDS (http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e) glossary. The different modules were subsequently submitted to an internal and an external review process and re-edited accordingly before final validation. The authors hope that this document will serve as a roadmap for both thoracic surgical trainees and mentors. It should further guide continuous professional development. However, evolving scientific and technological advances are expected to modify the diagnosis and treatment of diseases and disorders in the future and hence will mandate periodical revisions of the document.
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http://dx.doi.org/10.1093/ejcts/ezz361DOI Listing
March 2020

Commentary: Soft prognosticators following radical treatment of lung cancer: The time has come for a more integrated approach.

J Thorac Cardiovasc Surg 2020 07 14;160(1):287-288. Epub 2019 Dec 14.

Department of Thoracic Surgery, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.12.004DOI Listing
July 2020

International Delphi survey of the ESTS/AATS/ISTH task force on venous thromboembolism prophylaxis in thoracic surgery: the role of extended post-discharge prophylaxis.

Eur J Cardiothorac Surg 2020 05;57(5):854-859

Department of Surgery, McMaster University, Hamilton, ON, Canada.

Objectives: Venous thromboembolic events can be successfully prevented with chemical and/or mechanical prophylaxis measures, but evidence-based guidelines in thoracic surgery are limited, particularly regarding extended post-discharge prophylaxis. This study attempts to gather an international consensus on best practices to inform the development of such guidelines.

Methods: A series of 3 surveys was distributed to the ESTS/AATS/ISTH (European Society of Thoracic Surgeons, American Association of Thoracic Surgeons, International Society for Thrombosis and Haemostasis) venous thromboembolic events prophylaxis working group starting January 2017. This iterative Delphi consensus process sought to gather a consensus on (i) risk factors; (ii) preferred agents; (iii) duration; and (iv) perceived barriers to an extended thromboprophylaxis approach. Participant responses were expressed on a 10-point scale, and the results were summarized and circulated to all respondents in subsequent rounds. A coefficient of variance of ≤0.3 was identified pre hoc to identify agreement.

Results: A total of 21 Working Group members completed the surveys, composed of 19% non-surgeon thrombosis experts, and 48% from North America. Respondents largely saw agreement regarding risk factors that indicate a need for extended thromboprophylaxis. The group agreed that low-molecular-weight heparin is a suitable agent for use post-discharge, but there was a wide variety in response regarding agents, duration and barriers to extended prophylaxis, where no consensus was observed across the three rounds.

Conclusions: There is strong agreement around indications for extended venous thromboembolic events thromboprophylaxis after thoracic surgery, but there is little consensus regarding the agents and duration to be employed. Further research is required to better inform guideline development.
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http://dx.doi.org/10.1093/ejcts/ezz319DOI Listing
May 2020

A risk model to predict 2-year survival after video-assisted thoracoscopic surgery lobectomy for non-small-cell lung cancer.

Eur J Cardiothorac Surg 2020 04;57(4):781-787

Department of Thoracic Surgery, St. James's University Hospital, Leeds, UK.

Objectives: We sought to identify the risk factors associated with mortality post-video-assisted thoracoscopic surgery (VATS) lobectomy over a 2-year period.

Methods: Analysis was performed using a sample from an institutionally maintained database. All lobectomies for non-small-cell lung cancer from April 2014 to March 2018 started with VATS approach and with a complete follow-up were included (n = 732). Several clinical variables were screened using the Cox univariate analysis for their association with 2-year survival. Those with a P-value <0.1 were included in a Cox proportional hazard model.

Results: After multivariable analysis, the following variables showed significant association with 2-year survival: age >75 [hazard ratio (HR) 1.527, P = 0.043], carbon monoxide lung diffusion capacity <70 (HR 1.474, P = 0.061), body mass index (BMI) <18.5 (HR 2.628, P = 0.012), American Society of Anesthesiologist Physical Status >2 (HR 1.518, P = 0.047), performance status >1 (HR 1.822, P = 0.032) and male gender (HR 2.700, P < 0.001). A score of 2 was assigned to the male gender and BMI <18.5, with all other variables assigned a score of 1. Each patient was scored and placed into their risk class. A Kaplan-Meier estimate for 2-year survival was calculated for each class. These were collapsed into the following 3 classes of risk based on their similar 2-year survival: class A (score 0) 97%, 95% CI 88-99, class B (score 1-3) 84%, 95% CI 80-88, class C (score > 3) 66%, 95% CI 57-74.

Conclusion: Our scoring system can serve as an adjunct to a clinician's experience in risk-stratifying patients during multidisciplinary tumour board discussion and the shared decision-making process.
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http://dx.doi.org/10.1093/ejcts/ezz304DOI Listing
April 2020

Salvage Therapy for Locoregional Recurrence After Stereotactic Ablative Radiotherapy for Early-Stage NSCLC.

J Thorac Oncol 2020 02 9;15(2):176-189. Epub 2019 Nov 9.

Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address:

Although isolated local (LRs) and regional recurrences (RRs) constitute a minority of post-stereotactic ablative radiotherapy (SABR) relapses, their management is becoming increasingly important as the use of SABR continues to expand. However, few evidence-based strategies are available to guide treatment of these potentially curable recurrences. On behalf of the Advanced Radiation Technology Committee of the International Association for the Study of Lung Cancer, this article was written to address management of recurrent disease. Topics discussed include diagnosis and workup, including the roles of volumetric and functional imaging as well as histopathologic methods; clinical outcomes after salvage therapy; patterns of recurrence after salvage therapy; and management options. Our main conclusions are that survival for patients with adequately salvaged LRs is similar to that for patients after primary SABR without recurrence, and survival for those with salvaged RRs (regardless of nodal burden or location) is similar to that of patients with de novo stage III disease. Although more than half of patients who undergo salvage do not develop a second relapse, the predominant pattern of second failure is distant, especially for RRs. Management requires rigorous multidisciplinary coordination. Isolated LRs can be managed with resection and nodal dissection, repeat SABR, thermal ablation, or systemic therapies. RRs can be treated with combined chemoradiotherapy, radiation or chemotherapy alone, or supportive services. Finally, regular and structured follow-up is recommended after post-SABR salvage therapy.
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http://dx.doi.org/10.1016/j.jtho.2019.10.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7058490PMC
February 2020

Morbidity and mortality of lobectomy or pneumonectomy after neoadjuvant treatment: an analysis from the ESTS database.

Eur J Cardiothorac Surg 2020 04;57(4):740-746

University Hospital Strasbourg, Strasbourg, France.

Objectives: To evaluate the postoperative complications and 30-day mortality rates associated with neoadjuvant chemotherapy before major anatomic lung resections registered in the European Society of Thoracic Surgeons (ESTS) database.

Methods: Retrospective analysis on 52 982 anatomic lung resections registered in the ESTS database (July 2007-31 December 2017) (6587 pneumonectomies and 46 395 lobectomies); 5143 patients received neoadjuvant treatment (9.7%) (3993 chemotherapy alone and 1150 chemoradiotherapy). To adjust for possible confounders, a propensity case-matched analysis was performed. The postoperative outcomes (morbidity and 30-day mortality) of matched patients with and without induction treatment were compared.

Results: 8.2% of all patients undergoing lobectomies and 20% of all patients undergoing pneumonectomies received induction treatment. Lobectomy analysis: propensity score analysis yielded 3824 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the neoadjuvant group (626 patients, 16% vs 446 patients, 12%, P < 0.001), but 30-day mortality rates were similar (71 patients, 1.9% vs 75 patients, 2.0%, P = 0.73). The incidence of bronchopleural fistula and prolonged air leak >5 days were similar between the 2 groups (neoadjuvant: 0.5% vs 0.4%, P = 0.87; 9.2% vs 9.9%, P = 0.27). Pneumonectomy analysis: propensity score analysis yielded 1312 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the treated patients compared to those without neoadjuvant treatment (neoadjuvant 275 cases, 21% vs 18%, P = 0.030). However, the 30-day mortality was similar between the matched groups (neoadjuvant 68 cases, 5.2% vs 5.3%, P = 0.86). Finally, the incidence of bronchopleural fistula was also similar between the 2 groups (neoadjuvant 1.8% vs 1.4%, P = 0.44).

Conclusions: Neoadjuvant chemotherapy is not associated with an increased perioperative risk after either lobectomy or pneumonectomy, warranting a more liberal use of this approach for patients with locally advanced operable lung cancer.
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http://dx.doi.org/10.1093/ejcts/ezz287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825477PMC
April 2020

Devising the guidelines: the techniques of uniportal video-assisted thoracic surgery-postoperative management and enhanced recovery after surgery.

J Thorac Dis 2019 Sep;11(Suppl 16):S2069-S2072

Department of Thoracic Surgery, St. James's University Hospital, Leeds, UK.

Kehlet first introduced the notion of enhanced recovery after surgery (ERAS). Moreover, in the last years, the fast-track programmes demonstrated a reduction of complications and the hospital length of stay in general surgery. ERAS involves a multidisciplinary to development the value of care introducing the evidence-based knowledge into practice. ERAS has spread to other surgical specialities, showing the same improvements regarding clinical outcomes and costs. Therefore, there are numerous guidelines official published by the ERAS Society for many specialities, and many meta-analyses recognised the benefits of ERAS. ERAS pathways have demonstrable advantages in some specialities such as colorectal surgery. There is emerging evidence of ERAS efficacy in thoracic surgery. ERAS is safe and not increase postoperative morbidities, and ERAS guidelines should encourage future researches to address current knowledge gaps. Nevertheless, further prospective and randomised studies on the ERAS protocol, including the ones based on the uniportal video-assisted thoracic surgery (UniVATS), and focussing more on longitudinal outcomes over costs will be necessary. In fact, in the era of minimally invasive surgery traditional findings may not be appropriate to capture all benefits provided by ERAS. There is, therefore, a need to switch focus to endpoints linked to value in health care and patient centred efficiency.
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http://dx.doi.org/10.21037/jtd.2019.01.62DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6783708PMC
September 2019

Commentary: The power of indeterminacy.

J Thorac Cardiovasc Surg 2020 05 24;159(5):2041. Epub 2019 Sep 24.

Department of Thoracic Surgery, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.09.047DOI Listing
May 2020

Parsimonious Eurolung risk models to predict cardiopulmonary morbidity and mortality following anatomic lung resections: an updated analysis from the European Society of Thoracic Surgeons database.

Eur J Cardiothorac Surg 2020 03;57(3):455-461

Department of Thoracic Surgery, University Hospital Strasbourg, Strasbourg, France.

Objectives: To develop a simplified version of the Eurolung risk model to predict cardiopulmonary morbidity and 30-day mortality after lung resection from the ESTS database.

Methods: A total of 82 383 lung resections (63 681 lobectomies, 3617 bilobectomies, 7667 pneumonectomies and 7418 segmentectomies) recorded in the ESTS database (January 2007-December 2018) were analysed. Multiple imputations with chained equations were performed on the predictors included in the original Eurolung models. Stepwise selection was then applied for determining the best logistic model. To develop the parsimonious models, different models were tested eliminating variables one by one starting from the less significant. The models' prediction power was evaluated estimating area under curve (AUC) with the 10-fold cross-validation technique.

Results: Cardiopulmonary morbidity model (Eurolung1): the best parsimonious Eurolung1 model contains 5 variables. The logit of the parsimonious Eurolung1 model was as follows: -2.852 + 0.021 × age + 0.472 × male -0.015 × ppoFEV1 + 0.662×thoracotomy + 0.324 × extended resection. Pooled AUC is 0.710 [95% confidence interval (CI) 0.677-0.743]. Mortality model (Eurolung2): the best parsimonious model contains 6 variables. The logit of the parsimonious Eurolung2 model was as follows: -6.350 + 0.047 × age + 0.889 × male -0.055 × BMI -0.010 × ppoFEV1 + 0.892 × thoracotomy + 0.983 × pneumonectomy. Pooled AUC is 0.737 (95% CI 0.702-0.770). An aggregate parsimonious Eurolung2 was also generated by repeating the logistic regression after categorization of the numeric variables. Patients were grouped into 7 risk classes showing incremental risk of mortality (P < 0.0001).

Conclusions: We were able to develop simplified and updated versions of the Eurolung risk models retaining the predictive ability of the full original models. They represent a more user-friendly tool designed to inform the multidisciplinary discussion and shared decision-making process of lung resection candidates.
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http://dx.doi.org/10.1093/ejcts/ezz272DOI Listing
March 2020

Ten-Year Trends of Clinicopathologic Features and Surgical Treatment of Lung Cancer in China.

Ann Thorac Surg 2020 02 14;109(2):389-395. Epub 2019 Sep 14.

Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Electronic address:

Background: Lung cancer has changed significantly during the past 2 decades in its epidemiology and treatment. This retrospective analysis used data from 7 major areas of China over 10 years to evaluate clinicopathologic and surgical treatment trends of lung cancer in China during the past decade.

Methods: Data from 7184 patients with primary lung cancer who were treated between 2005 and 2014 in 8 provinces of China were retrospectively collected. Their clinicopathologic features and surgical treatment information were recorded. Simple linear regression models and the Cochrane-Armitage trend test were used to assess temporal trends.

Results: The proportion of female patients (from 57.4% to 59.6%; P < .001) and nonsmoking patients (from 37.1% to 48.9%; P < .001) and of patients with a family history of malignant tumors (from 7.0% to 11.5%; P < .001) increased significantly. The percentage of adenocarcinomas increased significantly (from 36.4% to 53.5%; P < .001), with a decrease in squamous cell carcinomas (from 45.4% to 34.4%; P < .001). After 2008, the application of minimally invasive surgery significantly increased in China (from 2.4% in 2008 to 34.4% in 2014; P < .001), with a decline in the rate of conversion to open operation (from 14.3% in 2008 to 4.8% in 2014; P = .146) and an increase in the proportion of systematic mediastinal lymph node dissection (from 50.0% in 2008 to 84.1% in 2014; P = .001).

Conclusions: This study investigated recent 10-year trends in the clinicopathologic features and surgical treatment of lung cancer in China and found significant important changes. These findings provide valuable information and evidence for the future control of the disease in China.
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http://dx.doi.org/10.1016/j.athoracsur.2019.08.017DOI Listing
February 2020