Anatomic Lung Resection Research Articles

ED08.01 Surgery of Early-Stage NSCLC

ED08.01 Surgery of Early-Stage NSCLC

Is Anatomic Lung Resection Necessary in Surgical Treatment of Giant Lung Hydatid Cysts in Childhood?

The aim of this study is to evaluate the results of parenchymal saving methods for giant lung hydatid cysts and to discuss the necessity of anatomic lung resection in childhood. The patients under the age of 16 years who were operated between January 2000 and January 2017 due to pulmonary hydatid cyst were evaluated retrospectively (n = 200). In all, 32 patients who had giant hydatid cyst were included in this study. Parenchymal saving methods (cystotomy-capitonnage) were preferred and decortication was also performed for pleural thickening if needed. No lung resections were applied. Male patients were 53.1%. The mean age was 11.3 ± 3.2 years. The total number of giant cysts was 32. The average size of the cysts was 11 cm. Thirty seven point five percent of the cysts were perforated. Postoperative complication rate was 31.3%. No recurrence and mortality were seen during follow-up period. Considering the high recovery capacity of lung tissue, a chance should be given to recover the existing infection, atelectasis, and parenchymal damage. Especially in areas where hydatid disease is endemic, children may be infected with the parasite again. For these reasons, we do not recommend resection with any indications.

Resection of superior sulcus cancers (anterior approach)

Tumors of superior sulcus are defined as primary lung cancers involving one or more structures of the apex of the thoracic cavity. Surgical access of lung tumors invading adjacent organs is classically performed through a postero-lateral thoracotomy; however, in case of proven or suspected infiltration of anterior cervico-mediastinal structures, an anterior approach should be considered. Division of the first rib cartilage and of the costoclavicular ligament, coupled to a manubriotomy or a partial sternotomy gives wide access to cervico-mediastinal structures. Through this wide anterior approach, vascular, osseous and/or nervous structures of the cervico thoracic junction are isolated and resected, as necessary. Once the mediastinum has been freed from tumoral invasion, anatomical lung resection and mediastinal lymphadenectomy are performed. The anterior approach is a useful surgical access in case of apical tumour invading anterior structures of the cervicothoracic junction and the preservation of the sterno-clavicular joint gives satisfactory aesthetic and functional results. The need for a complementary second posterior incision, however, is often required to complete parietal and/or pulmonary resection.

Video-Assisted Thoracic Surgery and Anatomical Lung Resections. Where Do We Stand? National Survey by the Spanish Society of Thoracic Surgery

IntroductionThe objective of this survey is to find out the cumulated experience and the current situation of video-assisted thoracic surgery (VATS) for anatomical lung resections in Spain. MethodsThis is a descriptive study performed from two independent surveys designed through the Survey Monkey® web platform. The first survey was aimed at 53 thoracic surgery departments from the public and state-assisted national health system. The second survey, of a personal nature, was directed at 315 thoracic surgeons in active service, including physicians at their residency program. The surveys were kept operative from 18/11/2014 to 15/01/2015. ResultsThe first survey was answered by 32 (60%) departments and the second by 167 (53%) professionals. A total of 29 (91%) of the thoracic surgery departments represented recognized having some level of experience in this technique. However, a great proportion of departments, 15 (52%), counted less than 100 procedures and the cumulated time of experience was lower than 5 years in 19 (66%) departments. Among all the individual respondents, 126 (77%) admitted having performed the procedure at some point. Of those without any experience, at least 36 (95%) of them recognized that future training in this technique is one of their future professional objectives. ConclusionsWaiting for future prospective national registries contribute further information about the expansion of this technique in our country, the results of the current survey show, up to now, the best reflection of clinical practice and opinion of the surgeons involved in the development of VATS.

SC20.01 Muscle-Sparing Thoracotomy: Can It Still Be Considered a Standard?

Muscle sparing thoracotomy has been a standard approach in thoracic surgery for a long time. Minimal invasive approaches have gained a widespread acceptance recently and were included in the treatment guidelines for early stage NSCLC by several societies. Prospective randomized trials comparing minimal invasive approaches versus muscle sparing thoracotomy in stage I NSCLC have already been performed more than twenty years ago and demonstrated equal morbidity and mortality. Nevertheless it took until 2013 that the American College of Chest Physician guidelines recommended a VATS approach for clinical stage I NSCLC over a thoracotomy in experienced centers.1 No recommendation is made for more advanced stages. When analyzing national registry data still a high percentage of procedures in performed in an open way. This means that in current practice thoracotomy is still used as a standard approach by many surgeons. Minimal invasive approaches – both videothoracoscopic and robotic – are not different operations but different approaches towards performing an operation. It has been proven in several studies that in early stage lung cancer minimal invasive approaches in its various form lead at least to equivalent or even better oncologic outcome compared to an open approach. Nevertheless in more advanced stages this proof is lacking. Experienced centers reported individual series of minimal invasive approaches towards advanced procedures such as sleeve resection, pneumonectomy, chest wall resection and Pancoast tumor resection. While this is technically feasible no data on long-term outcome of larger patient cohorts are available and an open approach is considered standard in these cases. Thus for tumors with invasion of hilar structures or sleeve resection a muscle sparing thoracotomy currently remains a standard approach. Perceived advantages of minimal invasive approaches – VATS as well as RATS – include less pain, fewer complications, shorter length of stay, faster return to normal activity and higher rate of adjuvant chemotherapy compliance. There are a few single center studies challenging these assumptions2,3 as well as a recent analysis of Danish national data,4 however the majority of studies are in favor of minimal invasive approaches. In summary muscle sparing thoracotomy remains a standard approach for advanced stage tumors, whereas early stage lung cancer should be treated minimally invasive in experienced centers. 1. Detterbeck FC1, Lewis SZ, Diekemper R, Addrizzo-Harris D, Alberts WM. Executive Summary: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):7S-37S. 2. Rizk NP, Ghanie A, Hsu M, Bains MS, Downey RJ, Sarkaria IS, Finley DJ, Adusumilli PS, Huang J, Sima CS, Burkhalter JE, Park BJ, Rusch VW. A prospective trial comparing pain and quality of life measures after anatomic lung resection using thoracoscopy or thoracotomy. Ann Thorac Surg. 2014 Oct;98(4):1160-6. 3. Kuritzky AM, Aswad BI, Jones RN, Ng T. Lobectomy by Video-Assisted Thoracic Surgery vs Muscle-Sparing Thoracotomy for Stage I Lung Cancer: A Critical Evaluation of Short- and Long-Term Outcomes. J Am Coll Surg. 2015 Jun;220(6):1044-53 4. Licht PB, Schytte T, Jakobsen E. Adjuvant chemotherapy compliance is not superior after thoracoscopic lobectomy. Ann Thorac Surg. 2014 Aug;98(2):411-5.

Robotic Right Middle Lobectomy

Lung cancer remains a significant health problem throughout the world. With the increasing adoption of lung cancer screening, there may be greater numbers and proportions of early-stage disease in the future. Anatomical pulmonary resection remains the major curative treatment, and minimally invasive approaches (video-assisted thoracic surgery and robotic surgery) are gradually becoming the standard of care for the surgical management of lung cancer. Compared with conventional video-assisted thoracic surgery, robotic technology offers advantages to the surgeon, including binocular and magnified optics, wristed instrumentation, and ergonomic comfort. Moreover, thoracic applications, particularly anatomical lung resection, are the fastest-growing field in robotic surgery. This article will review the technical steps required to perform robotic middle lobectomy. The incision strategy, the specific instrumentation utilized, and the stepwise approach are based on the author's preference and experience and are by no means either the preferred or only options available. One of the many advantages of robotic technology is the ability to tailor the technology to the individual surgeon's preferences.

SC20.02 What Have We Achieved? Should It Be Performed for Stages Higher Than Stage I Disease?

Since the introduction of the videothoracoscopic anatomical lung resections in the early 90-ties both indications and contraindications for this type of approach have changed dramatically.1,2 There is common agreement that the oncological principles during surgery for lung cancer have to be the same regardless the type of approach: standard, minimally invasive (MIS – VATS multi portal or uniportal, intubated or non-intubated) or robotic. It regards predominantly requirements such like careful and atraumatic dissection, sufficient free-of-neoplasm margins and proper lymphadenectomy (standard or extended). Keeping it in mind we have to admit that stage I NSCLC seems “ideal” indication for MIS, particularly for less experienced surgeons. This type of surgery (MIS for stage I) is widely accepted and performed worldwide in thousands of cases. However, many experienced centers and surgeons have moved the borders forward treating more advanced cases by MIS with acceptable results regarding complications, mortality, conversion rate or quality of lymphadenectomy. Gonzalez-Rivas presented the series of 43 advanced patients (tumors bigger > 5cm, T3 or T4, treated by neoadjuvant chemo- or radiotherapy) who were treated by uniportal VATS with good results comparable with earlier stages.3 Authors stated that, “Skilled VATS surgeons can perform 90% or more of their lobectomies thoracoscopically, reserving thoracotomy only for huge tumors or complex bronchovascular reconstructions.” Large multicenter series of more than 400 advanced cases treated by VATS approach compared with propensity score matched open thoracotomy group with no differences in overall survival was published by Cao et al.4 According to the VATS Consensus Statement (among 50 international experts to establish a standardized practice of VATS lobectomy after 20 years of clinical experience) eligibility for VATS lobectomy should include tumors <7cm and N0 or N1 status. Chest wall involvement was considered contraindication while centrality of tumor was considered a relative contraindication when invading hilar structures.5 This important statement is widely accepted however some surgeons consider it too restrictive regarding chest wall invasion. Currently there is a relatively small (but growing) group of thoracic surgeons who are performing double-sleeve (pulmonary vessels and bronchi) and carinal resections by MIS – extremely complex procedures even in open surgery.6 It requires modern instruments, sutures and definitely is not a procedure for beginners. Published series are small and overall experience is limited but this initial efforts are good example of the continuous drive of thoracic surgeons community to move indications for MIS further and further. Advanced NSCLC cases started to be treated by MIS just few years ago and there are no prospective randomized studies available in medical literature therefore we cannot definitively compare and assess the long term results but keeping in mind that the main oncological principles should be preserved and remain the same in every type of surgical approach we can expect comparable and similar results as it was reported in currently published papers. We all know that generally speaking the future is unpredictable but inevitable from the other side. Considering MIS in advanced NSCLC cases we can state with just minimal exaggeration that the future is now. 1. Roviaro G, Varoli F, Vergani C et al.: Long term survival after videothoracoscopic lobectomy for stage I lung cancer. Chest 2004;126:725-732 2. Hanna JM, Berry MF, D′Amico TA: Contraindications of videoassisted thracoscopic surgical lobectomy and determinants of conversion to open. J Thorac Dis 2013;5:182-189 3. Gonzalez-Rivas D, Fieira E, Delgado M et al.: Is uniportal thoracoscopic surgery a feasible approach for advanced stages of NSCLC? J Thorac Dis 2014;6:641-648 4. Cao C, Zhu ZH, Yan TD et al.: Videoassisted thoracic surgery versus open thoracotomy for NSCLC: a propensity score analysis based on a multi-institutional registry. Eur J Cardiothorac Surg 2013;44:849-54 5. Yan TD, Cao C, D′Amico TA et al.: Videoassisted thoracoscopic surgery lobectomy at 20 years: a consensus statement. Eur J Cardiothorac Surg 2014;45:633-639 6. Lyscov A, Obukhova T, Ryabova V et al.: Double-sleeve and carinal resections using the uniportal VATS technique: a single centre experience. J Thorac Dis 2016;8 (suppl 3):235-241. VATS, advanced cases, future

SC08.01 Impact and Management of Co-Morbidities

SC08.01 Impact and Management of Co-Morbidities

P1.08-008 Impact of Perioperative Redox Balance on Long-Term Outcome in Patients Undergoing Lung Resection

Surgical stress provokes a cytokine storm and systemic inflammatory response syndrome, and can also affect redox balance during the postoperative course. However, whether inflammatory status, especially redox balance, during the perioperative period has effects on long-term outcome following surgery for lung cancer remains unclear. The aim of this study was to determine whether redox balance during the perioperative period is associated with long-term survival of patients after undergoing lung resection. Consecutive patients who underwent an anatomical lung resection greater than a segmentectomy for non-small cell lung cancer from January to June 2013 at our institution were investigated. The Ethical Committee of Dokkyo Medical University Hospital approved this study (#24043) and all participating patients provided informed consent. Serum was collected during the operation, and on post-operative day (POD) 3 and 7, and the levels of reactive oxygen metabolites (d-ROM) and biological antioxidant potential (BAP) were measured using FREE carpe diem (Wismerll). We analyzed overall survival, relapse, and cause of death. Twenty-two patients (males 18, females; 69±7 years old) were enrolled, of whom 12 underwent open surgery and 6 VATS. Histology findings showed 12 adenocarcinomas, 6 squamous cell carcinomas, and 4 others. Comorbidities in the patients were chronic obstructive pulmonary disease in 8 and idiopathic pulmonary fibrosis in 5. d-ROM values on POD 3 and 7 were significantly increased as compared to those obtained during the operation (perioperative 288±65, POD 3 439±49, POD 7 479±49; p<0.001), whereas BAP did not change after surgery. Overall survival was 71.4% after 3 years. A receiver operating characteristic curve revealed a dROM cut-off value of 327 during the operation. Patients with a dROM value of 327 or less showed significantly superior 3-year survival as compared to those with a greater value (87.5% vs. 20.0%, p<0.001). Surgical stress caused an increase in dROM during the postoperative course. The dROM value obtained during the operation was correlated with long-term survival of patients after undergoing resection for lung cancer.

P1.08-029 Surgical Experience of Primary Salivary Gland Tumors of Lung: Experience from Tertiary Care Cancer Center in North India

Primary salivary gland type tumors of lung (PSGTTL) are rare intra-thoracic malignant neoplasm. Their description in literature is largely limited to a few case series/case reports. We herewith present our surgical experience and review its clinical presentation, management options and survival outcomes. We performed a retrospective analysis of prospectively maintained computerized data-base of lung cancer patients at department of surgical oncology, Dr BRA-IRCH, AIIMS, Delhi. A total of nine patients underwent treatment for PSGTTL during the period from January 2012 to December 2015. Details concerning the clinical presentation, preoperative therapy, operative procedure, histopathological examination, postoperative complications and outcome were retrieved and analyzed. Median age of patients was 42 years (range 24-52 years) with male: female ratio of 7:2. Median duration of symptoms before presentation was 12 months (range 4-24 months). Most common symptoms were Hemoptysis (77%) and dyspnea (66%). Fiber-optic bronchoscopy revealed endobronchial growth in all patients with six patients had growth in left main bronchus while one had growth in right main bronchus and two in right intermediate bronchus. Biopsy confirmed adenoid cystic carcinoma in 6 (66%) and muco-epidermoid carcinoma in 3 (33%) patients. Total seven patients underwent R‘0’ resection with pneumonectomy in five, bilobectomy in one, lower lobectomy in one patient. One patient developed pneumonia after left carinal pneumonectomy and succumbed to it. No major postoperative complication was encountered in remaining six patients. One patient refused surgery and one found unresectable in view of dense adhesions between lung and heart. Both patient received chemo-radiation and underwent bronchoscopic debulking and are in follow up. Median pathological tumor size was 3 cm. Median number of node harvested was 10 (range 4-18) however none showed metastasis. None of the operated patient developed relapse and overall eight patients are alive after a median follow up of 18 months. Primary salivary gland type tumors of lung (PSGTTL) are low grade malignancy and greater awareness of these tumors is necessary to avoid misdiagnosis and delay in treatment. Aggressive anatomical lung resection with preservation of functional lung parenchyma offers optimal outcome in such patients.

The causes and consequences of conversions during thoracoscopic anatomical lung resections

The causes and consequences of conversions during thoracoscopic anatomical lung resections

Evaluation of Cardiorespiratory Parameters Prior to Anatomical Lung Resection

The evaluation of cardiopulmonary parameters is an essential factor for ascertaining of functional operability prior to anatomical lung resection. A predictive formulae for estimating of functional operability based on analysis of cardiorespiratory parameters have not yet been described. In marginal cases, a precise assessment is an important decisive factor under fear of postoperative complication regarding more radical parenchymal resection.The functional tests such as spirometry, spiroergometry, stair climbing exercise, 6-Minute walk test, echocardiography, stress echocardiography and lung perfusion scintigram under consideration of general health situation could provide predictive postoperative information for ascertaining of functional operability.We describe in this review the meaningful cardiorespiratory tests for estimating of the outcome prior to anatomical lung resection.

P1.05-075 The Correlation between the Prognoses of Patients with Non-Small Cell Lung Cancer and Preoperative Platelet- Lymphocyte Ratio

The platelet- lymphocyte ratio (PLR) is a prognostic factor that correlates immunity or inflammation with tumor invasion. We retrospectively investigated the correlation between prognosis and preoperative PLR in patients with non-small cell lung cancer who underwent anatomical lung resection in our hospital. We conducted a retrospective study of 116 patients with primary lung cancer who underwent anatomical lung resection in our hospital from January 2009 to May 2014. We excluded patients who underwent previous lung resection or had intraoperative malignant pleural effusion or positive surgical margins. We analyzed 105 patients (65 with adenocarcinoma, 25 with squamous cell carcinoma, 9 with large cell carcinoma, and 2 with adenosquamous carcinoma). We constructed a ROC curve with PLR values calculated preoperative blood analyses and determined that the threshold was 160. We divided the patients into high and low PLR groups. We analyzed these two groups with respect to background, pathological findings, and cancer-specific survival. Additionally, we investigated factors that correlated with cancer-specific survival with. The median patient age was 71 years (range, 50-88 years). There were 75 male patients and 25 female patients. The median follow-up duration was 43 months (range, 0-85 months). Regarding surgical techniques, 101 patients underwent lobectomy, 3 underwent segmentectomy, and 1 patient underwent sleeve lobectomy. A total of 47, 34, 8, 9, 6, and 1 patients were diagnosed with pathological stage IA, IB, IIA, IIB, IIIA, and IIIB cancer. The overall survival rate was 71.3%. When examining background characteristics, tumor size was larger and T factor was more elevated in the high PLR groups, and pathological stage was more advanced in the high PLR group. N factor was not significantly different between the two groups. Cancer-specific survival was significantly poorer in the high PLR group than in the low group (p=0.0007). Considering tumor types, patients with adenocarcinoma in the high PLR group had poorer prognosis compared to the patients with adenocarcinoma in the low PLR group (p=0.0002), but for squamous cell carcinoma and in the other tumor types, there was no significant difference (p=0.20 and p=0.86, respectively). Multivariate analysis revealed that PLR was an independent prognosis factor for the cancer-specific survival. In the patients who underwent anatomical resection with lung cancer, PLR was correlated with prognosis.

PUB023 Effectiveness of Three-Dimensional Video System in Single Port Thorascopic Major Pulmonary Resection: Propensity Score Matched Analysis

The aim of this study was to evaluate the surgical outcomes of video assisted thoracoscopic surgery using three dimensional high definition video system compared to two-dimensional system during single port major lung resection by propensity score matched analysis. Between March 2012 and December 2015, 213 patients underwent single port thoracoscopic anatomic lung resection for lung malignancy by one surgeon. The patients who underwent wedge resection or converted to open thoracotomy were excluded from analysis. Patient group was divided into two group: two-dimensional (n=95) and three-dimensional group (n=118). Seventy-six patients of each group were matched using propensity score analysis. There were no significant differences in operation time (p=0.44), conversion to open thoracotomy (p=0.698) and postoperative complication (p=0.15) between two- and three-dimensional video system for major lung resection. Subgroup analysis showed that procedure times for lobectomy with segmentectomy (p<0.01), sleeve resection (p=0.64), and additional procedure (p=0.10) were likely to be shorter in three-dimensional group. The number of excised mediastinal lymph nodes was not significantly different (p=0.81). Eye discomfort or headache when using glasses for three-dimensional image was not observed in our study. Three-dimensional video system is a safe and feasible option for minimally invasive major lung resection for lung cancer and might be helpful in performing thoracoscopic complex procedures; segmentectomy, sleeve resection under single port thoracoscopic surgical field.

Cirugía torácica video-asistida y resecciones pulmonares anatómicas. ¿Dónde estamos? Encuesta nacional de la Sociedad Española de Cirugía Torácica

IntroductionThe objective of this survey is to find out the cumulated experience and the current situation of video-assisted thoracic surgery (VATS) for anatomical lung resections in Spain. MethodsThis is a descriptive study performed from two independent surveys designed through the Survey Monkey® web platform. The first survey was aimed at 53 thoracic surgery departments from the public and state-assisted national health system. The second survey, of a personal nature, was directed at 315 thoracic surgeons in active service, including physicians at their residency program. The surveys were kept operative from 18/11/2014 to 15/01/2015. ResultsThe first survey was answered by 32 (60%) departments and the second by 167 (53%) professionals. A total of 29 (91%) of the thoracic surgery departments represented recognized having some level of experience in this technique. However, a great proportion of departments, 15 (52%), counted less than 100 procedures and the cumulated time of experience was lower than 5 years in 19 (66%) departments. Among all the individual respondents, 126 (77%) admitted having performed the procedure at some point. Of those without any experience, at least 36 (95%) of them recognized that future training in this technique is one of their future professional objectives. ConclusionsWaiting for future prospective national registries contribute further information about the expansion of this technique in our country, the results of the current survey show, up to now, the best reflection of clinical practice and opinion of the surgeons involved in the development of VATS.

Operating room scheduling is not associated with early outcome following elective anatomic lung resections: a propensity score case-matched analysis†

To investigate the effect of operating room scheduling on the outcome of patients undergoing elective lung resection. In total, 420 patients submitted to anatomical pulmonary resections (363 lobectomies, 35 pneumonectomies, 22 segmentectomies) (April 2014-November 2015) were analysed. Ninety-two patients (22%) were operated on during weekends (Friday or Saturday) and 161 patients (38%) in the afternoon. Propensity score matching was performed to account for possible selection bias between the groups. The matched groups (weekdays versus weekends; morning versus afternoon) were compared in terms of cardiopulmonary complications, in-hospital mortality and length of stay (LOS). In total, 102 (24%) patients developed cardiopulmonary complications and 56 (13%) patients developed major complications. In-hospital mortality was 3.1% (13 patients). The case-matched comparison between patients operated on during the week versus those operated on during weekends (92 pairs) showed no differences of cardiopulmonary morbidity (22 vs 24, P = 0.8), major complications (14 in both groups), mortality (2 vs 4, P = 0.7) and LOS (7 vs 7.5 days, P = 0.6). The case-matched comparison between patients operated on in the morning versus those operated on in the afternoon (161 pairs) showed no differences of cardiopulmonary morbidity (32 vs 33, P = 0.9), major morbidity (17 vs 19, P = 1), mortality (7 vs 4, P = 0.5) and LOS (7.2 vs 5.9 days, P = 0.2). In our setting, operating room scheduling did not affect early outcome following elective lung resections, confirming the appropriate structural and procedural characteristics of a dedicated Thoracic Unit.

Reducing the risk of atrial fibrillation after anatomical lung resection

Reducing the risk of atrial fibrillation after anatomical lung resection

New-onset atrial fibrillation after anatomic lung resection: predictive factors, treatment and follow-up in a UK thoracic centre

Postoperative atrial fibrillation (POAF) increases morbidity, hospital stay and healthcare expenditure. This study aims to determine the perioperative factors correlating with POAF as well as to evaluate both treatment strategies and AF persistence beyond discharge. The records of all patients undergoing anatomical lung resection over a 1-year period were retrospectively reviewed. Patients with a history of arrhythmia were excluded. POAF was defined by clinical diagnosis and electrocardiography. Pre- and postoperative demographic and clinical data were collected, and uni- and multivariable regression were performed to determine the factors associated with POAF. POAF occurred in 11.4% (43/377) of patients with a mean of 3.55 days postoperatively and significantly increased hospital stay (6.78 ± 4.42 vs 10.8 ± 5.8 days (P = 0.0014)). No correlation was found with gender, hypertension, ischaemic heart disease, beta-blocker use, alcohol consumption or thyroid dysfunction. However, older age (P = 0.001) and postoperative infection (P < 0.0001; χ2 = 26.03) were found to be significant uni- and multivariable predictors of POAF. Open surgery rather than video assisted thoracoscopic surgery (VATS) (open 26/189 (13.8%); VATS 17/188 (9.0%); P = 0.150) demonstrated a tendency towards increased postoperative AF; however, this was not statistically significant. Four (9.3%) patients remained in AF on discharge, and three required long-term anticoagulation. Three (7%) patients were found to have ongoing AF at 1-month follow-up. Increasing age and postoperative infection are most strongly associated with POAF. Adoption of enhanced recovery protocols, along with more rigorous monitoring and early treatment of postoperative infection may help reduce POAF and its associated morbidity. Rhythm assessment is crucial to identify persistent AF after discharge, and clinicians should be vigilant for recurrence of AF at follow-up.

VATS lobectomy, a standardised approach?

The article by French and colleagues (1) published in Annals of Cardiothoracic Surgery has the merit of being the first published article on the transition from multiple port video-assisted thoracic surgery (VATS) to single port surgery (S-VATS) in minimally invasive anatomic pulmonary resections. The authors have carefully designed and conducted a comparative study to evaluate the safety and feasibility of this transition and to assess its impact on intraoperative and early postoperative outcomes. They add to the existing literature a series of 50 consecutive S-VATS anatomical lung resections which were compared to an equal, historical and prospective cohort of multiple port VATS cases; all of them were performed at the same institution and by the same surgeon. Its main clinical message is that the transition from multiple port VATS to S-VATS lung resection is safe, efficient and with good surgical quality. However they failed in their attempt to find differences in perioperative outcomes between approaches, specifically in patient reported pain in favor of S-VATS.

VATS surgery for anatomical lung resection: a different approach for every surgeon

Video assisted thoracic surgery (VATS) is becoming the standard of practice in the surgical treatment of lung cancer (1). French et al . made an important contribution having reported an interesting experience of transition from multiple ports to single port VATS for anatomic pulmonary resection (2), and they conclude that patient safety and oncologic quality are preserved during the transition period.