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Background: The aim of this study was to identify risk factors for surgical complications after anatomic lung resections in the era of video-assisted thoracic surgery (VATS) and enhanced recovery after surgery (ERAS)., Methods: A retrospective analysis of all consecutive adult patients who underwent elective anatomic lung resections between January and December 2020 at our institution was performed., Results: Eighty patients (40 VATS, 40 thoracotomy) were included. The 30-day mortality rate was 1.3%. The overall rate of major postoperative complications was 18.8%. Most major complications occurred in patients who underwent open surgery (complication rate 32.5%, share of total complications 86.7%). Major morbidity after VATS resection was rare (complication rate 2.5%, share of total complications 13.3%). In univariable analysis, thoracotomy (p = 0.003), impaired preoperative lung function (p = 0.003), complex surgery (p = 0.004) and sleeve resection (p = 0.037) were associated with adverse outcomes. In multivariable analysis, thoracotomy (p = 0.044) and impaired preoperative lung function (p = 0.028) were the only independent risk factors for major postoperative morbidity., Conclusion: Thoracotomy was associated with a 10-fold increased risk for postoperative complications compared with minimally invasive surgery and was an independent risk factor for surgical complications. In the era of VATS and ERAS, the fact that thoracotomy is performed may be a reliable parameter to identify patients at risk for postoperative complications., (© 2021 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Purpose: The study was performed to analyze the learning curve of performing uniportal video-assisted thoracoscopic surgery (uVATS) for lobectomy and lymphadenectomy, and to evaluate the possible disadvantages in outcomes during the course of learning. Materials and Methods: This is a prospective study of 52 consecutive patients undergoing uVATS lobectomy by a single surgeon from January 2016 to December 2017. Operation time (OPT) and the number of harvested lymph nodes (LNs) were evaluated by means of cumulative sum control chart by assessing efficiency (refinement in procedure to reach decreasing OPT and increasing number of harvested LNs) and mastery (absence of outliers). Failure rate, blood loss, and complications were retrospectively compared with the last 52 patients undergoing "classical" VATS lobectomy in the period before this study from January 2014 to December 2015. Results: Efficiency in OPT for uVATS was reached after 27 cases and mastery after 39 procedures (M 1st  = 172 ± 39 minutes; M 2nd  = 138 ± 34 minutes; p 1-2 = 0.022; M 3rd  = 120 ± 25 minutes; p 1-3 = 0.00; p 2-3 = 0.65). Efficacy in the number of harvested LNs was reached after 26 cases and mastery after the 42nd procedure (MED 1st  = 17, IQR 12-19; M 2nd  = 21, IQR 16.25-29.75; p 1-2 = 0.018; M 3rd  = 18, IQR 16-22; p 1-3 = 0.004; p 2-3 = 0.8). There were no significant differences in the failure rate (uVATS = 7.7%, VATS = 5.8%; P  = .7), blood loss (MED uVATS  = 250 mL, IQR 200-387.5; MED VATS  = 225 mL, IQR 200-300; P  = .77), and complications between the groups (uVATS = 13; 25%; VATS = 11; 21.2%; P  = .41). Finally no significant differences could be found in OPT (uVATS = 151.36 ± 41.55; VATS = 156.69 ± 40.08; P  = .52) or LNs (uVATS = 18, IQR 16-22; VATS = 19, IQR 14.25-20; P  = .71) between the groups. Conclusions: Assuming a surgeon is skilled in "classic" VATS lung resections, achieving efficiency and mastery in uVATS is possible after sufficient experience even without dedicated education in this procedure, without measurable disadvantages throughout the course of learning. This study created a benchmark for already experienced VATS surgeons who are novices in uVATS, elucidating the number of operations required to reach both efficiency and mastery.

Background: The prevalence of lung cancer and other tumors is increasing among the elderly people. The purpose of this study was to examine the influence of advanced age (80 + years) on the immediate perioperative outcome as well as to define potential risk factors that may lead to increasing morbidity and mortality after lung resections., Methods: A retrospective cohort analysis of the data from an electronic database of 208 elderly patients (165 patients ≥70 years, 45 patients ≥80 years) undergoing pulmonary anatomical resection for lung tumors during January 2013-December 2016 was conducted. The patients were initially observed and then divided into two groups: septuagenarians and octogenarians. The risk of developing postoperative complications in association with the numerous observed factors, which appeared significant in univariate tests, was assessed using univariate and multivariate logistic regression analyses to construct a risk model that assesses the highest chance of developing complications. Readmission rate and mortality within 90 days were recorded., Results: There were 140 men and 68 women with the mean age of 76 ± 4 years. A total of 15 pneumonectomies (7.2%), 11 bilobectomies (5.3%), 27 segmentectomies (13%), and 155 lobectomies (74.5%) were performed through 84 thoracotomies (40.4%) and 124 video-assisted thoracoscopic surgery (VATS) procedures (59.6%). Ninety-one patients (44%) exhibited at least one of 113 postoperative complications. There were four deaths (1.9%). Readmission rate was 12%, and 90-day mortality was 5.3%. There was no difference in postoperative morbidity among the groups according to their age (RR = 0.95; p = 78). According to multivariate logistic regression, adjusted Charlson Comorbidity Index≥11, FEV 1 ≤0.72, DLCO≤0.57, male gender, and nonsegmentectomies appeared to be strong predictors for the development of complications., Conclusions: In this cohort, age more than 80 years was not found to be significant for the development of complications, when compared to the septuagenarians. Female gender, better lung function (FEV1>72%, DLCO>57%), less comorbidities (ACCI<11), and segmentectomy type of lung resection were associated with improved outcomes., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Uniportal video-assisted thoracoscopic surgery (UVATS) for anatomical lung resections has gained popularity of late. This study aimed to elucidate the impediments to implementing the uniportal access method into the daily routine of VATS lung resections. To this end, we reviewed our initial experience and evaluated our progress., Methods: From January to May 2016, 24 consecutive UVATS anatomical lung resections (UVATS group) were performed by a single surgeon without any previous experience in UVATS surgery. These cases were matched in a one-to-one fashion with a cohort of 102 patients who had undergone "classical" VATS anatomical lung resections (VATS group) in the past 2’years performed by the same surgeon, using the nearest estimated propensity score. Based on an initial analysis, the UVATS group was further divided into two subgroups, UVATS 1 and UVATS 2 , consisting of the first and last 12 cases., Results: No UVATS patient required conversion to thoracotomy or needed an additional port. The VATS group had a shorter mean operation time if compared with the UVATS 1 subgroup (MVATS = 152, MUVATS 1  = 191; p = 0.019), but not if compared with the UVATS 2 subgroup (MVATS = 152, MUVATS 2  = 152; p = 1). There was no difference between the groups in the number of lymph node stations sampled (MVATS = 7, MUVATS 1  = 7, MUVATS 2  = 7; p = 0.92), the average number of dissected lymph nodes (MVATS = 19, MUVATS 1  = 15, MUVATS 2  = 18; p = 0.659), and the number and type of postoperative complications. As demonstrated on an audio-analogue pain scale (AAS), the UVATS groups needed significantly less pain medication until discharge (p < 0.001)., Conclusion: The adoption of uniportal VATS for anatomical lung resections can be accomplished without any impact on operative or clinical success, if performed by a surgeon already experienced in "classical" VATS. In our experience, there was no need for additional courses, proctored cases or modification of surgical instruments, although all options mentioned above may facilitate adoption., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Surgical approach into the fissural parenchyma may be an important and modifiable factor for the prevention of air leak after anatomical lung resections. Fissureless fissure-last technique has been described as useful technique to reduce air leak, yet in video-assisted thoracoscopic surgery (VATS) data are limited and mostly on the upper lobes. The purpose of this study is to evaluate the safety and feasibility of fissureless fissure-last VATS 'non-upper' lobectomies and the impact of it on the immediate outcome, especially relating to air leak., Methods: This study is a monocentric single-surgeon retrospective analysis on prospectively collected data. During 24 months, 46 patients underwent VATS 'non-upper' lobectomy or lower bilobectomy, with conventional (VATS-c) technique in 20 and fissureless fissure-last (VATS-f) technique in 26 patients. Results were evaluated according to preoperative, perioperative and postoperative parameters., Results: There were no differences between VATS-c and VATS-f groups in any characteristics or peri- and postoperative variables, except the number of staplers, where it was significantly higher in VATS-c group (MVATS-c = 5.7; MVATS-f = 7.7; P = 0.001). Operation time did not differ between the groups, but showed gender-related difference, being longer in males (MVATS-c = 188; MVATS-f = 157; P = 0.04). Prevalence of air leak was 20%; prolonged air leak (PAL) (>5 days) being 11% and PAL (>7 days) 0%. Patients with air leak were older by tendency (MVATS-c = 74.9; MVATS-f = 66.5; P = 0.08), had more complications (P = 0.025; relative risk = 2.65) and stayed longer at hospital (MVATS-c = 10.8; MVATS-f = 7.7; P = 0.02). Postoperative complications were present in 24% of patients., Conclusion: VATS-f lobectomy is safe and feasible not only for 'upper' but also for 'non-upper' lobes. When applied to properly selected patients, it may reduce air leak and PAL and thus may potentially reduce the rate of complications., (© 2017 Royal Australasian College of Surgeons.)

Diaphragmatic plication has been a well employed method for the treatment of diaphragmatic eventration and/or paralysis. Uniportal thoracoscopic procedures seem to offer substantial benefit in terms of postoperative pain and cosmesis with similar outcomes as other surgical techniques. A 60-year-old female patient was referred to our clinic for the surgical treatment of diaphragmatic eventration of an unknown cause. The patient was referred to our institution from another hospital, where she had undergone a femoro-popliteal and crural bypass which was unsuccessful, requiring amputation of her leg. Following surgery, she was unable to breath spontaneously without any specific reason. Cranial magnetic resonance imaging showed no pathology and the neurologists did not have a diagnosis for her comatose state. There was consensus in both hospitals that surgical plication of her elevated diaphragm might be the only option for respiratory improvement. We performed a double-lined diaphragmatic plication procedure by means of uniportal video-assisted thoracic surgery technique with CO2 insufflation using GelPort. Despite the time-consuming adhesiolysis and the need for lung suturing at the end of the procedure, the operative time was 120 min. Oxygenation remarkably improved after the operation, yet the patient remained in comatose state. She was referred back to the hospital where she had initially begun her therapy for further recovery., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Uniportal thoracoscopic resections offer less pain and better cosmetic results. They are usually performed through an antero-lateral incision. Posterior uniportal approach has not been described yet. A 65-year-old female was admitted to our clinic for the treatment of an adenocarcinoma, located in the apical segment of the right lower lobe. Owing to the ideal location and size, anatomical segment resection and radical lymphadenectomy was planned. Fissureless video-assisted thoracoscopic resection of the apical segment of the right lower lobe, using a uniportal posterior approach was performed, followed by mediastinal lymphadenectomy. However, resection margins showed microscopic presence of lepidic tumour on frozen section analysis, so we needed to proceed with a completion lower lobectomy. Postoperative course was event-free and the patient was discharged on the 4th postoperative day. The 1.8-cm large tumour was diagnosed to be primary lepidic (80%) and acinar (20%) adenocarcinoma and the final TNM was pT2aN0M0., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Prolonged air leak (PAL) after major lung resections is a common postoperative complication that leads to extended length of hospital stay (LOS) and increased hospital costs. Dissection of the lung tissue through the fissure may increase the incidence of PAL especially in the patients with incomplete fissures. The objective of this study was to evaluate the impact of the fissureless fissure-last technique in VATS lobectomy on immediate outcome, especially relating to air leak and LOS., Methods: This is an observational analysis on prospectively collected data of a single thoracic surgery unit. A total of 54 consecutive patients underwent VATS lobectomy and mediastinal lymphadenectomy-in 24 patients conventional VATS lobectomy (Group 1), in 30 patients fissureless VATS lobectomy (Group 2) was performed. The two groups were compared according to preoperative, operative and postoperative parameters., Results: No differences were found when comparing patient characteristics, operation time (M1 = 185 min; M2 = 176 min; P = 0.52) and number of staplers used (M1 = 6.2; M2 = 7.7; P = 0.088). The presence of air leak (P = 0.004; RR = 3.5), PAL (P = 0.003; RR = 10), in days with chest tube (M1 = 7.2; M2 = 4.2; P = 0.028) and LOS (M1 = 12.7; M2 = 8.9; P = 0.020) was significantly more frequent in patients that underwent conventional VATS lobectomy. Focusing on the air leak, significance was present in male gender (P = 0.034; RR = 2.41), higher ASA (M1 = 3.04; M2 = 2.67; P = 0.012), postoperative complications other than air leak (P = 0.001; RR = 5.78) and age between groups with and without air leak (M1 = 63.9; M2 = 74.1; P < 0.001)., Conclusions: Fissureless fissure-last VATS lobectomy is a feasible and equivalent to conventional VATS lobectomy in terms of operation time, stapler use and complications. Fissureless fissure-last VATS lobectomy, however, appears to be a superior technique to conventional VATS lobectomy in terms of preventing PAL and reducing the LOS., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)