Enhanced recovery after surgery and chest tube management

Comparison of single and double chest drains following pulmonary lobectomy

BACKGROUND

Chest tubes are commonly used to empty the chest cavity after pulmonary lobectomy. Although two drains have traditionally been used to guarantee proper air and fluid evacuation, they frequently cause patients more pain and lengthen their hospital stays. This study set out to compare the effectiveness of using a single chest drain versus using two chest drains after a pulmonary lobectomy.

METHODS

This retrospective trial was performed on 50 patients aged ≥18 years, both sexes, scheduled for Video-Assisted Thoracic Surgery (VATS) lobectomy. Patients were divided into two equal groups: Group S: single chest tube was used and Group D: double chest tubes were used.

RESULTS

The duration of drainage was 3.32 ± 0.69 days in group S and was 4.2 ± 1.29 days in group D (P < 0.05). The amount of drainage was 593.64 ± 45.94 ml in group S and was 910.04 ± 71.42 ml in group D (P < 0.05). Assessment of the pain using the visual analog scale on second day was insignificantly different between both groups and was significantly lower at the second postoperative week in group S than in group D (P = 0.005). Length of hospital stays and complications (pneumonia, re-drainage, and persistent air leak (> 7 days)) were insignificantly different between both groups.

CONCLUSIONS

The effectiveness of inserting one chest tube following a pulmonary lobectomy is comparable to that of inserting two tubes. Furthermore, employing a single tube is more advantageous than two tubes, as it is associated with lower postoperative pain, duration and amount of drainage.

Early versus late chest tube removal after surgery for primary spontaneous pneumothorax-a systematic review and meta-analysis

Background

The optimal timing of postoperative chest tube removal remains disputable. Traditionally, chest tubes are left in place for several days for adequate pleurodesis and recurrence prevention after surgery for primary spontaneous pneumothorax (PSP). Currently, early tube removal, defined as immediate removal upon cessation of air leakage, is increasingly practiced. This study aimed to evaluate the safety of early chest tube removal in terms of recurrence in these patients.

Methods

MEDLINE (PubMed), EMBASE and Cochrane databases were searched until January 2024. Inclusion criteria encompassed patients undergoing pleurodesis through video-assisted thoracoscopic surgery (VATS) for PSP if chest tube management was clearly described to discriminate between early and late tube removal protocols, and recurrence rate with a postoperative follow-up period of at least six months was reported. The primary outcome was recurrence rate, with secondary outcomes including postoperative length of stay (LOS), prolonged air leakage (PAL) and chest tube duration. Subgroup analysis contained type of pleurodesis. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation method.

Results

Thirty-six studies comprising 6,166 patients were included, lacking direct comparative studies on early versus late chest tube removal. Due to loss to follow-up, 6,063 patients were analysed regarding recurrence rate, resulting in 4.49% [95% confidence interval (CI): 3.33-6.03%; I2=65.6%] after late removal and 7.61% (95% CI: 5.44-10.57%; I2=8.2%) after early removal (P=0.02). Among the secondary outcomes only chest tube duration was significantly different between early and late removal [2.50 (95% CI: 2.31-2.71) versus 3.42 (95% CI: 3.08-3.81) days, P<0.001]. Subgroup analysis revealed the most pronounced difference in recurrence following pleurectomy as type of pleurodesis (P=0.003). The quality of evidence was considered low.

Conclusions

Although no direct comparative studies were retrieved, the best available evidence suggests that early chest tube removal may be associated with a slightly higher recurrence rate after surgical pleurodesis for pneumothorax. High-quality evidence is needed before implementing early removal.

Measures to accelerate recovery from stage III tuberculous empyema: tuberculous empyema surgical and recovery methods

OBJECTIVES

To evaluate the effects of video-assisted thoracoscopic decortication (VATD) and enhanced recovery after surgery (ERAS) in patients with stage III tuberculous empyema.

METHODS

The 360 participants were divided into four groups according to the treatment received: thoracotomy decortication (TD) + traditional recovery procedures (TRP), TD + ERAS, VATD + TRP, and VATD + ERAS. We evaluated the effects of the treatment modalities on various intraoperative and postoperative outcome measures. Multivariate analysis was then performed to identify risk factors associated with increased postoperative the length of hospital (LOS).

RESULTS

There were significant differences between the TD and VATS groups in terms of the duration of surgery, intraoperative blood loss, postoperative drainage, postoperative erythrocyte sedimentation rate (ESR), LOS, and pain levels. The use of ERAS also showed significant effects in certain outcome measures. There were no significant differences in the incidence of postoperative complications among the groups. The use of VATD and ERAS procedures, and preoperative antituberculosis therapy, was inversely associated with the LOS.

CONCLUSIONS

Implementation of VATD and ERAS procedures in patients with stage III tuberculous empyema can significantly reduce the LOS and improve patient outcomes in a safe and effective manner.

How soon should we remove a chest drain following anatomic lung resection?

OBJECTIVES

Chest drain duration has a key influence on recovery post-thoracic surgery. There is no universally accepted protocol determining the timing of chest drain removal. We aim to review and discuss the factors that determine how soon chest drains can be removed following anatomic lung resection.

METHODS

Fluid output and air leak are the main determinants of chest drain removal. We reviewed the literature to determine which cut offs have been proposed and the use of protocol for decision-making in chest drain removal.

RESULTS

Use of air leak alone as the determinant for chest drain removal optimizes chest drain management, and studies that have utilized this protocol can achieve drain removal on the 1st postoperative day in most cases. Moving forward, surgery without routine chest drains can help move towards day case thoracic surgery, even for anatomic lung resection.

CONCLUSIONS

Utilizing digital drainage with a strict air leak protocol helps to minimize drain duration post lung resection. The future landscape of chest drain management should focus on the usage of chest drains on an as required basis for air leak, even for anatomic lung resection.

Effects of post rib plating tube thoracostomy output on the need for thoracic re-intervention: Does the volume matter?

BACKGROUND

Surgical stabilization of rib fractures (SSRF) has been demonstrated to improve early clinical outcomes. Tube thoracostomy (TT) is commonly performed with SSRF, however there is a paucity of data regarding when removal of TT following SSRF should occur. This study aimed to compare patients undergoing thoracic reinterventions (reintubation, reinsertion of TT/pigtail, or video-assisted thoracic surgery) to those not following SSRF+TT, hypothesizing increased TT output prior to removal would be associated with thoracic reintervention.

METHODS

We performed a single center retrospective (2018-2023) analysis of blunt trauma patients ≥ 18 years-old undergoing SSRF+TT. The primary outcome was thoracic reinterventions. Patients undergoing thoracic reintervention ((+)thoracic reinterventions) after TT removal were compared to those who did not ((-)thoracic reintervention). Secondary outcomes included TT duration and outputs prior to removal.

RESULTS

From 133 blunt trauma patients undergoing SSRF+TT, 23 (17.3 %) required thoracic reinterventions. Both groups were of comparable age. The (+)thoracic reintervention group had an increased injury severity score (median: 29 vs. 17, p = 0.035) and TT duration (median: 4 vs. 3 days, p < 0.001) following SSRF. However, there were no differences in median TT outputs between both cohorts post-SSRF day 1 (165 mL vs. 160 mL, p = 0.88) as well as within 24 h (60 mL vs. 70 mL, p = 0.93) prior to TT removal.

CONCLUSION

This study demonstrated over 17 % of SSRF+TT patients required a thoracic reintervention. There was no association between thoracic reintervention and the TT output prior to removal. Future studies are needed to confirm these findings, which suggest no absolute threshold for TT output should be utilized regarding when to pull TT following SSRF.

Management of chest tube after thoracoscopic lung resection in children with congenital lung malformation: a multicenter retrospective study

This study aimed to investigate the safety and effect of omitting chest tubes after thoracoscopic lobectomy in children with congenital lung malformation. A multicenter retrospective study was performed with 632 thoracoscopic lobectomy CLM patients in four hospitals between 2014.1 and 2023.1, which were divided into non-chest tube (NCT)group and chest tube (CT)group. Baseline data, operation and follow-up outcomes were compared. In total, 312 patients were included in the NCT group, and 320 in the CT group. There were no statistically significant differences in baseline data between the two groups. The FLACC scale score in the NCT group was less than the CT group (2.7 ± 0.43 vs. 5.8 ± 0.26 p = 0.027). The median length of postoperative hospital stay in the CT group was significantly longer than the NCT group (5 d vs.3 d, p = 0.045). Eight (2.5%) patients developed chest tube related infections in the CT group(p = 0.004). Six patients developed atelectasis in the NCT group, which was significantly less than the 18 patients in the CT group(p = 0.014). No chest tube placement in selected CLM pediatric patients may be safe and avoid chest tube-related complications, which may also contribute to a rapid recovery.

Small incisions still require great anesthesia: anesthesiology techniques to enhance recovery in robotic coronary bypass grafting

Robotic coronary artery bypass grafting (CABG) has emerged as a promising minimally invasive surgical technique for the treatment of coronary artery disease. This paper provides an in-depth analysis of the anesthetic management for robotic CABG. Challenges associated with robotic CABG are discussed and various anesthetic techniques, perioperative elements and pain management modalities that can contribute to enhanced patient recovery are explored.

The Impact of Pain on Mobility in Patients with Cancer

OBJECTIVES

Provide an overview of how pain impacts mobility in patients with cancer.

METHODS

A literature search was conducted in PubMed and on Google Scholar using search terms, cancer pain with mobility, acute and chronic pain syndromes, enhanced recovery after surgery, nursing care, and rehabilitation. Peer-reviewed research studies, review articles, and pain guidelines and position papers were reviewed to provide an overview on cancer pain, its impact on mobility, and the nurse's role in managing pain and optimizing mobility and functional outcomes.

RESULTS

Firty-two references were included in this overview. This body of literature is replete with studies on the management of pain; however, the tie between pain and mobility has not been well described aside from the breakthrough pain literature. This manuscript weaves these two important concepts together to better inform nurses and other clinicians regarding the importance of managing pain to even begin mobilizing patients, especially following surgery and for other painful conditions.

CONCLUSIONS

Oncology nurses play an integral role in assessing and managing cancer pain. It is important for nurses to recognize how their pain management interventions lead to improved mobility and functioning in patients with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses comprise the largest workforce around the globe and are well-equipped to assess and manage cancer pain in all cancer care settings. As leaders within the healthcare team, making recommendations to better control pain and communicating with other team members regarding the pain plan is essential in improving mobility in patients with cancer.

Postoperative day 1 discharge following subxiphoid thoracoscopic anatomical lung resection: a single-centre, postoperative enhanced recovery experience

OBJECTIVES

The goal of this study was to assess the safety and quality of recovery (QOR) after discharge on postoperative day (POD) 1 following subxiphoid thoracoscopic anatomical lung resection within an advanced Enhanced Recovery After Surgery (ERAS) program.

METHODS

A retrospective analysis of prospectively collected data was conducted. Characteristics, perioperative and outcome data, compliance with ERAS pathways and a home-transition QOR survey were analysed using a multivariable logistic regression model.

RESULTS

From January 2020 to January 2022, a total of 201 consecutive patients underwent subxiphoid multiportal thoracoscopic anatomical lung resection, comprising 108 lobectomies and 93 sublobar resections (SLRs) (59 complex SLRs and 34 simple SLRs). Among them, 113 patients (56%) were discharged on POD 1, 49% after a lobectomy, 59% after a simple sublobar resection and 68% after a complex sublobar resection. In the multivariable analysis, age > 74 years and duration of the operation were associated with discharge after POD 1, whereas forced expiratory volume in 1 s and complex SLRs were associated with discharge on POD 1. Chest tube removal was achieved on POD 0 in 58 patients (29%), and 138 patients (69%) were free from a chest tube on POD 1. There were 13% with in-hospital morbidity, 10% with 90-day readmission (7% after POD 1 discharge and 14% in patients discharged after POD 1), and 0.5% with 90-day mortality. Patients discharged on POD 1 showed better compliance with the ERAS pathway with early chest tube removal and opioid-free analgesia. The home-transition QOR survey reported a better experience of returning home after discharge on POD 1 and similar pain scores.

CONCLUSIONS

Postoperative day 1 discharge can be safely achieved in appropriately selected patients after subxiphoid thoracoscopic anatomical lung resection, with excellent outcomes and high quality of recovery, supported by early chest tube removal as a determinant ERAS pathway.

Suction versus non-suction drainage strategy after uniportal thoracoscopic lung surgery: a prospective cohort study

Background

The postoperative outcomes of suction drainage versus non-suction drainage after uniportal video-assisted thoracoscopic surgery (UniVATS) come with little consensus. This study aimed to prospectively compare the postoperative outcomes of suction drainage versus non-suction drainage in patients who underwent UniVATS.

Methods

Between October 2022 and January 2023, patients undergoing UniVATS were prospectively enrolled. The choice of drainage strategy (suction or non-suction) was at the surgeon's discretion. The primary outcome was chest tube duration, with secondary outcomes including postoperative drainage volume, pain scores, postoperative complications, length of hospital stay, and hospitalization cost. Baseline characteristics and postoperative outcomes were compared. Univariable and multivariable analyses were used to identify risk factors for postoperative outcomes.

Results

A total of 206 patients were enrolled in this study, with 103 patients in each group. Baseline characteristics were well-balanced. The chest tube duration did not significantly differ between the two groups. However, suction drainage exhibited a significantly lower total drainage volume compared to non-suction drainage (280.00 vs. 400.00 mL, P=0.03). Suction drainage was associated with a significantly shorter postoperative hospital stay (3.00 vs. 4.00 days, P<0.001) and lower pain score on the second postoperative day (POD). Multivariable analyses also confirmed that suction drainage was significantly correlated with a lower total drainage volume and a shorter postoperative hospital stay.

Conclusions

These findings suggested that the suction drainage was superior to non-suction drainage in terms of postoperative drainage volume and length of hospital stay in patients undergoing UniVATS.

Effects of accelerated rehabilitation surgical care on the surgical site wound infection and postoperative complications in patients of lung cancer: A meta-analysis

To comprehensively evaluate the effect of accelerated rehabilitation surgical care on perioperative wound infections and complications in patients undergoing lung cancer surgery. A comprehensive computerised search for randomised controlled trials (RCTs) of accelerated rehabilitative surgical care applied to patients undergoing lung cancer surgery was conducted using the Web of Science, PubMed, Cochrane Library, Embase, Wanfang and China National Knowledge Infrastructure databases from inception to September 2023. The literature was screened and evaluated by two investigators, and data were extracted from the final included literature. Stata software (version 17.0) was used for data analysis. Overall, 21 RCTs involving 2187 patients were included, including 1093 cases in the accelerated rehabilitation surgical care group and 1094 cases in the conventional care group. The analyses revealed that patients with lung cancer surgery who implemented accelerated rehabilitation surgical care were significantly less likely to develop postoperative wound infections (odds ratio [OR] = 0.29, 95% confidence interval [CI]: 0.17-0.49, p < 0.001) and postoperative complications (OR = 0.26, 95% CI: 0.20-0.34, p < 0.001) and shortened the hospital length of stay (standardised mean differences [SMD] = -1.93, 95% CI: -2.32 to -1.53, and p < 0.001) compared with conventional care. The effect of accelerated rehabilitation surgical care intervention in the perioperative period of lung cancer surgery patients is remarkable, as it can effectively reduce the incidence of wound infection and complications, shorten hospitalisation time and promote patient recovery.

Intersurgeon variations in postoperative length of stay after video-assisted thoracoscopic surgery lobectomy

Objectives

To identify factors associated with prolonged postoperative length of stay (LOS) after VATS lobectomy (VATS-L), explore potential intersurgeon variation in LOS and ascertain whether or not early discharge influences hospital readmission rates.

Methods

We conducted a retrospective analysis of patients who underwent VATS-L at a single academic center between 2018 and 2021. Each VATS lobectomy procedure was performed by 1 of 7 experienced thoracic surgeons. The primary end point of interest was prolonged LOS, defined as an index LOS >3 days.

Results

Among 1006 patients who underwent VATS lobectomy, 632 (63%) had a prolonged LOS. On multivariate analysis, the factors independently associated with prolonged LOS were: surgeon (P < .001), patient age (odds ratio [OR], 1.03; 95% CI, 1.02-1.06), operation time (OR, 1.01; 95% CI, 1.01-1.01), postoperative complication (OR, 3.60; 95% CI, 2.45-5.29), and prolonged air leak (OR, 8.95; 95% CI, 4.17-19.23). There was no significant association between LOS and gender, body mass index, coronary artery disease, prior atrial fibrillation, American Society of Anesthesiologists score >3, and prior ipsilateral thoracic surgery or sternotomy. There was no association between LOS ≤3 days and hospital readmission (20 [5.3%] vs 39 [5.9%]; OR, 0.88; 95% CI, 0.50-1.53).

Conclusions

An intersurgeon variation in postoperative LOS after VATS-L exists and is independent of patient baseline characteristics or perioperative complications. This variation seems to be more closely related to differences in postoperative management and discharge practices rather than to surgical quality. Postoperative discharge within 3 days is safe and does not increase hospital readmissions.

Early Ambulation Following Lung Resection Surgery: Impact on Short-term Outcomes in Patients with Lung Cancer

OBJECTIVES

Previous studies indicated that early ambulation following lung resection can prevent postoperative pulmonary complications (PPCs). However, some patients fail to achieve early ambulation owing to factors such as postoperative nausea, vomiting, or pain, particularly on postoperative day 1. This study aimed to address the critical clinical question: Is ambulation for ≥10 m during initial pulmonary rehabilitation necessary after lung resection surgery?

METHODS

This retrospective observational cohort study included 407 patients who underwent lung resection surgery for lung cancer between January 2021 and December 2022. Twelve patients with a performance status of ≥2 and 21 patients lacking pulmonary rehabilitation prescriptions were excluded. Patients were categorized into the "early ambulation" group, which included individuals ambulating ≥10 m during rehabilitation on the first postoperative day, and the "delayed ambulation" group. The primary outcome was PPC incidence, with secondary outcomes encompassing pleural drain duration, hospital length of stay, and Δ6-minute walk distance (Δ6MWD: postoperative 6MWD minus preoperative 6MWD).

RESULTS

The early and delayed ambulation groups comprised 315 and 59 patients, respectively. Significant disparities were noted in the length of hospital stay (7 [6-9] days vs. 8 [6-11] days, P = 0.01), pleural drainage duration (4 [3-5] days vs. 4 [3-6] days, P = 0.02), and Δ6MWD (-70 m vs. -100 m, P = 0.04). However, no significant difference was observed in PPC incidence (20.6% vs. 32.2%, P = 0.06).

CONCLUSIONS

Ambulation for ≥10 m during initial pulmonary rehabilitation after lung resection surgery may yield short-term benefits as evidenced by improvements in various outcomes. However, it may not significantly affect the PPC incidence.

Modern fluid management in thoracic surgery

PURPOSE OF REVIEW

To provide an approach to perioperative fluid management for lung resection patients that incorporates the entire patient pathway in the context of international guidelines on enhanced recovery after surgery (ERAS).

RECENT FINDINGS

The concern with intraoperative fluid management is that giving too little or too much fluid is associated with worse outcomes after lung resection. However, it has not emerged as a key care element in thoracic ERAS programs probably due to the influence of other ERAS elements. Carbohydrate loading 2 h before surgery and the allowance of water until just prior to induction ensures the patient is both well hydrated and metabolically normal when they enter the operating room. Consequently, maintaining a euvolemic state during anesthesia can be achieved without goal-directed fluid therapy despite the recommendations of some guidelines. Intravenous fluids can be safely stopped in the immediate postoperative period.

SUMMARY

The goal of perioperative euvolemia can be achieved with the ongoing evolution and application of ERAS principles. A focus on the pre and postoperative phases of fluid management and a pragmatic approach to intraoperative fluid management negates the need for goal-directed fluid therapy in most cases.

Get your 7-point golden medal for pain management in video-assisted thoracoscopic surgery

PURPOSE OF REVIEW

Thoracic surgery is evolving, necessitating an adaptation for perioperative anesthesia and analgesia. This review highlights the recent advancements in perioperative (multimodal) analgesia for minimally invasive thoracic surgery.

RECENT FINDINGS

Continuous advancements in surgical techniques have led to a reduction in surgical trauma. However, managing perioperative pain remains a major challenge, impeding postoperative recovery. The traditional neuraxial technique is now deemed outdated for minimally invasive thoracic surgery. Instead, newer regional techniques have emerged, and traditional approaches have undergone (re-)evaluation by experts and professional societies to establish guidelines and practices. Assessing the quality of recovery, evenafter discharge, has become a crucial factor in evaluating the effectiveness of these strategies, aiding clinicians in making informed decisions to improve perioperative care.

SUMMARY

In the realm of minimally invasive thoracic surgery, perioperative analgesia is typically administered through systemic and regional techniques. Nevertheless, collaboration between anesthesiologists and surgeons, utilizing surgically placed nerve blocks and an active chest drain management, has the potential to significantly improve overall patient care.

Chest drains after open paediatric lung resections: not always required

INTRODUCTION

Chest drains are often a great source of pain and anxiety in paediatric patients. While there is growing evidence to support the selective omission of chest drains after thorascopic lung resection in children, the safety of this practice following open lung resection has yet to be evaluated. Chest drains are not routinely placed at our institution. We therefore aimed to describe our experience of selective chest drain placement in children undergoing open lung resection, and report the safety and complication profile of this practice.

METHODS

Retrospective review of all open lung resections performed at Wellington Regional Hospital, in children < 16 years of age, from June 2009 to June 2022. Clinical, radiological and operative outcomes were identified and analyzed. The cohort was divided into two groups - those that had a chest drain placed intraoperatively, and those that did not.

RESULTS

35 children underwent open lung resection over the study period. The mean operative age was 8.0 ± 5.4 months, with the most common resection being a lobectomy (80%). Eight children (23%) did not have a chest drain placed, whereas the remaining 29 children (77%) had at least one drain placed intraoperatively, with a median drainage time of 3.0 days. Length of stay was significantly shorter in children who did not have a chest drain placed intraoperatively, compared to those that did (2.5 vs. 5.0 days, p = 0.019). There were no significant differences observed in complication or reintervention rates between the two groups. Similarly, there were no significant differences in the incidence of a residual pneumothorax or effusion on the pre-discharge CXR between the groups.

CONCLUSIONS

Chest drains may not always be required following open paediatric lung resection. The selective omission of a chest drain following open lung resection, does not appear to result in a significantly higher rate of complications or reintervention, and is associated with significantly shorter hospital length of stay.

Temporal trends in neurosurgical volume and length of stay in a public healthcare system: A decade in review with a focus on the COVID-19 pandemic

Background

Over the past decade, neurosurgical interventions have experienced changes in operative frequency and postoperative length of stay (LOS), with the recent COVID-19 pandemic significantly impacting these metrics. Evaluating these trends in a tertiary National Health Service center provides insights into the impact of surgical practices and health policy on LOS and is essential for optimizing healthcare management decisions.

Methods

This was a single tertiary center retrospective case series analysis of neurosurgical procedures from 2012 to 2022. Factors including procedure type, admission urgency, and LOS were extracted from a prospectively maintained database. Six subspecialties were analyzed: Spine, Neuro-oncology, Skull base (SB), Functional, Cerebrospinal fluid (CSF), and Peripheral nerve (PN). Mann-Kendall temporal trend test and exploratory data analysis were performed.

Results

19,237 elective and day case operations were analyzed. Of the 6 sub-specialties, spine, neuro-oncology, SB, and CSF procedures all showed a significant trend toward decreasing frequency. A shift toward day case over elective procedures was evident, especially in spine (P < 0.001), SB (tau = 0.733, P = 0.0042), functional (tau = 0.156, P = 0.0016), and PN surgeries (P < 0.005). Over the last decade, decreasing LOS was observed for neuro-oncology (tau = -0.648, P = 0.0077), SB (tau = -0.382, P = 0.012), and functional operations, a trend which remained consistent during the COVID-19 pandemic (P = 0.01). Spine remained constant across the decade while PN demonstrated a trend toward increasing LOS.

Conclusion

Most subspecialties demonstrate a decreasing LOS coupled with a shift toward day case procedures, potentially attributable to improvements in surgical techniques, less invasive approaches, and increased pressure on beds. Setting up extra dedicated day case theaters could help deal with the backlog of procedures, particularly with regard to the impact of COVID-19.

What's new in minimally invasive thoracic surgery? Clinical application of augmented reality and learning opportunities in surgical simulation

Lung cancer represents the most lethal cancer worldwide. Surgery is the treatment of choice for early-stage non-small cell lung cancer, with an overall survival that can reach 90% at 5 years, but its detection is difficult to achieve due to the lack of symptoms. Screening programs are crucial to identify small cancer. Minimally invasive surgery has modified the therapeutical approach of these tumors, becoming the standard of care, with an important clinical yield in terms of reduction of postoperative pain and length of hospital stay. The aim of this mini-review is to explore and describe two important and innovative aspects in the context of "growing opportunities in minimally invasive thoracic surgery": the clinical application of augmented reality and its advantages for patient and surgeon, and the pedagogical issue through simulation-based training.

Practice patterns and trends in surgical treatment for chronic lung infections: a survey from the Brazilian Society of Thoracic Surgery

Background

Chronic lung infections represent a diversity of clinical entities that combined respond to significant public health, particularly in developing countries. However, there is no data regarding the practice patterns, surgeons' preferences, and technological usage, especially among Brazilian surgeons, in the setting of the surgical treatment of chronic lung infections. We, therefore, surveyed Brazilian thoracic surgeons from the Brazilian Society of Thoracic Surgery (SBCT) about practice patterns and trends in surgical treatment for chronic lung infections.

Methods

A cross-sectional anonymous survey of all thoracic surgeons from the Brazilian Society was conducted in 2019. As the study was purely descriptive no further statistical evaluation was performed.

Results

The responsive rate was 34% (259/766) from 23 of the 26 states in Brazil. A total of 141 (54.4%) participants reported their institution as a surgical reference for chronic infection lung disease, only 13.1% of surgeons have a high-volume service (more than 11 cases operated annually). The majority (76.2%) of respondents performed 1-5 surgical resection to treat tuberculosis (TB) sequelae, but only 62 (30.1%) had performed more than one resection to treat active TB. Chronic lung infection (76%) and hemoptysis (66%) were the most common symptoms as surgical indications. A proportion of 42.2% of the respondents do not have and/or perform routine drug sensitivity tests. In addition, 19.3% of respondents were not familiar with the recommendations of surgery in the treatment of pulmonary TB. Video-assisted thoracoscopic surgery (VATS) is available for 80% of respondents, while robotic surgery is for only 10%. Most (86%) surgeons have access to surgical staplers. Among the structural resources, respiratory isolation beds in the intensive care unit (ICU) (80%) and ward (79%) are frequently available resources. However, less than 12% of surgeons have in their institution a specific operating room for sputum-positive patients.

Conclusions

Lung resection for chronic infectious disease is an essential area of activity for thoracic surgeons in Brazil, which occurs mainly in the public sphere, with no concentration of cases per surgeon or institution. The lack of adequate resources in many centers justifies the creation of reference centers for improving care for these patients.

Predictors of Long-Term Survival of Thoracoscopic Lobectomy for Stage IA Non-Small Cell Lung Cancer: A Large Retrospective Cohort Study

The standard of care for patients with early-stage non-small cell lung cancer (NSCLC) is anatomical lung resection with lymphadenectomy. This multicenter, retrospective, cohort study aimed to identify predictors of 5-year survival in patients after thoracoscopic lobectomy for stage IA NSCLC. The study included 1249 patients who underwent thoracoscopic lobectomy for stage IA NSCLC between 17 April 2007, and December 28, 2016. The 5-year survival rate equaled 77.7%. In the multivariate analysis, higher age (OR, 1.025, 95% CI: 1.002 to 1.048; p = 0.032), male sex (OR, 1.410, 95% CI: 1.109 to 1.793; p = 0.005), chronic obstructive pulmonary disease (OR, 1.346, 95% CI: 1.005 to 1.803; p = 0.046), prolonged postoperative air leak (OR, 2.060, 95% CI: 1.424 to 2.980; p < 0.001) and higher pathological stage (OR, 1.271, 95% CI: 1.048 to 1.541; p = 0.015) were related to the increased risk of death within 5 years after surgery. Lobe-specific mediastinal lymph node dissection (OR, 0.725, 95% CI: 0.548 to 0.959; p = 0.024) was related to the decreased risk of death within 5 years after surgery. These findings provide valuable insights for clinical practice and may contribute to improving the quality of treatment of early-stage NSCLC.