OBJECTIVES:Immunotherapy (IO) has been associated with better outcomes in locally advanced non-small cell lung cancers (NSCLCs). In 2017, our center introduced compassionate use of immunotherapy for stage III NSCLC as follows: neoadjuvant chemotherapy combined to perioperative immunotherapy and surgery for resectable NSCLCs (PERIOPERATIVE) and chemo-radiation therapy followed by immunotherapy (PACIFIC) for non-resectable NSCLCs. We report the outcomes and complications of 78 patients. METHODS:IWe reviewed all stage III NSCLC patients treated in the Center or Thoracic Surgery of Romandie (CURCT) between 2017 and 2023 with chemo-immunotherapy and surgery and radiation therapy using our prospectively collected database. We compared groups using Stata®. RESULTS:Intention to treat population consisted in 52 PERIOPERATIVE and 26 PACIFIC patients. PERIOPERATIVE patients were significantly younger (64 [60-71]vs73 [67-80], p = 0.0001) and had better lung diffusion capacity compared to PACIFIC patients (%predicted DLCO: 74 ± 18vs48 ± 26, p = 0.0008). Complications over the course of therapy occurred in more than 50 % of patients but remained manageable in both groups. Forty-two of 52 PERIOPERATIVE (81 %) and 18 of 26 (69 %) PACIFIC patients completed the entire treatment plan. There was no 30-day mortality. Complete pathological response (pCR) occurred in 11 of the 50 operated PERIOPERATIVE patients (22 %) and was associated with a 100 % 5-year survival. Overall, 5-year survival was of 78 % and 30 % in the PERIOPERATIVE and PACIFIC groups respectively. CONCLUSION:The inclusion of immunotherapy in the management of stage III NSCLC has been associated with improved patient outcomes. Real life data suggests that patient complications are frequent but manageable and that patient dropout is low.

Advances in non-small cell lung cancer (NSCLC) management have extended survival rates, contributing to a higher incidence of second primary NSCLC (2-20%). Repeated anatomical pulmonary resection in these cases poses significant technical challenges and functional limitations due to previous surgery. This study evaluates the feasibility and short-term outcomes of repeated anatomical pulmonary resections for second primary NSCLC. We retrospectively reviewed all consecutive cases of repeated anatomical pulmonary resections for second primary NSCLC performed in our institution from January 2014 to December 2023. Clinical-pathological characteristics, postoperative complications, and oncological outcomes were analyzed. A total of 55 patients (median age 68 years [IQR: 61.5-72]) underwent repeated anatomical pulmonary resections for second primary NSCLC. Adenocarcinoma predominated in both primary (78.2%) and secondary (76.4%) cases. Video-Assisted Thoracoscopy (VATS) approach was used in 94.5% and 96.4% after first and repeated resection, respectively (p=0.647). The extent of pulmonary resection differed between first and second resection, with a predominance of lobectomy during first resection (56.4%) and segmentectomy during second resection (85.5%, p<0.001). We did not observe any significant difference in postoperative overall morbidity after first and second resection (23.6% vs. 40%, p=0.065). However, there was a significant increased incidence of cardiac complications (16.4% vs. 0%, p=0.007) and prolonged air leak (>5 days) after second resection (14.5% vs. 0%, p=0.014). The median length of hospital stay was similar after first and repeated resection (5 vs. 5 days, p=0.089) and the duration of chest drainage was marginally increased after the second surgery (2 vs. 1 day, p=0.065). Three-year overall survival after primary resection was 89%. Recurrence was documented in one patient (1.8%) after first resection and two patients (3.6%) after second resection (p=0.558). Our series demonstrated that second primary NSCLC can be safely managed by VATS segmentectomy, yielding favorable short-term survival and low recurrence rate.

BACKGROUND:Repeated anatomical pulmonary resections in second primary nonsmall-cell lung cancer (NSCLC) pose significant challenges due to prior surgery. This study evaluates the feasibility and short-term outcomes of repeated anatomical pulmonary resections for second primary NSCLC. METHOD:We retrospectively reviewed all consecutive cases of repeated anatomical pulmonary resections for second primary NSCLC performed in our institution from January 2014 to December 2023. RESULTS:A total of 55 patients (median age 68 years; interquartile range [IQR]: 61.5-72) underwent repeated anatomical pulmonary resections for second primary NSCLC. Adenocarcinoma predominated in both primary (78.2%) and secondary (76.4%) cases. Video-assisted thoracoscopy (VATS) approach was used in 94.5% and 96.4% for first and repeated resection, respectively (p = 0.647). The extent of pulmonary resection differed between first and repeated resection, with a predominance of lobectomy during first resection (56.4%) and segmentectomy during repeated resection (85.5%, p < 0.001). We did not observe any significant difference in postoperative overall morbidity after first and repeated resection (23.6% vs. 40%, p = 0.065). However, there was an increased incidence of atrial fibrillation (16.4% vs. 0%) and prolonged air leak (> 5 days) after repeated resection (25.5% vs. 5.5%, p = 0.008). The median length of hospital stay was similar after first and repeated resection (5 vs. 5 days, p = 0.089). The three-year overall survival (OS) was 73% after first resection and 87% after repeated resection. Overall disease recurrence rate was not statistically different between first and repeated resection (1.8% vs. 3.6%, p = 0.558). CONCLUSION:Our series demonstrated that second primary NSCLC can be safely managed by VATS segmentectomy, yielding favorable short-term survival and low recurrence rates.

: Mediastinal and hilar lymph node dissection is recommended during anatomical pulmonary resection in patients with non-small cell lung cancer (NSCLC). In case of early-stage NSCLC, video-assisted thoracic surgery (VATS) approach has became the preferred approach and has been associated with equivalent oncological outcomes in terms of lymph node dissection, and with decreased morbidity in comparison to standard thoracotomy. Recently, pulmonary segmentectomy has been reported with similar recurrence and survival rates in comparison with lobectomy in patients with small (diameter <2 cm), peripheral tumors when adequate surgical margins are obtained, and systematic lymph node dissection is performed. Thus, radical lymph node dissection is an important part of surgical management of NSCLC patients. Uniportal VATS (UVATS) approach has progressively gained acceptance for anatomical resections, but concern remains regarding the adequacy and the standardization of the lymphadenectomy. This approach requires specific instruments and exposure to achieve complete mediastinal lymph node dissection. We have successfully introduced the UVATS approach for all types of anatomical pulmonary resection and mediastinal lymph node dissection. In this paper, we describe the standardization of our approach for left- and right-sided systematic mediastinal lymph node dissection performed during UVATS anatomical pulmonary resections. We focus on the patient's positionning, the surgical material, the incision placement, and exposure tips for en-bloc resection of different lymph node stations.

Since the late 1990s, and Henrik Kehlet's hypothesis that a reduction of the body's stress response to major surgeries could decrease postoperative morbidity, "Enhanced Recovery After Surgery" (ERAS) care pathways have been streamlined. They are now well accepted and considered standard in many surgical disciplines. Yet, to this day, there is no specific ERAS protocol for chest wall resections (CWRs), the removal of a full-thickness portion of the chest wall, including muscle, bone and possibly skin. This is most unfortunate because these are high-risk surgeries, which carry high morbidity rates. In this review, we propose an overview of the current key elements of the ERAS guidelines for thoracic surgery that might apply to CWRs. A successful ERAS pathway for CWR patients would entail, as is the standard approach, three parts: pre-, peri- and postoperative elements. Preoperative items would include specific information, targeted patient education, involvement of all members of the team, including the plastic surgeons, smoking cessation, dedicated nutrition and carbohydrate loading. Perioperative items would likely be standard for thoracotomy patients, namely carefully selective pre-anesthesia sedative medication only in some rare instances, low-molecular-weight heparin throughout, antibiotic prophylaxis, minimization of postoperative nausea and vomiting, avoidance of fluid overload and of urinary drainage. Postoperative elements would include early mobilization and feeding, swift discontinuation of intravenous fluid supply and chest tube removal as soon as safe. Optimal pain management throughout also appears to be critical to minimize the risk of respiratory complications. Together, all these items are achievable and may hold the key to successful introduction of ERAS pathways to the benefit of CWR patients.

Background: Video-assisted thoracoscopic surgery (VATS) is the recommended approach for the management of early-stage operable non-small cell lung carcinoma as well as for other pathologies of the thoracic cavity. Although VATS approaches have been largely adopted in Europe and North America, teaching the technique to novice thoracic surgery trainees remains challenging and non-standardized. Our objective was to assess the impact of a VATS simulation training program on the dexterity of thoracic surgery residents in a prospective single institution study. Methods: We developed a 6-month VATS simulation training program on two different dry-lab simulators lobectomy model) and assessed the skills of first year thoracic surgery residents (study group, n=7) before and after this program using three standardized exercises on the Surgical Science Simball (R) Box (peg placement on a board, rope insertion in loops, precision circle cutting). The results were compared to those of last-year medical students who performed the same Simball (R) Box exercises at a 6-month interval without undergoing a training program (control group, n=5). For each participant, the travel distances of instruments, operation time and absences of periods of extreme motion were assessed for each exercise by the use of the computerbased evaluation of the Simball (R) Box. Results: After the 6-month VATS training program, all residents revealed a significant increase of their performance status with respect to instrument travel distances operation times and absence of periods of extreme motion in all three exercises performed. The performance of the control group was not different from the study group prior to the training program and remained unchanged 6 months later, for all exercises and parameters assessed. Conclusions: Our results suggest that the implementation of a VATS simulation training program objectively increases the dexterity of thoracic surgery residents and could be an interesting training tool for their surgical education.

We aimed to evaluate whether computed tomography (CT)-derived preoperative sarcopenia measures were associated with postoperative outcomes and survival after video-assisted thoracoscopic (VATS) anatomical pulmonary resection in patients with early-stage non-small cell lung cancer (NSCLC). We retrospectively reviewed all consecutive patients that underwent VATS anatomical pulmonary resection for NSCLC between 2012 and 2019. Skeletal muscle mass was measured at L3 vertebral level on preoperative CT or PET/CT scans to identify sarcopenic patients according to established threshold values. We compared postoperative outcomes and survival of sarcopenic vs. non-sarcopenic patients. A total of 401 patients underwent VATS anatomical pulmonary resection for NSCLC. Sarcopenia was identified in 92 patients (23%). Sarcopenic patients were predominantly males (75% vs. 25%; p < 0.001) and had a lower BMI (21.4 vs. 26.5 kg/m2; p < 0.001). The overall postoperative complication rate was significantly higher (53.2% vs. 39.2%; p = 0.017) in sarcopenic patients and the length of hospital stay was prolonged (8 vs. 6 days; p = 0.032). Two factors were associated with postoperative morbidity in multivariate analysis: BMI and American Society of Anesthesiologists score >2. Median overall survival was comparable between groups (41 vs. 46 months; p = 0.240). CT-derived sarcopenia appeared to have a small impact on early postoperative clinical outcomes, but no effect on overall survival after VATS anatomical lung resection for NSCLC.

disease-free and overall survival rates after sub-lobar (wedge, segmentectomy) or lobar resection during a median follow-up of 7 years (7). In light of these promising results, one might expect that the number of parenchyma-sparing, sub-lobar resections for carefully selected patients with peripheral stage IA NSCLC will increase in the coming years, not only for compromised patients with poor pulmonary functions, but also for fit patients who might have potentially tolerated lobectomy. Compared with non-anatomical wedge resection, pulmonary segmentectomy theoretically allows better safety margins and more extensive hilar lymph node dissection. Hence, oncological outcomes such as local tumor recurrence or long-term survival might be improved. We previously reported on the safety and feasibility of video-assisted thoracic surgery (VATS) segmentectomy for oncological or benign disease indications. Our results demonstrated better peri-operative outcomes in patients undergoing VATS segmentectomy (n=240) compared to

OBJECTIVES:The aim of this study was to compare short-term outcomes and local control in pT1c pN0 non-small-cell lung cancer that were intentionally treated by video-assisted thoracoscopic surgery (VATS) lobectomy or segmentectomy. METHODS:Multicentre retrospective study of consecutive patients undergoing VATS lobectomy (VL) or VATS segmentectomy (VS) for pT1c pN0 non-small-cell lung cancer from January 2014 to October 2021. Patients' characteristics, postoperative outcomes and survival were compared. RESULTS:In total, 162 patients underwent VL (n = 81) or VS (n = 81). Except for age [median (interquartile range) 68 (60-73) vs 71 (65-76) years; P = 0.034] and past medical history of cancer (32% vs 48%; P = 0.038), there was no difference between VL and VS in terms of demographics and comorbidities. Overall 30-day postoperative morbidity was similar in both groups (34% vs 30%; P = 0.5). The median time for chest tube removal [3 (1-5) vs 2 (1-3) days; P = 0.002] and median postoperative length of stay [6 (4-9) vs 5 (3-7) days; P = 0.039] were in favour of the VS group. Significantly larger tumour size (mean ± standard deviation 25.1 ± 3.1 vs 23.6 ± 3.1 mm; P = 0.001) and an increased number of lymph nodes removal [median (interquartile range) 14 (9-23) vs 10 (6-15); P < 0.001] were found in the VL group. During the follow-up [median (interquartile range) 31 (14-48) months], no statistical difference was found for local and distant recurrence in VL groups (12.3%) and VS group (6.1%) (P = 0.183). Overall survival (80% vs 80%) was comparable between both groups (P = 0.166). CONCLUSIONS:Despite a short follow-up, our preliminary data shows that local control is comparable for VL and VS.

Background:Video-assisted thoracic surgery (VATS) is now the preferred approach for standard anatomical pulmonary resections. This study evaluates the impact of operative time (OT) on post-operative outcomes after VATS anatomical pulmonary resection for non-small cell lung cancer (NSCLC). Methods:We retrospectively reviewed all consecutive patients undergoing VATS lobectomy or segmentectomy for NSCLC between November 2010 and December 2019. Postoperative outcomes were compared between short (<150 minutes) and long (≥150 minutes) OT groups. A multivariable analysis was performed to identify predictors of long OT and overall post-operative complications. Results:A total of 670 patients underwent lobectomy (n=496, 74%) or segmentectomy (n=174, 26%) for NSCLC. Mediastinal lymph node dissection was performed in 621 patients (92.7%). The median OT was 141 minutes (SD: 47 minutes) and 387 patients (57.8%) were operated within 150 minutes. Neoadjuvant chemotherapy was given in 25 patients (3.7%). Conversion thoracotomy was realized in 40 patients (6%). Shorter OT was significantly associated with decreased post-operative overall complication rate (30% vs. 41%; P=0.003), shorter median length of drainage (3 vs. 4 days; P<0.001) and shorter median length of hospital stay (6 vs. 7 days; P<0.001). On multivariable analysis, long OT (≥150 minutes) (OR 1.64, P=0.006), ASA score >2 (OR 1.87, P=0.001), FEV1 <80% (OR 1.47, P=0.046) and DLCO <80% (OR 1.5, P=0.045) were significantly associated with postoperative complications. Two predictors of long OT were identified: neoadjuvant chemotherapy (OR 3.11, P=0.01) and lobectomy (OR 1.5, P=0.032). Conclusions:A prolonged OT is significantly associated with postoperative complications in our collective of patients undergoing VATS anatomical pulmonary resection.

OBJECTIVES:We assessed the accuracy of 3 validated lobectomy scoring systems to predict prolonged air leak (PAL) in patients undergoing video-assisted thoracoscopic surgery (VATS) segmentectomy. METHODS:We reviewed all consecutive patients who had a VATS segmentectomy between January 2016 and October 2020. We determined PALs on postoperative day 5. These findings were correlated with the calculated Brunelli (gender, age, body mass index [BMI], forced expiratory volume in 1 s < 80 and pleural adhesion), Epithor (gender, location, dyspnoea score, BMI, type of resection and pleural adhesion) and European Society of Thoracic Surgeons (ESTS) (gender, BMI and forced expiratory volume in 1 s) scores of each patient. RESULTS:A total of 453 patients (mean age: 66.5 years, female/male sex ratio: 226/227) underwent a VATS segmentectomy for malignant (n = 400) and non-malignant (n = 53) disease. Postoperative cardiopulmonary complications and in-hospital mortality rates were 19.6% and 0.4%, respectively. Median chest tube drainage duration and hospital stay were 2 (interquartile range: 1-4) and 4 (interquartile range: 3-7) days, respectively. On day 5, the prevalence of PAL was 14.1%. The ESTS, Brunelli and Epithor scores for the treated population were, respectively, class A (6.8%), class B (3.2%), class C (10.8%) and class D (28.2%); very low and low (0%), moderate (5%), high (6.3%) and very high (21%); and class A (7%), class B (13.2%), class C (24%) and class D (27.8%). All scores correlated with PAL (p ≤ 0.001). The areas under the receiver operating characteristic (ROC) curve were 0.686, 0.680 and 0.644, respectively. CONCLUSIONS:All 3 scoring systems were correlated with PAL > 5 days following the VATS segmentectomies. ESTS scores seem easier to introduce in clinical practice, but validation by a multicentre cohort is mandatory.

A 47-year-old woman was diagnosed with pelvic endometriosis during a caesarean at the age of 37 years. Two years later, she presented two episodes of spontaneous right-sided pneumothorax occurring 2 days after the onset of her menses. The first episode was treated with pleural drainage and the chest CT scan did not show parenchymal or diaphragmatic anomalies. A second episode occurred 1 month later and the patient underwent thoracoscopic exploration, wedge resection of the lung apex and mechanical pleurodesis. During this intervention, multiple dark elliptical nodules were identified on the tendinous part of the diaphragm (figure 1A …

A 67-year-old woman consulted the emergency department because of a 3-day story of abdominal pain and vomiting. Since 12 years she was following a multimodal management of a rectal cancer with no recurrence since. An abdominal CT scan was performed and demonstrated a mechanical ileus with proximal

OBJECTIVES Although video-assisted thoracic surgery (VATS) has shortened hospitalization duration for non-small-cell lung cancer (NSCLC) patients, the factors associated with early discharge remain unclear. This study aimed to identify patients eligible for a 72-h stay after VATS anatomical resection. METHODS Monocentric retrospective study including all consecutive patients undergoing VATS anatomical resection for NSCLC between February 2010 and December 2019. Two groups were defined according to the discharge: 'early discharge' (within 72 postoperative hours) and 'routine discharge' (at >72 postoperative hours). RESULTS A total of 660 patients with a median age of 66.5 years (interquartile range 60-73 years) (female/male: 321/339) underwent VATS anatomical pulmonary resection for NSCLC [segmentectomy in 169 (25.6%), lobectomy in 481 (72.9%), bilobectomy in 8 (1.2%) and pneumonectomy in 2 (0.3%) patients]. The cardiopulmonary and Clavien-Dindo III-IV postoperative complication rates were 32.6% and 7.7%, respectively. The median postoperative length of stay was 6 days (interquartile range 4-10 days). In total, 119 patients (18%) could be discharged within 72 h of surgery. On multivariable analysis, the factors significantly associated with an increased likelihood of early discharge were: body mass index >20 kg/m2 [odds ratio (OR) 2.37], absence of prior cardiopathy (OR 2), diffusing capacity of the lung for carbon monoxide >60% (OR 1.82), inclusion in an enhanced recovery after surgery protocol (OR 2.23), use of a single chest tube (OR 5.73) and postoperative transfer to the ward (OR 4.84). Factors significantly associated with a decreased likelihood of early discharge were: age >60 years (OR 0.53), American Society of Anaesthesiologists score >2 (OR 0.46) and use of an epidural catheter (OR 0.41). Readmission rates were not statistically different between both groups (5.9% vs 3.1%; P = 0.17). CONCLUSIONS Age, pulmonary functions and comorbidities may influence discharge after VATS anatomical resection. The early discharge does not increase readmission rates.

Background: Sleeve lobectomy (SL) is a lung-sparing procedure, which is accepted as a valid operation for centrally-located advanced tumors. These tumors often require induction treatment by chemotherapy and/ or radiotherapy to downstage the disease and thus facilitate subsequent surgery. However, induction therapy may potentially increase the risk of bronchial anastomotic complications and related morbidity. This meta analysis aims to determine the impact of induction therapy on the outcomes of pulmonary SL. Methods: We compared studies of patients undergoing SL or bilobectomy for non-small cell lung cancer (NSCLC) with and without induction therapy. Outcomes of interest were in-hospital mortality, morbidity, anastomosis complication and 5-year survival. Odds ratio (OR) were computed following the MantelHaenszel method. Results: Ten studies were included for a total of 1,204 patients. There was no statistical difference for between patients who underwent induction therapy followed by surgery and patients who underwent surgery alone in term of post-operative mortality (OR: 1.80, 95% confidence interval (CI): 0.76-4.25, P value =0.19) and morbidity (OR: 1.17, 95% CI: 0.90-1.52, P value =0.237). Anastomosis related complications rate were 5.2% and appears increased after induction therapy with a statistical difference close to the significance (OR: 1.65, 95% CI: 0.97-2.83, P value =0.06). Patients undergoing surgery alone showed better survival at 5 years (OR: 1.52, 95% CI: 1.15-2.00, P value =0.003). Conclusions: SL following induction therapy can be safely performed with no increase of mortality and morbidity. However, the need for induction therapy before surgery is associated with increased anastomotic complications and poorer survival prognosis at 5 years.

Background: This study evaluates the effect of enhanced recovery after surgery (ERAS) pathways on postoperative outcomes of non-small cell lung cancer (NSCLC) patients undergoing video-assisted thoracic surgery (VATS) lobectomy. Methods: We retrospectively reviewed all consecutive patients undergoing VATS lobectomy for NSCLC between January 2014 and October 2019 and assigned them to the relevant group ("pre-ERAS" or "ERAS"). Length of stay, readmissions and complications within 30 days were compared between both groups. A propensity score-matched analysis was performed based on sex, age, type of operation, comorbidities, American Society of Anesthesiologists (ASA) score and preoperative pulmonary functions. Results: A total of 307 records (164 male/143 female; 140 ERAS/167 pre-ERAS; median age: 67) were reviewed. There was no statistical difference in patient's characteristics. Overall ERAS compliance was 81%. The ERAS group presented significantly shorter length of stay (median 5 vs. 7 days; P=0.004) without significant difference in cardiopulmonary complication rate (27.1% vs. 35.9%; P=0.1). Readmission (3.6% vs. 5.4%; P=0.75) and duration of drainage (median 2 vs. 3 days; P=0.14) were similar between groups. The propensity score-matched analysis showed that the length of hospital stay was reduced by 1.4 days (P=0.034) and the postoperative cardiopulmonary complication rate by 13% (P=0.044) in the ERAS group. Conclusions: Adoption of an ERAS pathway for VATS lobectomies in NSCLC patients has decreased the length of hospital stay and the cardiopulmonary complication rate without affecting the readmission rate.

AbstractIntroductionVATS pulmonary segmentectomy is increasingly proposed as a parenchyma‐sparing resection for tumors smaller than 2 cm in diameter. The aim of this study was to compare short‐term oncological results and local control in solid non‐small cell lung cancers (NSCLCs) <2 cm surgically treated by intentional VATS segmentectomy or lobectomy.MethodsThis study was a single center retrospective study of consecutive patients undergoing VATS lobectomy (VL) or segmentectomy (VS) for solid <2 cm NSCLC from January 2014 to October 2019.ResultsIn total, 188 patients with a median age of 65 years (male/female: 99/89) underwent VS (n = 96) or VL (n = 92). Segmentectomies in the upper lobes were performed in 57% and as a single segment in 55% of cases. There was no statistically significant difference between VS and VL in terms of demographics, comorbidities, postoperative outcomes, dissected lymph node stations (2.89 ± 0.95 vs. 2.93 ± 1, P = 0.58), rate of pN1 (2.2% vs. 2.1%, P = 0.96) or pN2 upstaging (1.09% vs. 1.06%, P = 0.98). Adjuvant chemotherapy was given in 15% of patients in the VL and 11% in the VS group. During follow‐up (median: 23 months), no patients presented with local nodal recurrence or on the stapler line (VS group). Three patients on VL and two in VS groups presented with recurrence on the remnant operated lung. New primary pulmonary tumors were diagnosed in 3.3% and 6.3% of patients in the VL and VS groups, respectively.ConclusionsDespite the short follow‐up, our preliminary data shows that local control is comparable for VATS lobectomy and VATS segmentectomy for patients with NSCLC <2 cm.