Treatment of postpneumonectomy empyema remains challenging, especially in presence of bronchopleural fistula. We analysed clinical outcome data of patients with and without bronchopleural fistula undergoing an accelerated empyema treatment concept. From November 2005 to July 2020, all patients with postpneumonectomy empyema were included. Therapy consisted of repeated surgical debridement of the pleural cavity, evaluation for loco-regional flap, negative pressure wound therapy and definitive closure after installation an antibiotic solution in the cavity. Primary endpoint was perioperative mortality, focusing on comparison between patients with (= group A) and without bronchopleural fistula (= group B). Secondary endpoints were empyema resolution/recurrence and length of stay. 58 patients underwent the treatment concept: 19 (32.8%) with bronchopleural fistula. Patients' mean age was 62.7 +/- 11.5 years. Nine patients (15.5%) deceased within 30 days: 3 (15.8%) in group A, 6 (15.4%) in group B. 90-days mortality tends to be lower in group A (n = 3 (15.8%)) compared to group B (n = 11 (28.2%)) (p = 0.078). Incidence of postoperative complication was 63.2% (n = 12) in group A compared to 56.4% (n = 22) in group B (p = 0.316). Postpneumonectomy empyema resolution was 100% in the cohort. 3 patients (15.8%) in the group A and 3 (7.7%) in group B (p = 0.175) developed an empyema-recurrence, successfully managed with the treatment concept again. Mean hospital length of stay was lower in group A (24.6 +/- 9.5 days vs 27.2 +/- 24.3 days in group B; p = 0.329). With our accelerated treatment concept, postpneumonectomy empyema with bronchopleural fistula could effectively and safely be treated while maintaining integrity of the chest wall.Clinical Registration Number: KEK-ZH-NR: 2021-01114.

Background: Size matching between donors and recipients is a major issue in lung transplantation (LTx), especially in patients with restrictive lung disease (RLD). This study aims to evaluate computed tomography (CT) as an additional method for defining the total lung capacity (TLC) in patients with end-stage interstitial disease awaiting LTx. Methods: Clinical data and CT scans from patients who underwent a first LTx from January 2014 to July 2018 in Bichat Hospital, Paris, were prospectively included in a database. CT TLC (ctTLC) was retrospectively calculated after semi-automatic contouring of the parenchyma and compared with measured TLC (mTLC) and predicted TLC (pTLC) values. Results: The study group included 89 patients (male:female =68:21; mean age, 59.5 +/- 10.0 years). The time between pulmonary function tests (PFTs) and CT scan was 162 +/- 270 days [median, 67 days; interquartile range (IQR), 0-233 days]. ctTLC was inferior to mTLC and pTLC (respectively 2,979 +/- 1,001 mL, 3,530 +/- 1,077 and 6,381 +/- 955 mL, P<0.001). The relative difference between CT lung volume (ctLV) and measured lung volume (mLV) was higher on the left than on the right side (25.4% vs . 16.3%, respectively, P=0.11). After exclusion of two outliers, we found a significant correlation between ctTLC and mTLC (r=0.762, P<0.001). Conclusions: CT volume is a feasible method to assess TLC in patients with end-stage interstitial disease awaiting LTx. This study highlights potential size-mismatch for graft selection before LTx and opens the perspective of a prospective trial evaluating impact of size-matching by donor-recipient (D-R) ctTLC ratio on postoperative outcomes.

Introduction With increasing experience in high-volume centers, age alone should not be an absolute contra-indication to lung transplantation (LT) but be considered as part of the patient's initial characteristics. The objective of this study is to provide early and long-term outcomes of LT in recipients aged 65 or older, compared with their younger counterparts. Methods This is a retrospective study, including all patients undergoing LT in Bichat Hospital (Paris, France) from January 2014 to March 2019. Two groups were defined depending on the patients’ age when they were transplanted: patients older than 65 were defined as the “elderly group”) and patients younger than 65 years old were defined as the « younger group ». Primary endpoint was 90-day mortality. Secondary endpoints included 1-year mortality, 1-year FEV1 (forced expiratory volume in one second), and 5-year overall survival. Results From September 2014 to March 2019, 22 patients were included in the “elderly group” and 213 were included in the « younger group ». The elderly group had more single LT (SLT) (82% vs. 29%, p<0.001), with a shorter cold ischemic time (243 min vs. 310 min, p=0.001) and a lower rate of early humoral rejection (9% vs. 30%, p=0.045) compared to the younger group. Ninety-day mortality was not significantly different between elderly and younger group (9% vs. 14%, p=0.95, respectively), nor were 1-year mortality (23% vs. 25%, p=0.9, respectively) and 5-year overall survival. Six months after LT, FEV1 was significantly better in the elderly group compared to the younger group (77.0% vs. 65.5%, p=0.037 respectively), but the difference did not reach statistical significance after one year (78.5 vs. 68.3%, p=0.18 respectively). Conclusion Elderly patients underwent more frequently single LT, and achieved similar short and long term postoperative outcomes compared to their younger counterparts. LT for patients 65 years or older should be routinely considered when carefully selected.

Introduction Non-small cell lung cancer (NSCLC) is often associated with compromised lung function. Real-world data on the impact of surgical approach in NSCLC patients with compromised lung function are still lacking. The objective of this study is to assess the potential impact of minimally invasive surgery (MIS) on 90-day post-operative mortality after anatomic lung resection in high-risk operable NSCLC patients. Methods We conducted a retrospective multicentre study including all patients who underwent anatomic lung resection between January 2010 and October 2021 and registered in the Epithor database. High-risk patients were defined as those with a forced expiratory volume in 1 s (FEV1) or diffusing capacity of the lung for carbon monoxide (DLCO) value below 50%. Co-primary end-points were the impact of risk status on 90-day mortality and the impact of MIS on 90-day mortality in high-risk patients. Results Of the 46 909 patients who met the inclusion criteria, 42 214 patients (90%) with both preoperative FEV1 and DLCO above 50% were included in the low-risk group, and 4695 patients (10%) with preoperative FEV1 and/or preoperative DLCO below 50% were included in the high-risk group. The 90-day mortality rate was significantly higher in the high-risk group compared to the low-risk group (280 (5.96%) versus 1301 (3.18%); p<0.0001). In high-risk patients, MIS was associated with lower 90-day mortality compared to open surgery in univariate analysis (OR=0.04 (0.02–0.05), p<0.001) and in multivariable analysis after propensity score matching (OR=0.46 (0.30–0.69), p<0.001). High-risk patients operated through MIS had a similar 90-day mortality rate compared to low-risk patients in general (3.10% versus 3.18% respectively). Conclusion By examining the impact of surgical approaches on 90-day mortality using a nationwide database, we found that either preoperative FEV1 or DLCO below 50% is associated with higher 90-day mortality, which can be reduced by using minimally invasive surgical approaches. High-risk patients operated through MIS have a similar 90-day mortality rate as low-risk patients.

The 5-year survival rates decrease from 92% % in patients with resected stage IA1 disease to 36% % in patients with stage IIIA disease.1 1 Improvements in outcome for locally advanced non-small cell lung cancer (NSCLC) have been achieved via improvements in systemic therapy and proper allocation to local therapy such as surgical resection or radiotherapy. New, attractive modalities such as immune checkpoint inhibitors (ICI) in patients with resectable stage IB to IIIB disease provide promising 2-year overall survival (OS) rates of 83% % or 85%.2-5 % . 2-5 In contrast, overall 2-year survival has been reported to be 66.3% % if stage III tumors were judged unresectable and treated with concurrent chemoradiotherapy and consolidation ICIs. However, poorer performance status scores and the inclusion of patients with stage IIIC disease in the cohort make a head- to-head comparison inappropriate.6 6 Given the wish to offer patients the opportunity for the highest probability of disease control, a critical decision point after completion of the diagnostic and staging evaluations centers on the concept of resectability, which is best determined in a multidisciplinary tumor board setting. Unfortunately, there is no standardized definition of resectability, neither for clinical decision making, nor for inclusion into clinical trials; and definitions vary between available guidelines (Table 1). Additionally, the complexity of defining resectability at baseline presentation is further challenged by the fact that clinical and pathological downstaging occurs in a significant number of patients undergoing induction regimens with ICI alone or in combination with chemotherapy. This downstaging effect results in prolongation of disease-free survival and OS. The objective of this article is to discuss how to define resectability in the midst of these important and evolving paradigm shifts. Medical operability influencing surgical risk, an important though perhaps less plastic or modifiable factor in decision making, will not be discussed.

Catamenial pneumothorax (CP) represent between 20 and 35 % of premenopausal pneumothorax and is related to endometriosis in 50 % of cases [1,2]. Endometriosis-related non-catamenial pneumothorax (ER non-CP) represent between 6 and 10 % of pneumothorax among women of child bearing age [2–6]. Macroscopic and pathological lesions, described in both CP and ER non-CP, include diaphragmatic defect and pleural nodules [7–10]. These macroscopic lesions impact surgical management. During follow-up, CP and ER non-CP are associated with higher rate of postoperative recurrence and prolonged air leaks compared to idiopathic pneumothorax [11].

Robotic-assisted thoracic surgery (RATS) is an effective treatment of non-small cell lung cancer (NSCLC) but the effects of its implementation in university hospital networks has not been described. We analyzed the early clinical outcomes, estimated costs, and revenues associated with three robotic systems implemented in the Paris Public Hospital network. A retrospective study included patients who underwent RATS for NSCLC in 2019 and 2020. Ninety-day morbidity, mortality, hospital costs, and hospital revenues were described. Economic analyses were conducted either from the hospital center or from the French health insurance system perspectives. Cost drivers were tested using univariate and multivariable analyses. Sensitivity analyses were performed to assess uncertainty over in-hospital length of stay (LOS), number of robotic surgeries per year, investment cost, operating room occupancy time, maintenance cost, and commercial discount. The study included 188 patients (65.8 ± 9.3 years; Charlson 4.1 ± 1.4; stage I 76.6

Background: Patients with initially unresectable advanced non-small cell lung cancer (NSCLC) might experience prolonged responses under immune checkpoint inhibitors (ICIs). In this setting, Multidisciplinary Tumor Board (MTB) seldomly suggest surgical resection of the primary tumor with the ultimate goal to eradicate macroscopic residual disease. Our objective was to report the perioperative outcomes of patients who underwent anatomic lung resection in these infrequent circumstances.Methods: We set a retrospective multicentric single arm study, including all patients with advanced-staged initially unresectable NSCLC (stage IIIB to IVB) who received systemic therapy including ICIs and eventually anatomical resection of the primary tumor in 10 French thoracic surgery units from January 2016 to December 2020. Coprimary endpoints were in-hospital mortality and morbidity. Secondary endpoints were the rate of complete resection of the pulmonary disease, major pathologic response, risk factors associated with post-operative complications, and overall survival. Results: Twenty-one patients (median age 64, female 62%) were included. Eighteen patients (86%) progressed after first line chemotherapy and received second line ICI. The median time between diagnosis and surgery was 22 months [interquartile range (IQR) 18-35 months]. Minimally-invasive approach was used in 10 cases (48%), with half of these requiring conversion to open thoracotomy. Nine patients (43%) presented early post-operative complications, and one patient died from broncho-pleural fistula one month after surgery. Rates of complete resection of the pulmonary disease and major pathologic response were 100% and 43%, respectively. In univariable analysis, diffusing capacity for carbon monoxide (DLCO) was the only factor associated with the occurrence of postoperative complications (P=0.027). After a median follow-up of 16.0 months after surgery (IQR, 12.0-30.0 months), 19 patients (90%) were still alive.Conclusions: Anatomic lung resections appear to be a reasonable option for initially unresectable advanced NSCLC experiencing prolonged response under ICIs. Nonetheless, minimally invasive techniques have a low applicability and post-operative complications remains higher in patients who had lower DLCO values. The late timing of surgery may also contribute to complications.

Le vie d’accesso mini-invasive hanno profondamente cambiato la pratica quotidiana della chirurgia toracica. Permettono di ottenere la stessa qualità di exeresi intratoracica di quella fornita da una via aperta, riducendo l’aggressione parietale. Riguardano sia la chirurgia oncologica che la chirurgia non oncologica. Due tecniche completano l’arsenale terapeutico a disposizione dei chirurghi toracici: la videotoracoscopia [video-assisted thoracoscopic surgery (VATS)] e la chirurgia robotica [robotic-assisted thoracoscopic surgery (RATS)]. Sono possibili molteplici vie d’accesso con ciascuna di queste tecniche, sia in chirurgia polmonare che in chirurgia mediastinica. L’obiettivo di questo articolo è quello di descrivere le principali vie d’accesso mini-invasive in chirurgia toracica. Noi insistiamo sulle indicazioni e sulle controindicazioni di ognuna di queste tecniche. A prescindere dall’approccio mini-invasivo adottato, tre elementi sembrano fondamentali: dare la priorità alla sicurezza del paziente fissando dei limiti, garantire l’exeresi completa R0 e promuovere l’uso di accessi mini-invasivi da parte dei chirurghi toracici con esperienza nel settore. La conversione preoperatoria per un approccio convenzionale non deve essere vista come un fallimento, ma piuttosto come un mezzo per garantire il rispetto di questi tre principi fondamentali.

Diaphragm neurostimulation consists of placing electrodes directly on or in proximity to the phrenic nerve(s) to elicit diaphragmatic contractions. Since its initial description in the 18th century, indications have shifted from cardiopulmonary resuscitation to long-term ventilatory support. Recently, the technical development of devices for temporary diaphragm neurostimulation has opened up the possibility of a new era for the management of mechanically ventilated patients. Combining positive pressure ventilation with diaphragm neurostimulation offers a potentially promising new approach to the delivery of mechanical ventilation which may benefit multiple organ systems. Maintaining diaphragm contractions during ventilation may attenuate diaphragm atrophy and accelerate weaning from mechanical ventilation. Preventing atelectasis and preserving lung volume can reduce lung stress and strain and improve homogeneity of ventilation, potentially mitigating ventilator-induced lung injury. Furthermore, restoring the thoracoabdominal pressure gradient generated by diaphragm contractions may attenuate the drop in cardiac output induced by positive pressure ventilation. Experimental evidence suggests diaphragm neurostimulation may prevent neuroinflammation associated with mechanical ventilation. This review describes the historical development and evolving approaches to diaphragm neurostimulation during mechanical ventilation and surveys the potential mechanisms of benefit. The review proposes a research agenda and offers perspectives for the future of diaphragm neurostimulation assisted mechanical ventilation for critically ill patients.

Background: Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH) with accessible lesions. Breathing pure oxygen (hyperoxia) during right heart catheterization (RHC) allows for the calculation of the right-to-left shunt fraction (Qs/Qt). In the absence of intracardiac shunt, Qs/Qt can be used as a marker of ventilation–perfusion mismatch in patients with CTEPH. This study involved investigating Qs/Qt after PEA and its relation to other disease-specific outcomes. Study design and Methods: This study is a retrospective study that focuses on patients with operable CTEPH who had Qs/Qt assessment during RHC before and 1 year after PEA. Additionally, 6 min walking distance (6MWD), WHO functional class (WHO-FC), and NT-proBNP were assessed to calculate a four-strata risk score. Results: Overall, 16 patients (6 females) with a median age of 66 years (quartiles 55; 74) were included. After PEA, an improvement in mean pulmonary artery pressure (38 [32; 41] to 24 [18; 28] mmHg), pulmonary vascular resistance (5.7 [4.0; 6.8] to 2.5 [1.4; 3.8] WU), oxygen saturation (92 [88; 93]% to 94 [93; 95]%), WHO-FC, and risk score was observed (all p < 0.05). No improvement in median Qs/Qt could be detected (13.7 [10.0; 17.5]% to 13.0 [11.2; 15.6]%, p = 0.679). A total of 7 patients with improved Qs/Qt had a significant reduction in risk score compared to those without improved Qs/Qt. Conclusion: PEA did not alter Qs/Qt assessed after 1 year in operable CTEPH despite an improvement in hemodynamics and risk score, potentially indicating a persistent microvasculopathy. In patients whose shunt fraction improved with PEA, the reduced shunt was associated with an improvement in risk score.

Journal Article Atypical mutation of epidermal growth factor receptor in resected stage I non-small-cell lung cancers Get access Harry Etienne, Harry Etienne Department of Thoracic and Vascular Surgery, Tenon Hospital, AP-HP, Sorbonne University, Paris, FranceExperimental and Clinical Respiratory Neurophysiology, Sorbonne University, INSERM, UMRS1158, Paris, France Corresponding author. Department of Thoracic and Vascular Surgery, Tenon University Hospital, AP-HP, Sorbonne University, 4 Rue de la Chine, 75020 Paris, France. Tel: +33 6 67 96 82 89; e-mail: h.etienne@hotmail.fr (H. Etienne). Search for other works by this author on: Oxford Academic PubMed Google Scholar Tristan Goudou, Tristan Goudou Department of Thoracic and Vascular Surgery, Tenon Hospital, AP-HP, Sorbonne University, Paris, FranceExperimental and Clinical Respiratory Neurophysiology, Sorbonne University, INSERM, UMRS1158, Paris, France Search for other works by this author on: Oxford Academic PubMed Google Scholar Jalal Assouad Jalal Assouad Department of Thoracic and Vascular Surgery, Tenon Hospital, AP-HP, Sorbonne University, Paris, FranceExperimental and Clinical Respiratory Neurophysiology, Sorbonne University, INSERM, UMRS1158, Paris, France Search for other works by this author on: Oxford Academic PubMed Google Scholar European Journal of Cardio-Thoracic Surgery, Volume 65, Issue 1, January 2024, ezad428, https://doi.org/10.1093/ejcts/ezad428 Published: 25 December 2023 Article history Published: 25 December 2023 Corrected and typeset: 11 January 2024

This pilot study conducted in Switzerland aims to assess the implementation, execution, and performance of low-dose CT lung cancer screening (LDCT-LCS). With lung cancer being the leading cause of cancer-related deaths in Switzerland, the study seeks to explore the potential impact of screening on reducing mortality rates. However, initiating a lung cancer screening program poses challenges and depends on country-specific factors. This prospective study, initiated in October 2018, enrolled participants meeting the National Lung Cancer Study criteria or a lung cancer risk above 1.5% according to the PLCOm2012 lung cancer risk-model. LDCT scans were assessed using Lung-RADS. Enrollment and follow-up are ongoing. To date, we included 112 participants, with a median age of 62 years (IQR 57–67); 42% were female. The median number of packs smoked each year was 45 (IQR 38–57), and 24% had stopped smoking before enrollment. The mean PLCOm2012 was 3.7% (±2.5%). We diagnosed lung cancer in 3.6% of participants (95%, CI:1.0–12.1%), with various stages, all treated with curative intent. The recall rate for intermediate results (Lung-RADS 3,4a) was 15%. LDCT-LCS in Switzerland, using modified inclusion criteria, is feasible. Further analysis will inform the potential implementation of a comprehensive lung cancer screening program in Switzerland.

Background: The RAPID [Renal (urea level), Age, Pleural fluid purulence, source of Infection and Denutrition (albumin level)] score classifies patients with pleural infection according to mortality risk at 3 months. This study aims to assess the applicability of this score in a thoracic surgery department and to determine the impact of surgery in the management of pleural infection depending on the Rapid score. Methods: In this single center retrospective study, patients managed for pleural infection, from January 1st 2013 to June 30th 2019, were included. The primary endpoint was the probability of survival at 6 months and 12 months depending on the RAPID score. Secondary endpoint was the probability of survival at 6 and 12 months in patients who had surgeries (surgical treatment group) and patients who didn’t have surgery (medical treatment group). Results: Seventy-four patients were included, with a median age of 54.5 years. According to the RAPID score, the low-, medium- and high-risk groups had 30, 30 and 14 patients respectively. The probability of survival at 6 and 12 months in the low- and medium-risk groups were both 0.967 [95% confidence index (CI95): 0.905–1] whereas, the probabilities of survival at 6 and 12 months in the high-risk group was significantly lower at 0.571 (CI95: 0.363–0.899) and 0.357 (CI95: 0.177–0.721) respectively (P<0.0001). The probabilities of survival at 6 months and 12 months in the medical treatment group was 0.875 (CI95: 0.786–0.974) and 0.812 (CI95: 0.704–0.931) respectively compared to the surgical treatment group where probabilities of survival at 6 and 12 months were both 0.923 (CI95: 0.826–1) (P=0.26). Conclusions: In our study, patients with pleural infection, classified as high-risk according to the RAPID score, had a lower survival rate compared to low- and medium-risk patients. No difference in survival rate was found between patients classified as low- and medium-risk. In selected patients, surgical management seems to decrease mortality compared to exclusive medical management: this result should be confirmed in larger prospective studies.

Background: Primary chest wall sarcomas are a rare and heterogeneous group of chest wall tumors that require multimodal oncologic and surgical therapy. The aim of this study was to review our experience regarding the surgical treatment of chest wall sarcomas, evaluating the short- and long-term results. Methods: In this retrospective single-center study, patients who underwent surgery for soft tissue and bone sarcoma of the chest wall between 1999 and 2018 were included. We analyzed the oncologic and surgical outcomes of chest wall resections and reconstructions, assessing overall and recurrence-free survival and the associated clinical factors. Results: In total, 44 patients underwent chest wall resection for primary chest wall sarcoma, of which 18 (41%) received surgery only, 10 (23%) received additional chemoradiotherapy, 7% (3) received surgery with chemotherapy, and 30% (13) received radiotherapy in addition to surgery. No perioperative mortality occurred. Five-year overall survival was 51.5% (CI 95%: 36.1–73.4%), and median overall survival was 1973 days (CI 95% 1461; -). As determined in the univariate analysis, the presence of metastasis upon admission and tumor grade were significantly associated with shorter survival (p = 0.037 and p < 0.01, respectively). Five-year recurrence-free survival was 71.5% (95% CI 57.6%; 88.7%). Tumor resection margins and metastatic disease upon diagnosis were significantly associated with recurrence-free survival (p < 0.01 and p < 0.01, respectively). Conclusion: Surgical therapy is the cornerstone of the treatment of chest wall sarcomas and can be performed safely. Metastasis and high tumor grade have a negative influence on overall survival, while tumor margins and metastasis have a negative influence on local recurrence.

Background The objective of this study was to assess the feasibility and safety of a novel, removable, surgically implanted, temporary neurostimulation approach involving the distal portion of the phrenic nerve. Methods Temporary phrenic nerve pacing electrodes were implanted surgically using an ovine model (4 animals). The primary endpoint was the ability to successfully match the animal’s minute-ventilation upon implantation of both phrenic nerve pacers on day 1. Secondary endpoints were successful phrenic neurostimulation by both electrodes 15 and 30 days after initial implantation. We also assessed safe removal of the electrodes at 15 and 30 days after implementation. Results In 3 of 4 animals, electrodes were successfully implanted in both right and left phrenic nerves. On day 1, median ventilation-minute induced by neurostimulation was not significantly different from baseline ventilation-minute [4.9 L·min−1 (4.4–5.5) vs. 4.4 L·min−1 (4.3–5.2); P=0.4] after 15 minutes. Neurostimulation was still possible 15 and 30 days after implementation in all left side phrenic nerves. On the right side, stimulation was possible at all times in 1 animal but not in the remaining 3 animals for at least one time point, possibly due to lead displacement. Analysis of pathology after percutaneous electrode removal showed integrity of the distal portion of all phrenic nerves. Conclusions Efficient temporary neurostimulation through the distal portion of the phrenic nerve was possible at baseline. The main complication was the displacement of electrodes on the right phrenic nerve on two occasions, which was due to the anatomy of the ovine model. It compromised diaphragm pacing on day 15 and day 30. The electrodes could be safely removed percutaneously without damage to the phrenic nerves.

Patients undergoing lung resection are often active or former smokers who have chronic disease related to tobacco (coronary artery disease, chronic obstructive bronchitis, arteritis of the inferior limbs...). Those co-morbidities increase the operative risk for surgery in which morbi-mortality is relevant. On top of this, we are witnessing an increasing number of non-small cell lung cancers in an aging population that might show signs of frailty. The challenge for the surgeon is to identify early those co-morbid and/or frail patients by using predictive scores like Thoracoscore, mFI (modified frailty index) or MSK-F1 (Memorial Sloan-Kettering Frailty Index). Screening for those high-risk patients implies adapting surgical management through a multidisciplinary approach. That is the objective of co-managment, which allows geriatricians and surgeons to collaborate, or enhanced recovery after surgery which is more accessible to all group ages. The objective of this article is to review the management of co-morbid patients in thoracic surgery, by detailing certain predictive scores available and the multidisciplinary approaches developed to treat the patients screened. (C) 2021 SPLF. Published by Elsevier Masson SAS. All rights reserved.

Le traitement curatif de référence pour les cancers bronchiques non à petites cellules reste la chirurgie d’exérèse carcinologique. L’objectif de cet article est de décrire les techniques chirurgicales et notamment, les voies d’abord qui sont à notre disposition pour le staging et traitement radical du cancer bronchique.

Principles of surgical training have not changed, but methods of training are evolving very fast. Online tools are being adopted in both knowledge and skills training for surgical residents. As a result, to evaluate the outcome of these tools, online assessment is also developing. Knowledge resources are very diverse ranging from lectures, webinars, surgical videos to three-dimensional planning and printing. Skills resources include virtual reality simulators, remote skills training and interdisciplinary teamwork. Assessment of E-learning tools can be performed using online questions, task-based simulations, branching scenarios and online interviews/discussions. In thoracic surgery, video assisted thoracic surgery (VATS) lobectomy simulator has been developed and it appears to be an important tool for minimally invasive thoracic surgery education. Training programs incorporate e-Learning in their curriculum and online training and assessment will become an important part of thoracic surgical training as well.