Objective Microlobectomy is a novel form of videoscopic-assisted thoracic surgery lobectomy. Strict inclusion criteria consist of the following: no intercostal incisions greater than 5 mm, 12 mm subxiphoid port, subxiphoid removal of the specimen, total endoscopic technique with CO 2 insufflation, vision through a 5-mm camera, stapling via the subxiphoid port, or with 5-mm stapling devices. Methods The combined early experiences of six hospitals from three countries were combined from September 2014 to May 2016. During that time, the study represents a consecutive cohort study of this technique. Results Seventy-two patients underwent microlobectomy. The median (range) age was 66 (27–82). Half of the patients were female. There were 48 right-sided resections and 24 on the left. There were four segmental resections and there was one right pneumonectomy. Four operations were performed robotically (with 8-mm intercostal incisions). The median (range) operative time was 180 (94–285) minutes and the blood loss was 118 (5–800) mL. There were three conversions to thoracotomy and two conversions to videoscopic-assisted thoracic surgery by means of an intercostal utility incision to complete the operation. The median (range)length of stay was 3(1–44) days and 30 patients (42%) when home by day 2 and 16 patients (22%) were discharged on day 1. There were no deaths. Five patients (7%) had a prolonged airleak. There were no wound infections and there was one incisional hernia. Conclusions We believe that microlobectomy is an interesting novel form of videoscopic-assisted thoracic surgery lobectomy and has several theoretical advantages. We have presented our early results and hope that this will stimulate others to investigate this type of videoscopic-assisted thoracic surgery lobectomy further.

Intranodal palisaded myofibroblastoma is a rare and benign tumor that usually presents in the inguinal region. We report the case of a 68-year-old woman with a right paratracheal mass and right upper lobe non-small cell lung carcinoma initially staged as T1b N2 M0. After mediastinal staging, the right paratracheal mass was found to be an intranodal palisaded myofibroblastoma, which had caused erroneous upstaging of the lung carcinoma to N2 disease. This had the potential of leading to suboptimal treatment of the primary lung carcinoma if formal mediastinal staging had not been performed. To the best of our knowledge, this is the first report in the English literature of an intranodal palisaded myofibroblastoma occurring concurrently with lung cancer. This case highlights the importance of mediastinal staging in lung cancer. Mediastinoscopy remains the gold standard.

The main goal for any doctor should be to give the patients the best possible treatment for their medical condition, whatever it is. The decision regarding treatment should be based on scientific evidence, ideally via clinical trials. This can often be quite straight forward in pharmaceutical medicine, where you can design randomized and double blinded studies in order to identify evidence for the superior treatment. In surgery, however, the preferred technique quite often is more eminence than evidence based. It is difficult to design adequately large studies and very difficult to do so in a double blinded fashion. Senior peer pressure and difficulty with constructing effective clinical surgical trials (often interlinked phenomena) leads to conservatism and resistance to radical new ideas.

Glomus tumors are rare tumors most often occurring in the extremities of the limbs. We report a unique case of a glomus tumor, originally arising in the paraspinal region, which was excised and subsequently recurred in the chest wall with malignant transformation. The recurrence is likely to have been caused by wound seeding. To the best of our knowledge, this is the first report in the English literature of a glomus tumor recurrence secondary to the notion of wound seeding. (C) 2016 by The Society of Thoracic Surgeons

Background: Cardiac arrest caused by accidental hypothermia is a rare phenomenon with a significant mortality rate if untreated. The consensus is that these patients should be rewarmed with extracorporeal life support (ECLS) with the potential for excellent survival and neurologic outcomes. However, given the lack of robust data and clinical trials, the optimal management of such patients remains elusive. Objective: In this single-center study, we looked at the outcomes of all adult patients undergoing salvage ECLS for cardiac arrest caused by accidental hypothermia over a 10-year period from June 2006 to June 2016. Methods: These data were obtained from the Royal Infirmary of Edinburgh cardiothoracic surgery database. The patients' hard copy case notes, TrakCare (InterSystems Corp, Cambridge, MA), picture archiving and communications system (PACS), and WardWatcher databases were used to cross-check the accuracy of the acquired data. Results: Eleven patients met the inclusion criteria. The etiology of hypothermia was exposure to cold air (64%) and cold water immersion (36%). Two (18%) were treated with extracorporeal membrane oxygenation and the rest with cardiopulmonary bypass. The mean age was 51 years (range 32-73), and the mean core body temperature on admission was 20.6 degrees C (range <18-24 degrees C). The overall survival rate to hospital discharge was 72%, with 75% of survivors having no chronic neurologic impairment. Conclusion: Our case series shows the remarkable salvageability of patients suffering prolonged cardiac arrest caused by accidental hypothermia, particularly in the absence of asphyxia, trauma, or severe hyperkalemia. ECLS is a safe and effective rewarming treatment and should be used to aggressively manage this patient group. (C) 2016 Elsevier Inc. All rights reserved.

Traditionally, lung resections were done through an open thoracotomy that involved an extensive incision through the latissimus dorsi muscle with rib spreading (figure). This approach remained the standard of care for patients with resectable non-small-cell lung cancer (NSCLC) for the second half of the 20th century. In 1993, clinical reports of video-assisted thoracoscopic surgery (VATS) lobectomy for NSCLC were first presented by Dr William Walker and colleagues.1Walker WS Carnochan FM Pugh GC Thoracoscopic pulmonary lobectomy. Early operative experience and preliminary clinical results.J Thorac Cardiovasc Surg. 1993; 106: 1111-1117PubMed Google Scholar Patients underwent an anatomical lobectomy with lymph node clearance through three stab incisions measuring 1 cm and a utility incision. Subsequently, Kirby and colleagues2Kirby TJ Mack MJ Landreneau RJ Rice TW Lobectomy—video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial.J Thorac Cardiovasc Surg. 1995; 109: 997-1001Summary Full Text Full Text PDF PubMed Scopus (393) Google Scholar and Sugi and colleagues3Sugi K Kaneda Y Esato K Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer.World J Surg. 2000; 24: 27-30Crossref PubMed Scopus (304) Google Scholar undertook two randomised trials that reported fewer overall short-term postoperative complications and similar long-term survival for VATS lobectomy compared with thoracotomy. However, both trials were quite small and used rib spreading, which was inconsistent with the accepted standard of “true” VATS lobectomy defined by the landmark Cancer and Leukemia Group B (CALGB) study.4Swanson SJ Herndon 2nd, JE D'Amico TA et al.Video-assisted thoracic surgery lobectomy: report of CALGB 39802—a prospective, multi-institution feasibility study.J Clin Oncol. 2007; 25: 4993-4997Crossref PubMed Scopus (450) Google Scholar CALGB was the first prospective study of VATS lobectomy to use a standardised surgical technique that mandated no rib spreading, a maximum incision size of 8 cm for access, individual dissection of the hilar structures, and standard lymph node sampling or dissection. So far, no randomised controlled trial has been done to assess true VATS lobectomy versus thoracotomy. Since CALGB, several observational studies have yielded encouraging results for selected patients with non-small-cell lung cancer who underwent VATS lobectomy, with fewer short-term morbidities and superior long-term survival compared with thoracotomy.5Yan TD Black D Bannon PG McCaughan BC Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer.J Clin Oncol. 2009; 27: 2553-2562Crossref PubMed Scopus (581) Google Scholar, 6Cao C Manganas C Ang SC Peeceeyen S Yan TD Video-assisted thoracic surgery versus open thoracotomy for non-small cell lung cancer: a meta-analysis of propensity score-matched patients.Interact CardioVasc Thorac Surg. 2013; 16: 244-249Crossref PubMed Scopus (151) Google Scholar Specifically, a meta-analysis of propensity-matched patients who had VATS lobectomy found that they had significantly lower incidences of postoperative prolonged air leak, pneumonia, atrial arrhythmias, and renal failure, and a shorter duration of hospital stay, when compared with thoracotomy.6Cao C Manganas C Ang SC Peeceeyen S Yan TD Video-assisted thoracic surgery versus open thoracotomy for non-small cell lung cancer: a meta-analysis of propensity score-matched patients.Interact CardioVasc Thorac Surg. 2013; 16: 244-249Crossref PubMed Scopus (151) Google Scholar Furthermore, patients who underwent VATS were able to achieve a significantly higher compliance rate for adjuvant chemotherapy, with earlier initiation7Teh E Abah U Church D et al.What is the extent of the advantage of video-assisted thoracoscopic surgical resection over thoracotomy in terms of delivery of adjuvant chemotherapy following non-small-cell lung cancer resection?.Interact Cardiovasc Thorac Surg. 2014; 19: 656-660Crossref PubMed Scopus (16) Google Scholar and higher rate of completion,8Petersen RP Pham D Burfeind WR et al.Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer.Ann Thorac Surg. 2007; 83: 1245-1249Summary Full Text Full Text PDF PubMed Scopus (259) Google Scholar compared with thoracotomy. Despite this growing body of clinical evidence, less than 20% of lobectomies are currently performed with the VATS approach in the USA and Europe.9Begum S Hansen HJ Papagiannopoulos K VATS anatomic lung resections-the European experience.J Thorac Dis. 2014; 6: S203-S210PubMed Google Scholar, 10Boffa DJ Allen MS Grab JD Gaissert HA Harpole DH Wright CD Data from The Society of Thoracic Surgeons General Thoracic Surgery database: the surgical management of primary lung tumors.J Thorac Cardiovasc Surg. 2008; 135: 247-254Summary Full Text Full Text PDF PubMed Scopus (406) Google Scholar The Cross-sectional Survey on Lobectomy Approach (X-SOLA) study was done to assess the attitudes of thoracic surgeons towards VATS lobectomy and identify the reasons for the slow adoption of this surgical technique.11Cao C Tian DH Wolak K et al.Cross-sectional survey on lobectomy approach (X-SOLA).Chest. 2014; 146: 292-298Crossref PubMed Scopus (16) Google Scholar The study was largest thoracic survey done so far, involving 838 international surgeons, and showed that 92% of surgeons who did not currently do VATS lobectomy were willing to learn this technique, and their most substantial limitations were related to resources, clinical exposure, and technical mentoring. This outcome represented a substantial change to the attitudes of surgeons in the 1990s, who were mainly concerned about the oncological efficacy of the VATS approach and the lack of specific instrumentation. This shift in attitude partly reflected the growing evidence to support the long-term efficacy of VATS lobectomy and the improvements of VATS instrumentation and techniques that have evolved during the past two decades. The X-SOLA study also showed that VATS surgeons prioritised the establishment of multi-institutional databases over randomised controlled trials. This situation might be due to the underlying lack of equipoise in some VATS surgeons, who now regard the allocation of patients to the open thoracotomy group of a randomised trial as ethically unjustified.11Cao C Tian DH Wolak K et al.Cross-sectional survey on lobectomy approach (X-SOLA).Chest. 2014; 146: 292-298Crossref PubMed Scopus (16) Google Scholar To address the surgeons' interest in establishing a large multi-institutional database, a collaborative effort by the International VATS Interest Group is now underway to create the largest retrospective and prospective databases so far, with the aim of identifying the optimum surgical approach for patients with resectable NSCLC. The Centralized Retrospective Analysis of Thoracoscopic lobectomy in patients with NSCLC (CREATION) study will aim to collect and analyse perioperative and long-term surgical outcomes of patients using retrospective data from selected institutions. This approach will help to establish a platform to collect more standardised and robust clinical data as part of the Prospective Registry on VATS Excisions for NSCLC (PROVEN) study. Data from the CREATION and PROVEN studies will hopefully provide definitive clinical evidence about the VATS lobectomy procedure and assess its suitability as the standard of care for patients with early-stage NSCLC. Secondary endpoints that have not been reported much previously, such as quality-of-life and cost-effectiveness assessments, will also be addressed. We declare no competing interests.

The reasons for improved survival following minimally invasive surgery remain elusive. Circulating mediators link surgical trauma, vascular and tissue homeostasis. Acute phase reactants, leukocytes and leukocyte Reactive Oxygen Species (ROS) are affected differentially by minimally invasive video-assisted thoracic surgery (VATS). Also, immunoglobulins, complement, TNF receptor and P-selectin changes have been observed, but the influence of minimally invasive surgery on these opsonins is less well defined. In this prospective randomised trial, 41 patients were randomly assigned to minimally invasive or open thoracic surgery, and immunoglobulins and vascular endothelial damage biomarkers were analysed. Humoral mediators (blood IgG, IgM, IgA; complement fragments C3, C4, and complement haemolytic index of activation CH50; TNF receptors I, II and P-selectin) were analysed before and 2, 5 and 7 days after surgery. Post-surgical changes in individual patients were determined.Substantial immunoglobulin decreases followed minimally invasive and open surgery. Decreased IgG, IgM and IgE were detected 2 days after surgery, and IgG and IgM after 7 days. These changes were greater than haemodilution, reaching greater significance in open surgery patients. Immunoglobulin decreases followed lymphocyte decreases. In contrast, increased complement and inflammatory endothelial cell signals (C3 and C4, soluble TNFR-II) were detected 7 days after surgery. In both groups, increased C3 and TNFR-II followed early acute phase reactants CRP, IL-6 and ROS. Acute phase reactants and CD4/CD8 lymphocytes were factors most attenuated in patients undergoing minimally invasive thoracic surgery (VATS). This study suggests local trauma mediators are better biomarkers than circulating opsonins in defining the response to minimally invasive surgery, and a systems approach, comparing individual metabolic responses, is effective in small patient groups.

Objectives The primary aim of this prospective study was to perform a comprehensive serial characterisation of monocyte and neutrophil function, circulating monocyte subsets, and bronchoalveolar lavage (BAL) fluid after lung resection. A secondary aim was to perform a pilot, hypothesis-generating evaluation of whether innate immune parameters were associated with postoperative pneumonia. Methods Forty patients undergoing lung resection were studied in detail. Blood monocytes and neutrophils were isolated preoperatively and at 6, 24 and 48 h postoperatively. BAL was performed preoperatively and immediately postoperatively. Monocyte subsets, monocyte responsiveness to lipopolysaccharide (LPS) and neutrophil phagocytic capacity were quantified at all time points. Differential cell count, protein and cytokine concentrations were measured in BAL. Pneumonia evaluation at 72 h was assessed using predefined criteria. Results After surgery, circulating subsets of classical and intermediate monocytes increased significantly. LPS-induced release of proinflammatory cytokines from monocytes increased significantly and by 48 h a more proinflammatory profile was found. Neutrophil phagocytosis demonstrated a small but significant fall. Factors associated with postoperative pneumonia were: increased release of specific proinflammatory and anti-inflammatory cytokines from monocytes; preoperative neutrophilia; and preoperative BAL cell count. Conclusions We conclude that postoperative lung inflammation is associated with specific changes in the cellular innate immune response, a better understanding of which may improve patient selection and prediction of complications in the future.

VATS lobectomy is a very successful procedure with proven benefits over open lobectomy, including reduced hospital stay, reduced tube drainage and better compliance with post operative chemotherapy (1-4). But there is a learning curve with this operation as with all complex procedures and thus surgeons must be aware of the particular complications that may face them, and the novel methods that are required to try to overcome them (5-7). In the case presented in this video, we were performing a left upper lobectomy for a proven T1bN0M0 adenocarcinoma (Video 1). The patient was 73 years old and had COPD with an FEV1 of 40%. He had undergone all routine preoperative tests including a CT Head and a mediastinoscopy to exclude N2 disease. Video 1 Pulmonary artery bleeding during VATS lobectomy The video clip commences after the posterior oblique fissure has been opened up, the pulmonary artery has been dissected out and its sheath opened up and we had already dissected out and divided the lingular artery and the posterior segmental artery. The artery that we were now isolating was an anteroapical truncal artery, as in this particular patient there was not further artery after the apical segmental artery to the left upper lobe, and this artery was therefore supplying both segments. In the video you will see that we had successfully gone round the artery with a 30 cm Roberts artery forcep. We then attempted to introduce the endo GIA stapler with a white 2.5 mm insert in order to divide this vessel. However you may also see that the angle of the stapler is not correct and it is pushing into the crux of the apicoanterior segmental artery and the main pulmonary artery. While attempting to pass the stapler round this vessel a sudden gush or dark blood is seen as the pulmonary artery is breached. The first step is to introduce a swab mounted on a rampleys forceps. This is our first move for any significant bleeding and such a ‘swab-on-a-stick’ should always be available in case of significant bleeding. It should be remembered that the pressure in the pulmonary artery is often 1/3rd or less of systemic pressure and therefore pressure via the anterior working port will most often control the bleeding. We pressed on this area for 10 minutes and during that time we first cleared the area of blood and secondly as the bleeding was now controlled, we performed some further dissection in order to gain us better access to the area of the tear. This is an important point in trying to obtain control. When you have temporary control of the bleeding point, you have time to inform your staff about the event, obtain additional instruments if required, make sure that you are ready to perform a thoracotomy, ensure that blood is available, and that any additional instruments such as artery forceps are available. We then removed the swab and as quite often occurs in these cases, the bleeding had actually stopped. This again allowed us to further mobilize around this vessel, in the hope that we might again be able to pass the stapler and obtain haemostasis endoscopically. Unfortunately it can be seen that on investigation by the sucker, the PA started to bleed again. While using the suction to investigate this area, a rampleys forcep was placed on the left upper lobe so that bleeding could be quickly covered and pressed on, which was the case. After this bled for a second time, the decision was made to perform a thoracotomy, but in a balanced and timely manner. On examination there was a large tear 50% of the diameter of the segmental vessel right at the crux with the main PA. We used a side biting clamp to resect the pulmonary artery branch, we then completed the lobectomy, and finally we placed a small bovine pericardial patch over the defect and sutured this in place with 5.0 prolene. We also covered this with coseal and the patient made an uncomplicated recovery.

Surgery is associated with release of local and systemic mediators which influence vascular and tissue homeostasis. The post-surgical release of acute phase reactants, particularly IL-6 and CRP, is reduced in minimally invasive surgery, compared with conventional surgery. Additionally, there is emerging evidence that leukocytes and Reactive Oxygen Species (ROS) are affected differentially by minimally invasive surgery. ROS and mediators of oxidative stress influence vascular endothelium, organ perfusion and angiogenesis, and may be critical determinants of survival and outcome.ROS also influence cell proliferation and cell death and have been implicated in neoplastic signalling. Advances in ROS detection and oxidative stress signalling have shown cellular changes affected by minimally invasive surgery. It has been observed that the invasiveness of surgery is proportional to changes in phagocyte and lymphocyte ROS. A potential role for ROS signalling in the immune system is suggested by evidence of closer ROS/leukocyte correlation in patients undergoing minimally invasive surgery. At lower ROS levels, phagocyte and lymphocyte ROS following minimally invasive surgery implicate a homeostatic response with closer leukocyte/ROS correlations, whereas higher ROS in open surgery and greater leukocyte depletion indicate more cytotoxic signalling.Interactions between humoral and cellular elements suggest that an integrated systems approach, using individual patient responses, should be used to analyse the response to surgical trauma and oxidative stress. These studies are being used to investigate ROS as biomarkers of the effects of surgery on vascular and pulmonary reactivity. ROS signalling may provide insights into post surgical trauma and its underlying pathology.

BACKGROUND Lobectomy for non-small cell lung cancer (NSCLC) can be performed either through open thoracotomy or video-assisted thoracoscopic surgery (VATS). To improve the understanding of current attitudes of the thoracic community toward VATS lobectomy, the Collaborative Research Group conducted the Cross-sectional Survey on Lobectomy Approach (X-SOLA) study. We surveyed a large cohort of lobectomy-performing thoracic surgeons to examine their adoption of VATS lobectomy and their opinions of this technique vs conventional open thoracotomy. METHODS Participants included thoracic surgeons identified through an international index search from the Web of Science and the cardiothoracic surgery network. A confidential questionnaire was e-mailed in June 2012. Nonresponders were given two reminder e-mails at monthly intervals. RESULTS The questionnaire, completed by 838 thoracic surgeons within a 3-month period, identified 416 surgeons who only performed lobectomy through open thoracotomy and 422 surgeons who performed VATS or robotic VATS. Of those who performed VATS, 95% agreed with the definition of "true" VATS lobectomy according to the Cancer and Leukemia Group B trial. Ninety-two percent of surgeons who did not perform VATS lobectomy responded that they were willing to learn this technique, but were hindered by limited resources, exposure, and mentoring. Both groups agreed there was a need for VATS lobectomy training in thoracic residency programs and in standardized workshops. CONCLUSIONS X-SOLA represents the largest cross-sectional report within the thoracic community to date, demonstrating the penetration of VATS lobectomy for NSCLC internationally. From our study, we were able to identify a number of obstacles to broaden the adoption of this minimally invasive technique.

Prolonged air leak is a common complication of pulmonary resection. However, while a bubbling chest drain is commonly related to parenchymal air leakage, it may also be caused by air entering the pleural cavity via an incomplete seal of the tissues at the chest tube insertion site. Examination alone is not sufficient to guide the surgeon as to which of the above complications is responsible for drain bubbling. We describe a simple method, whereby a CO2 monitoring device is attached to the chest drain to determine whether the air loss observed is in fact due to a pulmonary air leak.

Objective Innate immune responses to pulmonary resection may be critical in the pathogenesis of important postoperative pulmonary complications and potentially longer-term survival. We sought to compare innate immunity of patients undergoing major pulmonary resection for bronchogenic carcinoma via video-assisted thoracoscopic surgery (VATS) and thoracotomy. Methods Bronchoalveolar lavage was conducted in the contralateral lung before staging bronchoscopy and mediastinoscopy and immediately after lung resection. Blood and exhaled nitric oxide were sampled preoperatively and at 6, 24, and 48 hours postoperatively. Results Forty patients were included (26 VATS and 14 thoracotomy). There was a lower systemic cytokine response from lung resection undertaken by VATS compared with thoracotomy [interleukin 6 (IL-6), analysis of variance (ANOVA) P = 0.026; IL-8, ANOVA P = 0.018; and IL-10, ANOVA P = 0.047]. The VATS patients had higher perioperative serum albumin levels (ANOVA P = 0.001). Lower levels of IL-10 were produced by lipopolysaccharide-stimulated blood monocytes from the VATS patients compared with the thoracotomy patients at 6 hours postoperatively (geometric mean ratio, 1.16; 95% confidence interval, 1.08–1.33; P = 0.011). No statistically significant differences in the neutrophil phagocytic capacity, overall leukocyte count, or differential leukocyte count were found between the surgical groups (ANOVA P > 0.05). No statistically significant differences in bronchoalveolar lavage fluid parameters were found. Exhaled nitric oxide levels fell postoperatively, which reached statistical significance at 48 hours (geometric mean ratio, 1.2; 95% confidence interval, 1.02–1.46; P = 0.029). There were no significant differences found between the surgical groups (ANOVA P = 0.331). Conclusions Overall, a trend toward greater proinflammatory and anti-inflammatory responses is seen with lung resection performed via thoracotomy compared with VATS.

Obstruction of the tracheobronchial tree frequently occurs in children due to a lack of adequate dentition and immature swallowing coordination.1,2 This contrasts obstruction in adults which is caused by a failure of airway protection mechanisms due to neurological disorders and trauma.1 Obstruction has three clinical stages: choking and shortness of breath, an asymptomatic phase then a complication stage.2 The composition of the foreign matter determines the stage. Organic materials cause a severe mucosal inflammatory reaction and granulation tissue may develop over several hours. This causes subsequent swelling and partial obstruction warranting immediate clinical intervention. In contrast, inorganic materials can remain asymptomatic for longer periods of time unless the distal airways are compromised. This presents a therapeutic challenge even though two-thirds of objects lodge in main stem bronchi rather than distal bronchi.1,2 Complications of undetected foreign bodies include unresolved pneumonia and abscess formation, fibrosis and bronchiectasis.1 Our case is of a long forgotten toy traffic cone aspirated during childhood that remained undetected for 40 years.

OBJECTIVEVideo-assisted thoracoscopic surgery (VATS) lobectomy has been gradually accepted as an alternative surgical approach to open thoracotomy for selected patients with non-small-cell lung cancer (NSCLC) over the past 20 years. The aim of this project was to standardize the perioperative management of VATS lobectomy patients through expert consensus and to provide insightful guidance to clinical practice.METHODSA panel of 55 experts on VATS lobectomy was identified by the Scientific Secretariat and the International Scientific Committee of the '20th Anniversary of VATS Lobectomy Conference-The Consensus Meeting'. The Delphi methodology consisting of two rounds of voting was implemented to facilitate the development of consensus. Results from the second-round voting formed the basis of the current Consensus Statement. Consensus was defined a priori as more than 50% agreement among the panel of experts. Clinical practice was deemed 'recommended' if 50-74% of the experts reached agreement and 'highly recommended' if 75% or more of the experts reached agreement.RESULTSFifty VATS lobectomy experts (91%) from 16 countries completed both rounds of standardized questionnaires. No statistically significant differences in the responses between the two rounds of questioning were identified. Consensus was reached on 21 controversial points, outlining the current accepted definition of VATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions.CONCLUSIONThe present Consensus Statement represents a collective agreement among 50 international experts to establish a standardized practice of VATS lobectomy for the thoracic surgical community after 20 years of clinical experience.

This November, the pioneers of video-assisted thoracoscopic surgery (VATS) gathered in Edinburgh at the 3rd International VATS lobectomy meeting to celebrate the 20th anniversary of VATS pulmonary resection. Experts in the field from the United States, China, and Europe shared their experiences and discussed the innovations and technologies that would see the technique prosper in the 21st century. The first VATS lobectomy was reported in Italy in 1991.1 Several other centers were quick to implement the technique and report successful early operative experience.2, 3 The overall uptake worldwide was modest over the following decade. In 2006, the STS database reported that 32% of lobectomies were performed via VATS,4 whilst here in the UK, acceptance of the technique was slower with only 13% of lobectomies being performed by VATS in 2011.5 Despite obvious potential advantages, adoption of the technique has been slow, which is attributed to several factors. Understandably, there were early concerns from surgeons regarding immediate and long-term outcomes, with oncological efficacy being an initial focus of interest. Furthermore, the technique itself is challenging and is considered to have a demanding learning curve. For others, issues of safety have been paramount and the risks of managing complications, such as massive hemorrhage, have been a source of deterrence. In light of what has now become an overwhelming body of evidence in support of the VATS approach, the above arguments have begun to lose credibility. At the time of writing, VATS has become a well-established technique for the treatment of early stage non-small cell lung cancer (NSCLC).6-9 There are many potential benefits of VATS resection, compared with a traditional muscle-splitting thoracotomy. Established examples include reduced length of hospital stay, decreased blood loss, decreased pain, improved cosmesis, earlier return to normal activities, and improved tolerance of chemotherapy.10-13 Additionally, a reduced level of inflammatory response and preserved immune function has been demonstrated following VATS resections.14, 15 Pulmonary function testing, at one and two weeks post-operatively, has demonstrated accelerated recovery of FEV1 and FVC in VATS lobectomy, compared to the open approach.16 Of even greater significance were the results from a recent systematic review and meta-analysis, of both randomized and non-randomized trials, demonstrating improved outcomes for VATS in relation to systemic recurrence and overall five-year survival when compared with open thoracotomy.17 Despite a multitude of retrospective comparative studies in support of the VATS approach, an ongoing hurdle has been the lack of a large randomized controlled trial (RCT) comparing VATS with open thoracotomy. Critics of the VATS approach have suggested that selection bias in the non-randomized retrospective studies may create a false positive finding of superior outcomes in support of VATS, as a result of patients who are considered more “favorable” being selected in the study group. To date, there exists two small RCT's in which the authors compared patients with NSCLC undergoing VATS lobectomy with resection via open thoracotomy.18, 19 One of the studies demonstrated a significant reduction in overall complications in the VATS group, while the other reported no significant differences in recurrence and survival rates. In addition to small patient numbers, it is noteworthy that rib spreading was performed in the VATS group of both studies, which does not conform to the current “gold standard” definition of VATS as reported in the CALGB study.20 Accordingly, these studies have not satisfied the demand for a large RCT and opinion is currently divided as to whether one is necessary. It also remains uncertain as to whether such a study remains feasible and, indeed, ethical. Recruiting VATS enthusiasts to participate in such a study and subject patients to what they believe to be an inferior operation would no doubt be confounded by personal and ethical dilemmas. Other options might include a preference based study comparing “experts” in both fields or some form of prospective (i.e. prior to surgery) propensity scoring. A large multi-centered RCT has been proposed here in the UK. Whether or not this will prove a feasible project remains to be seen, but, if so, it might offer the opportunity to resolve this debate. At present there are no rigid guidelines regarding patient selection for VATS major pulmonary resection. Most groups currently employ the technique for patients with Stage I NSCLC, who have peripheral tumours, which are less than 6 cm in diameter. Most centers will operate on patients with N1 lymph node involvement with increasing support to operate on individuals with N2 disease. Age is not a contraindication and VATS is often possible in patients who would otherwise not survive an open thoracotomy because of extensive co-morbidities. Moderate (i.e. limited <2 cm diameter) chest wall and pericardial involvement are not necessarily contraindications to VATS resection. Perioperative assessment is patient specific and differs between centers. Most units will assess pulmonary function, via formal spirometry with a predicted FEV1 > 40%, as currently recommended by the British Thoracic Society for open and VATS lung resection,21 which is generally considered as acceptable. There is, in fact, an emerging body of evidence, however, to suggest that VATS resection can safely be performed on individuals with limited pulmonary function and predicted FEV1's of <40% with favourable outcomes in this patient group when compared to the traditional open approach.22-24 Pre-operative staging is achieved via a combination of bronchoscopy and positron emission tomography-computed tomography (PET-CT) scanning. Mediastinal lymph node biopsy is also routinely employed in some centres, because of reported false negative rates of around 5% for the detection of lymph node metastases with PET-CT.25 Endobronchial ultrasound (EBUS) biopsy of mediastinal lymph nodes is utilised as a convenient alternative. A consensus statement regarding patient selection is expected from the 3rd International VATS Lobectomy Conference in Edinburgh, based on the best current evidence and expert opinion. At present there are a number of VATS techniques employed worldwide which differ in both the direction of approach and the number of ports utilized. The approach is typically anterior or posterior (less commonly inferior) and traditionally anywhere between two to four port sites are created.26, 27 More recently, a series of publications have emerged from Spain reporting considerable success performing VATS major lung resections via a single incision.28 To date, there is no convincing evidence to suggest that one approach or technique is superior to the other, and that which is best in the hands of the individual surgeon, remains preferable. The last 10 years have also been witness to the emergence of pulmonary resection being performed by robotic-VATS. Whilst cost effectiveness remains an outstanding issue, early evidence has demonstrated comparable results to traditional VATS and open techniques.29 At present, less than 1% of pulmonary resections are performed by robotic-VATS.30 This is, in part, related to limited availability of the robots, which, even when present in hospitals, are almost exclusively employed in urological and gynaecological procedures. Utilisation of the robot for thoracic procedures is becoming increasingly popular, however. Theoretical advantages over traditional VATS include permission of superior degrees of movement, improved visualization, improved instrumentation and simulated training. In light of these benefits, there are a number of technological innovations specific to robotic-VATS, such as robotic staplers, which will become available in the near future. At present, there is only a single supplier of the robot, and given the cost of the system, it remains to be seen whether the technology adds benefit at a cost that is reasonable. The efficacy of mediastinal lymph node dissection during VATS lobectomy is a further area of controversy. There is limited evidence to suggest that complete dissection of all removable nodes will improve survival and reduce the rates of local recurrence31-33 Current guidelines from the European Society of Thoracic Surgeons have advised the removal of at least three hilar and interlobar nodes, with a further three mediastinal nodes from different stations of which the subcarinal node is always removed.34 Because of a lack of strict regional guidelines, however, this is rarely performed in practice, with selective lymph node sampling being the preference of most thoracic surgeons. Despite concerns that this was related to technical difficulty, there is good evidence to suggest that lymph node dissection with VATS is comparable to open resection35, 36 In light of such findings, it would appear that sub-optimal lymph node sampling/dissection is unrelated to whether the resection has been performed by VATS and is, therefore, a result of non-technical factors. The argument that VATS resections are in some way less effective in terms of oncological efficacy would, therefore, appear invalid and efforts should be made to encourage thorough lymph node dissection until more conclusive evidence becomes available. Looking to the future, it is encouraging to see that the individuals, whose dedication and perseverance ensured that VATS became an established technique for major lung resections, continue to push the boundaries of achievement two decades later. As interest grows, the technologies inevitably continue to advance. High definition camera systems are now commonplace and provide a remarkable improvement in exposure, when compared with the imaging systems employed in the early days of VATS. The instruments themselves have become better refined and the development of endoscopic staplers specific for VATS has been one of the greatest innovations to date. These technological advances have led to safer surgery and expanded the potential for curative surgery in patients who previously may have been declared inoperable. Perhaps the greatest advances, however, will arise as a product of education and training. The limited dissemination of VATS in many countries has been, in part, because of a lack of individuals with sufficient experience to teach the technique. In general surgery, junior trainees are now as familiar with routine laparoscopic operations as with the traditional open techniques. This has yet to become the case with thoracic surgery, where trainees often have limited, if any, exposure to VATS major lung resections. We are, however, part of an era where emphasis is given to minimally invasive techniques, cost effectiveness, and rapid recovery from surgery. In light of this drive, it is hoped that training in VATS lobectomy will become a compulsory component of thoracic surgical training worldwide. Initial fears regarding the oncological efficacy of VATS resections have not been realized. The technique is now well established as a safe and cost effective alternative to open surgery in patients with early stage NSCLC. The technique has also expanded the potential for curative disease in elderly, frail, co-morbid patients who would otherwise not have tolerated an open resection. In a climate where practice is based on the best available evidence it would seem inevitable that VATS major lung resection will soon be universally accepted as the gold-standard. No authors disclose any conflict of interest.

Introduction Despite the advent of PET scanning and endoscopic minimally invasive methods of sampling mediastinal lymph nodes, surgical assessment, particularly by mediastinoscopy, remains an important tool for staging non-small cell lung cancer.Methods We carried out a retrospective review of mediastinoscopic lymph node biopsies taken at The Royal Infirmary of Edinburgh between 1996 and 2006 and performed additional histological investigations on select cases.Results In total, 89/802 (11%) patients had a negative mediastinoscopy but final resection stage of N2/N3. Within this group, 41/89 (46%) patients had positive resection lymph nodes in stations potentially accessible to biopsy at mediastinoscopy. Of these, 30 (34%) patients had had the metastatic station sampled at mediastinoscopy. Further histopathological examination (multiple levels and pancytokeratin immunohistochemistry) of these original biopsies detected micrometastases in two cases, one of which, in retrospect, had been missed on the original section at the time of reporting. Isolated tumour cells were detected by immunohistochemistry in another two cases.Conclusions Routine examination of additional levels and immunohistochemical staining of mediastinal lymph nodes biopsies is not required and would not improve the overall negative predictive value of the procedure.

OBJECTIVES:The observation that pathogenic bacteria are commonly tolerated in the human nose, yet drive florid inflammation in the lung, is poorly understood, partly due to limited availability of primary human cells from each location. We compared responses to bacterial virulence factors in primary human nasal and alveolar cells, and characterised the distribution of Toll-interacting protein (TOLLIP; an inhibitor of Toll-like receptor (TLR) signalling) in the human respiratory tract.METHODS:Primary cells were isolated from nasal brushings and lung tissue taken from patients undergoing pulmonary resection. Cells were exposed to lipopolysaccharide, lipoteichoic acid, peptidoglycan, CpG-C DNA or tumour necrosis factor (TNF). Cytokines were measured in cell supernatants. TOLLIP was characterised using quantitative real-time PCR and immunofluorescence.RESULTS:In primary alveolar, but not primary nasal, cells peptidoglycan significantly increased secretion of interleukin (IL)-1β, IL-6, IL-8, IL-10 and TNF. TLR2 expression was significantly higher in alveolar cells and correlated with IL-8 production. TOLLIP expression was significantly greater in nasal cells.CONCLUSION:In conclusion, primary human alveolar epithelial cells are significantly more responsive to peptidoglycan than primary nasal epithelial cells. This may partly be explained by differential TLR2 expression. TOLLIP is expressed widely in the human respiratory tract, and may contribute to the regulation of inflammatory responses.