Cezary Piwkowski

OBJECTIVE: Video-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. METHODS: A 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. RESULTS: Fifty 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. CONCLUSION: The 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.

OBJECTIVES: A multicentre evaluation of the frequency and nature of major intraoperative complications during video-assisted thoracoscopic (VATS) anatomical resections. METHODS: Six European centres submitted their series of consecutive anatomical lung resections with the intention to treat by VATS. Conversions to thoracotomy, vascular injuries and major intraoperative complications were studied in relation to surgeons' experience. Major complications included immediate life-threatening complications (i.e. blood loss of more than 2 l), injury to proximal airway or other organs or those leading to unplanned additional anatomical resections. All cases were discussed by a panel and recommendations were drafted. RESULTS: A total of 3076 patients were registered. Most resections (90%, n = 2763) were performed for bronchial carcinoma. There were 3 intraoperative deaths, including 1 after conversion for technical reasons. In-hospital mortality was 1.4% (n = 43). Conversion to open thoracotomy was observed in 5.5% (n = 170), of whom 21.8% (n = 37) were for oncological reasons, 29.4% (n = 50) for technical reasons and 48.8% (n = 83) for complications. Vascular injuries were reported in 2.9% (n = 88) patients and led to conversion in 2.2% (n = 70). In 1.5% (n = 46), major intraoperative complications were identified. These consisted of erroneous transection of bronchovascular structures (n = 9); injuries to gastrointestinal organs (n = 5) or proximal airway (n = 6); complications requiring additional unplanned major surgery (n = 9) or immediate life-threatening complications (n = 17). Twenty-three percent of the in-hospital mortalities (n = 10/43) were related to major intraoperative complications. Eight pneumonectomies (five intraoperative and three postoperative at 0.3%) were a consequence of a major complication. Surgeon's experience was related to non-oncological conversions, but not to vascular injuries or major complications in a multivariable logistic regression analysis. CONCLUSION: Major intraoperative complications during VATS anatomical lung resections are infrequent, seem not to be related to surgical experience but have an important impact on patient outcome. Constant awareness and a structured plan of action are of paramount importance to prevent them.

OBJECTIVE: The aim of this study was to analyze the early and long-term results of simultaneous surgical treatment of both coronary heart disease (CHD) and lung cancer. METHODS: Twenty-five patients with the diagnoses of both non-small cell lung cancer (NSCLC) and unstable angina were operated on between 2001 and 2006 in the Department of Cardiothoracic Surgery at the University of Medical Sciences in Poznań, Poland. Myocardial revascularization was performed simultaneously with the lung resection. The mean patient age was 63 years. The majority (18 patients) were male and the stage of lung cancer was predominantly AJCC II. Most of the patients were classified as stage II or III CCS and the predominant pathology was a two-vessel disease. Fifteen lobectomies, six pneumonectomies and four wedge resections were performed together with the aortocoronary graft implantation (mean: 1.9 graft per patient). RESULTS: There were no postoperative deaths or perioperative myocardial infarctions (MI). The most frequent complications were as follows: atrial fibrillation (24%), atelectasis (12%) and residual pneumothorax (12%). All the patients were followed up for 8-60 months. Within this period, eight patients (32%) died, mostly due to the cancer relapse. The local recurrence of lung cancer and distant metastases were the only factors statistically influencing the late survival. No patient in the entire follow-up period had a MI. In three patients, the symptoms of recurrent angina occurred and one of them underwent a coronary stent implantation. CONCLUSIONS: Simultaneous off-pump myocardial revascularization and lung resection is a safe and effective treatment when unstable CHD and lung cancer coexist. In selected patients, this combined procedure may be an alternative to the two-stage approach, surgical or non-surgical (cardiologic) interventions preceding the pulmonary resection. The only statistically significant factor having an impact on long-term survival is the recurrence of the cancer.