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.

The number of patients requiring tracheal intubation rose dramatically in March and April 2020 with the COVID-19 outbreak. Our thoracic surgery department has seen an increased incidence of severe pneumomediastinum referred for surgical opinion in intubated patients with COVID-19 pneumonitis. Here we present a series of five cases of severe pneumomediastinum requiring decompression therapy over a 7-day period in the current COVID-19 outbreak. We hypothesise that the mechanism for this is the aggressive disease pathophysiology with an increased risk of alveolar damage and tracheobronchial injury along with the use of larger bore tracheal tubes and higher ventilation pressures. We present this case series in order to highlight the increased risk of this potentially life-threatening complication among the COVID-19 patient cohort and offer guidance for its management to critical care physicians.

Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov , NCT04384926 . Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include...

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted thoracoscopic surgical decortication (VATSD) might be superior to open decortication (OD) (or chest tube drainage) for the management of adults with primary empyema? Altogether 68 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATSD has superior outcomes for the treatment of persistent pleural collections in terms of postoperative morbidity, complications and length of hospital stay, and gives equivalent resolution when compared with OD. One study comparing VATSD and chest tube drainage of fibrinopurulent empyema found video-assisted thoracoscopic surgery (VATS) had higher treatment success (91% vs. 44%; P<0.05), lower chest tube duration (5.8+/-1.1 vs. 9.8+/-1.3 days; P=0.03), and lower number of total hospital days (8.7+/-0.9 vs. 12.8+/-1.1 days; P=0.009). Eight studies comparing early and late empyema report conversion rates to OD of 0-3.5% in early, 7.1-46% in late stage and significant reductions in length of stay with VATSD compared with OD both postoperatively (5 vs. 8 days; P=0.001) and in total stay (15 vs. 21; P=0.03). Additionally VATS resulted in reduced postoperative pain (P<0.0001) and complications including atelectasis (P=0.006), prolonged air-leak (P=0.0003), sepsis (P=0.03) and 30-day mortality (P=0.02). Five studies considered only chronic persistent empyema of which two directly compared VATSD to tube thoracostomy (TT). VATS resolved 88% of cases and had mortality rates of 1.3% compared with 62% and 11%, respectively, for TT. Moreover, conversion to OD was 10.5-17.1% with VATS and 18-37% with TT (P<0.05). In agreement with mixed stage empyema, hospital stay was reduced both postoperatively (8.3 vs. 12.8 days; P<0.05) and in total (14+/-1 vs. 17+/-1 days; P<0.05), and when compared with OD (one study), pain (P<0.0001), postoperative air-leak (P=0.004), hospital stay (P=0.020) and time to return to work (P<0.0001) were all reduced with VATS. Additionally, re-operation (4.8% vs. 1%; P=0.09) and mortality (4/123% vs. 0%) were lower in VATS vs. OD.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was how video-assisted thoracoscopic surgery (VATS) compares to median sternotomy in the surgical management of patients with myasthenia gravis (MG)? Overall 74 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that VATS produces equivalent postoperative mortality and complete stable remission (CSR) rates, with superior results in terms of hospital stay, operative blood loss and patient satisfaction at the expense of a doubling of operative time. Six studies comparing VATS and transsternal sternotomy in non-thymomatous myasthenia gravis (NTMG) patients found VATS to have lower operative blood loss (73.8±70.7 vs. 155.3±91.7 ml; P<0.05), reduced total hospital stay (5.6±2.2 vs. 8.1±3.0 days; P=0.008), whilst maintaining equivalent remission rates (33 vs. 44.7%; P=0.16) and mass of thymic tissue resection (37 vs. 34 g; P>0.05). One study comparing video-assisted thoracoscopic extended thymectomy to transsternal thymectomy in only thymoma-associated myasthenia gravis (T-MG) patients found equivalent CSR (11.3 vs. 8.7%, P=0.1090) at six-year follow-up. Thymoma recurrence rate (9.64%) was not significantly different (P=0.1523) between the two groups. Eight studies comparing VATS and transsternal approach in mixed T-MG and NTMG patients found a lower hospital stay (1.9±2.6 vs. 4.6±4.2 days, P<0.001), reduced need for postoperative medication (76.5 vs. 35.7%, P=0.022), lower intensive care unit stay (1.5 vs. 3.2 days, P=0.018), greater symptom improvement (100 vs. 77.9%, P=0.019) and better cosmetic satisfaction (100 vs. 83, P=0.042) with VATS. In concordance with NTMG and T-MG alone patient groups, VATS and transsternal methods had equivalent complication rates (23 vs. 19%, P=0.765) with no mortalities in either group. Even though VATS has a longer operative time (268±51 vs. 177±92 min, P<0.05), its improved cosmesis, reduced need for postoperative medication and equivalent disease resolution outcomes make it a preferable surgical option to the transsternal approach.

Titanium devices (clips and bars; screws and plates) are effective and safe for repair of rib fractures and large chest wall defect reconstruction with minimal complications and good long-term results.

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A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether blood pleurodesis is effective for cessation of persistent air leak (PAL). Altogether more than 43 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that autologous blood pleurodesis has superior outcomes when compared with conservative management for treatment of postoperative PAL. In addition, for PAL causing pneumothorax, blood pleurodesis [optimal volume 100 ml (from two studies)] should be considered in patients who are unsuitable for surgery, talc pleurodesis is ineffective or not viable (including cases complicated by acute respiratory distress syndrome) and a prompt resolution is required. Some 70-81% of patients treated for postoperative air leak resolved within 12 h and 95-100% within 48 h vs. a mean of 3-6.3 days (from two studies) with simple drainage. Resolution of pneumothorax with blood pleurodesis was also significantly shorter (P<0.01). Overall success rates (from all studies) were 92.7% (n=133) from patients having undergone pulmonary surgery (76.6% in one injection, n=111), and 91.7% (n=109) of patients with pneumothorax. Recurrence rates were between 0 and 29% compared with 35-41% for simple drainage, although one controlled study in which the recurrence rate was improved from 16% in controls to 0% in the blood pleurodesis group (at 12-48 months). Minor complication (empyema/fever/pleural effusion) rates varied between studies (0-18%), although they show reduced incidence in line with improving technique over time. A controlled study looking at acute respiratory distress syndrome complicated by pneumothorax showed a significant reduction in mortality (odds ratio 0.6), time to cessation of air leak (P<0.01), weaning time (P<0.01) and intensive treatment unit (ITU) stay (P<0.01) whilst another randomized control study showed significant reduction in hospital stay following pulmonary resection (P<0.001).