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It has been suggested that video-assisted (VATS) lobectomy is safer than open lobectomy in patients with compromised lung function, but data regarding this are limited. We assessed acute outcomes of VATS compared to open lobectomy in these high-risk patients using a systematic literature review and meta-analysis of data. The databases PubMed and Scopus were searched for studies published between 2000 and 2013 that reported mortality and morbidity of VATS in high-risk lung cancer patients defined as having compromised pulmonary or cardiopulmonary function. Study selection, data collection and critical assessment of the included studies were performed according to the recommendations of the Cochrane Collaboration. Three case-control studies and three case series that included 330 VATS and 257 open patients were identified for inclusion. Operative mortality, overall morbidity and pulmonary morbidity were 2.5%, 39.3%, 26.2% in VATS patients and 7.8%, 57.5%, 45.5% in open lobectomy group, respectively. VATS lobectomy patients experienced significantly lower pulmonary morbidity (RR = 0.45; 95% CI, 0.30 to 0.67; p = 0.0001), somewhat reduced operative mortality (RR = 0.51; 95% CI, 0.24 to 1.06; p = 0.07), but no significant difference in overall morbidity (RR = 0.68; 95% CI, 0.41 to 1.14; p = 0.14). The existing data suggest that VATS lobectomy is associated with lower risk for pulmonary morbidity compared with open lobectomy in lung cancer patients with compromised lung function.

The Risk Analysis Index (RAI) is a frailty assessment tool based on an accumulation of deficits model. We mapped RAI to data from the Society of Thoracic Surgeons (STS) Database to determine whether RAI correlates with postoperative outcomes following lung cancer resection. This was a national database retrospective observational study based on data from the STS Database. Study patients underwent surgery 2018 to 2020. RAI was divided into four increasing risk categories. The associations between RAI and each of postoperative complications and administrative outcomes were examined using logistic regression models. We also compared the performance of RAI to established risk indices (American Society of Anesthesiology (ASA) and Charlson Comorbidity Index (CCI)) using areas under the Receiver Operating Characteristic (ROC) curves (AUC). Results: Of 29,420 candidate patients identified in the STS Database, RAI could be calculated for 22,848 (78%). Almost all outcome categories exhibited a progressive increase in marginal probability as RAI increased. On multivariable analyses, RAI was significantly associated with an incremental pattern with almost all outcomes. ROC analyses for RAI demonstrated \"good\" AUC values for mortality (0.785; 0.748) and discharge location (0.791), but only \"fair\" values for all other outcome categories (0.618 to 0.690). RAI performed similarly to ASA and CCI in terms of AUC score categories. RAI is associated with clinical and administrative outcomes following lung cancer resection. However, its overall accuracy as a surgical risk predictor is only moderate and similar to ASA and CCI. We do not recommend routine use of RAI for assessment of individual patient risk for major lung resection.

Immune checkpoint blockade (ICB) improves outcomes in non-small cell lung cancer (NSCLC) though most patients progress. There are limited data regarding molecular predictors of progression. In particular, there is controversy regarding the role of CDKN2A loss-of-function (LOF) in ICB resistance. We analyzed 139 consecutive patients with advanced NSCLC who underwent NGS prior to ICB initiation to explore the association of CDKN2A LOF with clinical outcomes. 73% were PD-L1 positive (≥ 1%). 48% exhibited high TMB (≥ 10 mutations/megabase). CDKN2A LOF was present in 26% of patients and was associated with inferior PFS (multivariate hazard ratio [MVA-HR] 1.66, 95% CI 1.02–2.63, p  = 0.041) and OS (MVA-HR 2.08, 95% CI 1.21–3.49, p  = 0.0087) when compared to wild-type (WT) patients. These findings held in patients with high TMB (median OS, LOF vs. WT 10.5 vs. 22.3 months; p  = 0.069) and PD-L1 ≥ 50% (median OS, LOF vs. WT 11.1 vs. 24.2 months; p  = 0.020), as well as in an independent dataset. CDKN2A LOF vs. WT tumors were twice as likely to experience disease progression following ICB (46% vs. 21%; p  = 0.021). CDKN2A LOF negatively impacts clinical outcomes in advanced NSCLC treated with ICB, even in high PD-L1 and high TMB tumors. This novel finding should be prospectively validated and presents a potential therapeutic target.

Strategies to stage and treat cancer rely on a presumption of either localized or widespread metastatic disease. An intermediate state of metastasis termed oligometastasis(es) characterized by limited progression has been proposed. Oligometastases are amenable to treatment by surgical resection or radiotherapy. We analyzed microRNA expression patterns from lung metastasis samples of patients with ≤ 5 initial metastases resected with curative intent. Patients were stratified into subgroups based on their rate of metastatic progression. We prioritized microRNAs between patients with the highest and lowest rates of recurrence. We designated these as high rate of progression (HRP) and low rate of progression (LRP); the latter group included patients with no recurrences. The prioritized microRNAs distinguished HRP from LRP and were associated with rate of metastatic progression and survival in an independent validation dataset. Oligo- and poly- metastasis are distinct entities at the clinical and molecular level.

Despite progress in locoregional and systemic therapies, patient survival from lung cancer remains a challenge. Receptor tyrosine kinases are frequently implicated in lung cancer pathogenesis, and some tyrosine kinase inhibition strategies have been effective clinically. The EphB4 receptor tyrosine kinase has recently emerged as a potential target in several other cancers. We sought to systematically study the role of EphB4 in lung cancer. Here, we demonstrate that EphB4 is overexpressed 3-fold in lung tumors compared to paired normal tissues and frequently exhibits gene copy number increases in lung cancer. We also show that overexpression of EphB4 promotes cellular proliferation, colony formation, and motility, while EphB4 inhibition reduces cellular viability in vitro, halts the growth of established tumors in mouse xenograft models when used as a single-target strategy, and causes near-complete regression of established tumors when used in combination with paclitaxel. Taken together, these data suggest an important role for EphB4 as a potential novel therapeutic target in lung cancer. Clinical trials investigating the efficacy of anti-EphB4 therapies as well as combination therapy involving EphB4 inhibition may be warranted.

Background For older, frail adults, exercise before surgery through prehabilitation (prehab) may hasten return recovery and reduce postoperative complications. We developed a smartwatch-based prehab program (BeFitMe) for older adults that encourages and tracks at-home exercise. The objective of this study was to assess patient perceptions about facilitators and barriers to prehab generally and to using a smartwatch prehab program among older adult thoracic surgery patients to optimize future program implementation. Methods We recruited patients, aged ≥50 years who had or were having surgery and were screened for frailty (Fried’s Frailty Phenotype) at a thoracic surgery clinic at a single academic institution. Semi-structured interviews were conducted by telephone after obtaining informed consent. Participants were given a description of the BeFitMe program. The interview questions were informed by The Five “Rights” of Clinical Decision-Making framework (Information, Person, Time, Channel, and Format) and sought to identify the factors perceived to influence smartwatch prehab program participation. Interview transcripts were transcribed and independently coded to identify themes in for each of the Five “Rights” domains. Results A total of 29 interviews were conducted. Participants were 52% men ( n  = 15), 48% Black ( n  = 14), and 59% pre-frail ( n  = 11) or frail ( n  = 6) with a mean age of 68 ± 9 years. Eleven total themes emerged. Facilitator themes included the importance of providers (right person) clearly explaining the significance of prehab (right information) during the preoperative visit (right time); providing written instructions and exercise prescriptions; and providing a preprogrammed and set-up (right format) Apple Watch (right channel). Barrier themes included pre-existing conditions and disinterest in exercise and/or technology. Participants provided suggestions to overcome the technology barrier, which included individualized training and support on usage and responsibilities. Conclusions This study reports the perceived facilitators and barriers to a smartwatch-based prehab program for pre-frail and frail thoracic surgery patients. The future BeFitMe implementation protocol must ensure surgical providers emphasize the beneficial impact of participating in prehab before surgery and provide a written prehab prescription; must include a thorough guide on smartwatch use along with the preprogrammed device to be successful. The findings are relevant to other smartwatch-based interventions for older adults.

Background The paucity of literature on surgical outcomes of Jehovah’s Witness (JW) patients undergoing lung resection suggests some patients with operable lung cancers may be denied resection. The aim of this study is to better understand perioperative outcomes and long-term cancer survival of JW patients undergoing lung resection. Methods All pulmonary resections in JW patients at one institution from 2000 through 2020 were examined. Demographics, comorbidities, operative parameters, and perioperative outcomes were reviewed. Among operations performed for primary non-small cell lung cancer (NSCLC), details regarding staging, extent of resection, additional therapies, recurrence, and survival were abstracted. Results Seventeen lung resections were performed in fourteen patients. There were nine anatomic resections and eight wedge resections. Fourteen resections (82%) were approached thoracoscopically, of which 3 of 6 anatomic resections were converted to thoracotomy as compared to 1 of 8 wedge resections. There was one (6%) perioperative death. Ten resections in 8 patients were performed for primary pulmonary malignancies, and two patients underwent procedures for recurrent disease. Median survival for resected NSCLCs (N = 7) was 65 months. Three of 6 patients who survived the immediate perioperative period underwent additional procedures: 2 pulmonary wedge resections for diagnosis and one pleural biopsy. Conclusions This series of JW patients undergoing lung resections demonstrates that resections for cancer and inflammatory etiologies can be performed safely in the setting of both primary and re-operative procedures.

ObjectivesTo develop consensus statements regarding the regional-level or district-level distribution of surgical services in low and middle-income countries (LMICs) and prioritisation of service scale-up.DesignThis work was conducted using a modified Delphi consensus process. Initial statements were developed by the International Standards and Guidelines for Quality Safe Surgery and Anesthesia Working Group of the Global Alliance for Surgical, Obstetric, Trauma and Anesthesia Care (G4 Alliance) and the International Society of Surgery based on previously published literature and clinical expertise. The Guidance on Conducting and REporting DElphi Studies framework was applied.SettingThe Working Group convened in Suva, Fiji for a meeting hosted by the Ministry of Health and Medical Services to develop the initial statements. Local experts were invited to participate. The modified Delphi process was conducted through an electronically administered anonymised survey.ParticipantsExpert LMIC surgeons were nominated for participation in the modified Delphi process based on criteria developed by the Working Group.Primary outcome measuresThe consensus panel voted on statements regarding the organisation of surgical services, principles for scale-up and prioritisation of scale-up. Statements reached consensus if there was ≥80% agreement among participants.ResultsFifty-three nominated experts from 27 LMICs voted on 27 statements in two rounds. Ultimately, 26 statements reached consensus and comprise the current recommendations. The statements covered three major themes: which surgical services should be decentralised or regionalised; how the implementation of these services should be prioritised; and principles to guide LMIC governments and international visiting teams in scaling up safe, accessible and affordable surgical care.ConclusionsThese recommendations represent the first step towards the development of international guidelines for the scaling up of surgical services in LMICs. They constitute the best available basis for policymaking, planning and allocation of resources for strengthening surgical systems.

Introduction Epiphrenic diverticula of the esophagus are usually associated with a concomitant esophageal motility disorder. The main symptoms experienced by patients are dysphagia, regurgitation, and aspiration. The best surgical treatment is still debated, particularly the need for a myotomy in addition to resection of the diverticulum. Discussion While for many decades the traditional approach was through a left thoracotomy, more recently, minimally invasive techniques have been successfully used and are now the procedure of choice in most cases. The purpose of this article was to review (a) the current understanding of the pathophysiology of epiphrenic diverticulum, (b) how this understanding should guide the surgical treatment, and (c) the surgical approach.

Background and Aims Frailty is an age‐related syndrome associated with poor surgical outcomes, but the impact of insurance payer status on frailty is not fully understood. We sought to evaluate the association between insurance payer status and frailty among thoracic surgery patients. Methods This retrospective study included all patients undergoing routine frailty screening in a general thoracic surgery clinic at a single center from December 2020 to December 2022. Insurance payers were collected (Medicare, Medicaid, or private). Frailty was measured using the Fried's Frailty Phenotype (FFP) (0: not frail, 1–2: prefrail, 3–5: frail) and the Modified 5‐Item Frailty Index (mFI‐5) (≥ 2 vs. 0–1). Fisher's Exact and Kruskal–Wallis tests and multivariable logistic regressions were performed. A final sensitivity analysis was conducted to examine the association of insurance and frailty in patients who underwent surgery. Results Of the 430 screened patients, 41% (183) were female, median age was 68 (IQR: 62–74), and 48% (207) were non‐White. Insurance coverage was 63% (271) Medicare, 15% (64) Medicaid, and 22% (95) private insurance. Of the cohort, 44% (189) of patients underwent subsequent surgery. After adjusting for age, sex, BMI, race/ethnicity, income, smoking status, medications, cancer history, and healthcare utilization, patients with Medicare were more likely to be frail than those with private insurance (FFP: Medicare—OR: 3.17, CI: [1.14–9.72], p < 0.05 | mFI‐5: OR: 3.40, CI: [1.45–8.55], p < 0.01). This association was seen in patients with Medicaid by mFI‐5 (OR: 3.35, CI: [1.24–9.51], p < 0.05). Furthermore, these findings were consistent with our sensitivity analysis. Conclusion Publicly insured surgical patients are more likely to be frail than those privately insured. The etiology of this disparity is multifactorial and may be a result of healthcare inaccessibility, limitations of coverage, and lower socioeconomic status. Future policy‐based interventions to address social determinants of health may reduce insurance disparities.