A collaboration of multidisciplinary experts on the functional evaluation of lung cancer patients has been facilitated by the European Respiratory Society (ERS) and the European Society of Thoracic Surgery (ESTS), in order to draw up recommendations and provide clinicians with clear, up-to-date guidelines on fitness for surgery and chemo-radiotherapy.The subject was divided into different topics, which were then assigned to at least two experts. The authors searched the literature according to their own strategies, with no central literature review being performed. The draft reports written by the experts on each topic were reviewed, discussed and voted on by the entire expert panel. The evidence supporting each recommendation was summarised, and graded as described by the Scottish Intercollegiate Guidelines Network Grading Review Group. Clinical practice guidelines were generated and finalised in a functional algorithm for risk stratification of the lung resection candidates, emphasising cardiological evaluation, forced expiratory volume in 1 s, systematic carbon monoxide lung diffusion capacity and exercise testing.Contrary to lung resection, for which the scientific evidences are more robust, we were unable to recommend any specific test, cut-off value, or algorithm before chemo-radiotherapy due to the lack of data. We recommend that lung cancer patients should be managed in specialised settings by multidisciplinary teams.

Video-assisted thoracoscopic anatomical resections are increasingly used in Europe to manage primary lung cancer. The purpose of this study was to compare the outcome following thoracoscopic versus open lobectomy in case-matched groups of patients from the European Society of Thoracic Surgeon (ESTS) database. All patients having lobectomy as the primary procedure via thoracoscopy [video-assisted thoracoscopic surgery (VATS)-L)] or thoracotomy (TH-L) were identified in the ESTS database (January 2007 to December 2013). A propensity score was constructed using several patients' baseline characteristics. The matching using the propensity score was responsible for the minimization of selection bias. A propensity score-matched analysis was performed to compare the incidence of postoperative major complications (according to the ESTS database definitions) and mortality at hospital discharge between the matched groups. After exclusions, 28 771 patients were identified: 26 050 having thoracotomy and 2721 having thoracoscopy. Propensity score yielded two well-matched groups of 2721 patients. Numeric variables were compared by Student's t -tests and categorical variables were compared by McNemar's tests. Compared with TH-L, VATS-L was associated with a lower incidence of total complications [ n = 792 (29.1%) vs 863 (31.7%), P = 0.0357], major cardiopulmonary complications [ n = 316 (15.9%) vs 435 (19.6%), P = 0.0094], atelectasis requiring bronchoscopy [ n = 65 (2.4%) vs 150 (5.5%), P < 0.0001], initial ventilation >48 h [ n = 18 (0.7%) vs 38 (1.4%), P = 0.0075] and wound infection [ n = 6 (0.2%) vs 17 (0.6%), P = 0.0218]. There was no difference in the incidence of postoperative atrial fibrillation between the two groups ( P = 0.14). Postoperative hospital stay was 2 days shorter in the VATS-L patients (mean: 7.8 vs 9.8 days; P = 0.0003). In terms of outcome at hospital discharge, there were 27 deaths in the VATS-L group (1%) versus 50 in the TH-L group (1.9%, P = 0.0201). Data from the ESTS database confirmed that lobectomy performed through VATS is associated with a lower incidence of complications compared with thoracotomy.

Prolonged air leak (PAL) after pulmonary surgery is a frequent occurrence and is reported to cause increased length of stay (LOS) and hospital costs although the costs directly attributable to PAL have never been published. The present study aims to compare the prevalence of pulmonary complications (atelectasis, pneumonia and pleural empyema) in patients with or without PAL and to quantify economic costs directly incurred by PAL in a series of pulmonary lobectomies. A series of 238 patients scheduled for pulmonary lobectomy (January 2001-December 2003) have been reviewed. PAL was defined as air leakage which prevented hospital discharge for 5 postoperative days or over. Hospital costs (excluding operating room) for pulmonary lobectomies have been obtained and calculated as mean daily costs. Age, body mass index, diagnosis, Charlson co-morbidity index, ppoFEV1 and major post-operative cardio-pulmonary morbidity have been used to construct a Cox-regression model for hospital stay, considering deaths as censored cases. Individual risk function has been used as a new variable and expected LOS calculated for each case. This data has been used to estimate total excess hospital stay and costs incurred by cases with PAL. Prevalence of PAL was 23 cases (9, 7%). Mean daily hospital cost for lobectomy was 632.49. For the whole series, mean hospital stay was 5 days (10 days for patients with PAL). PAL cases had more postoperative pulmonary morbidity (risk-ratio: 2.78). Variables showing independent influence on stay were: diagnosis of non-malignant disease (P=0.001); FEV1ppo (P=0.032) and cardio-respiratory morbidity (P<0.001). Calculated total excess stay for PAL patients was 62 days. A total expense of 39,437.39 (38,724.96 hospital and 712.43 pharmacy charges) were estimated to result from postoperative air-leak. PAL patients are prone to developing major postoperative morbidity. PAL calculated costs are over 13,000 per year. This data is useful for designing technical cost-effective strategies to avoid post-lobectomy PAL.

The European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS) established a joint task force with the purpose to develop clinical evidence-based guidelines on evaluation of fitness for radical therapy in patients with lung cancer. The following topics were discussed, and are summarized in the final report along with graded recommendations: Cardiologic evaluation before lung resection; lung function tests and exercise tests (limitations of ppoFEV1; DLCO: systematic or selective?; split function studies; exercise tests: systematic; low-tech exercise tests; cardiopulmonary (high tech) exercise tests); future trends in preoperative work-up; physiotherapy/rehabilitation and smoking cessation; scoring systems; advanced care management (ICU/HDU); quality of life in patients submitted to radical treatment; combined cancer surgery and lung volume reduction surgery; compromised parenchymal sparing resections and minimally invasive techniques: the balance between oncological radicality and functional reserve; neoadjuvant chemotherapy and complications; definitive chemo and radiotherapy: functional selection criteria and definition of risk; should surgical criteria be re-calibrated for radiotherapy?; the patient at prohibitive surgical risk: alternatives to surgery; who should treat thoracic patients and where these patients should be treated?