Background: Near-infrared fluorescence mapping with indocyanine green dye is a recent advancement in minimally invasive segmental resection. This technique has not yet been reproduced, validated, or objectively evaluated in a large prospective case series. We hypothesized that near-infrared fluorescence mapping is associated with an increased oncological margin distance from the tumor, over and above the best judgment of the surgeon.Methods: This was a phase 2 prospective cohort trial in patients who are undergoing robotic segmentectomy for lung tumors <3 cm. The predicted intersegmental plane was first identified by consensus between 2 thoracic surgeons. The true plane was then mapped by indocyanine green injection. A 7-item binary rating scale was used for the evaluation of feasibility, reproducibility, and added oncological margin distance from the tumor. The margin distance between the tumor and the true plane was compared with the margin distance between the tumor and the predicted plane.Results: Fifty-three patients were enrolled between September 2016 and May 2018 and 31 patients (58.4%) received the planned operation with indocyanine green mapping. In 74.2% of cases (23 out of 31), a score of 7 out of 7 was achieved, indicating the true intersegmental plane identified by indocyanine green mapping was different than the predicted plane identified by the surgeon. In 61.2% (19 out of 31) of those cases, the mean additional margin distance from the tumor to the staple line attributable to the indocyanine green mapping was 2.41 AE 1.6 cm. The overall complication rate was 18.5% (10 out of 53) and there were no deaths.Conclusions: Near-infrared fluorescence mapping in robotic segmentectomy is associated with increased oncological margin length, over and above the best judgment of the surgeon, in the majority cases where it is used.

OBJECTIVES The large volume of scientific publications and the increasing emphasis on high-quality evidence for clinical decision-making present daily challenges to all clinicians, including thoracic surgeons. The objective of this study was to evaluate the contemporary trend in the level of evidence (LOE) for thoracic surgery clinical research. METHODS All clinical research articles published between January 2010 and December 2017 in 3 major general thoracic surgery journals were reviewed. Five authors independently reviewed the abstracts of each publication and assigned a LOE to each of them using the 2011 Oxford Centre for Evidence-Based Medicine classification scheme. Data extracted from eligible abstracts included study type, study size, country of primary author and type of study designs. Three auditing processes were conducted to establish working definitions and the process was validated with a research methodologist and 2 senior thoracic surgeons. Intra-class correlation coefficient was calculated to assess inter-rater agreement. Chi-square test and Spearman correlation analysis were then used to compare the LOE between journals and by year of publication. RESULTS Of 2028 publications reviewed and scored, 29 (1.4%) were graded level I, 75 (3.7%) were graded level II, 471 (23.2%) were graded level III, 1420 (70.2%) were graded level IV and 33 (1.6%) were graded level V (lowest level). Most publications (94.9%) were of lower-level evidence (III–V). There was an overall increasing trend in the lower LOE (P &lt; 0.001). Inter-rater reliability was substantial with 95.5% (95%, confidence interval: 0.95–0.96) level of agreement between reviewers. CONCLUSIONS General thoracic surgery literature consists mostly of lower LOE studies. The number of lower levels of evidence is dominating the recent publications, potentially indicating a need to increase the commitment to produce and disseminate higher-level evidence in general thoracic surgery.

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