Abstract
Objectives
This study aimed to assess whether the use of the non-powered AEON Endostapler during lung resection in patients with severe lung emphysema reduces the duration of postoperative air leak, as measured by the air leak volume over time, in comparison to the Echelon Flex Powered Plus Stapler.
Methods
A total of 32 lung volume reduction surgeries were performed on 19 patients, stratified by side of the operation. These procedures were randomly assigned to utilize either the non-powered or the powered stapler. Postoperative air leak was monitored using a digital recording system. The time to air leak closure, the incidence and severity of air leaks, and the duration of chest tube placement were evaluated.
Results
Immediate postoperative air leaks were observed in 6 of 17 procedures (35.3%) using the non-powered stapler and in 9 of 15 procedures (60%) performed with the powered stapler. The median time to closure of the air leak was also considerably shorter in the non-powered procedures: 14.3 hours [6.7, 116] compared to 93.2 hours [2.1, 159] for the powered treatments. Cox regression analysis yielded a hazard ratio of 1.6 (95% CI, 0.73-3.3) for a faster air leak closure with the non-powered stapler (P = .25).
Conclusions
Both stapler systems are feasible for use in patients with severe lung emphysema. However, our results show an earlier air leak closure and a lower incidence of postoperative air leaks with the use of a non-powered stapler.
Clinical registration number
https://clinicaltrials.gov/study/NCT05628415? term=LVRS&rank=9, 28.11.2022
Keywords: Endostapler, lung volume reduction, air leak
Severe chronic obstructive pulmonary disease (COPD) is a progressive condition that significantly contributes to global mortality and morbidity.
Graphical abstract
Graphical Abstract.
Overview of the study’s primary outcome comparing non-powered and powered staplers in lung volume reduction surgery, emphasizing air-leak closure time. The schematic depicts cumulative events over time until air-leak resolution.
INTRODUCTION
Severe chronic obstructive pulmonary disease (COPD) is a progressive condition that significantly contributes to global mortality and morbidity.1,2 While medications and pulmonary rehabilitation can alleviate symptoms, they are often inadequate in advanced case.3,4 In such instances, surgical interventions like Lung Volume Reduction Surgery (LVRS) offer promising results, particularly in improving lung function, reducing breathlessness, and enhancing quality of life.
The NETT trial and other studies have shown LVRS’s effectiveness but also highlighted risks,3 particularly prolonged air leak (PAL), defined as an air leak lasting more than 5 days post-surgery. PAL occurs in 24%-50% of cases5–8 and is associated with increased morbidity, extended hospital stays, higher infection risk, and increased healthcare costs.9,10 Surgical staplers are commonly used to manage this risk. They come in powered and non-powered models, with powered staplers designed to eliminate the manual firing force and improve precision, potentially lowering air leak rates.11 However, PAL remains a significant challenge.
The non-powered AEON Endostapler (Lexington Medical) offers innovations to reduce tissue damage and air leaks. Its features include a multi-speed gear system to reduce firing force by 50%, manual pause/restart functionality, sharp single-use knives, and design elements optimized for lung tissue, such as a fixed anvil and teardrop-shaped buckets. These are intended to improve surgeon’s control and reduce complications during surgery.
Our lead surgeon, with decades of LVRS experience, observed reduced air leak and more controlled tissue compression while using the AEON as compared to the powered Echelon FLEX stapler (Ethicon) in LVRS. To evaluate this, we initiated a prospective, randomized study comparing the non-powered and the powered stapler in LVRS patients, hypothesizing that the non-powered stapler would reduce air leak incidence by minimizing tissue tension.
METHODS
This study was approved by the Ethics Committee of Northwest and Central Switzerland (EKNZ) on October 26, 2022 (BASEC 2022-D0079) and registered under ClinicalTrials.gov identifier NCT05628415. Patients provided informed written consent for their participation and publication of their data. Data collection and storage followed the guidelines of the WMA Declaration of Taipei. No biological samples were involved.
Between November 2022 and February 2025, 25 patients were enrolled. Six were withdrawn due to protocol violations, including lobectomy, manipulation of the drainage system postoperatively, failure to receive planned LVRS, and use of pneumostatics intraoperatively. A total of 19 patients, 10 women and 9 men, with a mean age of 68.3 years (range: 47-84), completed the study.
INCLUSION CRITERIA
Patients aged ≥ 18 years who were discussed in the interdisciplinary emphysema treatment board and found to be eligible for LVRS, or who met the criteria in accordance with pneumology recommendations for bilateral or unilateral LVRS due to lung emphysema (including all morphologies such as COPD GOLD III and IV), as well as patients who underwent surgery for pathologies other than lung emphysema requiring lung resection in the presence of severe lung emphysema.
EXCLUSION CRITERIA
Patients with non-bullous pulmonary emphysema, severely impaired DLCO and FEV1 (≤ 20% of predicted value), homogeneous emphysema morphology, symptomatic severe pulmonary arterial hypertension (mPAP > 35 mmHg), significant (ie, clinically relevant and symptomatic) Coronary Arterial Disease (CAD), inability to comply with the study procedures (eg, language barriers, psychological disorders, dementia, etc.); investigators, their family members, employees, and other dependent persons; as well as those currently enrolled in another clinical trial studying an experimental treatment, or who were pregnant, were excluded.
Methods of minimizing bias
The staplers were assigned to a preselected side for operation using sequentially numbered opaque envelopes containing randomized stapler names in a 1:1 ratio (block randomization), created by a designated statistician, otherwise not involved in this study. The participants were blinded.
INTERVENTION
A total of 32 procedures (based on the number of sides operated on) were randomized to either the non-powered (n = 17) or the powered stapler (n = 15) during LVRS (Figure S1). The side designated for the first surgical treatment, and consequently the side to be operated on using the randomized device, was preselected depending on the findings on SPECT-CT.
Thirteen of the 19 patients underwent bilateral surgeries (n = 26 procedures). In these cases, 1 side was randomly assigned to 1 type of stapler at the beginning of the operation, and the contralateral side automatically received the other type of stapler. This offered an advantage in that both staplers could be tested on 1 individual and hence under constant variables in the patients with bilateral surgery.
Six patients underwent unilateral surgery utilizing a randomized stapler (n = 6).
During surgery, two 24 Charriere apical chest tubes were placed on each treated side and connected to the digital Thopaz (Medela AG) recording system, set to a suction pressure of −10 cm H2O.
Air leakage was monitored immediately following skin closure (0 hours), at 2, 4, 8, and 12 hours postoperatively, and subsequently twice daily at 8 am and 5 pm employing the Thopaz system. The primary outcome was the time to first closure of the air leak (in hours), calculated by subtracting the time of skin closure from the time until the air leak was closed. Air leak closure was defined as a volume of either 0 mL/minute or less than 30 mL/minute, measured twice at the time points mentioned above utilizing the Thopaz system. Secondary outcomes included the incidence and severity of air leaks, time to chest tube removal, postoperative complications classified according to the Clavien-Dindo-Classification, reoperation rate, duration of hospitalization and length of the staple line.
For the intensity of air leaks [mL/minute], the area under the curve (AUC) was calculated from skin closure to initial closure of the air leak over a period of 7 days using linear interpolation. An air leak duration of more than 7 days was considered a system failure of the stapler used.
The first chest tube was removed postoperatively upon achieving initial closure of the air leak, as described above. The duration until removal of the chest tube was calculated as the time (hours) elapsed from skin closure to drain removal. Hospitalization time (days) was calculated from incision time to discharge time. All surgeries were performed by the same surgeon using VATS, except for 1 treatment that was conducted via thoracotomy.
Statistical methods
A sample size calculation was performed to detect a clinically relevant difference of 36 hours in time to air leak closure, assuming a SD of 48 hours. This yielded a required sample size of 16 patients treated bilaterally with both staplers. In practice, 13 of 19 patients (≈70%) received both devices, and repeated measurements were accounted for in the regression analysis. Air leaks persisting beyond 7 days (168 hours) were censored for clinical reasons.
To analyse time to air leak closure, Cox regression was used, accommodating censored data and time courses. Proportional hazards and potential non-linearities were assessed. Hazard ratios with 95% CI and P-values were calculated, and Kaplan–Meier curves were used for visualization.
Secondary outcomes, including air leak intensity (AUC, AUC24) and time to chest tube removal, were analysed using mixed-effects models, with outcomes log-transformed (AUC = 0 adjusted to 1 mL). Geometric mean ratios were reported. Logistic regression assessed air leak incidence within the first 24 hours, and duration of hospitalization was analysed via linear modelling. All regression models were adjusted for age and sex; staple line length was excluded. Descriptive statistics included means with SD or medians with IQR. Statistical significance was set at P < .05. Analyses were conducted in R version 4.4.1.
RESULTS
Demographic and clinical characteristics are summarized in Table 1. All patients demonstrated severe obstructive lung function, with the following % predicted mean values: FEV1 = 34.47% ± 7.46%, DLCO = 35.9% ± 16.2%, TLC = 142.3% ± 19.47%, RV = 249.4% ± 58.09% (5.6 ± 1.4 l), and RV/TLC ratio = 144.1% ± 53.1%. Fifteen patients had markedly heterogeneous emphysema predominantly in the upper lobes, and 4 had intermediate-type emphysema. None had a homogeneous pattern (Table 2).
Table 1.
Demographics and Clinical Characteristics
| Total (n = 19) | Female (n = 10) | Male (n = 9) | P | |
|---|---|---|---|---|
| Age (years) | 68.3 (6.5) | 68.4 (7.4) | 68.1 (5.9) | .93a |
| BMI (kg.m−2) | 20.8 (3.3) | 21.2 (3.8) | 20.3 (2.8) | .58a |
| FEV1 (% of predicted value) | 34.47 (7.46) | 38.20 (7.33) | 30.33 (5.29) | .017a |
| DLCO (% of predicted value) | 35.9 (16.2) | 36.65 (17.4) | 35.3 (15.9) | .87a |
| TLC (% of predicted value) | 142.3 (19.47) | 146.9 (25.46) | 137.2 (8.29) | .29a |
| RV (% of predicted value) | 249.4 (58.09) | 249.4 (79.74) | 249.4 (20.92) | <1.0b |
| RV/TLC (%) | 144.1 (53.1) | 136.2 (55.1) | 152.8 (52.7) | .51a |
Reported as mean values with SD. Significance tests between sex were t-test and
ranksum test.
Table 2.
Clinical Features and Surgery
| Total (n = 19) | Female (n = 10) | Male (n = 9) | P | |
|---|---|---|---|---|
| Lung side | .51 | |||
| Left | 3 (15.8%) | 1 (10%) | 2 (22.2%) | |
| Left/right | 13 (68.4%) | 8 (80%) | 5 (55.6%) | |
| Right | 3 (15.8%) | 1 (10%) | 2 (22.2%) | |
| Emphysema type | .30 | |||
| Markedly heterogenous | 15 (78.9%) | 9 (90%) | 6 (66.7%) | |
| Intermediate heterogenous | 4 (21.1%) | 1 (10%) | 3 (33.3%) | |
| Location of disease | ||||
| Left lobe | .30 | |||
| Upper | 10 (62.5%) | 7 (77.8%) | 3 (42.9%) | |
| Upper, lower | 6 (37.5%) | 2 (22.2%) | 4 (57.1%) | |
| Right lobe | .14 | |||
| Upper | 6 (37.5%) | 5 (55.6%) | 1 (14.3%) | |
| Upper, lower | 7 (43.8%) | 2 (22.2%) | 5 (71.4%) | |
| Lower | 1 (6.2%) | 1 (11.1%) | 0 (0%) | |
| Upper, middle | 2 (12.5%) | 1 (11.1%) | 1 (14.3%) | |
| Surgery type | ||||
| Left | .44 | |||
| Open | 1 (6.2%) | 0 (0%) | 1 (14.3%) | |
| VATS | 15 (93.8%) | 9 (100%) | 6 (85.7%) | |
Reported as n and %. Significance tests between staplers were Fisher’s exact test.
Primary endpoint
Air leak monitoring was conducted for up to 7 days (168 hours). This time interval was exceeded (PAL) in 6 cases: 2 cases (11.8%) in the non-powered stapler group and 4 (26.7%) in the powered stapler group. We classified these instances as system failures of the respective device.
The median time to air leak closure was markedly lower with the non-powered compared to the powered stapler, 14.3 [6.7, 116] vs 93.2 [2.1, 159] hours, P = .34 (Figure 1, Table 3, and Table S1). Cox regression analysis revealed a clear effect between the 2 staplers, showing a hazard ratio of 1.55 (95% CI, 0.73, 3.3) in favour of the non-powered stapler (P = .25) (Table 4). A hazard ratio of 1.6 means that the likelihood of the event «air leak closure» occurring is 1.6× higher when using the non-powered stapler compared to the powered stapler over a specified period.
Figure 1.
Box Plot of Time to Air Leak Closure.
Table 3.
Procedure Specific Characteristics
| Non-powered stapler (n = 17) | Powered stapler (n = 15) | P | |
|---|---|---|---|
| Time to air leak closure [hour] | 14.3 [6.7, 116] | 93.2 [2.1, 159] | .34a |
| Incidence of post-operative air leak | 6 (35.3%) | 9 (60%) | .30b |
| Total air leak volume [mL] | 1925 [363, 9982] | 12310 [219, 27398] | .41a |
| Air leak volume in 24 hours [mL] | 1925 [363, 3975] | 5122 [233, 15826] | .34a |
| Chest tube placement (days) | 3.1 (2.7) | 4.9 (3.3) | .11c |
| Clavien-Dindo-Classification | 1d | ||
| I | 5 (29.4%) | 4 (26.7%) | |
| II | 1 (5.9%) | 1 (6.7%) | |
| III-b | 2 (11.8%) | 2 (13.3%) | |
| none | 9 (52.9%) | 8 (53.3%) | |
| Duration of hospitalization (days) | 11 [9, 15] | 11 [9, 16.5] | .91a |
| Length of staple line (cm) | 27.4 (9.7) | 31.2 (11.8) | .33c |
Reported as median (IQR), n and %, or mean values with SD. Significance tests between staplers were ranksum test,
Chi2 test,
t-test, and
Fisher’s exact test.
Table 4.
Results of the Regression Analysis Comparing the Non-Powered vs the Powered Stapler
| Primary outcome | |||
|---|---|---|---|
| Difference (low, high) | Hazard ratio (95% CI) | P | |
| Time to air leak closure a | 1.55 (0.73, 3.30) | .25 | |
| Age | 9.25 (63.75, 73.0) | 1.25 (0.78, 2.00) | .35 |
| Sex (male vs female) | 1.07 (0.50, 2.32) | .86 | |
| Secondary outcomes | |||
| Crude OR (95% CI) | Adj. OR (95% CI) | P | |
| Incidence of postoperative air leaks within the first 24 hoursb | 0.36 (0.09, 1.53) | 0.31 (0.07, 1.42) | .13 |
| GMR (95% CI) | P | ||
| Intensity of postoperative air leaks (AUC [mL])c | 0.32 (0.02, 4.97) | .38 | |
| Intensity of postoperative air leaks within 24 hours (AUC [mL])c | 0.38 (0.04, 4.11) | .39 | |
| Chest tube placement (days)c | 0.67 (0.36, 1.24) | .18 | |
| Duration of hospitalization (days)d | 0.95 (0.68, 1.34) | .76 | |
Analysed by a cox regression adjusted for age and sex.
Analysed by a logistic regression analysis adjusted for age and sex.
Analysed by a mixed-effects model with log-transformed values adjusted for age and sex.
Analysed by a linear model with log-transformed values adjusted for age and sex.
Kaplan–Meier curves, shown as cumulative event rates (Figure 2), illustrated the timelines for air leak closure. Within the first 24 hours, a significantly higher number of air leak closures were observed in the non-powered stapler group (n = 11, or 64.7%) compared to the powered stapler group (n = 6, or 40%).
Figure 2.
Kaplan–Meier Cumulative Event Curves for Time to Air Leak Closure.
Secondary endpoints
The incidence of air leaks was 6 out of 17 cases (35.3%) in the non-powered stapler group and 9 out of 15 (60%) in the powered stapler group (P = .30).
The incidence of air leaks within the first 24 hours was less than 67% of the value observed with the powered stapler when using the non-powered stapler, with an adjusted odds ratio of 0.31 (P = .13). (Table 4).
For the non-powered stapler, the total median air leak volume (AUC) was 1925 mL [363, 9982], whereas for the powered one, it was 12310 mL [219, 27398] (P = .41). The total AUC values of the non-powered stapler were only 32% of those of the powered stapler (P = .38). For one patient (powered stapler), the AUC was only calculated up to 93 hours due to a reoperation on postoperative day (POD) 4 caused by a significantly elevated air leak. However, the patient was included in AUC24 calculations (Tables 2 and 3).
The median volume of air leak in the first 24 hours (AUC24) was 1925 mL [363, 3975] for the non-powered stapler and 5122 mL [233, 15826] for the powered stapler (P = .34). AUC24 values of the non-powered stapler are 38% of the powered stapler (P = .39) (Tables 2 and 3).
Eight patients (47.1%) in the non-powered group and 7 (46.7%) in the powered stapler group experienced complications ranging from I to IIIb as per Clavien-Dindo-Classification. No major complication occurred in either group; however, 1 patient from the non-powered group who had a unilateral operation was reoperated due to PAL on POD 13 owing to a significant increase of air leak with time. The air leak sites in both reoperated patients were within the staple line. In contrast, the second patient with PAL from the group was treated by retracting the drainage. All 4 patients in the powered stapler group with PAL were treated conservatively with retraction of the drainage tubes.
The use of non-powered staplers reduces the duration of chest drain placement by 33.3% compared to powered staplers (P = .18) (Table 3).
There was no significant difference in the median duration of hospitalization between the 2 groups, the non-powered stapler group of 11 [9, 15] days and the powered group time of 11 [9, 16.5] days (P = .76) (Table 3).
An analysis of potential confounders influencing the time interval until initial air leak closure, specifically gender, age, and staple line length, revealed that staple line length had the most significant impact. For instance, increasing the staple line length by 10 cm would result in a 5-fold increase in the time required for air leak closure, as illustrated in Figure 3. Notably, there was no difference between the 2 staplers. It is noted that the AEON non-powered stapler is approximately half the price of its powered counterpart, Echelon.
Figure 3.
Impact of Staple Line Length on Time to Air Leak Closure.
DISCUSSION
In contemporary practice, minimally invasive surgery has emerged as the standard approach for LVRS. The use of endoscopic staplers has facilitated the widespread adoption of minimally invasive approaches in patients with severe lung emphysema.
Cerfolio and colleagues noted that persistent air leaks were more common in patients with an FEV1 below 79% predicted, linking air leaks to patient characteristics and disease severity rather than surgical technique.12 In our study, the mean FEV1 was 35%. However, patient characteristics didn’t account for differences between the non-powered and powered groups, as most of the patients received bilateral surgeries with both staplers. All surgeries were performed by the same surgeon using the same technique.
Most patients in our cohort presented with a markedly heterogenous distribution of emphysema, with predominance in the upper lobe. This seemed to be associated with a higher incidence and intensity of air leaks, which is consistent with the findings of other studies.10 Presumably because upper lobe resections often result in a large apical air space with poor visceral-parietal apposition and thus frequently predispose these patients to PAL.13,14
Various methods are available to reduce postoperative air leaks at the staple line, such as buttressing, fibrin sealants, collagen fleece, and synthetic glues. However, recommendations in the literature are inconsistent and are based on cost-effectiveness and the varying benefits reported in large studies and meta-analysis.6,8 Furthermore, the use of bovine pericardium for buttressing has been associated with an inflammatory response that may lead to dense adhesions, which could complicate potential lung transplantation after LVRS, if indicated.
Endostaplers play a crucial role in reducing PAL, as it is possible to reliably resect and close the lung tissue.9,10 To reduce the incidence of PAL, stapler devices are undergoing continuous development focused on enhancing device-to-tissue interaction.
Studies investigating the efficacy of non-powered and powered staplers on the occurrence of PAL in LVRS are rare and show controversial results.11 A study comparing both types of staplers reported comparable results.15
In the literature, it is described that powered staplers may increase the likelihood of achieving a tight tissue closure, ultimately resulting in less PAL.11 However, our prospective randomized study indicated that the non-powered stapler tends to yield better results than the powered stapler in patients with severe lung emphysema, reducing the frequency of air leaks and shortening the time to air leak closure. This may be due to its multi-speed gear system (thick-thin mode), which reduces the firing force by 50%, likely being, to our observation, the main reason for its advantage over the powered stapler, which, on the other hand, fires at a constant speed when activated. The option to pause or restart firing manually gives surgeons the control over how fast they would like to apply compression and cut through tissue, depending on their assessment of tissue quality. In addition, the non-powered stapler uses new sharp knives with each reload. Design elements such as a fixed anvil, teardrop-shaped anvil buckets, uniform staple lengths, and short reload tips tailored for lung surgery may also contribute to its advantage in LVRS. Although the powered stapler can also be activated and deactivated using the fire button, the compression and cutting speed are constant and cannot be adjusted for different tissue qualities. Furthermore, the powered stapler reuses the knife, which can lead to dullness with repeated use, increasing the likelihood of tearing tissue rather than cutting.
The median duration of stay in both of our groups was 11 days, which was consistent with the duration of stay reported in other studies.6 However, it is important to note that in our study, all patients were referred to rehabilitation after LVRS, which involved varying waiting times for vacancy.
A longer staple line is associated with a higher risk for air leak, which usually occurs at the overlapping site of 2 consecutive stapler loads. The shorter tip of the non-powered stapler allows for staple application as far as the blade cuts, hence reducing the possibility of air leaks.
LIMITATIONS
Although this study was conducted in a prospective design, it has its limitations, among them being a small sample size.
The sample size calculation was based on an assumed SD of 2 days (48 hours) for the primary endpoint, time to air leak closure. However, the pooled SD observed was approximately 70 hours, indicating that a clinically relevant difference of 1.5 days (concerning time to air leak closure) between the 2 stapler groups would likely not reach statistical significance. In fact, 32 pairs would have been needed. Therefore, the interpretations of results should emphasize effect sizes over P-values. Additionally, the primary endpoint was not determined on minute-level precision during the observation period but was assessed at predefined time points (0, 2, 4, 8, 12 hours, etc.). As a result, the reported values for time to air leak closure may overestimate the actual values. The study is single-centred, and all surgeries were performed by a single surgeon hence generalization may be limited.
CONCLUSION
Our study suggests that the non-powered stapler may be more effective in reducing tissue tension, hence reducing the risk of air leaks. This is demonstrated by a shorter time interval to air leak closure and a lower incidence of air leaks compared to the powered stapler in the context of LVRS in patients with severe lung emphysema. Further studies with larger sample sizes are warranted to validate and expand upon these findings.
Supplementary Material
ACKNOWLEDGEMENTS
The authors thank Tibor Polanyi-Schmidt, particletree, for data bank production and data management, and Cecile Buenter, Surgical Outcome Research Center, for editorial and language assistance.
Glossary
ABBREVIATIONS
- AUC
Area under the curve
- AUC24
Area under curve in the first 24 hours
- COPD
Chronic Obstructive Pulmonary Disease
- DLCO
Diffusing Capacity for Carbon Monoxide
- ELVR
Endoscopic Lung Volume Reduction
- LVRS
Lung Volume Reduction Surgery
- PAL
Prolonged Air Leak
- SD
Standard Deviation
- SPECT-CT
Single Photon Emission Computed Tomography—Computed Tomography
- POD
Postoperative Day
Contributor Information
Eric Francis Macharia-Nimietz, Department of Thoracic Surgery, University Hospital Basel, 4031 Basel, Switzerland.
Makhmudbek Mallaev, Department of Thoracic Surgery, University Hospital Basel, 4031 Basel, Switzerland.
Paulius Gecas, Department of Thoracic Surgery, University Hospital Basel, 4031 Basel, Switzerland.
Jovan Vujic, Department of Thoracic Surgery, University Hospital Basel, 4031 Basel, Switzerland.
Urs Simmen, Statistical Consulting Basel, 4052 Basel, Switzerland.
Aljaz Hojski, Department of Thoracic Surgery, University Hospital Basel, 4031 Basel, Switzerland.
Michael Tamm, Faculty of Medicine of the University of Basel, 4056 Basel, Switzerland.
Didier Lardinois, Department of Thoracic Surgery, University Hospital Basel, 4031 Basel, Switzerland.
AUTHOR CONTRIBUTIONS
Eric Francis Macharia-Nimietz (Conceptualization, Data curation, Investigation, Methodology, Visualization, Writing—original draft, Validation), Makhmudbek Mallaev (Investigation, Data curation), Paulius Gecas (Investigation, Data curation), Jovan Vujic (Investigation, Data curation), Aljaz Hojski (Investigation, Data curation), Urs Simmen (Formal analysis, Validation), Michael Tamm (Validation), Didier Lardinois (Conceptualization, Supervision, Validation, Review & editing)
SUPPLEMENTARY MATERIAL
Supplementary material is available at ICVTS online.
FUNDING
This work was funded by the Department of Thoracic Surgery, University Hospital Basel.
CONFLICTS OF INTEREST
The authors have no relevant conflicts of interest to disclose.
DATA AVAILABILITY
The data underlying this article will be shared on reasonable request to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data underlying this article will be shared on reasonable request to the corresponding author.