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after adjusting for covariates on Cox regression (hazard ratio, 1.69; P < 0.01). The authors concluded that,
operable patients considering primary SBRT should be educated regarding this difference in survival. Even
though they reported that in the surgery group, 102,596 (75.0%) underwent lobectomy and 25,048 (18.3%)
sub-lobar resection with the remaining patients undergoing other or unspecified types of resection, they
did not report how many patients who refuse surgery were offered minimally invasive surgery, or whether
they were offered lobectomy or sub-lobar resection and whether this was a point of refusal for surgical
[24]
option or not. According to Sihoe , for any new technique or procedure, the evolution of research and
evidence-gathering can be categorized into five distinct phases that neatly correspond to the development
of a human. Awake uniportal VATS must go to from Infancy-safety & feasibility and Childhood-crude
benefit to the next level of technique maturity in this stage which is Adolescence-objective, quantifiable
benefit then to Adulthood-treatment efficacy and finally to Maturity-sustainability.

CONCLUSION
Although there is cumulative evidence of the safety and feasibility of awake uniportal VATS lung resection
for early stage lung cancer and the preliminary results suggesting benefits for patients with limited
pulmonary functions, more prospective studies are needed to investigate long-term outcome on patients
who have limited pulmonary reserve and increased frailty.

DECLARATIONS
Authors’ contributions
Collection and assembly of data, data analysis and interpretation: Elkhayat H
Manuscript writing: Elkhayat H, Gonzalez Rivas D
Conception and design, administrative support, provision of study material: Gonzalez Rivas D

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2020

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