Pulmonary Resection For Lung Cancer Research Articles

Does surgical margin affect recurrence and survival after sublobar pulmonary resection for lung cancer?

SummaryA best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: How does surgical margin distance affect recurrence and survival after sublobar pulmonary resection for lung cancer? Altogether, 172 papers were found using the search strategy, of which 12 studies with 1946 stage I non-small-cell lung cancer (NSCLC) patients using sublobar resection (wedge resection or segmentectomy) represented to be the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Overall, 11 cohort studies and 1 prospective study were included. Four cohort studies demonstrated positive prognostic significance of surgical margin with specific cut-off points in each paper (ranged from 9 to 15 mm). Two retrospective studies and 1 prospective study found that a margin-to-tumour ratio of ≥1 was associated with better cytology and prognosis results. Other 5 studies showed that larger margin distance provided a favourable prognosis for NSCLC patients with poor-prognostic factors, including solid-dominant type, high invasive component size and Spread through Air Spaces-positive subtype. After reviewing all the included articles, we conclude that the standard of margin distance of >10 mm or margin-to-tumour ratio ≥ 1 should be recommended for stage I NSCLC patients undergoing sublobar resection, especially in wedge resection. Patients with poor-prognostic factors like solid-predominant tumour or non-lepidic adenocarcinoma may benefit from larger margin distance and the proper margin distance for them still needs to be determined. For Spread through Air Spaces-positive patients, sublobar resection may not be the alternative to lobectomy.

SMOKING AND POSTOPERATIVE PULMONARY COMPLICATIONS AFTER LUNG RESECTION: DID SOMETHING CHANGE OVER TIME?

TOPIC: Tobacco Cessation and Prevention TYPE: Original Investigations PURPOSE: In the last 20 years, preoperative smoking cessation has been widely accepted as a crucial step in patients preparation before lung surgery in order to reduce postoperative morbidity. Nevertheless, an evident reduction in the number of active smokers at surgery (ASS) has not been demonstrated. The aim of the study was to review a single center cohort of lung cancer patients operated during the last 20 years testing the hypothesis that the number of ASS and subsequently the number of postoperative respiratory complications (PRC) reduced over time. METHODS: A cohort of patients who underwent pulmonary resection for lung cancer at the Thoracic Surgery Division of the S.Luigi Hospital, University of Torino, in the period 2001-2021 was reviewed. Data were obtained from the institutional research database. According to their smoking status at the time of surgery, patients were classed as ASS (patients who smoked in the year preceding surgery), ex smokers (having quit smoking at least 12 months before surgery), never smokers. The incidence of postoperative respiratory complications in the first (2001-2011) and second period (2011-2021) of the series were compared. RESULTS: From January 2001 to March 2021, 2437 patients were operated and 1053 of them were ASS (43.2%). The rate of PRC was 14% in ASS and 10% in non smokers (ex + never smokers, p 0.009). The rate of ASS increased from the first period (n=463, 34%) to the second period of the study (n= 590, 53%, p 0.0001), as long as the number of never smokers (n=151, 11%, and 200, 18%, respectively). No difference between groups in terms of PRC was detected in the first period (smokers 12%, non smokers 13.5%). During the second period, ASS had an higher risk of PRC as compared to non smokers (16% vs 5%, p 0.0001). The rate of ex-smokers decreased over time from 53.6% (712) in the first decade to 28.8% (321) in the second decade. CONCLUSIONS: In our center, protocols of preoperative smoking cessation has to be implemented, as the number of ASS increased over time. Despite the fact that the risk of PRC was increased for ASS in the whole series and in the second decade, surprisingly this effect was not evident in the first decade of the study. In fact, during this period ex smokers had not the expected benefit from smoking cessation. No evidence was found to explain this difference. It can be argued that italian legislation limiting tar content in cigarettes in 2003 could have change pattern of lung damage. CLINICAL IMPLICATIONS: The fact that smoke has been recognised as being a major and modifiable risk factor in patients undergoing lung resection does not automatically translates into a significant reduction over time of the number of active smokers at the time of surgery. DISCLOSURES: No relevant relationships by Luca Errico, source=Web Response No relevant relationships by Stefano Ganio, source=Web Response No relevant relationships by Francesco Leo, source=Web Response No relevant relationships by Federica Mellone, source=Web Response No relevant relationships by Jacopo Moro, source=Web Response No relevant relationships by Roberta RAPANA', source=Web Response No relevant relationships by Stefano Rudella, source=Web Response No relevant relationships by Alberto Sandri, source=Web Response No relevant relationships by simona sobrero, source=Web Response No relevant relationships by Federico Vaisitti, source=Web Response

Minimally invasive open surgery (MIOS) for clinical stage I lung cancer: diversity in minimally invasive procedures.

Many thoracic surgeons have tried to make lung cancer surgery less invasive. Among the minimally invasive approaches that are currently available, it is controversial which is optimal. Minimally invasive open surgery, i.e. hybrid video-assisted thoracic surgery, has been adopted for lung cancer surgery at our institute. The objective of this study was to evaluate minimally invasive open surgery in terms of perioperative outcomes over the most recent 5years. Between 2015 and 2019, 2738 patients underwent pulmonary resection for lung cancer at National Cancer Center Hospital, Japan. Among them, 2174 patients with clinical stage I lung cancer who underwent minimally invasive open surgery were included. Several perioperative parameters were evaluated. The patients consisted of 1092 men (50.2%) and 1082 women (49.8%). Lobectomy was performed in 1255 patients (57.7%), segmentectomy in 603 (27.7%) and wide wedge resection in 316 (14.5%). Median blood loss was 30ml (interquartile range: 15-57ml) for lobectomy, 17ml (interquartile range: 10-31ml) for segmentectomy and 5ml (interquartile range: 2-10ml) for wide wedge resection. Median operative time was 120min (interquartile range: 104-139min) for lobectomy, 109min (interquartile range: 98-123min) for segmentectomy and 59min (interquartile range: 48-76min) for wide wedge resection. Median length of postoperative hospital stay was 4days (interquartile range: 3-5days). The 30-day mortality rate was 0.08% for lobectomy, 0.17% for segmentectomy and 0.00% for wide wedge resection. Minimally invasive open surgery for clinical stage I lung cancer is a feasible approach with a low mortality and a short hospital stay. Oncological outcomes need to be investigated.

Predictive factors and economic impact of prolonged air leak after pulmonary resection.

Prolonged air leak (PAL) is one of the most common complications after pulmonary resection for lung cancer. This study aimed to identify the factors that predict PAL, and to evaluate the impact of PAL on the development of additional complications and cost of hospitalization. A total of 2278 patients who underwent pulmonary resection other than pneumonectomy for lung cancer from 2014 to 2018 were retrospectively enrolled in this study. PAL was defined as air leak that continued more than 5days after the operation. Multivariate analyses were conducted to identify significant predictors of PAL, using clinical information. Development of complications other than PAL, and cost of hospitalization care were also analyzed. PAL was observed in 91 (4.0%) cases. Multivariate logistic regression analysis revealed that the presence of intrathoracic adhesion (odds ratio [OR] 4.476, p < 0.001), smoking history > 20 pack-year (OR 2.441, p = 0.005), male sex (OR 2.269, p = 0.013), and lobectomy or bilobectomy (OR 1.935, p = 0.025) were significant risk factors for PAL. The presence of PAL was related to the development of additional complications (p < 0.001). The cost of hospitalization care in patients with PAL was about 1.3times higher than that in patients without PAL (p < 0.001). PAL is related to additional complications and higher cost of hospitalization care. Surgeons should pay careful attention to minimize the incidence of PAL in patients with risk factors including intrathoracic adhesion, history of heavy smoking, male sex, and lobectomy or bilobectomy.

Les réadmissions après résection pulmonaire en France : la base de données du PMSI

Readmission within 30 days is an indicator of the quality of care, because it often reflects post-discharge care that is not optimal. The objective of this work is to measure over time on the one hand the readmission rate and on the other hand the number of hospitals with a standardized readmission rate beyond the national average. All patients with major pulmonary resection for lung cancer in France were extracted from the PMSI national database. Readmission within 30 days was defined as any new hospitalization either in the same hospital or in another establishment. From January 1, 2005 to December 31, 2018, 110,603 patients were included. The 30-day all-cause readmissions rate was 24.9% (n=27,540). Patients after pneumonectomy had a readmission rate of 37% (n=4918) and 23% after lobectomy (n=2684) (P<0.0001). For the first period, we counted 10 hospitals with a standardized readmissions rate above the 99.8 limit and 10 hospitals above the 95% limit. For the second period, 8 hospitals had a standardized readmission rate above the 99.8% limit and 11 hospitals above the 95% limit. For the third period, 7 hospitals had a standardized readmission rate above the 99.8% limit and 6 hospitals above the 95% limit. Readmissions to hospital 30 days after major lung resection for cancer in France declined little during these three periods. Measures to prevent readmissions should be introduced.

Autologous blood patch pleurodesis for prolonged postoperative air leaks.

BackgroundA prolonged air leak (PAL) is the most frequent complication after pulmonary resection. This study aimed to assess the safety and efficacy of autologous blood patch pleurodesis (ABPP) to treat PAL.MethodsA prospectively maintained database identified patients with a PAL after pulmonary resection for lung cancer between 2015–2019. In this observational cohort study, clinical data were collected to retrospectively compare patients undergoing ABPP to no ABPP in a propensity-matched analysis. Kaplan Meier estimates and Cox models accounting for inverse probability weighting (IPTW) were used to assess the association of ABPP with each outcome.ResultsOf the 740 patients undergoing lung resection, 110 (15%) were identified as having a PAL at postoperative day (POD) 5. There was no difference between baseline characteristics among those undergoing ABPP (n=34) versus no ABPP (n=76). Propensity-weighted analysis did not reveal a significant association of ABPP treatment with in-hospital complication (P=0.18), hospital length of stay (LOS) (P=0.13), or post-discharge complication (P=0.13). However, ABPP treatment was associated with a lower risk of hospital readmission [P=0.02, hazard ratio (HR) 0.16] and reoperation for air leak or empyema (P=0.05, HR 0.11). Although not statistically significant, the mean chest tube (CT) removal of 11 days for the ABPP group was less than the no ABPP group (16 days) (P=0.14, HR 1.5–2). Those treated with ABPP were less likely to be discharged with a CT (ABPP 7/34, 21% vs. no ABPP 40/76, 53%). There was no statistical difference in empyema development between groups (ABPP 0/34, 0% vs. no ABPP 4/76, 5%, P=0.39, HR 0.24).ConclusionsABPP administration is safe compared to traditional PAL management. In a retrospective propensity-matched analysis, postoperative patients treated with ABPP required less readmission and reoperation for PAL. Larger powered randomized trials may demonstrate the magnitude of benefit from treatment with ABPP.

Comparison of non-intubated and intubated video-assisted thoracoscopic surgeries of major pulmonary resections for lung cancer\u2014a meta-analysis

ObjectiveThe aim of this study was to compare the safety feasibility and safety feasibility of non-intubated (NIVATS) and intubated video-assisted thoracoscopic surgeries (IVATS) during major pulmonary resections.MethodsA meta-analysis of eight studies was conducted to compare the real effects of two lobectomy or segmentectomy approaches during major pulmonary resections.ResultsResults showed that the patients using NIVATS had a greatly shorter hospital stay and chest-tube placement time (weighted mean difference (WMD): − 1.04 days; 95% CI − 1.50 to − 0.58; P < 0.01) WMD − 0.71 days; 95% confidence interval (CI), − 1.08 to − 0.34; P < 0.01, respectively) while compared to those with IVATS. There were no significant differences in postoperative complication rate, surgical duration, and the number of dissected lymph nodes. However, through the analysis of highly selected patients with lung cancer in early stage, the rate of postoperative complication in the NIVATS group was lower than that in the IVATS group [odds ratio (OR) 0.44; 95% CI 0.21–0.92; P = 0.03, I2 = 0%].ConclusionsAlthough the comparable postoperative complication rate was observed for major thoracic surgery in two surgical procedures, the NIVATS method could significantly shorten the hospitalized stay and chest-tube placement time compared with IVATS. Therefore, for highly selected patients, NIVATS is regarded as a safe and technically feasible procedure for major thoracic surgery. The assessment of the safety and feasibility for patients undergoing NIVATS needs further multi-center prospective clinical trials.

CHANGES IN THE LEVEL OF NT-proBNP AND MEAN PULMONARY ARTERY PRESSURE FOLLOWING BRONCHOPLASTIC LOBECTOMY OR PNEUMONECTOMY AS MARKERS OF RIGHT VENTRICULAR DYSFUNCTION

Background There are scanty data of right ventricular dysfunction markers after major pulmonary resection.Objective To study the changes of plasma level of N-terminal pro-brain natriuretic peptide (NT-proBNP) and its association with pulmonary artery pressure (PAP) as markers of right ventricular dysfunction in patients who underwent bronchoplastic lobectomy or pneumonectomy.Material and Methods The study population consisted of 36 patients aged 40–65 who underwent major pulmonary resection for lung cancer in 2016–2018. Patients were stratified into two groups according to the type of surgical procedure: bronchoplastic lobectomy, the main group (n = 19), and pneumonectomy, control group (n = 17). They were then analyzed for plasma NT-proBNP concentration, operative time, blood loss, intraoperative fluid administration, intraoperative urine output, and mean PAP level before and after an operation.Results The mean PAP level correlated positively with the plasma NT-proBNP concentration in the pneumonectomy group (Pearson r = 0.916754; p &lt; 0.001). This correlation was no evident in the subset of patients undergoing bronchoplastic lobectomy at the same determination point (Pearson r = 0.234741; p = 0.330).Conclusion The mean PAP increased significantly after pneumonectomy and is closely correlated with plasma NTproBNP concentration. These findings support the conclusion that bronchoplasty is preferable over pneumonectomy for lung cancer patients.

Is lung resection appropriate for late octogenarians? Surgical outcomes of patients aged ≥ 80years with lung cancer.

This study aimed to determine the outcomes and prognostic factors associated with octogenarians who underwent pulmonary resection for lung cancer. From 2009 to 2018, 76 octogenarians underwent pulmonary surgery for lung cancer at the Kanazawa Medical University, Japan. They were divided into two groups (early and late octogenarians), and their clinicopathological characteristics and outcomes were investigated. Overall survival rates and recurrence-free survival rates were determined using Kaplan-Meier curves. Univariate and multivariate analyses were performed to identify prognostic factors. Limited surgery was performed more often in the late octogenarian group; however, most perioperative factors were not significantly different between the two groups. The 3-year overall survival and recurrence-free survival rates were 61.2% and 52.8%, respectively. The median observation period was 37.5 (8.9-112.3) months postoperatively. Kaplan-Meier curves showed that age ≥ 85years (late octogenarian), smoking history, and squamous cell carcinoma on histology were associated with worse survival rates. Multivariate analysis identified age ≥ 85years (late octogenarian) (p = 0.011) and cigarette smoking (p = 0.025) as unfavorable prognostic factors for overall survival and recurrence-free survival, respectively. Most octogenarians with an indication for surgery can tolerate pulmonary surgery. However, owing to the limitations of this retrospective, single-center study, future studies involving multiple-institutions are required to confirm our findings.

Diffusion-weighted whole-body imaging with background suppression (DWIBS) is effective and economical for detection of metastasis or recurrence of lung cancer.

BackgroundDiffusion‐weighted whole‐body imaging with background suppression (DWIBS) is used for the diagnosis and staging of cancers. The medical cost of an MR examination including DWIBS is $123, which is 80% less expensive than the cost ($798) of F18‐fluorodeoxyglucose positron emission tomography/computed tomography (FDG‐PET/CT) examination.MethodsThis study examined the efficacy of DWIBS for relapses after lung cancer resection. A total of 55 patients who had pulmonary resection of lung cancer, postoperative computed tomography (CT) every six months, and DWIBS and FDG‐PET/CT (every year) were enrolled in this study. If a metastatic lesion was detected on CT scan, DWIBS and FDG‐PET/CT were also used.ResultsA total of 55 patients who underwent pulmonary resections for lung cancer, and had CT, DWIBS and FDG‐PET/CT examination during follow‐up after pulmonary resection were enrolled in this study. Lung cancer in 32 patients relapsed. Postoperative radiographic examinations revealed pulmonary metastases in 17 patients, bone metastases in seven, liver metastases in five, lymph node metastases in five, pleural metastases in four, metastases to the chest wall in two, brain metastases in two, adrenal gland metastasis in one, and renal metastasis in one. The mean apparent diffusion coefficient (ADC) value of the relapse was 0.9 to 1.70 × 10−3 mm2/s. The accuracy 0.98 (54/55) of DWIBS for detecting multiple metastatic lesions was likely to be higher than 0.94 (52/55) of CT or 0.94 (52/55) of FDG‐PET/CT, but there were no significant differences.ConclusionsDWIBS can detect multiple metastatic lesions throughout the entire body and differentiate malignancy from benignity in only one examination. DWIBS has benefits of diagnostic accuracy and is less expensive in medical costs for the detection of a relapse. DWIBS could potentially replace FDG‐PET/CT after lung cancer resection.

Factors Associated with Unexpected Readmission Following Lung Resection.

Identification of the predictors of readmission can facilitate appropriate perioperative management. The current study aimed to investigate the potential predictors of unexpected readmission after lung resection for primary lung cancers. This retrospective study enrolled 1000 patients who underwent pulmonary resection for lung cancer at our institution between January 2016 and December 2017. Unexpected readmission was defined as unscheduled readmission to our hospital within 30days after discharge. Univariate and multivariate analyses were performed for identification of perioperative factors associated with readmission. Forty-three patients (4.3%) required unexpected readmission, and the median interval between the day of discharge and readmission was 10days (range 1-29days). The reasons for readmission included empyema and pleural effusion (n = 11), acute exacerbation of idiopathic pulmonary fibrosis (n = 7), pneumothorax (n = 7), and others (n = 18). The median hospitalization length after readmission was 14days (range 2-90days). Four patients (9.3%) died in the hospital because of acute exacerbation of idiopathic pulmonary fibrosis after readmission. In multivariate logistic regression analysis, postoperative refractory air leakage, defined as prolonged air leakage lasting > 5days or requiring reoperation, was identified as a significant predictor associated with an increased risk of readmission (odds ratio 2.87; 95% confidence interval 1.22-6.72; p = 0.015). Unexpected readmission was an inevitable event following lung resection. Patients with readmission had an increased risk of death. Refractory air leakage after lung resection for primary lung cancer was strongly associated with unexpected readmission.

Differentiation between suture recurrence and suture granuloma after pulmonary resection for lung cancer by diffusion-weighted magnetic resonance imaging or FDG-PET / CT

There has been no publication which supports the usefulness of DWI differentiating for suture recurrence and suture granuloma after resection for lung cancer. We presented efficacy of DWI or FDG-PET/CT for an assessment of suture lesions after resection for lung cancer. Thirteen suture recurrences and 15 suture granulomas were examined. There were 24 adenocarcinomas and 4 squamous cell carcinomas, and 26 partial resections and 2 segmentectomies. The period of time (907±907 days) between surgery and suture recurrence was not significantly longer than that (546±547 days) between surgery and suture granuloma. Diffusion detectability scores (a 5-point scale) of suture recurrences was significantly higher than that of suture granulomas. The ADC value (1.35±0.24 × 10−3mm2/sec) of suture recurrences was significantly lower than that (1.85±0.60 × 10−3mm2/sec) of suture granulomas. The SUVmax (6.1 ± 5.0) of suture recurrences was not significantly higher than that (4.2 ± 2.5) of suture granulmas. The sensitivity of 85% (11/13) with DWI was not significantly higher than 69% (9/13) with FDG-PET/CT for suture recurrences. The specificity of 73% (11/15) with DWI was not significantly higher than the 60% (9/15) with FDG-PET/CT for suture granulomas. The accuracy of 79% (22/28) with DWI was not significantly higher than that of 64% (18/28) with FDG-PET/CT for suture recurrences and granulomas. DWI can differentiate suture granuloma from suture recurrence after resection of lung cancer. DWI is more useful than FDG-PET/CT for the differentiation between suture recurrence and suture granuloma after resection for lung cancer.

Lung function tests, exercise capacity and postoperative outcomes of patients with pulmonary resections

Abstract Aim: Postoperative complications, especially pulmonary complications, are described after lung resections, with different risk factors involved. We evaluate the relationship between lung function, exercise test parameters and the occurrence of postoperative outcomes in patients with pulmonary resections. Methods: A 5 years prospective observational study on patients with lung resection (lobectomy, bilobectomy and pneumonectomy) for lung cancer and other pulmonary pathologies has been performed. All the patients were preoperatively evaluated using spirometry, plethysmography, diffusing capacity test and cardio-pulmonary exercise test (CPET). Data were analysed regarding the linkage between cardiopulmonary fitness and postoperative outcomes (respiratory complications and 90-day mortality). Results: Of 155 consecutive patients (109 male, mean age 61.2 ± 9.8 years), 130 (83.9%) underwent pulmonary resection for lung cancer. Nearly 24% of patients developed postoperative respiratory complications (mainly atelectasis, prolonged air leak and respiratory failure). The 90-day mortality was 5.2%. A reduced absolute value of forced expiratory volume in 1 s (FEV1) was found to be associated with postoperative atelectasis [odds ratio (OR) 0.33; 95% confidence interval (CI) 0.11–0.99], but with low accuracy. The most related variable and a predictor to prolonged air leak was FEV1/vital capacity (VC) ratio (OR 0.90; 95% CI 0.83–0.99). Patients who developed respiratory failure had lower values of static volumes and breathing reserve (BR%) compared to those without respiratory failure, but with no significant difference (P &gt; 0.050). No relationship to mortality was noted. Conclusion: In our study group, lower values of FEV1 were related to postoperative atelectasis and obstructive dysfunction with persistent air leak, with no significant association with mortality.

Multiinstitutional Phase 2 Clinical Trial of Intraoperative Molecular Imaging of Lung Cancer

Intraoperative molecular imaging (IMI) may improve surgical outcomes during pulmonary resection for lung cancer. A multiinstitutional phase 2 IMI clinical trial was conducted using a near-infrared, folate receptor-targeted contrast agent for lung adenocarcinomas, OTL38. The primary goal was to determine whether OTL38 improved surgeons' ability to identify difficult to find nodules, occult cancers, and positive margins. Patients with lung nodules received OTL38 (0.025 mg/kg) preoperatively. Patients had IMI sequentially during lung inspection, tumor resection, and margin check. Efficacy was evaluated by occurrence of clinically significant events, occurrences that caused the surgeon to modify the operation or upstage the patient's cancer. Safety was assessed for a single intravenous dose of OTL38. Of 110 patients recruited, 92 were eligible for analysis. During lung inspection, IMI found 24 additional nodules, 9 (10%) of which were cancers that had not been known preoperatively. During tumor resection, IMI located 11 (12%) lesions that the surgeon could not find. During the margin check, IMI revealed 8 positive margins (9%) that the surgeon thought were negative. Benefits of IMI were pronounced in patients undergoing sublobar pulmonary resections and in patients with ground-glass opacities. There were no serious adverse events. All surgeons felt comfortable with the procedures by 10 cases. In this phase 2 clinical trial, IMI improved outcomes for 26% of patients. A randomized, multiinstitutional phase 3 clinical trial is underway.

Sex and Survival After Surgery for Lung Cancer: A Swedish Nationwide Cohort

BackgroundPrior reports on a possible female survival advantage in both surgical and nonsurgical cohorts of patients with lung cancer are conflicting. Previously reported differences in survival after lung cancer surgery could be the result of insufficient control for disparities in risk factor profiles in men and women.Research QuestionDo women who undergo pulmonary resections for lung cancer have a better prognosis than men when taking a wide range of prognostic factors into account?Study Design and MethodsWe performed a nationwide population-based observational cohort study analyzing sex-specific survival after pulmonary resections for lung cancer. We identified 6356 patients from the Swedish National Quality Register for General Thoracic Surgery and performed individual-level record linkage to other national health-data registers to acquire detailed information regarding comorbidity, socioeconomic status, and vital status. Inverse probability of treatment weighting was used to account for differences in baseline characteristics. The association between female sex and all-cause mortality was assessed with Cox regression models, and flexible parametric survival models were used to estimate the absolute survival differences with 95% CIs. We also estimated the difference in restricted mean survival time.ResultsWe observed a lower risk of death in women compared with men (hazard ratio, 0.73; 95% CI, 0.67-0.79). The absolute survival difference at 1, 5, and 10 years was 3.0% (95% CI, 2.2%-3.8%), 10% (95% CI, 7.0%-12%), and 12% (95% CI, 8.5%-15%), respectively. The restricted mean survival time difference at 10 years was 0.84 year (95% CI, 0.61-1.07 years). The findings were consistent across several subgroups.InterpretationWomen who underwent pulmonary resections for lung cancer had a significantly better prognosis than men. The survival advantage was evident regardless of age, common comorbidities, socioeconomic status, lifestyle factors, physical performance, type and extent of surgery, tumor characteristics, and stage of disease.Trial RegistryClinicalTrials.gov; No.: NCT03567538; URL: www.clinicaltrials.gov

Household disposable income and long-term survival after pulmonary resections for lung cancer

IntroductionSocioeconomic disparities have been linked to survival differences in patients with lung cancer. Swedish healthcare is tax-funded and provides equal access to care, therefore, survival following lung cancer surgery should...

The Year in Thoracic Anesthesia: Selected Highlights from 2019

THIS special article is the 4th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan; the associate editor-in-chief, Dr. Augoustides; and the editorial board for the opportunity to expand this series, the research highlights of the year that specifically pertain to the specialty of thoracic anesthesia. The major themes selected for 2019 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in this specialty for 2019 include updates in the preoperative assessment and optimization of patients undergoing lung resection and esophagectomy, updates in one lung ventilation (OLV) and protective ventilation during OLV, a review of recent meta-analyses comparing truncal blocks with paravertebral catheters and the introduction of a new truncal block, meta-analyses comparing nonintubated video-assisted thoracoscopic surgery (VATS) with those performed using endotracheal intubation, a review of the Society of Thoracic Surgeons (STS) recent composite score rating for pulmonary resection of lung cancer, and an update of the Enhanced Recovery After Surgery (ERAS) guidelines for both lung and esophageal surgery.

Cost in video-assisted thoracic surgery versus robotic-assisted thoracic surgery for lung cancer: should we focus on other metrics?

Historically, pulmonary resections for lung cancer have been done in an open fashion. With the adoption of VATS, incisions became smaller but challenges such as cost, safety, and quality of resection became the center of the discussion. However, now we have extensive evidence of the benefit of minimally invasive approaches. With the introduction of robotic-assisted thoracic surgery (RATS), the discussion has gone back to cost as the main driver. This increased robotic cost has been evaluated by multiple studies without a general consensus, given the varying definitions of cost. Medical institutions and health systems will never share the details of what those technologies cost, which makes comparisons not truly significant. In this article, we analyzed the pros and cons of RATS versus VATS and tried to answer if cost is the adequate metric when comparing both techniques.

Perioperative Outcomes of Patients Undergoing Pulmonary Resection for Lung Cancer after Coronary Stenting

背景与目的肺癌患者合并有冠心病是很常见的一种情况，部分患者既往植入冠脉支架并接受抗血小板治疗。对于带有冠脉支架需要行肺切除手术的肺癌患者，围手术期是否停用抗血小板药物仍然存在争议。本研究通过回顾我院的数据来明确这部分特殊人群的围手术期结局。方法回顾性分析了2013年1月-2019年9月冠脉支架术后在北京大学第一医院胸外科行肺切除手术的肺癌患者的临床数据。所有患者术前暂停口服抗血小板药物至少5 d。主要研究终点是院内的心血管并发症和死亡。结果本研究共纳入111例患者。支架放置和肺癌手术间隔的时间在1个月-3个月、3个月-12个月、超过12个月的患者分别为6.3%、13.5%和80.2%。亚肺叶切除、肺叶切除、联合肺叶切除、全肺切除以及肺叶袖式切除的患者分别为10.8%、71.2%、9.0%、2.7%和6.3%。总的心血管并发症发生率为11.6%，包括不稳定心绞痛（n=1, 0.9%）、低血压（n=1, 0.9%）、充血性心力衰竭（n=2, 1.8%）和新发心房纤颤（n=10, 9.0%）。本组病例无围手术期死亡，无主要不良心血管事件（major adverse cardiac events, MACE）。结论术前暂停口服抗血小板药物是安全的，围手术期未发生MACE和死亡。

Preoperative Heparin for Lung Cancer Resection Increases Risk of Reoperation for Bleeding

Lung cancer patients are at risk for venous thromboembolism (VTE). Preoperative heparin administration may increase the risk of bleeding requiring reoperation. The purpose of this study was to evaluate preoperative heparin's effect on reoperation for bleeding. A retrospective review compared outcomes for patients undergoing pulmonary resection for primary lung cancer from January 2006 to April 2018. Preoperative heparin was administered at the discretion of the attending surgeon. Comparisons were performed between preoperative subcutaneous heparin (5000 U) and no heparin groups. A total of 3325 lung resections were reviewed, 1.4% (n = 48) required reoperation for bleeding. VTE occurred in 1.1% (n = 38). Four hundred sixty-four patients (14.0%) did not receive preoperative heparin. The preoperative heparin group had increased rates of prior thoracic surgery (5.1% [n = 146] vs 1.7% [n = 8], P < 0.001), minimally invasive approach (40.2% [n = 1150] vs 10.6% [n = 49], P < 0.001), and sublobar resections (17.7% [n = 506] vs 10.6% [n = 49], P < 0.001). There were no differences in blood loss/transfusions. Reoperation for bleeding was significantly increased in the preoperative heparin group (1.6% [n = 47] vs 0.2% [n = 1], P = 0.017). There were no differences in VTE (1.5% [n = 7] vs 1.1% [n = 31], P = 0.424). On logistic regression, preoperative heparin was independently associated with increased reoperation for bleeding (odds ratio 8.13, P = 0.039); however, preoperative heparin was not independently associated with VTE. Preoperative heparin was associated with increased reoperation for bleeding. VTE rates are low after pulmonary resection for lung cancer and are not decreased by preoperative heparin. Preoperative heparin use should be determined by risk factor stratification for VTE and reoperation for bleeding in patients undergoing lung cancer resection.