Thoracic Centre Research Articles

Impact of High-Grade Patterns in Early-Stage Lung Adenocarcinoma: A Multicentric Analysis

ObjectiveThe presence of micropapillary and solid adenocarcinoma patterns leads to a worse survival and a significantly higher tendency to recur. This study aims to assess the impact of pT descriptor combined with the presence of high-grade components on long-term outcomes in early-stage lung adenocarcinomas.MethodsWe retrospectively collected data of consecutive resected pT1-T3N0 lung adenocarcinoma from nine European Thoracic Centers. All patients who underwent a radical resection with lymph-node dissection between 2014 and 2017 were included. Differences in Overall Survival (OS) and Disease-Free Survival (DFS) and possible prognostic factors associated with outcomes were evaluated also after performing a propensity score matching to compare tumors containing non-high-grade and high-grade patterns.ResultsAmong 607 patients, the majority were male and received a lobectomy. At least one high-grade histological pattern was seen in 230 cases (37.9%), of which 169 solid and 75 micropapillary. T1a-b-c without high-grade pattern had a significant better prognosis compared to T1a-b-c with high-grade pattern (p = 0.020), but the latter had similar OS compared to T2a (p = 0.277). Concurrently, T1a-b-c without micropapillary or solid patterns had a significantly better DFS compared to those with high-grade patterns (p = 0.034), and it was similar to T2a (p = 0.839). Multivariable analysis confirms the role of T descriptor according to high-grade pattern both for OS (p = 0.024; HR 1.285 95% CI 1.033–1.599) and DFS (p = 0.003; HR 1.196, 95% CI 1.054–1.344, respectively). These results were confirmed after the propensity score matching analysis.ConclusionspT1 lung adenocarcinomas with a high-grade component have similar prognosis of pT2a tumors.

Real-life long-term outcomes of upfront surgery in patients with resectable stage I-IIIA non-small cell lung cancer.

BackgroundTreatment of early-stage non-small cell lung cancer (NSCLC) is rapidly evolving. When introducing novelties, real-life data on effectiveness of currently used treatment strategies are needed. The present study evaluated outcomes of stage I–IIIA NSCLC patients treated with upfront radical surgery in everyday clinical practice, between 2010–2017.Patients and methodsData of 539 consecutive patients were retrieved from a prospective hospital-based registry. All diagnostic, treatment and follow-up procedures were performed at the same thoracic oncology centre according to the valid guidelines. The primary outcome was overall survival (OS) analysed by clinical(c) and pathological(p) TNM (tumour, node, metastases) stage. The impact of clinicopathological characteristics on OS was evaluated using univariable (UVA) and multivariable regression analysis (MVA).ResultsWith a median follow-up of 53.9 months, median OS and 5-year OS rate in the overall population were 90.4 months and 64.4%. Five-year OS rates by pTNM stage I, II and IIIA were 70.2%, 60.21%, and 49.9%, respectively. Both cTNM and pTNM stages were associated with OS; but only pTNM retained its independent prognostic value (p = 0.003) in MVA. Agreement between cTNM and pTNM was 69.0%. Next to pTNM, age (p = 0.001) and gender (p = 0.004) retained their independent prognostic value for OS.ConclusionsThe study showed favourable outcomes of resectable stage I–IIIA NSCLC treated with upfront surgery in real-life. Relatively low agreement between cTNM and pTNM stages and independent prognostic value of only pTNM, observed in real-life data, suggest that surgery remains the most accurate provider of the anatomical stage of disease and important upfront therapy.

Incidence of Air Leak in Stapled Versus Hand Sewn Pulmonary Resections

Postoperative air leak is a frequent complication after pulmonary resection. Different approaches have been used to control the incidence of air leaks after pulmonary resection. Objectives: To compare stapled pulmonary resection and hand-sewn, i.e. manual pulmonary resection for the incidence and duration of resolution of air leaks. Methods: This was a prospective comparative study, conducted from August 2019 to July 2020 in the Department of Thoracic Surgery Jinnah Postgraduate Medical Centre, Karachi. Patients indicated for pulmonary resection were randomized to either stapled pulmonary resection (Group A) or manually sutured (Group B) pulmonary resection and were followed till their discharge or resolution of air leak. Results: The total number of air leaks in group A was 9 (30%), out of which 8 (26.6%) resolved conservatively and only one (3.3%) required re-exploration and surgical intervention. The total number of air leaks in group B was 7 (25%), out of which 6 (21.4%) resolved conservatively and only one (3.5%) required re-exploration and surgical intervention. The difference was not significant in the incidence of air leak of both groups. Persistent air leak (PAL) was present in 5 (16.6%) patients in group A and 3 (10.7%) patients in group B. Conclusion: Our study suggests that both stapled pulmonary resection and manually sutured pulmonary resection techniques are comparable in terms of incidence of air leak and its resolution. Hence, the choice of technique should be based on parameters, including the technical aspects and surgeon's preference.

3Dimaging of supraspinal inputs to the thoracic and lumbar spinal cord mapped by retrograde tracing and light‐sheet microscopy

The supraspinal inputs play a major role in tuning the hindlimb locomotion function. While most research on spinal cord injury (SCI) with rodents is based on thoracic segments, the difference in connectivity of the supraspinal centers to the thoracic and lumbar cord is still unknown. Here, we combined retrograde tracing and 3D imaging to map the connectivity of supraspinal neurons projecting to thoracic (T9-vertebral) and lumbar (T13-vertebral) spinal levels in adult female mice. We dissected the difference in connections of corticospinal neurons (CSNs), rubrospinal neurons, and reticulospinal neurons projecting to thoracic and lumbar cords. The ratio of double-labeled neurons is higher in T13-vertebral projection CSNs and parvocellular part of the red nucleus (RPC) than in T9-vertebral projection. Using the Cre-DIO system, we precisely targeted CSNs projecting to T9-vertebral or T13-vertebral. We found that abundant axon branches communicated with the red nucleus and reticular formation and distributed from cervical gray matter to the lumbar cord. Their collateral branches showed a distinct innervation pattern in thoracic and lumbar gray matters and a similar distribution pattern in the cervical spinal cord. These results revealed the difference in connectivity between the thoracic and lumbar projection supraspinal centers and clarified the collateralization of thoracic/lumbar projection CSNs throughout the brain and spinal cord. This study highlights brain-spinal cord neural networks and the complexity of the axon terminals of spinal projection CSNs, which could contribute to the development of targeted therapeutic strategies connecting CST fibers and hindlimb function recovery. Cover Image for this issue: https://doi.org/10.1111/jnc.15414.

Az unilateralis videoasszisztált torakoszkópos thymomaeltávolítás javallata, korai és középtávú eredményei.

Introduction. Thymomais the most common tumour of the anterior mediastinum. Video-Assisted Thoracic Surgery technique of thymomaresection is spreading world-wide, but the thoracoscopic method is still contentious in many ways. Authors evaluate the early and mid-term results of a17 years period of VATS unilateral approach at 2 Hungarian thoracic surgical centers. Method. Depending on the anatomical situation of the thymoma, we performed thymectomy, or partial thymectomy (thymomectomy) for the Masaoka–KogaI–II–III stage thymomafrom the right or left side through 2 or 3 intercostal ports. We managed the operations with ultrasonic dissector and electrocauter. By using international standards we evaluated perioperative morbidity, mid-term oncological results and clinical symptoms of myasthenia. Results. 23 of the 54 patients were man, 31 were woman, the average age was 58 (26–79) years, 23 of them had myasthenia. The conversion rate was 11,5% (7/61). The average operation time was 84(39–150) minutes. The average hospitalisation time was 5.5 (3–19) days. The average size of the thymomas was 46 (18–90) mm. The histology resulted thymomatype Ain 2 cases, AB in 19 cases, B1/2/3 in 11/11/1 cases, mixed B in 10 cases. The examination of the resection line was R0/1/2 in 42/11/1 cases. The Masaoka–Kogastages were: I (17), IIA(28), IIB (2), III (7). There was 25 thymomectomies, and 29thymectomies. In seven cases there were extension of the operation to the pericardium (2), to the lung (2), to the phrenic nerve (6), and to innominate vein (1). The in-hospital mortality over 30 day was in 1 case (1.85%). The morbidity was 11/54 (20.4%). The average follow-up time was 62.56 (5–198) months. In the group with myastheniathe effectivity of the operation was 18/21 (85.7%), including complete remission of 5/21 (23.8%). Post-thymectomy myastheniagravis developed in 2/31 cases (6.5%). The average 5 years survival was 100%, tumour-free 5 years survival was 96%. Conclusions. The higher proportion of the thymomectomy in the early results, higher conversion rate and lower R0 proportion might be in connection with the attitude of the surgeons, with the learning curve and with the limitations of the unilateral method. After alonger follow-up time late results may become more real and comparable. Instead of unilateral VATS technique we have changed to the subxyphoideal approach of VATS because of its better visualisation.

Re-Assessment of the Plant Protection Product PROMAN – with the Active Ingredient Metobromuron [Edition 2

Proman is a broad spectrum selective herbicide for potatoes grown outdoors, containing the active substance metobromuron. VKM’s Panel on Plant Protection Products has previously discussed questions concerning Proman raised by The Norwegian Food Safety Authority, and stated its opinion in a report of 21. January 2015 (http://www.vkm.no/dav/3c64afe035.pdf). 
 Following this report, The Norwegian Food Safety Authority turned down the application to register Proman as a plant protection product in Norway. The applicant filed a complaint on this decision, and the VKM Panel has been asked to reassess its previous opinion in light of the information given by the applicant in the complaint. 
 The VKM Panel has discussed the arguments put forward in the complaint. The arguments did not change the Panel’s main conclusions in the original assessment. Some changes in the wording of the conclusions were however done, in order to put more emphasis on areas of uncertainty. 
 These are the standing conclusions of VKM’s Panel on Plant Protection Products:
 
 On the relevance of the carcinogenic effects observed in the rat carcinogenicity study; fibrosarcomas in females and pheochromocytomas and Leydig cell tumours in males: 
 It is the opinion of VKM’s Panel for Plant Protection Products that the relevance of the observed incidences of mammary gland tumours and Leydig cell tumours in the rat carcinogenicity study is strengthened by the fact that the increases in tumours associated with exposure to metobromuron are observed in hormone responsive tissues. The panel concludes that the carcinogenic effects observed in the rat carcinogenicity study could be relevant for tumour induction in humans. 
 Higher incidences of still dumbbell-shaped centres of thoracic vertebrae and nonossification of the 13th rib observed in the rat developmental toxicity study and whether these are considered to be malformations: 
 VKM’s Panel on Plant Protection Products has discussed the classification of the different types of incomplete ossifications and concluded that incomplete ossification of sternebrae and non-ossification of the 13th rib in rats should by itself be considered to be variations, and not adverse developmental effects. On the other hand, the Panel agrees with ECHA that the “thoracic vertebral centres still dumbbell-shaped” should be considered as malformations, due to limited data and understanding of the mechanism underlying the observed slow reversal of these anomalies. Furthermore, it is the view of the Panel that the different types of retarded ossification induced by the exposure should be considered as a whole when assessing for developmental effects. 
 Establishment of the NOAEL for the developmental toxicity study in rats and the reference value (ARfD): 
 VKM’s Panel on Plant Protection Products supports the proposal of an ADI value of 0.008 mg/kg bw/day based on a NOAEL of 0.8 mg/kg bw/day from the 2-year study in mouse, and AOEL of 0.016 mg/kg bw/day based on the NOAEL of 1.6 mg/kg bw/day from the 1-year feeding study in dog. The panel suggests an alternative ARfD value of 0.03 mg/kg bw based on a LOAEL of 10 mg/kg bw /day for the observations of incomplete ossification in the rat developmental study. 
 The anti-androgenic potential of metobromuron: 
 The rat carcinogenicity study indicates that metobromuron may interact with the endocrine system. The data from the Hershberger in vivo rat study, the in vitro studies, as well as the comparison with demonstrated effects and mechanisms for flutamide and linuron is suggestive of an anti-androgenic effect. Thus, it is the opinion of the VKM Panel on Plant Protection Products that an anti-androgenic effect of metobromuron cannot be excluded.

Feasibility study of a randomised controlled trial of preoperative and postoperative nutritional supplementation in major lung surgery

ObjectivesMalnutrition and weight loss are important risk factors for complications after lung surgery. However, it is uncertain whether modifying or optimising perioperative nutritional state with oral supplements results in a...

Neoadjuvant chemoradiotherapy is superior to chemotherapy alone in surgically treated stage III/N2 non-small-cell lung cancer: a retrospective single-center cohort study

BackgroundThere is lack of consensus whether neoadjuvant chemoradiotherapy (CHT/RT) is superior to neoadjuvant chemotherapy (CHT) alone in patients with potentially resectable stage III/N2 non-small-cell lung cancer (NSCLC).Patients and methodsWe retrospectively evaluated clinical parameters and outcomes in patients with clinical stage III/N2 NSCLC treated with neoadjuvant CHT/RT versus CHT followed by surgery. Nearest-neighbor propensity score (PS) matching was used to correct for pretreatment differences.ResultsA total of 84 patients were enrolled. Thirty-four (40%) and 50 (60%) patients received CHT/RT or CHT followed by curative-intent surgery, respectively. Overall 90-day mortality and morbidity were 0% versus 0.04% and 21% versus 18%, respectively, with no significant difference between the CHT/RT and the CHT-alone cohorts (P = 0.51 and P = 0.70). In the PS-matched cohort, complete pathological response was recorded in 25% after CHT/RT versus 0% after CHT at the time of surgery. Patients receiving neoadjuvant CHT/RT exhibited significantly better 5-year disease-free survival (DFS) [45% versus 16% CHT group; hazard ratio (HR) 0.43, P = 0.04]; 5-year overall survival (OS) was 75% after CHT/RT and 21% after CHT (HR 0.37, P = 0.001). CHT/RT more often induced pathological mediastinal downstaging (P = 0.007), but CHT/RT remained the only independent factor for DFS and OS and did not depend on mediastinal downstaging.ConclusionsIn this retrospective PS-matched long-term analysis, neoadjuvant CHT/RT conferred improved DFS and OS compared with CHT alone in stage III/N2 NSCLC. These highly challenging results require confirmation in well-designed randomized controlled trials conducted at highly specialized thoracic oncology centers.

The effects of paravertebral blockade usage on pulmonary complications, atrial fibrillation and length of hospital stay following thoracoscopic lung cancer surgery

Study objectiveAlthough combined thoracic paravertebral blockade (TPVB)-general anesthesia (GA) could improve pain control compared to GA alone after thoracoscopic lung cancer surgery, it has not been established whether this improvement in pain control could reduce associated adverse outcomes. Thus, this study aimed to explore the association between TPVB usage and adverse outcomes after thoracoscopic lung cancer surgery. DesignRetrospective cohort study from a prospective database. SettingA high-volume thoracic center in China. Patients13966 consecutive patients who received thoracoscopic lung cancer surgery from January 2016 to December 2018 in Shanghai Chest Hospital were enrolled. MeasurementsWith a 1:1 propensity score matching (PSM) analysis, adverse outcomes between GA alone and GA-TPVB were investigated. Multivariate and multiple linear regression analysis were used to identify factors and calculate odds radio (OR) for adverse outcomes. ResultsThe rate of TPVB usage was 14.8% (2070 out of 13,966). TPVB combined with GA was associated with lower rates of postoperative pulmonary complications (PPCs) (30.4% vs 33.5%, P = 0.005) and postoperative atrial fibrillation (POAF) (2.1% vs 2.9%, P = 0.041), and shorter length of hospital stay (LOS) (Median [IQR]; 5[4-5] vs 5[4-6]) days, P < 0.001) compared to GA alone. After a 1:1 PSM analysis, we investigated adverse outcomes in 2640 (1320 pairs) patients with or without TPVB usage, and this association remained existed, namely, the rates of PPCs (29.8% vs 34.2%, P = 0.014) and POAF (2.2% vs 3.6%, P = 0.028) were lower and LOS was shorter (5[4-5] vs 5[4-6] days, P < 0.001) in the GA-TPVB group. In multivariate analysis, the combination of GA plus TPVB was independent predictor for PPCs (OR = 0.879, 95%CI, 0.793–0.974, P = 0.014) and POAF (OR = 0.714, 95%CI, 0.516–0.988, P = 0.042), respectively. However, in multiple linear analysis, lower rates of PPCs and POAF associated with TPVB usage, rather than TPVB usage, were responsible for the reduced LOS. ConclusionsThe usage of TPVB may be a feasible and adjustable approach to reduce the rates of PPCs and POAF and associated LOS in thoracoscopic lung cancer surgery.

Impact of an Embedded Palliative Care Clinic on Healthcare Utilization for Patients With a New Thoracic Malignancy.

IntroductionPalliative care is beneficial for patients with advanced lung cancer, but the optimal model of palliative care delivery is unknown. We investigated healthcare utilization before and after embedding a palliative care physician within a thoracic medical oncology “onco-pall” clinic.MethodsThis is a retrospective cross-sectional cohort study comparing healthcare outcomes in two cohorts: “pre-cohort” 12 months prior to and “post-cohort” 12-months after the onco-pall clinic start date. Patients were included if they had a new diagnosis of lung cancer and received care at The Ohio State University Thoracic Oncology Center, and resided in Franklin County or 6 adjacent counties. During the pre-cohort time period, access to palliative care was available at a stand-alone palliative care clinic. Palliative care intervention in both cohorts included symptom assessment and management, advance care planning, and goals of care discussion as appropriate. Outcomes evaluated included rates of emergency department (ED) visits, hospital admissions, 30-day readmissions, and intensive care unit (ICU) admissions. Estimates were calculated in rates per-person-years and with Poisson regression models.ResultsIn total, 474 patients met criteria for analysis (214 patients included in the pre-cohort and 260 patients in the post-cohort). Among all patients, 52% were male and 48% were female with a median age of 65 years (range 31-92). Most patients had non-small cell lung cancer (NSCLC - 17% stage 1-2, 20% stage 3, 47% stage 4) and 16% had small cell lung cancer. The post-cohort was older [median age 66 years vs 63 years in the pre-cohort (p-value: < 0.01)]. The post-cohort had a 26% reduction in ED visits compared to the pre-cohort, controlling for age, race, marital status, sex, county, Charlson score at baseline, cancer type and stage (adjusted relative risk: aRR: 0.74, 95% CI: 0.58-0.94, p-value = 0.01). Although not statistically significant, there was a 29% decrease in ICU admissions (aRR: 0.71, 95% CI: 0.41-1.21, p-value = 0.21) and a 15% decrease in hospital admissions (aRR: 0.85, 95% CI: 0.70-1.03, p-value = 0.10). There was no difference in 30-day readmissions (aRR: 1.03, 95% CI: 0.73-1.45, p-value = 0.85).ConclusionsEmbedding palliative care clinics within medical oncology clinics may decrease healthcare utilization for patients with thoracic malignancies. Further evaluation of this model is warranted.

Wrapping technique of ascending aorta in Hybrid procedure for complex aortic arch disease

Background: The hybrid procedure proved to be very suitable for Vietnamese conditions in the treatment of complex aortic diseases in the arch and on supra-renal lesion. There is a difficult situation when the ascending aorta is more dilated than can be accommodated by stent-grafts. Wrapping techique is a solution to this situation. Methods: Report on a clinical case of successful application of aortic wraping technique to treat complex aortic cross injuries at Cardiovascular and Thoracic Center, Viet Duc University Hospital. Results: A 73-year-old female patient was admitted to the hospital because of sudden chest pain. History of high blood pressure, heart failure, dyslipidemia and hypothyroidism. MSCT revealed type B aortic dissection, left hemothorax complication, the entire ascending aorta and a part of cross dilated to 50mm (maximum stent-graft size is 46mm). Poor general condition, severe and complicated acute aortic injury, if the classic surgery requires total thoracic aorta replacement – ​​the risk of death is very high, so the hybrid solution is a reasonable choice if having the solution is to solve the problem to create a landing zone for stent-graft. Hybrid surgery was started with open sternotomy, bilateral aortic - carotid bypass with Dacron prothesis 9mm, using a large artificial vessel to wrap around the ascending aorta to reduce the medium size to 38mm. Drain and close the sternum. Next is endovascular intervention – installing a stent-grafts of 42x42x200 and 42x38x150 then 38x34x150 to the diaphragm, plug for left subclavian artery. Left pleural drainage. The patient was discharged 10 days after surgery. Follow-up after 2 years for good results. Conclusion: The hybrid procedure can still be applied in the situation of ascending aorta dilatation with wrapping technique – decreasing the size of the aorta to fit the size of the stent-graft in some high-risk situations. with classic surgery.

Wrapping technique of ascending aorta in Hybrid procedure for complex aortic arch disease

Background: The hybrid procedure proved to be very suitable for Vietnamese conditions in the treatment of complex aortic diseases in the arch and on supra-renal lesion. There is a difficult situation where the ascending aorta is more dilated than can be accommodated by stent-grafts. Wrapping techique is a solution to this situation. Methods: Report on a clinical case of successful application of aortic wrap technique to treat complex aortic cross injuries at Cardiovascular and Thoracic Center, Viet Duc University Hospital. Results: A 73-year-old female patient was admitted to the hospital because of sudden chest pain. History of high blood pressure, heart failure, dyslipidemia and hypothyroidism. MSCT revealed type B aortic dissection, left hemothorax complication, the entire ascending aorta and a part of cross dilated to 50mm (maximum stent-graft size is 46mm). Poor general condition, severe and complicated acute aortic injury, if the classic surgery requires total thoracic aorta replacement – ​​the risk of death is very high, so the hybrid solution is a reasonable choice if having the solution is to solve the problem to create a landing zone for stent-graft. Hybrid surgery was started with open sternotomy, bilateral aortic - carotid bypass with Dacron prothesis 9mm, using a large artificial vessel to wrap around the ascending aorta to reduce the medium size to 38mm. Drain and close the sternum. Next is endovascular intervention – installing a stent-grafts of 42x42x200 and 42x38x150 then 38x34x150 to the diaphragm, plug for left subclavian artery. Left pleural drainage. The patient was discharged 10 days after surgery. Follow-up after 2 years for good results. Conclusion: The hybrid procedure can still be applied in the situation of ascending aorta dilatation with wrapping technique – decreasing the size of the aorta to fit the size of the stent-graft in some high-risk situations. with classic surgery.

Regional anesthesia for cardiothoracic surgery

Cardiac and thoracic surgery have been connected to high perioperative opioid use for a long time. With increasing knowledge of regional anesthesia in the thoracic region, thoracic nerve blocks have become supplemental methods of analgesia. As part of multimodal analgesia, they are important factors of enhanced recovery after surgery and contribute to a diminished opioid use. Myofascial nerve blocks are more superficial than the classic thoracic epidural anesthesia or paravertebral block and are therefore safer for use in anticoagulated patients. In this article, we present a number of thoracic blocks; the paraneuraxial paravertebral block; the myofascial plane blocks which are the retrolaminar block, the erector spinae plane block, the serratus anterior plane block, the pectoral nerves I and II block, the transversus thoracis plane block and the parasternal intercostal nerve block; the perineural intercostal nerve block and also local anesthetic infusion by a wound catheter. We conclude with local experience from a cardiac and thoracic surgical center.

An International Consensus on Actions to Improve Lung Cancer Survival: A Modified Delphi Method Among Clinical Experts in the International Cancer Benchmarking Partnership.

BackgroundResearch from the International Cancer Benchmarking Partnership (ICBP) demonstrates that international variation in lung cancer survival persists, particularly within early stage disease. There is a lack of international consensus on the critical contributing components to variation in lung cancer outcomes and the steps needed to optimise lung cancer services. These are needed to improve the quality of options for and equitable access to treatment, and ultimately improve survival.MethodsSemi-structured interviews were conducted with 9 key informants from ICBP countries. An international clinical network representing 6 ICBP countries (Australia, Canada, Denmark, England, Ireland, New Zealand, Northern Ireland, Scotland & Wales) was established to share local clinical insights and examples of best practice. Using a modified Delphi consensus model, network members suggested and rated recommendations to optimise the management of lung cancer. Calls to Action were developed via Delphi voting as the most crucial recommendations, with Good Practice Points included to support their implementation.ResultsFive Calls to Action and thirteen Good Practice Points applicable to high income, comparable countries were developed and achieved 100% consensus. Calls to Action include (1) Implement cost-effective, clinically efficacious, and equitable lung cancer screening initiatives; (2) Ensure diagnosis of lung cancer within 30 days of referral; (3) Develop Thoracic Centres of Excellence; (4) Undertake an international audit of lung cancer care; and (5) Recognise improvements in lung cancer care and outcomes as a priority in cancer policy.ConclusionThe recommendations presented are the voice of an expert international lung cancer clinical network, and signpost key considerations for policymakers in countries within the ICBP but also in other comparable high-income countries. These define a roadmap to help align and focus efforts in improving outcomes and management of lung cancer patients globally.

Pneumonectomy for primary lung cancer: contemporary outcomes, risk factors and model validation.

OBJECTIVESDespite the increased rate of adverse outcomes compared to lobectomy, for selected patients with lung cancer, pneumonectomy is considered the optimal treatment option. The objective of this study was to identify risk factors for mortality in patients undergoing pneumonectomy for primary lung cancer.METHODSData from all patients undergoing pneumonectomy for primary lung cancer at 2 large thoracic surgical centres between 2012 and 2018 were analysed. Multivariable logistic and Cox regression analyses were used to identify risk factors associated with 90-day and 1-year mortality and reduced long-term survival, respectively.RESULTSThe study included 256 patients. The mean age was 65.2 (standard deviation 9.4) years. In-hospital, 90-day and 1-year mortality were 6.3% (n = 16), 9.8% (n = 25) and 28.1% (n = 72), respectively. The median follow-up time was 31.5 months (interquartile range 9–58 months). Patients who underwent neoadjuvant therapy had a significantly increased risk of 90-day [odds ratio 6.451, 95% confidence interval (CI) 1.867–22.291, P = 0.003] and 1-year mortality (odds ratio 2.454, 95% CI 1.079–7.185, P = 0.044). Higher Performance Status score was associated with higher 1-year mortality (odds ratio 2.055, 95% CI 1.248–3.386, P = 0.005) and reduced overall survival (hazard ratio 1.449, 95% CI 1.086–1.934, P = 0.012). Advanced (stage III/IV) disease was associated with reduced overall survival (hazard ratio 1.433, 95% CI 1.019–2.016, P = 0.039). Validation of a pneumonectomy-specific risk model demonstrated inadequate model performance (area under the curve 0.54).CONCLUSIONSPneumonectomy remains associated with a high rate of perioperative mortality. Neoadjuvant chemoradiotherapy, Performance Status score and advanced disease emerged as the key variables associated with adverse outcomes after pneumonectomy in our cohort.

Superior vena cava graft infection in thoracic surgery: a retrospective study of the French EPITHOR database.

OBJECTIVESTo report our experience on the management of superior vena cava graft infection.METHODSBetween 2001 and 2018, patients with superior vena cava synthetic graft or patch reconstruction after resection of intrathoracic tumours or benign disease were selected retrospectively from the French EPITHOR database and participating thoracic centres. Our study population includes patients with superior vena cava graft infection, defined according to the MAGIC consensus. Superior vena cava synthetic grafts in an empyema or mediastinitis were considered as infected.RESULTSOf 111 eligible patients, superior vena cava graft infection occurred in 12 (11.9%) patients with a polytetrafluoroethylene graft secondary to contiguous contamination. Management consisted of either conservative treatment with chest tube drainage and antibiotics (n = 3) or a surgical graft-sparing strategy (n = 9). Recurrence of infection appears in 6 patients. Graft removal was performed in 2 patients among the 5 reoperated patients. The operative mortality rate was 25%.CONCLUSIONSSuperior vena cava graft infection may develop as a surgical site infection secondary to early mediastinitis or empyema. Graft removal is not always mandatory but should be considered in late or recurrent graft infection or in infections caused by aggressive microorganisms (virulent or multidrug resistant bacteria or fungi).

Challenges for expansion of thoracic transplant clinical pharmacy in a developing country: comparison with U.S. accredited centres and call for action.

Clinical pharmacists' involvement in the care of solid organ transplant recipients has been discussed worldwide given its potential to improve clinical outcomes. As thoracic transplant activity grows in Brazil, it is important to understand how pharmacists are inserted in transplant programmes nationwide. We conducted a survey to explore clinical pharmacy activities in thoracic transplant centres in Brazil and compared them with accredited programmes in the United States. An electronic questionnaire was distributed to all 40heart and lung transplant centres registered in the Brazilian Organ Transplantation Agency (ABTO) in May 2019. Survey findings were compared to previously published data from accredited U.S. centres. From 22 centre respondents, ten (45.5%) declared not to have a pharmacist at any part of the transplantation process, which translated into 158 (37.6%) transplant recipients without any direct pharmaceutical care. In centres with pharmacists (n=12), none had a full-time professional dedicated to their heart and/or lung programmes. When compared to U.S. centres, there was a significantly lower insertion of clinical pharmacist activities among Brazilian centres. Our findings point to an unmet need related to clinical pharmacy activity within thoracic transplant programmes, especially in a developing country, and highlight a call for action in order to reach higher accredited regulatory standards regarding pharmacist-driven workforce in transplant care worldwide.

Complications of gastroesophageal reflux disease: 10-year experience

Purpose: Gastroesophageal reflux disease (GERD) is a common condition of modern times resulting from chronic reflux of gastric contents into the esophagus. The cause underlying GERD involves an imbalance between noxious and protective factors of the esophageal mucosa and a functional disorder of the lower esophageal sphincter (LES). The transitional release of the LES appearing more frequently and longer than physiologically normal is the main cause for the development of GERD. The negative effects of reflux can increase by disturbed esophageal motility, which is unable to regularly clear the esophagus in esophageal motility disorders and disturbed gastric emptying in large hiatal hernias and peptic ulcers. Typical GERD symptoms include a burning sensation or pain behind the sternum, return of bitter or acidic gastric content into the esophagus, rare odynophagia and extraesophageal signs, such as non-cardiac chest pain, chronic cough, and hoarseness&#x0D; Methods: A literature revue and a review of clinical cases over a 10-year span in the Department for Thoracic Surgery University Medical Centre Maribor.&#x0D; Results: The study was also drawn from 10 years of experience with surgical treatment of GERD and its complications. The treatment of reflux esophagitis and asthma as a GERD complication is not the domain of a surgeon. Surgical treatment is indicated in passage-blocking conditions and in cases in which GERD cannot be managed with medical therapy. In the period from 2006–2015 we performed 928 surgeries to remove and prevent GERD complications.&#x0D; Conclusion: Several possible complications of GERD are known, among which the development of Barret’s esophagus as a pre-malignant condition of the esophageal mucosa and the development of glandular carcinoma of distal esophagus are especially dangerous. Therefore, a precise diagnostic treatment is necessary when treating the underlying disease of patients as the clinical picture of GERD often resembles problems related to other thoracic pathologies.

Outcome of parapneumonic empyema managed surgically or by fibrinolysis: a multicenter study.

BackgroundParapneumonic empyema (PPE) management remains debated. Here we present the outcome of a comparable population with PPE treated over a 4-year period in two Thoracic Surgery University Centers with different approaches: one with an early “surgical” and the other with a “fibrinolytic” approach.MethodsAll operable patients with PPE managed in both centers between January 2014 and January 2018 were reviewed. Patients with persistent pleural effusion/loculations following drainage were managed by a “surgical” approach in one center and by “fibrinolytic” approach in the other. For each patient, we recorded the age, sex, hospital stay, morbidity/mortality and change in pleural opacity on chest X-ray before and at the end of the treatment.ResultsDuring the study period, 66 and 93 patients underwent PPE management in the “surgical” and “fibrinolytic” centers respectively. The population characteristics were comparable. Infection was controlled in all patients. In the “fibrinolytic” group, 20 patients (21.5%) underwent an additional drain placement while 12 patients (12.9%) required surgery to correct PPE. In the “surgical” group, 4 patients (6.1%) developed postoperative arrhythmia while 2 patients (3%) underwent a second surgery to evacuate a hemothorax. Median drainage {3 [2–4] vs. 5 [4–7] days} and hospital {7 [5–10] vs. 11 [7–19] days} durations were significantly lower in the “surgical” compared to the “fibrinolytic” center. Pleural opacity regression with therapy was significantly more important in the “surgical” compared to the “fibrinolytic” group (−22%±18% vs. −16%±17%, P=0.035).ConclusionsSurgical management of PPE was associated with shorter chest tube and hospital duration and better pleural space control. Prospective randomized studies are mandatory.

Results of endoscopic thoracic for Post-traumatic pleural empyema treatment at Viet Duc University Hospital

Abstract Introduction: Post-traumatic pleural empyema tends to increase in recent years, related to the severity of chest trauma and postoperative care. There are very few studies on this type of disease. The study aims to describe some etiological, clinical, and paraclinical characteristics and evaluate early results of endoscopic thoracic surgery to treat this disease. Patients and Methods: A retrospective descriptive study of cases with a confirmed diagnosis of post-traumatic empyema and treated by thoracoscopic surgery, at the Cardiovascular and Thoracic Center, Viet Duc university hospital, from January 2017 to April 2021. Results: Including 52 patients, with 46 men - 6 women, the average age was 44.87 years old; the average time from accident to surgery was 31.17 days, the average surgery time was 86.83 minutes; thoracoscopic surgery was 100% successful. Intensive respiratory physiotherapy was performed in 100% of patients; the average postoperative hospital stay was 8.13 days; the most common postoperative complication was wound infection (3.8%); 100% of patients discharged from the hospital were stable, with no mortality. Conclusion: Endoscopic thoracic surgery combined with intensive respiratory physiotherapy after surgery is an effective solution in treating post-traumatic pleural empyema. Keywords: Post-traumatic empyema, chest trauma, endoscopic thoracic.