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Interact CardioVasc Thorac Surg 2007;6:S181-S217. doi:10.1510/icvts.2007.0000S4 © 2007 European Association of Cardio-Thoracic Surgery
AbstractsSuppl. 2 to Vol. 6 (May 31, 2007)Wyser C, Am J Resp Crit Care Med 1999
Miller JI, Chest Surg Clin N Am 1992
Deslauriers J, Chest 1994
001-O MULTICENTRIC ANALYSIS OF PERFORMANCE AFTER MAJOR LUNG RESECTIONS BY USING THE EUROPEAN SOCIETY OBJECTIVE SCORE A. Brunelli1, G. Varela2, P. Van Schil3, M. Salati1, N. Novoa2, J.M. Hendriks3, M.F. Jimenez2, P. Lauwers3 1Umberto I Regional Hospital, Ancona, Italy;2Salamanca University Hospital, Salamanca, Spain;3University Hospital of Antwerp, Antwerp, Belgium Objective: Outcome endpoints are still the most widely used indicators of performance. However, they need to be risk-adjusted in order to be reliable instruments of audit. Recently, the European Society Objective Score (ESOS) was developed from the online European Thoracic Surgery Database as an audit tool. In this study, we applied for the first time the ESOS.01 to assess the performance of three European thoracic surgery units during three successive years of activity. Methods: This study is a retrospective analysis performed on prospective databases. We analyzed 695 patients submitted to pneumonectomy (117) or lobectomy (578) for lung neoplasms at three European dedicated thoracic surgery units (unit A 264 patients, unit B 262, unit C 169) from January 2004 through December 2006. All patients gave their informed consent to use their data in the datasets, approved by the local IRBs. Qualified thoracic surgeons performed all the operations. No patient in this series was used in the original ESOS development set. ESOS.01 was used to estimate the risk of in-hospital mortality. Three successive periods of activity were assessed (years 2004, 2005 and 2006). Observed and predicted mortality rates occurring at each unit were compared within each period by the z-test. Results: Cumulative observed mortality rates in unit A, B and C were 2.3% (six cases), 2.7% (seven cases) and 4.1% (seven cases), respectively. Observed mortality rates resulted not significantly different from the predicted ones during each of the periods in all three units (Table). Conclusions: The use of ESOS.01 model revealed that the performances of all units were in line with the predicted ones during each period under analysis. The results of our study warrant future efforts to refine the ESOS model and to develop other risk-adjusted outcome indicators with the aim to establish European benchmarks of performance.
1UO Thoracic Surgery, University of Parma, Parma, Italy; 2UO Anaesthesia, University of Parma, Parma, Italy Objective: Continuous Positive Airway Pressure (CPAP) is an effective treatment of postoperative hypoxemia. The effect of prophylactic postoperative CPAP on gas exchange of patients undergoing pulmonary lobectomy is evaluated. Methods: A prospective randomized trial including forty consecutives patients operated on for a lobectomy was conducted. One hour after extubation patients were allocated to receive conventional oxygen therapy (group Control, n=19) with facemask ventilation (FiO2:0.4) or at least two cycles of prophylactic helmet ventilation therapy (group CPAP, n=22) (airway pressure 8 cm H2O, FiO2:0.4). Patients with preoperative hypoxemia (PaO2). Results: No differences in preoperative clinical characteristic between the two groups of patients were noted. As compared with Control group, CPAP group patients had a significant amelioration of PaO2/FiO2 that prolonged for twelve hours after the end of CPAP. No mortality was noted among study population. No differences in duration of hospital days, postoperative respiratory complication, as well as incidence and duration of pulmonary air leaks were reported between the two groups. Conclusions: Early prophylactic CPAP after lobectomy improves blood oxygenation; the effect of CPAP support on postoperative outcome after pulmonary resection still need to be established.
1University Hospitals Leuven, Leuven, Belgium;2Centre Hospitalier Luxembourg, Luxembourg, Luxembourg Objective: Since 1993, various combinations of thoracoscopy, VATS, laparoscopy or hand-assisted laparoscopy have been used to perform esophagectomy for cancer. Despite widespread current use, the indications and benefits of these approaches remain controversial. Methods: A systematic Medline (PUBMED) literature search was conducted. Of 83 papers, 42 were excluded from analysis (redundant publications, review papers, series with less than ten patients...). The remaining 41 original series (1684 patients) were analysed for surgical and oncological outcome. Results: No prospective randomized trial has compared any MIE technique to another or to open surgery. Most publications are retrospective single center series reporting on highly selected patients, excluding high-risk patients and locally advanced (T3) tumors. All 41 series together, conversion rate was 6%, mortality 3.1% and morbidity 42% (many papers report only major complications). Overall, pulmonary complication rate was 20%, leakage rate 9.4%, vocal cord palsy rate 10.6% and 17 cases of tracheo-bronchial injuries (1%) were reported. Laparoscopy+VATS resections were reported in nine papers (n=532 patients, 4% conversion rate, 2% mortality). VATS combined with (mini)-laparotomy was reported in 12 papers (n=580, 8% conversions, 3% mortality). Laparoscopic transhiatal resections were reported in 13 papers (n=310, 7% conversions, 3.9% mortality). Morbidity rates for these three main approaches were 42%, 40% and 45%, respectively. Oncological data are scarce. Lymph node retrieval is mostly inferior to open surgery standards and follow-up too short to allow any definitive conclusion on long-term survival. Conclusions: Currently available data on MIE derive from highly selected case series (evidence level 3). Morbidity and mortality is substantial and not clearly inferior to open esophagectomy in experienced centres. Oncologic outcome remains unknown by lack of good quality data. Currently all purported benefits might be based on selection bias rather than on the operative techniques. Awaiting better evidence, MIE for invasive esophageal cancer should still be considered an investigational technique.
University of the Mediterranean Sainte Marguerite University Hospital, Marseille, France Objective: To evaluate the clinical relevance of preoperative airway colonization in patients undergoing oesophagectomy for cancer after a neoadjuvant chemoradiotherapy. Methods: From 1998 to 2005, 117 patients received a neoadjuvant chemoradiotherapy for an advanced oesophageal cancer. Among them, 45 non-randomised patients underwent a bronchoscopic broncho alveolar lavage (BAL group) prior to surgery to assess airways colonization. The remaining patients (n=72) constituted the control group. The two groups were similar with respect to various clinical or pathological characteristics. Results: Thirteen of the 45 BAL patients (28%) had a preoperative bronchial colonization by either potentially pathogenic microorganisms (PPMs) (n=7, 16%) or nonpotentially pathogenic microorganisms (n=6, 13%). Cytomegalovirus (CMV) was cultured from BAL in four patients. Pre-emptive therapy was administrated in seven patients: four antiviral and three antibiotic prophylaxes. Postoperatively, 14 patients (19%) developed ARDS in the control group and three (7%) in the BAL group (P=0.05). The cause of ARDS was attributed to CMV pneumonia in six control group patients on the basis of the results of open lung biopsies (n=3) or BAL cultures (n=3) vs. none of the BAL group patients (P=0.04). Timing for extubation was shorter in the BAL group (mean 13±3 h) as compared with the control group (mean 19.5±14 h; P=0.01). Hospital mortality rates were similar in both groups (9% and 8%). Conclusions: Airway colonization by PPMs after neoadjuvant therapy is suggested as a possible cause of postoperative ARDS after oesophagectomy. Pre-emptive treatment of bacterial and viral (CMV) colonization seems an effective option to prevent postoperative pneumonia.
Department of Thoracic Surgery Albert Ludwigs University Freiburg, Freiburg, Germany Objective: Sublobar resections spare pulmonary function and offer a method of increasing resection rates in patients with lung cancer and limited functional operability. Previous studies demonstrated an increased local recurrence rate after wedge resections compared to segmentectomies in stage IA NSCLC. However, a prognostic impact of this observation has never been shown and is still under debate. Therefore, this study has been performed to analyse the cancer-related survival of sublobar resections in stage IA patients. Methods: Over a 17-year period 87 patients underwent sublobar complete resection (R0) of stage IA NSCLC. Sublobar resection was reserved for patients with cardiopulmonary impairment. Wedge resections with selective lymphadenectomy were performed in 31 patients (36%) and segmentectomies with systematic lymphadenectomy in 56 (64%). Patient characteristics, functional parameters, tumour specifics and follow-up duration were analysed concerning their distribution between the two groups. Kaplan–Meier curves were compared and possible joint effects between prognostic parameters were analysed by multivariate Cox regression analysis. Results: The median follow-up duration was 45 months. There was no significant difference between the two groups in gender (P=0.11), age (P=0.08), ASA-score (P=0.32), FEV1% (P=0.08), tumour size (P=0.30), histology (P=0.17), grading (P=0.62), complication rate (P=0.15) and follow-up duration (P=0.29). The mean number of dissected lymph nodes in segmentectomies (12±6) was higher than in wedge resections (6±3) (P=0.0001). Five-year survival was 63%. There were significantly less locoregional recurrences (P=0.001), an equal distribution of distant metastases (P=0.53) and a better cancer-related survival (P=0.016) after segmentectomies compared to wedge resections. Cox regression analysis showed that the prognostic effect of the resection type was independent from gender, age, ASA-score, respiratory function, tumour size, tumour histology, grading and number of dissected lymph nodes (P=0.04, relative risk 1.16). Conclusions: Studies investigating survival after sublobar resection of stage IA NSCLC should always distinguish between anatomical segmentectomies and wedge resections. When limited functional operability requires a sublobar resection of stage IA NSCLC, segmentectomy with systematic lymphadenectomy should be preferred.
1Department of Thoracic Surgery, University Hospitals of Leuven, Leuven, Belgium; 2Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota, USA; 3Division of Thoracic Surgery, Klinik Schillerhoehe, Gerlingen, Germany;4Department of Cardiothoracic Surgery, Guy's Hospital, London, UK;5European Society of Thoracic Surgeons, Exeter, UK Objective: No randomised controlled trials exist to guide thoracic surgeons in the field of lung metastasectomy. This study investigates the current clinical practice among ESTS members. Methods: A web-based questionnaire was created exploring the current clinical approach to lung metastasectomy: diagnosis, multidisciplinary management, perceived contraindications, surgical approach, extent of resection, role of lymph node assessment. All ESTS members were surveyed. Results: One hundred and forty six questionnaires were completed from the 570 consultant ESTS members surveyed (25.6%). For most respondents (68%), lung metastasectomy represents a minor proportion (0–10%) of their clinical volume. Approximately 90% of respondents always/usually review their lung metastasectomy cases within a multidisciplinary meeting. Helical computed tomography is most commonly used (74%) for the detection of metastases, while positron emission tomography is used additionally in less than 50%. The vast majority of respondents consider unresectable primary tumor and predicted incomplete metastasectomy as absolute contraindications to lung metastasectomy. The most frequently performed resection (92%) is wedge excision (82% by stapler), while metastasectomy requiring pneumonectomy is a relative contraindication for 2/3 of respondents. Palpation of the lung is felt to be always necessary for 65%, while 40% use a thoracoscopic approach with therapeutic intent. The preferred approach for resection of bilateral disease is staged thoracotomies (62% of respondents). Despite the fact that 65% consider pathologically positive nodes an absolute contraindication to metastasectomy, the same percentage rarely/never perform mediastinoscopy prior to metastasectomy. At the time of metastasectomy 55% perform a mediastinal lymph node sampling whereas 33% perform no nodal dissection whatsoever. Conclusions: The survey provides a large, time-sensitive database summarizing the clinical practice of pulmonary metastasectomy in Europe. Responses demonstrate a remarkable consistency of practice patterns, though certain areas of potential controversy showed greater variance. Conceivably, these divergent approaches will encourage future collaborative studies aimed at identifying evidence-based best practices for patients with pulmonary metastases.
1Division of Thoracic Surgery, University Hospital, Zurich, Switzerland;2Department of Clinical Pathology, University Hospital, Zurich, Switzerland; 3Department of Biostatistics, University Hospital, Zurich, Switzerland; 4 Department of Oncology, University Hospital, Zurich, Switzerland Objective: Malignant pleural mesothelioma (MPM) is a highly aggressive tumor with poor prognosis and limited response to chemotherapy. Tumor markers may describe tumor aggressiveness and may be potential targets for therapy. Methods: Formalin-fixed paraffin embedded tissue blocs from 470 MPM patients were retrieved from the archives of Institutes of Surgical Pathology in Switzerland and tissue micro-arrays (TMA) were constructed using quadruplicate punches. Clinical data of these patients were assessed from medical archives of the different hospitals and the local cancer regis-tries. The expression level of the tumor supressor gene PTEN was determined by immunohistochemistry with PTEN antibody. Intensity was scored semiquantitatively 0–3. Statistical analysis was performed using Kaplan–Meier curves for correlation of survival time with expression of PTEN. Results: Clinical data from 206 patients were available and retrospectively analyzed. One hundred and four patients were in stage T4 and 91 patients presented with regional and mediastinal lymph node metastasis. PTEN was expressed in 34% of the cases. The expression of PTEN was significantly higher in patients with epithelial mesothelioma (P=0.0001). The survival time was evaluated and correlated to PTEN expression in 111 cases in which follow-up data were complete. Comparing strong versus no expression of PTEN, median survival time was significantly longer (log rank test P=0.0001) in patients with PTEN expression (21 months; 95% CI: 7; 36 vs. 10 months; 95% CI: 8; 12). Conclusions: The expression of the tumour suppressor gene PTEN seems to be strongly correlated to tumour histology and survival time in mesothelioma patients. Prospective evaluation of this marker will further elucidate its role in the context of mesothelioma treatment.
Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK Objective: Extrapleural Pneumonectomy (EPP) has high mortality and morbidity; Radical Pleurectomy Decortication (P/D) carries less mortality but still significant morbidity. This surgery is not suitable for many patients with MPM for whom VATS offers a minimally invasive alternative. We assessed the role of VATS decortication for MPM. Methods: Over a nine-year period 208 patients underwent therapeutic surgery for MPM in our unit. One hundred and twelve of the patients underwent EPP, 29 had a P/D and 67 had VATS decortication. Sixty-three of the 208 patients (EPP n=13, P/D n=8 and VATS Decortication n=42) were 65 years of age or older at the time of the operation (61 male and 2 female, age 65–80, average 70 years). We analyzed for this (>65) group of patients the perioperative morbidity and mortality and long-term survival data. We also compared the survival of patients with Epithelioid pathology and pN2 disease in the EPP group and those with Epithelioid pathology in the VATS Decortication group. Results: Survival data and hospital stay for the over 65 group are presented in the table. Postoperative stay and 30-day mortality was significantly lower for VATS than for EPP. There was no significant difference in the mean survival between the two groups. The small number of patients in the P/D group (n=8) did not allow us to extract statistically significant results. For patients with Epithelioid MPM and pN2 stage that underwent EPP (n=32) median survival was not significantly different compared to the Epithelioid VATS group (n=50): 12 vs. 15 months respectively, P=0.1925. These results suggest that VATS decortication for Epithelioid disease has at least as good survival as EPP for N2 positive Epithelioid MPM with less mortality. Conclusions: VATS decortication should be considered in therapeutic strategy for MPM particularly in those patients with N2 disease or those over 65 years.
009-I SEVERE LUNG ABSCESS AND HAEMOPTOE CAUSED BY COMMUNICATING BRONCHOPULMONARY PANCREATIC FOREGUT MALFORMATION – OPERATED CASE A. Vagvolgyi1, P. Sapy1, L. Toth2, E. Szolnoki3, S. Sz Kiss1 1Auguszta Surgical Center of Surgical Institute, University of Debrecen, Medical and Health Science Center, Debrecen, Hungary; 2Institute of Pathology, DEOEC, Debrecen, Hungary; 3Clinic of Pulmonology, DEOEC, Debrecen, Hungary Objective: Abdominal disease can cause haemoptoe and lung abscess rarely. We describe a disease which resulted progrediating haemoptoe, pneumonia, lung abscess and hydrothorax-causing differential-diagnostical difficulties. Methods: A 45 years old female patient's complains were back pain since 10 years, hyperacidity, haemoptoe one year before, epigastrial pain. In 2004 haemoptoe repeated. She was treated at a pulmonology, the diagnoses were a suspicion of aspiration/lung embolisation, acute pneumonia, right side pleural fluid. Against the therapy a right lower lobe lung abscess developed and ruptured to the right pleural cavity, haemoptysis occured. Thoracocentesis verified serothorax, a thoracal drainage had been started. The inflammatory parameters became worse, a right side empyema developed. By vital indication because of the therapy-resistant lung abscess and haemoptoe we performed thoracotomy and right lower lobectomy of the lung. Cutting through the pulmonary ligament we found a duct with regular wall-structure. Intraoperative oesophago-gastro-duodenoscopy had not found any damage or diverticulum. The tube leaded through the oesophageal hiatus to the abdominal cavity. After closing the chest we performed upper median laparotomy. We exstirpated the duct, that joined to the pancreatic duct and caused the destruction of the right lower lobe of the lung. Results: The postoperative period was uneventful, the patient healed, she is free from complains and symptoms 28 months after the operation. Conclusions: In case of haemoptoe, therapy-resistant lung abscess, bronchopleural fistula, we have to think about the possibility of a relatively rare pancreatico-bronchial communication. Most of this connections are originated by a pancreatic fistula, but in a few percent of all cases can be caused by a congenital abnormality called ‘Congenital Broncho-Pulmonary Foregut Malformation’. As a literary curiosity, CBPFM can develop between the pancreatic duct and the bronchial tree. Fistule-origin can be excluded, foregut origin can be proofed by histopathological examination included immunhistochemical analysis.
1Department of Thoracic Surgery, Athens Veterans Hospital, Athens, Greece; 2Intensive Care Unit of Athens Veterans Hospital, Athens, Greece Objective: The purpose of these case-report is to present a 58-years-old patient who was transferred to our hospital emergency room suffering trauma following impalement injury on the left frontal upper part of his chest. On admission, he was cyanotic with distended neck veins, hypotensive with weak peripheral arterial pulse, and severely distressed. Admission cardiac echo revealed pericardial tamponade, and thoracoabdominal CT (mediastinal window) showed a large quantity of mediastinal blood, left pneumothorax, and contusion in the left upper lung lobe. Methods: The patient was rushed to operating room where medial sternotomy was performed. The pericardium was opened widely, blood clots and free blood were removed. A rupture of the base cone of the pulmonary artery was discovered. The pulmonary artery was clamped partially and sutured directly with use of pledget felts. A thoracic tube was placed in the left plural space. Results: The patient was transferred intubated to the ICU in extremely severe clinical situation. While on mechanical ventilation, after three days he was developed acute lung injury, clinically manifested by severe and intractable hypoxemia. After 23 days, he was discharged from ICU with improved pulmonary function, hemodynamically stable, and in high spirit. Conclusions: Rupture of the base cone of the pulmonary artery after traumatic injuries are relatively uncommon. In selected emergent cases with patient in extremies these rupture can be treated with partial clamp and direct suture of the pulmonary artery, with good results.
1Department of Surgery, Kantosspital Chur, Chur, Switzerland; 2Lungenpraxis Morgenthal, Zürich, Switzerland; 3Department of Pathology, Kantonsspital GR, Chur, Switzerland; 4Department of Internal Medicine, Kantonsspital GR, Chur, Switzerland Objective: The inflammatory pseudotumor of the lung (IPTL) is a rare differential diagnosis of bronchial carcinoma. The incidence is reported to be 0.04–1% of all pulmonary tumors while histological diagnosis seem to be difficult. In 2005 we observed two cases with IPTL both successfully treated by surgical resection. Methods: First case: A 59-year-old non-smoking woman, after right lumpectomy for breast cancer three years ago, was admitted to our hospital for hemoptysis. Her chest X-ray presented a small lesion in the right lower lobe. CT-scan confirmed the central tumor involving the proximal lower lobe bronchus. Biopsy, taken by bronchoscopy, showed a variety of inflammatory and spindle cells not allowing a conclusive diagnosis. To gain further material endoluminal laser resection was performed. The histology presented an IPTL based on its morphologic features, small size and its immunoprofile. Open resection of the right middle and lower lobe was performed. The postoperative course was uneventful. Results: Second case: A 74-year-old woman was recovered for cough, haemoptysis and fever. She had been a heavy smoker for many years. The chest X-ray showed a tumor at the left pulmonary hilum. In CT-scan the tumor was identified to obstruct the left upper lobe. Biopsy, taken by bronchoscopy, showed non-malignant inflammatory cells. Potential metastasis could not be found. Nevertheless, we suspected a bronchial carcinoma of the left upper lobe and resection was performed. The histology presented an IPTL. Six months after the operation the patient stays perfectly well. Conclusions: The literature-search does confirm the difficulties in diagnosis of IPTL. In our two cases we could establish the diagnosis preoperatively in only one case. Radical surgical resection is the treatment of choice to rule out definitively a bronchial carcinoma and to prevent recurrence of IPTL.
012-O THE DANISH RANDOMIZED LUNG CANCER CT SCREENING TRIAL. RESULTS AT BASELINE J.H. Pedersen, A. Dirksen, K. Bach, H. Hansen, B.G. Skov, P. Tonnesen Gentofte University Hospital, Copenhagen, Denmark Objective: The Danish lung cancer screening trial is a randomized trial comparing CT screening with no screening. The trial is done with the NELSON trial in the Netherlands, Europe. The final end point is lung cancer mortality. Methods:
Results:
Conclusions: Lung cancer screening facilitates minimal invasive treatment and can be performed with a low rate of false positive diagnoses.
1Clinic for Thoracic Surgery HSK Wiesbaden, Wiesbaden, Germany; 2Institute for Pathology and Cytology HSK Wiesbaden, Wiesbaden, Germany; 3Clinic for Anesthesiology and Intensive Care Medicine HSK Wiesbaden, Wiesbaden, Germany Objective: The most reports on sleeve resections are based on retrospective analysis over such a long period of many decades. Functional results and perioperative risks are not analyzed yet. Methods: In a prospective study all patients undergoing bronchoplastic and/or angioplastic sleeve resection with systematic lymph node dissection from 01.01.1999 till 31.12.2004 were analyzed. We reported the clinical characteristics, surgical techniques, perioperative risk factors, pre- and postoperative functional results (FEV1, perfusion scan), recurrence rate and survival. Results: Hundred patients (male 78, female 12, age 62±12) were enrolled in this study. With nine different surgical techniques a R0-resection-rate of 99% could be accomplished and a pneumonectomy could be avoided. The number of dissected lymph nodes were in average 30 right-sided and 33 left-sided. The morbidity and mortality were 39% and 2%, respectively. The leading indication was lung cancer (74%). At this the local and distant recurrence rate were 1% and 16%, respectively. The overall 5-year-survival rate was 83%. No significant risk factors were the different disorders, ASA-classification, a compromised lung function and age. Six month after surgery there were no significant differences in pre- and postoperative perfusion scans and FEV1. Conclusions: Bronchoplastic and angioplastic sleeve resections are safe resections. With a broad variety of surgical techniques healthy lung tissue can be preserved. The surgery has no effect on pulmonary function because of achieving preoperative FEV1 and lung perfusion six month after surgery. Even patients with high-risk scores and intense compromised lung function should be considered for sleeve resections.
Seoul National University Hospital, Seoul, Korea (South) Objective: The inaccuracy of conventional CT makes open thoracotomy and manual palpation inevitable in pulmonary metastasectomy. However, the introduction of multi–detector row CT technology made it possible to detect pulmonary nodules with a diameter smaller than 1 mm. The purpose of this study was to investigate the accuracy of 1-mm thin sectioned 16-channel multi-detector row CT (TSMDCT) in the detecting metastatic pulmonary nodules. Methods: Twenty-four patients who underwent pulmonary metastasectomy from November 2005 to September 2006 were included in the study. The primary tumors were colorectal cancer (n=11), renal cell carcinoma (n=5), hepatocellular carcinoma (n=3), thymic tumor (n=2), bladder cancer (n=1), thyroid cancer (n=1), and primitive neuroectodermal tumor (n=1). For the evaluation of location and number of metastatic nodules, TSMDCT was performed in all patients. Thirty thoracotomies were performed in the study group (18 unilateral and 6 bilateral thoracotomies). The accuracy of TSMDCT was evaluated by comparing with the pathology reports. Results: There were 105 nodules detected by TSMDCT scanning preoperatively (median 2 nodules per hemithorax). 150 nodules were resected (median 4 nodules per thoracotomy) and 67 nodules were pathologically confirmed to be metastatic nodules. Overall sensitivity of TSMDCT for detecting metastatic nodules was 97.0% and overall specificity was 50.0%. The sensitivities of TSMDCT were 98.2% for the nodules exceeding 3 mm in long-diameter and 75.0% for the nodules smaller than 3 mm in long-diameter (P=0.002). The sensitivities of TSMDCT were 100% for the lesions with <5 nodules in hemithorax and 89.2% for the lesions exceeding 5 nodules in hemithorax. Conclusions: TSMDCT was a highly sensitive method and showed nearly comparable detection rates to that of manual palpation in the patients who had nodules with larger size and fewer numbers. Therefore, TSMDCT can be a useful diagnostic tool to perform throacoscopic pulmonary metastasectomy in selected patients.
CH Avignon and Institut Sainte Catherine, Avignon, France Objective: Preoperative treatment of stage IIB/II NSCLC is a subject of controversy. According to results of the INT0139 trial, induction chemo-RT (CRT) seems superior without increasing periopertaive mortality. Our goal is to confirm feasibility and pathologic response rates of CRT (3D-technique) in our center. Methods: Patients were selected in a multidisciplinary committee. CRT comprised 45 Gy RT delivered to primary tumor, hilar and mediastinal nodes on CT-scan. Concurrent CT regimen was CDDP 20 mg/m2 d1-d5 and Etoposide 50 mg/m2 d1-d5 (PE), d1-5 d29-33. Surgery was performed 4–6 weeks after CRT in patients deemed resectable. Results: From 1996 to 2005, 107 patients (91H/16F, median age: 59 years. [31-81]) were initially selected and received CRT (18 stage IIB-Pancoast, 58 IIIA and 31 IIIB). Two patients stopped treatment prematurely, 100 patients/105 received 45 Gy and 2 cycles de PE concurrently. Seventy two patients (67%) had a thoracotomy (pneumonectomy 21, lobectomy 45, bilobectomy 5) and all but one had a macroscopic complete resection. During the 3-months postop time, five patients (6.9%) died, four after pneumonectomy (R 3, L 1). The analysis of tumoral samples showed a pathologic complete response rate of 39.5% in 71 resected patients and a sterilized mediastinal nodes rate of 60.9% in 46 cTanyN2 patients. Median (med) follow-up time of survivors was 36.8 months, two years and three years. -OS was 55 and 40% respectively (med=26.7 months) for all the ITT population (n=107), 62 and 51% (med=36.5 months) for 71 resected, 41 and 16% for the 36 non-resected patients (med=19.1 months). On multivariate analysis, surgical resection and tumoral necrosis >50% were the most predictive factors of the risk of death. Conclusions: Surgery is feasible after CRT, especially if lobectomy (or bilobectomy) is considered at the beginning. Pathological response to CRT is complete in 39.5% of patients and is a major predictive factor of OS.
1Kliniken der Stadt Koeln gGmbH, Cologne, Germany; 2University Hospital, Freiburg, Germany Objective: To compare the number of suspected lung metastases seen preoperatively in the computed tomography with the number of resected pulmonary nodules and the number of histologically proven lung metastases. Is VATS resection the method of choice for solitary pulmonary nodules? Methods: Between 1998 and 2003, we operated on 281 patients with suspicion of lung metastases. Children and patients with incomplete records were excluded. The histology of the primary tumour, the number of preoperative lung metastases, the number of lesions removed during surgery and the number of histologically confirmed metastases of 276 patients are presented. Results: Resection of lung metastases was performed in 276 patients. The average age was 61 years. The average number of nodules seen on the CT-scan was 1.9 (total: 835 nodules), 2.9 pulmonary lesions were removed and 2.1 nodules were confirmed as lung metastases. In 39%, the number of lesions found and removed during the operation was higher than on the preoperative CT-scan. A benign solitary lesions was found in 15.2% of the patients and in 7.9% a primary carcinoma of the lung was diagnosed. The patients were divided into two groups; those with one lesion and those with more than one lesion. In patients with one lesion in the preoperative CT-scan, we confirmed histologically; no metastasis in 16.4%, one lung metastasis 76.7%, and more than one lung metastasis in 6.9%. When more than one preoperative nodule was seen on the CT-scan, we confirmed less metastases in 37.6%, the same number in 35% and more than expected in 27.4%. Conclusions: In patients with a previous history of malignant disease, 15.2% of the solitary pulmonary lesions are benign. VATS is a safe diagnostic method for solitary lesions, with little discomfort for the patient. In patients with more than one nodule manual exploration of the lung is necessary to detect further lesions.
1Thoracic Surgery Unit, Florence, Italy; 2Department of Human Pathology and Oncology, Florence, Italy; 3Clinical Epidemiology Center for Study and Prevention of Cancer, Florence, Italy; 4Pneumology Unit, Florence, Italy Objective: N1 disease in non-small cell lung cancer represents an heterogeneous patient sub-group with a variable prognosis. We retrospectively analyzed the factors that influenced prognosis, including the level of N1 lymph node involvement. Methods: We used the Tuscan Cancer Registry archives to retrieve records on 2896 patients who had lung tumors diagnosed during the period from January 1996 and December 2000. We exlcuded 480 patients with small-cell carcinoma and six patients with nonepithelial tumors. Among 2410 patients, 768 patients (31.8%) underwent complete resection. Radical mediastinal lymph node dissection was undergone by 757 patients. Among 158 patients with pathologic N1 status, the following variables were analyzed for their influence on postoperative survival: gender, age, cell type, pathologic tumor status, the number and level (hilar versus non-hilar) of envolved lymph nodes, tumor grade and the type of surgical resection. The survival of patients who had pN0 disease, non-hilar pN1 disease, hilar pN1 disease and pN2 disease were compared. Results: The overall 5-year survival rate was: 43.9% for patients with pN0 disease (n=417); 10.8% for patients with pN2 disease (n=176); 31.6% for patients with pN1 disease. Among 158 pN1 patients the overall 5-year survival rates for patients with hilar and non-hilar lymph node involvement were 26.9% and 36.2%, respectively. Univariate analysis demonstrated that pathological T factor and level of pN1 envolvement were significant prognostic factors (P=0.009 and P=0.02 respectively). A Cox proportional hazards model analysis indicated that the presence of hilar lymph node involvement was an independent prognostic factor. No differences in survival were observed between non-hilar pN1 disease and pN0 disease (P=0.2). There were statistically significance differences in survival between hilar pN1 disease and pN2 disease (P=0.01). Conclusions: N1 pathologic lymph node status was identified in a combination of subgroups with different prognoses, and the presence of hilar lymph node disease had prognostic significance.
018-F EFFECTIVENESS OF GABAPENTIN IN THE TREATMENT OF CHRONIC POST-THORACOTOMY PAIN S. Okan1, M. Muzaffer2, E. H  dr1, S. Özlem3, Y. Mehmet4, P. Atilla2, G. Atilla2, K. Vural3 1Afyon Kocatepe University School of Medicine Department of Thoracic Surgery, Afyon, Turkey; 2Yedikule Training and Research Hospital for Pulmonary Diseases and Chest Surgery, Istanbul, Turkey; 3Afyon Kocatepe University School of Medicine, Department of Physical Medicine and Rehabilitation, Afyon, Turkey; 4Afyon Kocatepe University School of Medicine, Department of Neurology, Afyon, Turkey Objective: Postthoracotomy pain is a chronic condition. Chronic postthoracotomy pain (CPTP) is often refractory to conventional analgesic strategies. We compared the effectiveness of Gabapentin (GP) and Naproksen Sodium (NS) in CPTP.
Methods: Forty consecutive patients who had postthoracotomy pain (VAS Results: The mean VAS scores before therapy were 6.4±0.6 and 6.8±0.6, the mean LANSS scores before therapy were 18.8±1.6 and 20.7±2.6 in GP group and NS group, respectively (P>0.05). All the patients completed drug therapy lasted for 12 weeks. Minor adverse events which did not cause the discontinuation of therapy were observed in seven patients (35%) in GP group and in four patients (20%) in NS group. The number of the patients whose pain were below five on the VAS scale on the 60th day were 17 (85%) and 3 (15%), in GP and NS group, respectively (P<0.001). Neuropathic pain score decreased below 12 on the LANSS scale on the 60th day in 17 patients (85%) in GP group, but no patient's LANSS score decreased below 12 in NS group on the 60th day. Conclusions: Gabapentin can be an effective and safe choice in the management of CPTP. However, these results must be supported with multidisciplinary and larger sampled studies.
1Thoracic Surgery Department, Sagrat Cor University Hospital, Barcelona, Spain; 2Anesthesiology Department, Sagrat Cor University Hospital, Barcelona, Spain Objective: Paravertebral block is an effective alternative to epidural analgesia in the management of post-thoracotomy pain, however, there are no established guidelines regarding to which is the most suitable strategy, varying drugs and dosages between different groups. Our objective was to evaluate the effectiveness of paravertebral block comparing the most frequently employed drugs in this procedure (Bupivacaine 0.5% vs. Ropivacaine 0.2%). Methods: Prospective randomized study of 62 patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy –AT- and posterolateral thoracotomy –PT-). At the end of surgery a catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group (AT or PT) patients were randomized to receive a bolus of 15 ml of Bupivacaine 0.5% or Ropivacaine 0.2% before closing the thoracotomy. They received postoperatively 15 ml of the anesthetic every six hours combined with Methamizol (every six hours). Meperidine was employed as rescue drug. The level of pain was measured with the Visual Analogic Scale (VAS) at 6, 24, 48 and 72 h after surgery. It was also recorded the need of Meperidine as rescue drug and the secondary effects. Results: We did not register secondary effects relation with the paravertebral catheter. Ten patients (16.1%) needed Meperidine as rescue drug at some moment. VAS values were the following: (AT: Anterior Thoracotomy/PT: Posterolateral Thoracotomy) P=NS Conclusions: Post-thoracotomy analgesia combining paravertebral catheter and a nonsteroidal anti-inflammatory drug is a safe and effective practice, VAS values are acceptable (only 16.1% of patients required Meperidine as rescue drug). It prevents the risk of side effects related to epidural analgesia. Patients submitted to AT experienced less pain than those with PT (4.6 vs. 5.9). Bupivacaine got slightly better VAS values than Ropivacaine (4.9 vs. 5.5), however, there were no statistically significant differences (P>0.05).
Department of Surgery Intensive Care and Organ Transplantation, Division of Esophageal and Pulmonary Surgery, Villa Maria Cecilia e San Pier Damiano Hospitals, Cotignola and Faenza University of Bologna, Bologna, Italy Objective: Results of Heller myotomy for the treatment of sigmoid achalasia are worst than those achieved for fusiform achalasia. We retrospectively examined two groups of sigmoid achalasias in which we performed (1) the standard Heller-Dor procedure, (2) the Heller-Dor plus a technique apt to obtain the verticality of the esophageal axis. We verified if the latter technique had improved long-term results. Methods: Among a total of 188 laparotomic and laparoscopic case series (1979–2005) we considered 33 patients affected by primitive esophageal sigmoid achalasia consecutively operated upon. Diagnosis was based on symptoms, manometry, radiology and endoscopy. Since 1987 before performing the Heller-Dor procedure we routinely isolated 360° the ge-junction and the lower esophagus and we applied U stitches at the right side of the lower esophagus in order to pull down and to rotate toward the right side the ge-junction. Fifteen patients had the No Pull-down and 18 patients had the Pull-down technique. Postoperative follow-up included barium swallow, endoscopy, objective clinical evaluation (questionnaire filled by a surgeon SR reflux symptoms, D dysphagia, E, endoscopic reflux esophagitis), subjective evaluation (self evaluation SF-36 questionnaire). Results: No postoperative complications were secondary to the pull down technique. Conclusions: The clinical objective and subjective evaluations show a trend toward the results improvement with the pull-down technique. Stronger statistical significance would probably be obtained inside a larger case series. A multicentric study could help to know more on this interesting topic. Results:
Glenfield Hospital, Leicester, UK Objective: LVRS is thought to result in significant improvements in BMI. Patients with a higher BMI at the time of diagnosis of COPD are known to have better survival, and those with a low BMI prior to LVRS have significantly worse perioperative morbidity. We aimed to assess the influence of BMI on the outcome of LVRS in our own experience.
Methods: Complete preoperative BMI data was available in 114/131 patients who have undergone LVRS since 1995. These patients were placed in three categories: underweight (BMI Results: Expressed as median (range). There were no significant differences in pre-op variables. There were significantly more post op ITU admissions among the lowest two BMI groups (12/29, 18/58 and 3/27, respectively, P=0.02), and significantly shorter hospital stay in overweight patients [16 days (5–79) v 18 days (6–111) v 13 days (6-25) respectively, P=0.005]. There was no difference in survival between the three groups (P=0.21). Significant correlations for one year post op were found between pre op BMI and percent change in FEV1 (r=0.29, P=0.02) and DLCO (r=0.33, P=0.02). BMI was significantly increased in the underweight and significantly decreased in the overweight at all time points. Conclusions: Higher preoperative BMI reduces hospital stay and ITU admissions and is associated with better spirometric improvement and gas transfer. Future work is needed to explore the roles of changing energy requirements and muscle mass following LVRS. Would optimisation of BMI preoperatively improve outcome?
1Clinic of Thoracic Surgery HSK Wiesbaden, Wiesbaden, Germany; 2Institute for Pathology and Cytology HSK Wiesbaden, Wiesbaden, Germany; 3Clinic for Anesthesiology and Intensive Care Medicine HSK Wiesbaden, Wiesbaden, Germany Objective: The aged population tends upwards. Despite advanced perioperative management and enhanced surgical techniques, are there only limited resections possible with the increasing age of the patient with non-small-cell cancer? Methods: From January 1999 to December 2004, all patients older than 75 years of age undergoing pulmonary resection for non-small cell lung cancer were enrolled in this prospective study. The patients were divided up into two groups: age 75 years and older (group I) and age 80 years and older (group II). Morbidity, mortality, intraoperative complication rate and risk factors were analyzed in the overall collective and the both groups, and compared, respectively. Results: In a total number of 157 patients (group I: 110, group II: 47) following resections were performed: 104 lobectomies (group I: 73, group II: 31), 8 bilobectomies (group I: 6, group II: 2), 11 pneumonectomies (group I: 9, group II: 2), 15 sleeve resections (group I: 11, group II: 4) and 19 segmentectomies (group I: 11, group II: 8). For all resections the intraoperative complication rate was 1.9% (group I: 2.7%, group II: 0%) with a mortality of 3.8% (group I: 3.6%, group II: 4.3%) and morbidity of 38.2% (group I: 39.1%, group II:36.2%). There was no significant difference in morbidity, mortality and intraoperative complication rate between two groups. In our study no risk factors could be pointed out concerning increased morbidity or mortality. Conclusions: Pulmonary resections for non–small-cell lung cancer in patients older than 75 years is feasible. Low morbidity and mortality can be achieved with advanced perioperative management, enhanced surgical techniques and a good conduct of the patients. Even extended resections are possible.
Yedikule Teaching Hospital for Chest Diseases and Thoracic Surgery, Department of Thoracic Surgery, Istanbul, Turkey Objective: If maximum standard uptake value (SUVmax) of a tissue at PET is <2.5 that tissue accepted with high risk of malignancy. We studied accuracy rate of this level and tried to designate optimum level to detect mediastinal lymphatic metastasis in NSCLC patients. Methods: PET-CT was carried out to 170 operable NSCLC patients between 2004 and 2006. Reported SUVmax levels of carcinoma at the lung and at all mediastinal stations were recorded. Additionally, ratio of SUVmax level of mediastinal lymph nodes to the level of the carcinoma was calculated as a new variable (SUVln/SUVca). Later, cervical mediastinoscopy was done to all the patients and mediastinal lymphatic dissection via thoracotomy was performed to patients who were not detected mediastinal metastasis at mediastinoscopy. Mediastinal lymph nodes examined histopathologically. Accuracy of SUVmax level 2.5 was calculated. Optimum level of SUVmax was investigated by ROC analysis. Additionally, another ROC analysis was done to detect accuracy of SUVln/SUVca ratio. Results: PET's sensitivity, specificity, positive predictive value, negative predictive value and accuracy rates to detecting mediastinal lymphatic metastasis with level of 2.5 as cut-off point were calculated as 74%, 73%, 55%, 87% and 74%, respectively. At ROC analysis, 65%, 97%, 90%, 87% and 88% of sensitivity, specificity, positive predictive value, negative predictive value and accuracy rates were accessed with 5.0 level as a as cut-off value for SUVmax and 44% as cut-off ratio for SUVln/SUVca together. Conclusions: Accuracy rate of PET to detect mediastinal lymphatic metastasis of NSCLC can increase with use of 5.0 level of SUVmax instead of 2.5. Furthermore, with 44% level of SUVln/SUVca as a cut-off point, more accurate results can be obtained.
2, S. Görgül2, C. Gebitekin1 1Department of Thoracic Surgery of Medical Faculty of Uludag University, Bursa, Turkey; 2Department of Surgery of School of Veterinary Medicine of Uludag University, Bursa, Turkey; 3Department of Thoracic Surgery of Technical University of Blacksea, Trabzon, Turkey Objective: Sleeve resection, with or without lung resection, is a valid conservative operation for patients with benign or malignant tumors, allowing conservation of lung parenchyma. The aim of this prospective randomized study was to compare complications, operating time and bronchial healing of interrupted and continuous suture techniques for bronchial anastomosis in dogs. Methods: Twenty adult Mongorel dogs each weighing 18 to 22 kg (average 20 kg) were divided into two groups according to the anastomosis technique, interrupted suturing Group A and continuous suturing Group B. Ten dogs were included in each group. Following the right thoracotomy, sleeve resection of the right cranial lobe was carried out in all dogs. Basic interrupted sutures using 4/0 Vicryl (Ethicon, USA) was used in group A and continuous suture technique in group B. Results: The median anastomosis time was 15.2 (13–21) min. in group A and 9.6 (8–13) min. in group B. Right pneumonectomy was carried out and theanastomosis line was removed for histopathological investigation in all dogs one month after sleeve resection. Histopathological examination revealed that the healing of anastomosis was not effected by the suturing technique (Fisher's exact test P=0.763). Neither morbidity nor mortality was observed. Conclusions: Our research revealed that healing of anastomosis was not effected by the suturing technique.
Medical University of Vienna, Vienna, Austria Objective: Hemodynamic impairments after pneumonectomy are rare complications and present in two different forms or a combination of both. Changes in the anatomical situation of the left atrium and elevated pulmonary-artery-pressure can lead to a significant right-left shunt via a previously closed foramen ovale (PFO) and diaphragmatic relaxation can lead to a dislocation of the liver into the right hemithorax, compressing the right atrium with subsequent inflow obstruction. Methods: We retrospectively analysed our patient cohort from 1997 to 2006 for occurrence of hemodynamic complications requiring intervention after pneumonectomy. Results: Five patients (1 female, 4 male, age 59+9 years) were identified. All underwent right pneumonectomy due to NSCLC (n=4) or atypical carcinoid (n=1). Two patients were readmitted three months and two years postoperatively due to increasing platypnoea and orthodeoxia. After closure of a PFO which was found as the underlying pathological mechanism respiratory symptoms were resolved. One patient required reintubation already two hours postoperatively; after surgical closure of a PFO the respiratory situation significantly improved. One patient was readmitted due to right atrial inflow obstruction 17 months after right pneumonectomy. Underlying cause was a severe diaphragmatic relaxation with compression of the atrium by the liver. After diaphragmatic plication all symptoms resolved. One patient was readmitted three months after pneumonectomy and partial atrial resection due to cyanosis and dyspnoea. Diagnostics revealed a PFO and a massive raise of the right diaphragm with compression of the right atrium. After surgical correction of the contorted foramen ovale and diaphragmatic plication symptoms vanished. Conclusions: Hemodynamic alterations due to a reopened foramen ovale or right atrial inflow obstruction are rare, however, severe complications after pneumonectomy. They occur at variable points in time after pneumonectomy. Closure of the PFO either surgical or interventional and/or plication of the elevated diaphragm are mandatory. In our experience these complications occur only after right pneumonectomy.
University of The Mediterranean Assistance Publique Hopitaux de Marseille Sainte Marguerite Hospital, Marseille, France Objective: T4-disease for Non Small Cell Lung Cancer (NSCLC) includes different conditions: mediastinal invasion, neoplastic pleural cytology, and multifocal disease in the same lobe. Regarding the last category, no strict criteria allows to differentiate satellite nodules from synchronous multiple primary tumours. Methods: Retrospective study of 56 patients who underwent a complete resection from 1985 to 2006 of a NSCLC graded pT4N0 due to a multifocal disease. A small nodule (<1 cm), closed to the primary tumour, in a same pulmonary segment with an identical histolology was considered as a satellite nodule (pT4sn). Multiple tumours, sized more than 1 cm, with an identical histology, located in the same lobe but in different segments were considered as synchronous cancers (pT4sc). Results: There were 44 males and 12 females: 35 patients were staged T4sn and 21 patients T4sc. The median age was 62.5 years. The two groups were similar for sex, age, tobacco consumption, ASA score, NYHA, Charlson's index, spirometric parameters, cardiovascular comorbidity and history of previous extra-thoracic malignancies. All had a complete anatomic resection with mediastinal lymphadenectomy. Thirty-day mortality rate was 3.6%. Overall 5-years and 10-years survival rates were 48.2% and 29.9%, respectively. There was a non-significant trend for a worse survival in T4sn group patients when compared to that of T4sc group patients: 42.9% vs. 52.3% at five years, and 25% vs. 34.9% at ten years (P=0.62). Conclusions: Multifocal T4 stage IIIB disease is an heterogeneous category which overall prognosis is far better than those of other T4 subgroups. Survival rates associated with pT4sn and pT4sc look roughly similar because of the small size of the subgroups usually submitted to comparison in most series. In the present experience, respective survival curves diverge, suggesting different biological behaviours
027-O OXYGEN DESATURATION DURING MAXIMAL STAIR CLIMBING TEST AND POSTOPERATIVE COMPLICATIONS M. Refai, A. Brunelli, F. Xiumé, M. Salati, R. Marasco, V. Sciarra, L. Socci, A. Sabbatini Umberto I Regional Hospital, Ancona, Italy Objective: Non-univocal conclusions have been published regarding the definition of oxygen desaturation in relation to postoperative outcome. We aimed to verify whether oxygen desaturation during maximal stair climbing test was associated with postoperative cardiopulmonary complications and to assess which definition of oxygen desaturation (satO2 <90% or desaturation >4% regardless the level of oxygen saturation) discriminates better between complicated and uncomplicated patients. Methods: Five hundred and thirty-six consecutive patients performing maximal stair climbing test prior to major lung resection were analyzed. Data were retrieved from a prospective database. All patients performed the test on room air. Patients with and without cardiopulmonary complications were compared in terms of several preoperative and operative characteristics by univariate analysis, including the presence of oxygen desaturation at peak exercise. Logistic regression analysis was then performed and validated by bootstrap procedure to identify predictors of complications and to see whether the exercise oxygen desaturation retained its significancy after multivariable adjustment. Results: Twenty-seven patients had an exercise desaturation below 90%, but this parameter was not significantly associated with complications. Seventy-five patients experienced an exercise desaturation >4%, which resulted significantly associated with postoperative complications at univariate analysis (P=0.008) (36% vs. 22% complication rate). After adjusting for age, ppoFEV1, ppoDLCO, type of operation and cardiac co-morbidity, a desaturation >4% retained its significancy at logistic regression and proved to be stable at bootstrap. Conclusions: Stair climbing test is an intense constant-workload exercise, challenging a large amount of muscle mass, and appears particularly appropriate to elicit oxygen desaturation, which in turn may be a reliable marker of deficits in the oxygen transport system. The amount of the desaturation (>4%) is more important than the level (4%) at peak exercise.
1Ahepa University Hospital, Thessaloniki, Greece; 2Athens Chest Diseases Hospital, Sotiria, Athens, Greece; 3Sismanoglion General Hospital, Athens, Greece Objective: To identify simple laboratory parameters which influence the 6month clinical post-pneumonectomy state. Methods: Thirty-five patients who underwent pneumonectomy (mean age: 61.5±7.2 years, left sided: 23, men: 32) for lung carcinoma (1996–2001) were prospectively studied with preoperative and 6-month postoperative spirometry, Doppler echocardiography for calculation of right ventricular systolic pressure (RVSP) and arterial blood gases determination. The parameters actual and percent of the predicted for the age, height and weight of the patient FEV1 and FVC (index of ventilatory pump function), RVSP (index of right ventricle pump function) and partial pressures of oxygen and carbon dioxide in the arterial blood (index of oxygenation and ventilation respectively) were studied as determinant parameters of the post-pneumonectomy state. The clinical postpneumonectomy state was considered to be expressed by the class of dyspnea on exertion, according to the following classification: Class I=dyspnea on heavy exertion, Class II=dyspnea on moderate exertion, Class III=dyspnea on mild exertion, Class IV=dyspnea on minimal exertion. Statistical analysis was made using the one-way ANOVA test for normal distributions or the Kruskal-Wallis test for abnormal distributions and the multiple regression analysis. Results: The parameters FEV1 (P=0.001), FVC and percent of the predicted FVC (P=0.032 and P=0.06 respectively) were found to significantly differ between patients with Class I and II and patients with class III and IV dyspnea on exertion. The parameter PASP had significant difference (P=0.016) between patients with class IV and class I, II and III dyspnea on exertion. Performing multiple regression analysis, the parameter FEV1 was found to be the only independent parameter, which affect the post-pneumonectomy state of patients (multiple R2=0.293, ß=0.541). Conclusions: Dyspnea on minimal and mild exertion is related to low post-pneumonectomy FEV1 values. Postoperative FEV1 is the only independent determinant parameter of the 6-month post-pneumonectomy state of patients.
1European Institute of Oncology, Milan, Italy; 2CHU Nice, Nice, France; 3National Cancer Institute, Milan, Italy; 4CHU Bordeaux, Bordeaux, France; 5University of Turin, Turin, Italy Objective: One of the characteristics of COPD is the tendency to develop acute exacerbation, defined by the presence of different clinical findings as worsening dyspnea, increase in sputum purulence and volume. This study was designed to verify if definition of acute COPD exacerbation is appliable to patients who underwent pulmonary surgery, and if it has any impact on postoperative morbidity and mortality. Methods: This study was designed to prospectively enroll 1000 patients undergoing pulmonary resection for lung cancer from five different thoracic surgery centers. In absence of concomitant pulmonary complication, severe postoperative exacerbation of COPD was defined as the presence of a deteriorating dyspnea score, purulent sputum, and a bronchial secretion volume >10 ml/24 h; moderate exacerbation was defined as the presence of two of these findings; mild exacerbation was defined as the presence of one of these finding and one of the following clinical criteria: fever without other apparent cause, increased wheezing, increased cough. Results: Postoperative stay in exacerbated patients was significantly longer as compared to uncomplicated patients without exacerbation (6.3±1.3 vs. 8.3±1.1, P=0.00). A postoperative exacerbation of COPD was recorded in 276 patients and 152 of them (55%) subsequently developed respiratory complications. Univariate analysis identified sex, ASA score, FEV 1%, COPD exacerbation and type of operation as risk factors for the occurrence of respiratory complications. Three of them were confirmed as risk factors for respiratory complications in the multivariate analysis: sex (female OR 0.54, CI 1.2–3.5), ASA score (OR 1.5, CI 1.1–8.1), and COPD exacerbation (OR 7.6, CI 1.9–6.9). Conclusions: Postoperative exacerbation of COPD is an existing, frequent clinical entity after lung resection and increases the risk of developing pulmonary complications. The existing guidelines for the treatment of acute exacerbation should be adapted to the postoperative management of surgical patients in order to test the hypothesis that they could reduce respiratory morbidity.
Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium Objective: To prospectively evaluate quality of life (QoL) evolution after surgery for primary or secondary spontaneous pneumothorax with the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30. Methods: From January 2003 till December 2004, QoL was prospectively recorded in 20 consecutive patients. Questionnaires were administered before surgery and 1, 3, 6 and 12 months postoperatively (MPO) with response rates of 100%, 85%, 80%, 65% and 60%, respectively. In this prospective, non-randomized study, all patients had wedge resection and apical pleurectomy, 45% by video-assisted thoracic surgery (VATS), and 55% by anterolateral thoracotomy (AT). Results: In general, patients QoL subscales improved after surgery. After VATS, pain (three MPO P=0.012), dyspnea (one MPO P=0.030) and thoracic pain (one MPO P=0.038) decreased significantly. After AT, a significant increase was seen in general QoL (1 MPO P=0.036, 3 MPO P=0.034, 12 MPO P=0.025), physical (six MPO P=0.025) and emotional functioning (12 MPO P=0.017). Dyspnea (12 MPO P=0.042) and coughing (six MPO P=0.046) decreased after AT. After surgery, AT and VATS are comparable in QoL evolution with exception of a significant difference one MPO in physical, role and cognitive functioning (P=0.002, P=0.002 and P=0.0018, respectively) and dyspnea (P=0.041) in favor of VATS. Comparing VATS and AT in QoL evolution, significant differences are seen in thoracic pain evolution in favor of VATS (six MPO P=0.037). Conclusions: After surgery, AT and VATS are comparable in QoL subscales with exception of a significant difference one MPO in favor of VATS. Dyspnea and coughing improved after surgery.
1Division of Thoracic and Hyperbaric Surgery, University Medical School, Graz, Austria; 2Institute for Empirical Health Economics, Burscheid, Germany Objective: Postoperative persistent air leaks in patients after pulmonary resections are a determining factor for the length of hospital stay. Except for the standard techniques (ST) consisting of suturing, stapling and electrocautery the surgeon can also employ sealing with the surgical patch TachoSil® (TS). The aim of this model analysis is a pharmacoeconomic evaluation of these two alternative methods. Methods: A randomised clinical trial involving 152 patients with pulmonary lobectomy/segmentectomy (ST: 77 patients; TS: 75 patients) established the basis of this pharmacoeconomic model analysis. The efficacy endpoints of this study were the postoperative quantification of air leakage as well as the chest drainage time and length of hospitalisation. A cost-benefit analysis was carried out from the hospital's economic prospective, taking into consideration the resource consumption for the two alternatives as well as the mean time of hospital stay. Results: The clinical study demonstrates significantly smaller postoperative air leaks in the TS group. The mean times to chest drain removal and to hospital discharge were significantly reduced in the TachoSil® group (5.1 vs. 6.3 days, P=0.022 and 6.2 vs. 7.7 days; P=0.01, respectively).
The resources required for air leak closure were Conclusions: The use of TachoSil® following pulmonary resection resulted in a reduction in air leakage compared to standard techniques with the additional effect of a reduction in both the mean time to chest drain removal and time to hospital discharge. The reduced length of hospital stay necessarily involves treatment cost savings when fleece-bound sealing is employed to treat air leakage after lung surgery.
Department of Cardiothoracic Surgery, Gentofte University Hospital, Copenhagen, Denmark Objective: VATS lobectomies is a difficult and somewhat controversial operation. This study addresses the shift from a posterior to an anterior approach. Methods: A program was set up in 1999 with total endoscopic non-rib-spreading VATS lobectomies. Until late 2004, a posterior approach with the camera and a total of four ports was used. By 2005, we changed to a uniform anterior three port technique, with the ports identically placed (a 5 cm anterior incision to specimen retraction, a low anterior camera-port in the middle and a more posterior placed 15 mm port. All operations are done by a single surgeon well trained in VATS and with a 10 mm 30° angled thoracoscope. Results: By 1st of February 2007, 140 major VATS resections have been performed. (131 lobectomies, 7 bi-lobectomies and 2 pneumonectomies.) In this period 26 cases were converted to an open procedure. One hundred and forty-nine of the 166 cases were NSCLC. Until 1st January 2005, 72 cases were performed with 23.9% converted to an open procedure. Eight out of 17 (47.1%) of the conversions was due to surgical complications. In the second-half since 1st January 2005 (95 cases) the conversion rate was 9.5% and in 2006 4.1%. All but two due to unexpected pathology (77.8%). In 2005, 40% and in 2006 53% of all cancer lobectomies in our institution was done by VATS. Conclusions: This study shows a learning curve for VATS lobectomy, but we also find that the anterior approach diminish the conversion rate and the morbidity. It allows more lobectomies to be done safely by VATS. A uniform anterior approach facilitates VATS lobectomies and makes this advanced procedure more easily adapted by many surgeons who are used to an open anterior approach.
033-F THE RIGHT UPPER LOBE PULMONARY RESECTION PERFORMED THROUGH THE TRANSCERVICAL APPROACH M. Zielinski1, J. Pankowski2, L. Hauer1, J. Kuzdzal1, T. Nabialek3 1Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland; 2Department of Pathology, Pulmonary Hospital, Zakopane, Poland; 3Department of Anesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland Objective: Preliminary report: presentation of the new technique of transcervical right upper lobectomy with transcervical extended mediastinal lymphadenectomy (TEMLA) for NSCLC. Methods: The operation was performed through the collar incision, with elevation of the sternal manubrium with the mechanical sternal retractor. TEMLA and bilateral mediastinal lymph node excision (stations 1, 2R, 4R, 2L, 4L, 3A, 3P, 7 and 8) and bilateral supraclavicular lymph node excision was performed (frozen section analysis-all nodes negative). The mediastinal pleura was opened and the following structures were dissected in the open fashion with standard surgical instruments and divided with use of endostaplers: the azygos vein, the upper trunk of the right pulmonary artery, the branch of the superior pulmonary vein to the upper lobe, the upper lobe bronchus, the segment two artery, the posterior part of the oblique fissure and the horizontal fissure. The operation was performed with use of one videothoracoscopic (VTS) port for insertion of 5 mm, 30° VTS camera for intraoperative control and for single thoracic drain for the postoperative period. Results: The operative time was 250 min; intraoperative blood loss was 110 ml. There were no intraoperative complications. The postoperative course was remarkably smooth. The final pathologic report: large cell carcinoma pT2N0M0, no metastatic changes of 38 mediastinal and ten intrapulmonary nodes (stations 10, 11 and 12). Conclusions: This preliminary report indicates possible advantages of the transcervical right upper lobe pulmonary resection including:
University Hospital of Saint Etienne, Saint Etienne, France Objective: Our aim was to assess the efficacy of intercostal nerve block on post-thoracotomy pain relief, pulmonary function and arm mobilization.
Methods: After institutional approval, fifty patients undergoing lung resection through a lateral axillary thoracotomy were enrolled in a prospective, double-blinded study. They were randomized to receive either ropivaca
Results: Both groups were comparable (spirometry, type and length of procedure). In the ropivaca Conclusions: Intercostal block is a simple and effective that maily improves peak expiratory flow rate, providing better dynamic than resting analgesia.
Royal Devon and Exeter NHS Foundation Trust, Exeter, UK Objective: We describe a new technique for maintaining patency of the injured/perforated oesophagus while providing drainage of the mediastinum in patients with a lower oesophageal defect. Methods: Decontamination of the chest and repair of the oesophageal defect is performed if the patient's condition allows. A small midline laparotomy is performed. A 36F soft chest drain is passed into the oesophagus through the mouth and withdrawn through a small gastrotomy in the greater curve of the stomach. The drain is brought out through the abdominal wall and the stomach is sutured to the peritoneum. The upper end of the chest drain is placed at least 5 cm proximal to the proximal end of the oesophageal defect. A feeding jejunostomy is placed. The patient takes sterile water by mouth to mainta |
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Monday 4 June 2007...
Monday 4 June 2007...
5, LANSS
19 kg/m2), normal (BMI 20–25 kg/m2), and overweight (BMI>26kg/m2). The in-hospital course and peri-operative change in BMI at 3, 6, 12, 24 and 36 months were recorded for each category and compared. 
47 per patient for ST and 
ne through three indwelling intercostal catheters every four hours (thoracocomy±1 IS), or placebo. Both groups had morphine IV PCA for five days. The primary endpoint was morphine consumption at 24 h. Secondary endpoints were pain at rest and during arm mobilization (visual analog scale), respiratory function (bedside spirometry), active and passive shoulder elevation and abduction range of motion (handheld goniometer) and radiographic complications. All data were mean±S.E.M. P<0.05 was considered statistically significant.