Objective: To evaluate type of surgery, long-term survival and factors influencing outcome in pulmonary carcinoid tumors. Patients and methods: We reviewed data of 252 patients who underwent surgery ...for carcinoid tumor in 1968–1989 (Group A) and in 1990–2005 (Group B). All cases were reviewed and classified as typical (TC) or atypical carcinoid (AC) according to WHO criteria (1999). Results: There were 174 (69%) patients with TC (167 N0, 6 N1 and 1 N2) and 78 (31%) with AC (56 N0, 13 N1, 9 N2). Surgery consisted of 163 (64.7%) formal lung resections (121 lobectomies, 18 bilobectomies, 14 segmentectomies, 10 pneumonectomies), 76 (30.1%) sleeve or bronchoplastic resections and 13 (5.2%) wedge resections. No perioperative mortality occurred, 17 (6.7%) patients experienced complications. Overall 5, 10 and 15-year survival rate was 90%, 83% and 77%. TC showed a more favourable prognosis than AC (10-year survival rate 93% and 64%; p = 0.00001) as well as N0 patients in comparison with N1-2 patients (10-year survival rate 87% and 50%; p = 0.00005). Group A received lymph-node sampling, Group B received a systematic lymphadenectomy. No difference was found between Group A and B in detection of nodal metastases (10.9% versus 11.9%; p = 0.79), but in Group A we observed 2 lymph-node relapses. In Group B number of sleeve resections significantly increased (2.7% versus 20.4%; p = 0.0001) and number of pneumonectomies showed a significant reduction (7.2% versus 1.4%; p = 0.01). Conclusions: Typical histology and N0 status were important prognostic factors in carcinoid tumors. Parenchyma-sparing procedures must be considered the treatment of choice with systematic lymphadenectomy.
The treatment of non-small cell lung cancer is based, when suitable, on surgical resection. Pneumonectomy has been considered the standard surgical procedure for locally advanced lung cancers but it ...is associated with high mortality and morbidity rates. Reconstruction of the pulmonary artery, associated with parenchyma-sparing techniques, is meant to be an alternative to pneumonectomy.
This retrospective single-center study is based on a detailed and comprehensive analysis of the clinical and oncologic data of patients treated between 2004 and 2016 through pneumonectomy or lobectomy with reconstruction of the pulmonary artery. A propensity score weighting approach, based on the preoperative characteristics of two groups of 124 patients each was performed. The subsequent statistical analysis evaluated long-term and short-term clinical outcomes together with risk factors analysis.
The comparison between pneumonectomy and pulmonary artery reconstructions showed a higher 30-day (P = .02) and 90-day (P = .03) mortality rate in the pneumonectomy group, together with a higher incidence of major complications (P = .004). Long-term results have shown comparable outcomes, both in terms of 5-year disease-free survival (52.2% for pneumonectomy vs 46% for pulmonary artery reconstructions, P = .57) and overall 5-year survival (41.9% vs 35.6%, respectively; P = .57). Risk factors analysis showed that cancer-specific survival was related to lymph node status (P < .01) and absence of adjuvant therapy (P = .04). Lymph node status also influenced the risk of recurrence (P < .01).
Lobectomy with reconstruction of the pulmonary artery is a valuable and oncologically safe alternative to pneumonectomy, with lower short-term mortality and morbidity, without affecting long-term oncologic results.
Chest tube management represents a major issue after lung surgery as no protocol is widely accepted and tube management is generally based on local or personal habits. Aim of this study is to ...evaluate the impact of a standardized protocol for chest tube management after pulmonary resections on the post-operative outcomes. We performed a single center retrospective analysis of all adult patients undergoing thoracoscopic pulmonary resection from January 2020 to December 2021. Starting from January 2021 a standardized protocol of chest tube management was applied after all procedures. Patients were divided into two groups according to the chest tube management strategy. he two groups had similar pre-operative characteristics and the extent of lung resection was comparable. Intervention group had significantly shorter time to chest tube removal (median 1 vs 3 days, p < 0.001) and post-operative length of stay (median 3 vs 4 days, p < 0.001). Despite earlier chest tube removal, there was not an increased incidence of post-removal complications. On multivariable analysis, the new chest drain management strategy was an independent predictor of earlier chest tube removal. A standardized protocol of chest tube management allows for an earlier chest tube removal and a shorter hospital stay, without an increase in post-operative complications.
OBJECTIVES
Sublobar resection for early-stage lung cancer is still a controversial issue. We sought to compare sublobar resection (segmentectomy or wedge resection) with lobectomy in the treatment of ...patients with a second primary lung cancer.
METHODS
From January 1995 to December 2010, 121 patients with second primary lung cancer, classified by the criteria proposed by Martini and Melamed, were treated at our Institution. We had 23 patients with a synchronous tumour and 98 with metachronous. As second treatment, we performed 61 lobectomies (17 of these were completion pneumonectomies), 38 atypical resections and 22 segmentectomies. Histology was adenocarcinoma in 49, squamous in 38, bronchoalveolar carcinomas in 14, adenosquamous in 8, large cells in 2, anaplastic in 5 and other histologies in 5.
RESULTS
Overall 5-year survival from second surgery was 42%; overall operative mortality was 2.5% (3 patients), while morbidity was 19% (22 patients). Morbidity was comparable between the lobectomy group, sublobar resection and completion pneumonectomies (12.8, 27.7 and 30.8%, respectively, P = 0.21). Regarding the type of surgery, the lobectomy group showed a better 5-year survival than sublobar resection (57.5 and 36%, respectively, P = 0.016). Compared with lobectomies, completion pneumonectomies showed a significantly less-favourable survival (57.5 and 20%, respectively, P = 0.001).
CONCLUSIONS
From our experience, lobectomy should still be considered as the treatment of choice in the management of second primary lung cancer, but sublobar resection remains a valid option in high-risk patients with limited pulmonary function. Completion pneumonectomy was a negative prognostic factor in long-term survival.
Objective
The objective of the study is to analyse the causes and impact of conversion from VATS to thoracotomy identifying any possible pre-operative risk factors and related consequences.
Methods
...Data from patient who underwent VATS lobectomy (VATS-L) for NSCLC at VATS Group participating centres were retrospectively analysed and divided in two groups: patients treated with VATS-L and patients who suffered from conversion. Predictors of conversion were assessed with univariate and multivariable exact logistic regression. Complications were evaluated as dependent variables of conversion in a Cox multivariable logistic regression model.
Results
A total of 4629 patients underwent planned VATS-L for NSCLC and of these, 432 (9.3%) required conversion; the most frequent causes were bleeding (30.4%) and fibro-calcified hilar lymph nodes (23.9%). The independent risk factors at multivariable analysis model were sex male (OR 1.458,
p
< 0.01), age older than 70 years (OR 1.248,
p
= 0.036) and the clinically node-positive disease (OR 2.258,
p
< 0.01). The mortality rate was similar, but the percentage of patients who suffered from any complication (41.7% vs 24.4%,
p
< 0.01), the complication rate (65% vs 32.2%,
p
< 0.01), chest tube duration (
p
< 0.01) and the hospitalisation rate (
p
< 0.01) were higher for patients converted. Atrial fibrillation (OR 1.471,
p
= 0.019), prolonged air leak (OR 1.403,
p
= 0.043), blood transfusions (OR 4.820,
p
< 0.01), sputum retention (OR 1.80,
p
= 0.027) and acute kidney failure (OR 2.758,
p
= 0.03) were significantly associated with conversion at multivariable analysis.
Conclusions
Conversion is associated with increased surgical morbidity, blood loss and hospital stay. Sex male, old age and the clinical involvement of lymph nodes were the strongest predictors of conversion.
Aim of this study is to identify the factors that may influence the lymphadenectomy during VATS anatomical lung resection with particular interest on operator experience.
Clinical and pathological ...data from the prospective VATS Italian nationwide registry were reviewed and analysed. Patients with incomplete data regarding tumor and surgical characteristics, GGO, or with distant metastases were excluded. Patients clinical data, tumor characteristics, operation information and surgeon experience were collected and compared to resected lymph nodes number (#RN), resected N2 nodes number (#N2RN) and resected N2 stations number. A multivariable model was built using logistic regression analysis. Surgeon experience was categorized considering the number of VATS major anatomical resection and years after residency.
The final analysis was conducted on 3727 patients. The median #RN and #N2RN were 11 (1–51) and 5 (0–41). Regarding the analysed outcomes, #N2RN > 6 resulted in 1812 (48.8%)cases, #RN > 10 in 2124 (57.0%)cases and more than 3 N2 stations were harvested in 1447 (38.8%)patients.
First operator experience with number of VATS lobectomies>50 (p < 0.001), operator seniority after residency5-10years (p < 0.001), cTNM II/III(p = 0.017), lobectomy/bilobectomy vs segmentectomy (p < 0.001), and upper/middle lobe tumor location (p < 0.005)resulted significantly associated to #N2RN > 6 at the multivariable analysis. First operator experience with number of VATS lobectomies>50 (p < 0.001), operator seniority after residency5-10years (p < 0.001) and lobectomy/bilobectomy (p < 0.001) resulted significantly associated to #RN > 10 at the multivariable analysis.
Our study showed that lymphadenectomy during VATS lobectomy is influenced by tumor factors such as cTstage and tumor location but also by operator experience, with a higher number of resected lymph nodes in surgeons with a high number of VATS procedures and years after residency compared to surgeons with less experience.
Abstract
OBJECTIVES
Only few studies compared the surgical morbidity and mortality of thoracoscopic segmentectomy versus lobectomy for non-small-cell lung cancer, in particular, by relating the ...segmental resections with the corresponding anatomical lobes.
METHODS
We enrolled a total of 7487 patients who underwent VATS lobectomy (7269) or segmentectomy (218) from January 2014 to July 2019. A propensity score matching approach was used to account for potential confounding factors between the 2 groups. After matching, 349 lobectomies and 208 segmentectomies were included in the analysis. We analysed the operative and postoperative outcomes of video-assisted anatomical segmentectomy compared with video-assisted lobectomy and, in details, the results of segmentectomy with its corresponding lobectomy in a large cohort of patients from the Italian VATS Group Registry.
RESULTS
The overall conversion rate to thoracotomy was not statistically different between the groups (27 patients 8% vs 7 patients 3%, P = 0.1). The lobectomy group had a greater number of resected lymph nodes (median 11 vs 8, P = 0.006). No significant differences were detected in 30-day mortality (1.4%, 5 patients vs 0.9%, 2 patients), overall complications (18%, 62 patients vs 14%, 29 patients) and prolonged air leakage (31 patients, 9% vs 12 patients, 6%) between lobectomy and segmentectomy, respectively. No statistical differences were found regarding the median duration of drainage (3.2 days, P = 1) and the overall median length of hospital stay (6.4 days, P = 0.1) between the 2 groups. In the context of segmentectomy versus corresponding lobectomy, the right upper lobectomy compared with right upper segmentectomy showed a higher number of resected lymph nodes (P = 0.027). No statistical differences were reported in terms of conversion rate and postoperative complication and mortality.
CONCLUSIONS
Segmentectomy could be considered a safe procedure without significant differences compared to thoracoscopic lobectomy in terms of postoperative morbidity and mortality.
Since 2000, many studies have been published, including randomized ones, which have demonstrated that anatomical segmentectomy for early-stage non-small-cell lung cancer (NSCLC) yields oncological equivalent results with respect to those of lobectomy, with a potential lung-sparing effect 1–4.
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