OBJECTIVES
Video-assisted thoracoscopic anatomical resections are increasingly used in Europe to manage primary lung cancer. The purpose of this study was to compare the outcome following ...thoracoscopic versus open lobectomy in case-matched groups of patients from the European Society of Thoracic Surgeon (ESTS) database.
METHODS
All patients having lobectomy as the primary procedure via thoracoscopy video-assisted thoracoscopic surgery (VATS)-L) or thoracotomy (TH-L) were identified in the ESTS database (January 2007 to December 2013). A propensity score was constructed using several patients' baseline characteristics. The matching using the propensity score was responsible for the minimization of selection bias. A propensity score-matched analysis was performed to compare the incidence of postoperative major complications (according to the ESTS database definitions) and mortality at hospital discharge between the matched groups. After exclusions, 28 771 patients were identified: 26 050 having thoracotomy and 2721 having thoracoscopy. Propensity score yielded two well-matched groups of 2721 patients. Numeric variables were compared by Student's t-tests and categorical variables were compared by McNemar's tests.
RESULTS
Compared with TH-L, VATS-L was associated with a lower incidence of total complications n = 792 (29.1%) vs 863 (31.7%), P = 0.0357, major cardiopulmonary complications n = 316 (15.9%) vs 435 (19.6%), P = 0.0094, atelectasis requiring bronchoscopy n = 65 (2.4%) vs 150 (5.5%), P < 0.0001, initial ventilation >48 h n = 18 (0.7%) vs 38 (1.4%), P = 0.0075 and wound infection n = 6 (0.2%) vs 17 (0.6%), P = 0.0218. There was no difference in the incidence of postoperative atrial fibrillation between the two groups (P = 0.14). Postoperative hospital stay was 2 days shorter in the VATS-L patients (mean: 7.8 vs 9.8 days; P = 0.0003). In terms of outcome at hospital discharge, there were 27 deaths in the VATS-L group (1%) versus 50 in the TH-L group (1.9%, P = 0.0201).
CONCLUSIONS
Data from the ESTS database confirmed that lobectomy performed through VATS is associated with a lower incidence of complications compared with thoracotomy.
Although often investigated in locally advanced esophageal cancer (EC), the impact of neoadjuvant chemoradiotherapy (NCRT) in early stages is unknown. The aim of this multicenter randomized phase III ...trial was to assess whether NCRT improves outcomes for patients with stage I or II EC.
The primary end point was overall survival. Secondary end points were disease-free survival, postoperative morbidity, in-hospital mortality, R0 resection rate, and prognostic factor identification. From June 2000 to June 2009, 195 patients in 30 centers were randomly assigned to surgery alone (group S; n = 97) or NCRT followed by surgery (group CRT; n = 98). CRT protocol was 45 Gy in 25 fractions over 5 weeks with two courses of concomitant chemotherapy composed of fluorouracil 800 mg/m(2) and cisplatin 75 mg/m(2). We report the long-term results of the final analysis, after a median follow-up of 93.6 months.
Pretreatment disease was stage I in 19.0%, IIA in 53.3%, and IIB in 27.7% of patients. For group CRT compared with group S, R0 resection rate was 93.8% versus 92.1% (P = .749), with 3-year overall survival rate of 47.5% versus 53.0% (hazard ratio HR, 0.99; 95% CI, 0.69 to 1.40; P = .94) and postoperative mortality rate of 11.1% versus 3.4% (P = .049), respectively. Because interim analysis of the primary end point revealed an improbability of demonstrating the superiority of either treatment arm (HR, 1.09; 95% CI, 0.75 to 1.59; P = .66), the trial was stopped for anticipated futility.
Compared with surgery alone, NCRT with cisplatin plus fluorouracil does not improve R0 resection rate or survival but enhances postoperative mortality in patients with stage I or II EC.
The history of esophagectomy reflects a journey of dedication, collaboration, and technical innovation, with ongoing endeavors aimed at optimizing outcomes and reducing complications. From its early ...attempts to modern minimally invasive approaches, the journey has been marked by perseverance and innovation. Franz J. A. Torek’s 1913 successful esophageal resection marked a milestone, demonstrating the feasibility of transthoracic esophagectomy and the potential for esophageal cancer cure. However, its high mortality rate posed challenges, and it took almost two decades for similar successes to emerge. Surgical techniques evolved with the left thoracotomy, right thoracotomy, and transhiatal approaches, expanding the indications for resection. Mechanical staplers introduced in the early 20th century transformed anastomosis, reducing complications. The advent of minimally invasive techniques in the 1990s aimed to minimize complications while maintaining oncological efficacy. Robot-assisted esophagectomy further pushed the boundaries of minimally invasive surgery. Collaborative efforts, particularly from the Worldwide Esophageal Cancer Collaboration and the Esophageal Complications Consensus Group, standardized reporting and advanced the understanding of outcomes. The introduction of risk prediction models aids in making informed decisions. Despite significant improvements in survival rates and postoperative mortality, anastomotic leaks remain a concern, with recent rates showing an increase. Prevention strategies include microvascular anastomosis and ischemic preconditioning, yet challenges persist.
Abstract Introduction Whenever feasible, sleeve lobectomy is recommended to avoid pneumonectomy for lung cancer, but these guidelines are based on limited retrospective series. The aim of our study ...was to compare outcomes following sleeve lobectomy and pneumonectomy using data from a national database. Methods From 2005 to 2014, 941 sleeve lobectomy and 5318 pneumonectomy patients were recorded in the French database Epithor. Propensity score was generated with 15 pretreatment variables and used to create balanced groups with matching (794 matches) and inverse probability of treatment weighting (standardized difference was 0 for matching, and 0.0025 after weighting). Odds ratio (OR) of postoperative complications and mortality and hazard ratio (HR) for overall survival and disease-free survival were calculated using propensity adjustment techniques and a sensitivity analysis. Results Postoperative mortality after sleeve resection was similar to that after pneumonectomy (matching OR, 1.24; P = .4; weighting OR, 0.77; P = .4) despite significantly lower odds of pulmonary complications with pneumonectomy (matching OR, 0.4; P < .0001; weighting OR, 0.12; P < .001). The adjusted HR for death after pneumonectomy was significantly higher when analyzed using matched analysis but not with weighting (matching HR, 1.63; P = .002; weighting HR, 0.97; P = .92). The same was true for disease-free survival (matching HR, 1.49; P = .01; weighting HR, 1.03; P = .84). Conclusions Despite early differences in perioperative pulmonary outcomes favoring pneumonectomy, early overall and disease-free survival was in favor of sleeve lobectomy in the matched analysis but not the weighted analysis. In our opinion, when it is technically feasible, sleeve lobectomy should be the preferred technique.
Uncontrolled inflammation of the airways in chronic obstructive lung diseases leads to exacerbation, accelerated lung dysfunction and respiratory insufficiency. Among these diseases, asthma affects ...358 million people worldwide. Human bronchial epithelium cells (HBEC) express both anti‐inflammatory and activating molecules, and their deregulated expression contribute to immune cell recruitment and activation, especially platelets (PLT) particularly involved in lung tissue inflammation in asthma context. Previous results supported that HLA‐G dysregulation in lung tissue is associated with immune cell activation. We investigated here HLA‐F expression, reported to be mobilised on immune cell surface upon activation and displaying its highest affinity for the KIR3DS1‐activating NK receptor. We explored HLA‐F transcriptional expression in HBEC; HLA‐F total expression in PBMC and HBEC collected from healthy individuals at rest and upon chemical activation and HLA‐F membrane expression in PBMC, HBEC and PLT collected from healthy individuals at rest and upon chemical activation. We compared HLA‐F transcriptional expression in HBEC from healthy individuals and asthmatic patients and its surface expression in HBEC and PLT from healthy individuals and asthmatic patients. Our results support that HLA‐F is expressed by HBEC and PLT under healthy physiological conditions and is retained in cytoplasm, barely expressed on the surface, as previously reported in immune cells. In both cell types, HLA‐F reaches the surface in the inflammatory asthma context whereas no effect is observed at the transcriptional level. Our study suggests that HLA‐F surface expression is a ubiquitous post‐transcriptional process in activated cells. It may be of therapeutic interest in controlling lung inflammation.
Objective Our objective was to analyze the time trend variation of 30-day mortality after lung cancer surgery, and to quantify the impact of surgeon and hospital volumes over a 5-year period in ...France. Methods We used Epithor, the French national thoracic database and benchmark tool, which catalogues more than 180,000 procedures of 89 private and public hospitals in France. From January 2005 to December 2010, 19,556 patients who underwent major lung resection (lobectomy, bilobectomy, pneumonectomy) were included in our study. Multilevel logistic models were designed to investigate the relationship between 30-day mortality and surgeon (model 1) or hospital (model 2) volumes. The 3 levels considered were the patient, the surgeon, and the hospital. Results From 2005 to 2007, the 30-day mortality of patients who underwent major lung resection averaged 10%, and then decreased until it reached 3.8% in 2010 ( P < .0001). A significant decrease in 30-day mortality was observed over time ( P = .0046). During the study period, the mean annual number of procedures per surgeon was 46.1 (standard deviation SD = 23.6) and per hospital was 97.9 (SD = 50.8). Model 1 showed that surgeon volume had a significant impact on 30-day mortality ( P = .03), whereas model 2 failed to show that hospital volume influenced 30-day mortality ( P = .75). Conclusions Since 2007, when France's first National Cancer Plan became effective, 30-day mortality of primary lung cancer surgery has decreased and currently measures 3.8%. Low mortality was correlated with higher surgeon volume but was not influenced by hospital volume, which cannot be considered a proxy measure for determining the safety of lung cancer surgery.
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