Time trends in surgery for lung cancer in France from 2005 to 2012: a nationwide study.

The aim of this study was to assess the evolution of survival in patients treated surgically for non-small cell lung cancer (NSCLC) between 2005 and 2012.From January 2005 to December 2012, 34 006 patients underwent pulmonary resection for NSCLC and were included in the French national database Epithor. Patients' characteristics, procedures and survival were analysed. Survival according to the management was evaluated for each 2-year period separately: 2005-2006, 2007-2008, 2009-2010 and 2011-2012.The proportions of early-stage cancers and adenocarcinomas increased significantly over the periods. 3-year overall survival (OS) increased significantly from 80.5% for the first period to 81.4% for the last period. For the periods 2005-2006 and 2007-2008, 3-year OS was lower after segmentectomy than after lobectomy (77 and 73% versus 82 and 83%, respectively). For the periods 2009-2010 and 2011-2012, 3-year OS in the two sub-groups was similar. OS after bi-lobectomy or pneumonectomy was lower than after lobectomy for all periods analysed. Systematic nodal dissection increased OS for all periods. Chemotherapy but not radiotherapy improved OS in the first 12 postoperative months for all periods.Changes in histological type and stage linked to advances in surgical and medical practices since 2005 led to an increase in OS in patients with surgical-stage NSCLC.

A comparison of the standard bolia technique versus subintimal recanalization plus Viabahn stent graft in the management of femoro-popliteal occlusions.

OBJECTIVE: To assess the potential benefit of the addition of a covered stent to a subintimal recanalized artery in patients with femoro-popliteal occlusions. METHODS: From September 2003 to October 2005, we retrospectively analyzed all patients admitted for severe claudication or critical limb ischemia related to long femoro-popliteal occlusions and treated with subintimal recanalization. Patients were divided into two groups depending on whether they received a stent or not. All patients in the group treated with stent received a stent graft, and the entire length of the recanalized artery was covered in each case. Demographic data, indications, procedure, and outcomes were examined using survival analysis statistical techniques. RESULTS: Fifty-three patients (54 limbs) were treated consecutively for severe claudication (n=19) or critical limb ischemia (n=34). Thirty-four (64%) had a stent placed, while 19 (35.8%) did not. The mean length of the lesions treated was 20.11 cm (range, 5-35 cm). Statistically, there was no significant difference in lesion length, Rutherford stage of peripheral-artery disease, Transatlantic Inter-Society Consensus classification, and distal run-off between the two groups. The technical success rate was 94.5%, and two out of the three failures were treated with surgical bypass in one case and major amputation in the other. The third patient received only medical treatment. Combined procedures were required in the treatment of 68.2% of limbs in the no-stent group and 55.8% in the stent group. Mean follow up was 16.9 months (range, 1-35 months). At 1 year, primary, primary-assisted, and secondary patency for the stent vs no-stent groups was, respectively, 61.8% vs 78.9% (P=.49), 70.6% vs 78.9% (P=.78), and 88.2% vs 78.9% (P=.22). The 1-year limb salvage rate for the stent vs no-stent group was 94.1% vs 100% (P=.7). CONCLUSION: Combining subintimal angioplasty with a stent graft in femoro-popliteal lesions does not improve patency. The limb salvage rate remains high after addition of a stent graft. Rigorous monitoring is recommended to diagnose and treat restenosis early in order to improve patency.

Renal artery thrombosis caused by stent fracture: the risk of undiagnosed renal artery entrapment.

We report a case of renal artery thrombosis resulting from a stent fracture in a patient with a solitary functional kidney. It was successfully revascularized by surgical repair despite renal ischemia lasting more than 48 hours. This article illustrates the danger of generalizing endovascular stenting in renal artery disease regardless of the etiology. Renal artery entrapment must be kept in mind as a possible cause of renal artery stenosis. Treatment of compressive pathologies with stenting can lead to stent failure. Surgery remains the best approach for the treatment of this type of lesion.

Oropharyngeal and nasopharyngeal decontamination with chlorhexidine gluconate in lung cancer surgery: a randomized clinical trial.

PURPOSE: Respiratory complications are the leading causes of morbidity and mortality after lung cancer surgery. We hypothesized that oropharyngeal and nasopharyngeal decontamination with chlorhexidine gluconate (CHG) would be an effective method to reduce these complications as reported in cardiac surgery. METHODS: In this multicenter parallel-group randomized double-blind placebo-controlled trial, we enrolled consecutive adults scheduled for anatomical pulmonary resection for lung cancer. Perioperative decontamination consisted in oropharyngeal rinse solution (0.12% CHG) and nasopharyngeal soap (4% CHG) or a placebo. The primary outcome measure was the proportion of patients requiring postoperative invasive and/or noninvasive mechanical ventilation (MV). Secondary outcome measures included occurrence of respiratory and non-respiratory healthcare-associated infections (HAIs) and outcomes within 90 days. RESULTS: Between July 2012 and April 2015, 474 patients were randomized. Of them, 24 had their surgical procedure cancelled or withdrew consent. The remaining 450 patients were included in a modified intention-to-treat analysis: 226 were allocated to CHG and 224 to the placebo. Proportions of patients requiring postoperative MV were not significantly different [CHG 14.2%; placebo 15.2%; relative risks (RRs) 0.93; 95% confidence interval (CI) 0.59-1.45; P = 0.76]. Neither of the proportions of patients with respiratory HAIs were different (CHG 13.7%; placebo 12.9%; RRs 1.06; 95% CI 0.66-1.69; P = 0.81). The CHG group had significantly decreased incidence of bacteremia, surgical-site infection and overall Staphylococcus aureus infections. However, there were no significant between-group differences for hospital stay length, change in tracheal microbiota, postoperative antibiotic utilization and outcomes by day 90. CONCLUSIONS: CHG decontamination decreased neither MV requirements nor respiratory infections after lung cancer surgery. Additionally, CHG did not change tracheal microbiota or postoperative antibiotic utilization. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov, number NCT01613365.

Comparative study for surgical management of thymectomy for non-thymomatous myasthenia gravis from the French national database EPITHOR.

OBJECTIVES: Thymectomy may be part of the therapeutic strategy in patients with myasthenia gravis (MG) without thymoma. Median sternotomy is still considered as the gold standard, but during the last 15 years, several groups have demonstrated the non-inferiority of cervicotomy with upper sternotomy and minimally invasive techniques. To date, there is no consensus on surgical procedure choice. The aim of our study was to compare the morbidity and mortality of three techniques [cervicotomy with upper sternotomy versus sternotomy versus video-assisted thoracic surgery (VATS)/robotic-assisted thoracic surgery (RATS)] from the national database EPITHOR and to analyse French epidemiology. METHODS: From the national thoracic surgery database EPITHOR, we have extracted all the details regarding thymectomies performed for non-thymomatous MG. We have divided thymectomy into three groups: A-sternotomy; B-cervicotomy with upper sternotomy; C-VATS/RATS. We investigated the postoperative morbidity and mortality without analysis of the long-term evolution of the disease not available on EPITHOR. RESULTS: From 2005 to 2013, 278 patients were included: 131 (47%) in Group A, 31 (11%) in Group B and 116 (42%) in Group C. The sex ratio F/M was 2.3. The mean age was, respectively, 42 ± 17, 42 ± 16, 35 ± 14 years old (P < 0.01). The number of patients without comorbidities was 63 (48%), 25 (81%) and 78 (65%), respectively (P < 0.01). The operative time was 94 ± 37, 79 ± 42 and 112 ± 59 min, respectively (P < 0.01). The number of patients who presented at least one postoperative complication was 12 (14%), 0 and 3 (9%) (P= 0.03), respectively. The postoperative lengths of stay were 7.7 ± 4.5, 5 ± 1.7 and 4.5 ± 2 days, respectively (P < 0.01). There was no death. CONCLUSIONS: In our study, we were unable to prove the superiority of minimally invasive techniques due to the important differences between the groups. However, this study shows us major changes in French surgical procedures during the last decade with an increase in minimally invasive procedures such as VATS and RATS.

Propensity Score Analysis Comparing Videothoracoscopic Lobectomy With Thoracotomy: A French Nationwide Study.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) lobectomy has recently become the recommended approach for stage I non-small cell lung cancer. However, these guidelines are not based on any large randomized control trial. Our study used propensity scores and a sensitivity analysis to compare VATS lobectomy with open thoracotomy. METHODS: From 2005 to 2012, 24,811 patients (95.1%) were operated on by open thoracotomy and 1,278 (4.9%) by VATS. The end points were 30-day postoperative death, postoperative complications, hospital stay, overall survival, and disease-free survival. Two propensity scores analyses were performed: matching and inverse probability of treatment weighting, and one sensitivity analysis to unmask potential hidden bias. A subgroup analysis was performed to compare "high-risk" with "low-risk" patients. Results are reported by odds ratios or hazard ratios and their 95% confidence intervals. RESULTS: Postoperative death was not significantly reduced by VATS whatever the analysis. Concerning postoperative complications, VATS significantly decreased the occurrence of atelectasis and pneumopathy with both analysis methods, but there were no differences in the occurrence of other postoperative complications. VATS did not provide a benefit for high-risk patients. The VATS approach decreased the hospital length of stay from 2.4 days (95% confidence interval, -1.7 to -3 days) to -4.68 days (95% confidence interval, -8.5 to 0.9 days). Overall survival and disease-free survival were not influenced by the surgical approach. The sensitivity analysis showed potential biases. CONCLUSIONS: The results must be interpreted carefully because of the differences observed according to the propensity scores method used. A multicenter randomized controlled trial is necessary to limit the biases.

Index of prolonged air leak score validation in case of video-assisted thoracoscopic surgery anatomical lung resection: results of a nationwide study based on the French national thoracic database, EPITHOR.

OBJECTIVES: The incidence rate of prolonged air leak (PAL) after lobectomy, defined as any air leak prolonged beyond 7 days, can be estimated to be in between 6 and 15%. In 2011, the Epithor group elaborated an accurate predictive score for PAL after open lung resections, so-called IPAL (index of prolonged air leak), from a nation-based surgical cohort constituted between 2004 and 2008. Since 2008, video-assisted thoracic surgery (VATS) has become popular in France among the thoracic surgical community, reaching almost 14% of lobectomies performed with this method in 2012. This minimally invasive approach was reported as a means to reduce the duration of chest tube drainage. The aim of our study was thus to validate the IPAL scoring system in patients having received VATS anatomical lung resections. METHODS: We collected all anatomical VATS lung resections (lobectomy and segmentectomy) registered in the French national general thoracic surgery database (EPITHOR) between 2009 and 2012. The area under the receiver operating characteristic (ROC) curve estimated the discriminating value of the IPAL score. The slope value described the relation between the predicted and observed incidences of PALs. The Hosmer-Lemeshow test was also used to estimate the quality of adequacy between predicted and observed values. RESULTS: A total of 1233 patients were included: 1037 (84%) lobectomies and 196 (16%) segmentectomies. In 1099 cases (89.1%), the resection was performed for a malignant disease. Ninety-six patients (7.7%) presented with a PAL. The IPAL score provided a satisfactory predictive value with an area under the ROC curve of 0.72 (0.67-0.77). The value of the slope, 1.25 (0.9-1.58), and the Hosmer-Lemeshow test (χ(2) = 11, P = 0.35) showed that predicted and observed values were adequate. CONCLUSION: The IPAL score is valid for the estimation of the predictive risk of PAL after VATS lung resections. It may thus a priori be used to characterize any surgical population submitted to potential preventive measures.

Pulmonary Endogenous Fluorescence Allows the Distinction of Primary Lung Cancer from the Perilesional Lung Parenchyma.

BACKGROUND: Pre-therapeutic pathological diagnosis is a crucial step of the management of pulmonary nodules suspected of being non small cell lung cancer (NSCLC), especially in the frame of currently implemented lung cancer screening programs in high-risk patients. Based on a human ex vivo model, we hypothesized that an embedded device measuring endogenous fluorescence would be able to distinguish pulmonary malignant lesions from the perilesional lung tissue. METHODS: Consecutive patients who underwent surgical resection of pulmonary lesions were included in this prospective and observational study over an 8-month period. Measurements were performed back table on surgical specimens in the operative room, both on suspicious lesions and the perilesional healthy parenchyma. Endogenous fluorescence signal was characterized according to three criteria: maximal intensity (Imax), wavelength, and shape of the signal (missing, stable, instable, photobleaching). RESULTS: Ninety-six patients with 111 suspicious lesions were included. Final pathological diagnoses were: primary lung cancers (n = 60), lung metastases of extra-thoracic malignancies (n = 27) and non-tumoral lesions (n = 24). Mean Imax was significantly higher in NSCLC targeted lesions when compared to the perilesional lung parenchyma (p<0,0001) or non-tumoral lesions (p<0,0001). Similarly, photobleaching was more frequently found in NSCLC than in perilesional lung (p<0,0001), or in non-tumoral lesions (p<0,001). Respective associated wavelengths were not statistically different between perilesional lung and either primary lung cancers or non-tumoral lesions. Considering lung metastases, both mean Imax and wavelength of the targeted lesions were not different from those of the perilesional lung tissue. In contrast, photobleaching was significantly more frequently observed in the targeted lesions than in the perilesional lung (p≤0,01). CONCLUSION: Our results demonstrate that endogenous fluorescence applied to the diagnosis of lung nodules allows distinguishing NSCLC from the surrounding healthy parenchyma and from non-tumoral lesions. Inconclusive results were found for lung metastases due to the heterogeneity of this population.

Sternal dehiscence after clamshell incision in lung transplantation treated with the STRAsbourg Thoracic Osteosyntheses System (STRATOS).

Clamshell incision with transverse sternotomy is the approach of choice for bilateral lung transplantation when cardiopulmonary bypass becomes necessary or to improve exposure. Sternal dehiscence is a well-known complication of this approach. This results in chronic thoracic pain and contributes to a delayed pulmonary rehabilitation. Sternal dehiscence can be treated with conservative therapy, but severe dehiscence requires secondary surgical closure. Several techniques of osteosynthesis have been reported with conflicting results. We describe the first use of the STRAsbourg Thoracic Osteosyntheses System (STRATOS) devices in three cases of secondary sternal closure without infection after bilateral lung transplantation.

Incidence and management of anastomotic complications after bronchial resection: a retrospective study.

BACKGROUND: Bronchial resection and reimplantation in surgical management of lung cancer is intended to spare lung parenchyma, with curative intent. We studied the incidence and management of anastomotic complications after such procedures. METHODS: We retrospectively reviewed charts of patients referred to our center for lung tumors who underwent bronchial resection and reimplantation from 1992 to 2011. RESULTS: A total of 108 patients were included. Sixty-eight percent were male, and mean age was 58 years. Sleeve lobectomies were performed in 100 patients, bronchial resections without lung parenchymal resection in 8 patients. Squamous cell carcinoma represented 46.3% of cases, carcinoid tumors 22.2%, and adenocarcinoma 18.5%. Mean time between surgery and first bronchoscopic examination was 4.47 days. During the follow-up, anastomotic abnormalities were detected in 23 patients (21.3%): malacic or fibrotic bronchial stenoses in 9 cases (39.1%), dehiscences in 7 (30.4%), obstructive granulomas in 4 (17.4%), and bronchopleural fistulas in 3 (13.0%). Endoscopic treatment was indicated in 14 patients (13%) and consisted of stent placement in 6 cases (26%), mechanical dilations in 3 (13%), laser treatment for 1 case of bronchomalacia (4.3%), and resection of granulomas in 4 (17.4%). No risk factors were identified as predisposing for bronchial complications. There was a trend toward lower 1-year survival in patients with bronchial complications compared with those without (71.9% versus 83.4%; p = 0.114). CONCLUSIONS: Bronchial resection and reimplantation is a surgical procedure associated with an anastomotic complication rate of 21.3%, but only 13% required endoscopic management. Regular endoscopic surveillance is advised to detect and treat early complications.

High-emergency waiting list for lung transplantation: early results of a nation-based study.

OBJECTIVES: The high mortality rate observed on the regular waiting list (RWL) before lung transplantation (LTx) prompted the French organ transplantation authorities to set up in 2007 a dedicated graft allocation strategy, the so-called 'high-emergency waiting list' (HEWL), for patients with an abrupt worsening of their respiratory function. This study reports on the early results of this new allocation system. METHODS: Among 11 active French LTx programmes, 7 were able to provide full outcome data by 31 December 2011. The medical records of 101 patients who were listed on the HEWL from July 2007 to December 2011 were reviewed for an intention-to-treat analysis. RESULTS: Ninety-five patients received LTx within a median waiting time on the HEWL of 4 days (range 1-26), and 6 died before transplantation. Conditions were cystic fibrosis (65.2%), pulmonary fibrosis (24.8%), emphysema (5%) and miscellaneous (5%). The median age of the recipient was 30 years (range 16-66). Patients listed on the HEWL came from the RWL in 48.5% of the cases and were new patients in 51.5%. Forty-nine were placed under invasive ventilation and, in 26 cases, extracorporeal membrane oxygenation (ECMO) prior to transplantation was necessary as a complementary treatment. ECMO for non-intubated patients was performed in 6 cases. Eighty-one bilateral and 14 single LTx were performed, with an overall in-hospital mortality rate of 29.4%. One- and 3-year survival rates were 67.5 and 59%, respectively. Multivariate analysis shows that the use of ECMO prior to transplantation was the sole independent mortality risk factor (hazard ratio = 2.77 [95% CI 1.26-6.11]). CONCLUSIONS: The new allocation system aimed at lowering mortality on the RWL, but also offered an access to LTx for new patients with end-stage respiratory failure. The HEWL increased the likelihood of mortality after LTx, but permitted acceptable mid-term survival rates. The high mortality associated with the use of ECMO should be interpreted cautiously.

Twinned single-lung transplantation: a privileged model for the study of recipient-dependent factors of outcome.

OBJECTIVES: Lung transplantation is the only life-saving treatment for end-stage respiratory disease. The outcome will depend on the graft quality, surgical conditions and recipient factors. Twinned single-lung transplantation defines as two different recipients treated with lung grafts from the same donor. Recipient-dependent factors of the outcome can be studied more accurately as the graft quality is supposed equal for both recipients. METHODS: We reviewed all single-lung transplantations performed in France between 1998 and 2008 in the French registry run by the 'Agence de Biomédecine'. Criteria for donor lung quality and twinned recipient data were recorded in a database. The whole medical history and the transplantation outcome were reviewed for each patient and compared with its twin recipient. We compared twins on the basis of their opposed characteristics and on the basis of the opposed endpoint outcome. Endpoints were primary graft dysfunction (PGD) grade III, and mortality at 1, 3 and 12 months. RESULTS: A total of 387 single-lung transplantations were performed in 10 French centres; 180 were twinned recipients from 90 donors. Statistical analysis revealed a significantly different outcome for PGD only. PGD was significantly higher (P < 0.05) in fibrosis recipients compared with emphysema twins. In 28 pairs (31%), the outcome was discordant for PGD, and fibrosis was significantly more often involved compared with emphysema (P = 0.04). Sixty-two pairs had a similar outcome: two pairs showed PGD in both recipients while 60 pairs were free of PGD. CONCLUSIONS: We conclude that recipient's disease is a major determinant of the outcome. Fibrosis is associated with an increased risk for PGD.