Summary of the best evidence for the prevention and management of myasthenic crisis after thymectomy.

Background: Myasthenic crisis (MC) may occur after thymectomy in patients with myasthenia gravis (MG), but effective preventive interventions can reduce the occurrence of this complication. Previous research on MC focused on risk factors, emergency treatment, etc., which was relatively scattered and did not form a comprehensive management framework. This study sought to retrieve and summarize the relevant evidence on the prevention and management of postoperative MC to provide a theoretical reference for clinical medical staff. Methods: According to the evidence pyramid model, relevant articles were retrieved from UpToDate, British Medical Journal (BMJ) Best Practice, World Health Organization (WHO), Scottish Intercollegiate Guidelines Network (SIGN), Guidelines International Network (GIN), Australian Joanna Briggs Institute (JBI) Healthcare Database, Medlive, PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang. The types of evidence included clinical guidelines, expert consensus articles, clinical decisions, systematic reviews, and randomized controlled trials (RCTs). The quality evaluations were conducted using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) evaluation tool for guidelines, the Australian JBI Evidence-Based Healthcare Center evaluation tool for expert consensus articles, the Critical Appraisal for Summaries of Evidence (CASE) evaluation tool for clinical decisions, the Assessment of Multiple Systematic Reviews (AMSTAR) evaluation tool for systematic reviews, and the Cochrane risk-of-bias tool for RCTs. Results: A total of 12 articles were included in this study, including three clinical guidelines, three expert consensus articles, three clinical decisions, two systematic reviews, and one RCT. From these articles, we summarized 39 pieces of evidence on the prevention and management of postoperative MC. Conclusions: This study summarized the best evidence on the prevention and management of postoperative MC and provided to clinical staffs evidence-based clinical approaches to help reduce the incidence of this complication.

Spontaneous Ventilation Thoracoscopic Lung Biopsy in Undetermined Interstitial Lung Disease: Systematic Review and Meta-Analysis.

Thoracoscopic surgical biopsy has shown excellent histological characterization of undetermined interstitial lung diseases, although the morbidity rates reported are not negligible. In delicate patients, interstitial lung disease and restrictive ventilatory impairment morbidity are thought to be due at least in part to tracheal intubation with single-lung mechanical ventilation; therefore, spontaneous ventilation thoracoscopic lung biopsy (SVTLB) has been proposed as a potentially less invasive surgical option. This systematic review summarizes the results of SVTLB, focusing on diagnostic yield and operative morbidity. A systematic search for original studies regarding SVTLB published between 2010 to 2023 was performed. In addition, articles comparing SVTLB to mechanical ventilation thoracoscopic lung biopsy (MVTLB) were selected for a meta-analysis. Overall, 13 studies (two before 2017 and eleven between 2018 and 2023) entailing 675 patients were included. Diagnostic yield ranged from 84.6% to 100%. There were 64 (9.5%) complications, most of which were minor. There was no 30-day operative mortality. When comparing SVTLB to MVTLB, the former group showed a significantly lower risk of complications (p < 0.001), whereas no differences were found in diagnostic accuracy. The results of this review suggest that SVTLB is being increasingly adopted worldwide and has proven to be a safe procedure with excellent diagnostic accuracy.

Ergonomic Assessment of Robotic versus Thoracoscopic Thymectomy.

Introduction: Robotic and thoracoscopic surgery are being increasingly adopted as minimally invasive alternatives to open sternotomy for complete thymectomy. The superior maneuverability range and three-dimensional magnified vision are potential ergonomical advantages of robotic surgery. To compare the ergonomic characteristics of robotic versus thoracoscopic thymectomy, a previously developed scoring system based on impartial findings was employed. The relationship between ergonomic scores and perioperative endpoints was also analyzed. Methods: Perioperative data of patients undergoing robotic or thoracoscopic complete thymectomy between January 2014 and December 2022 at three institutions were retrospectively retrieved. Surgical procedures were divided into four standardized surgical steps: lower-horns, upper-horns, thymic veins and peri-thymic fat dissection. Three ergonomic domains including maneuverability, exposure and instrumentation were scored as excellent(score-3), satisfactory(score-2) and unsatisfactory(score-1) by three independent reviewers. Propensity score matching (2:1) was performed, including anterior mediastinal tumors only. The primary endpoint was the total maneuverability score. Secondary endpoints included the other ergonomic domain scores, intraoperative adverse events, conversion to sternotomy, operative time, post-operative complications and residual disease. Results: A total of 68 robotic and 34 thoracoscopic thymectomies were included after propensity score matching. The robotic group had a higher total maneuverability score (p = 0.039), particularly in the peri-thymic fat dissection (p = 0.003) and peri-thymic fat exposure score (p = 0.027). Moreover, the robotic group had lower intraoperative adverse events (p = 0.02). No differences were found in residual disease. Conclusions: Robotic thymectomy has shown better ergonomic maneuverability compared to thoracoscopy, leading to fewer intraoperative adverse events and comparable early oncological results.

Adjuvant Transthoracic Negative-Pressure Ventilation in Nonintubated Thoracoscopic Surgery.

BACKGROUND: To minimize the risks of barotrauma during nonintubated thoracoscopic-surgery under spontaneous ventilation, we investigated an adjuvant transthoracic negative-pressure ventilation (NPV) method in patients operated on due to severe emphysema or interstitial lung disease. METHODS: In this retrospective study, NPV was employed for temporary low oxygen saturation and to achieve end-operative lung re-expansion during nonintubated lung volume reduction surgery (LVRS) for severe emphysema (30 patients, LVRS group) and in the nonintubated wedge resection of undetermined interstitial lung disease (30 patients, wedge-group). The results were compared following 1:1 propensity score matching with equivalent control groups undergoing the same procedures under spontaneous ventilation, with adjuvant positive-pressure ventilation (PPV) performed on-demand through the laryngeal mask. The primary outcomes were changes (preoperative-postoperative value) in the arterial oxygen tension/fraction of the inspired oxygen ratio (ΔPO2/FiO2;) and ΔPaCO2, and lung expansion completeness on a 24 h postoperative chest radiograph (CXR-score, 2: full or 1: incomplete). RESULTS: Intergroup comparisons (NPV vs. PPV) showed no differences in demographic and pulmonary function. NPV could be accomplished in all instances with no conversion to general anesthesia with intubation. In the LVRS group, NPV improved ΔPO2/FiO2 (9.3 ± 16 vs. 25.3 ± 30.5, p = 0.027) and ΔPaCO2 (-2.2 ± 3.15 mmHg vs. 0.03 ± 0.18 mmHg, p = 0.008) with no difference in the CXR score, whereas in the wedge group, both ΔPO2/FiO2 (3.1 ± 8.2 vs. 9.9 ± 13.8, p = 0.035) and the CXR score (1.9 ± 0.3 vs. 1.6 ± 0.5, p = 0.04) were better in the NPV subgroup. There was no mortality and no intergroup difference in morbidity. CONCLUSIONS: In this retrospective study, NITS with adjuvant transthoracic NPV resulted in better 24 h oxygenation measures than PPV in both the LVRS and wedge groups, and in better lung expansion according to the CXR score in the wedge group.

The Naples Prognostic Score Is a Useful Tool to Assess Surgical Treatment in Non-Small Cell Lung Cancer.

Different prognostic scores have been applied to identify patients with non-small cell lung cancer who have a higher probability of poor outcomes. In this study, we evaluated whether the Naples Prognostic Score, a novel index that considers both inflammatory and nutritional values, was associated with long-term survival. This study presents a retrospective propensity score matching analysis of patients who underwent curative surgery for non-small cell lung cancer from January 2016 to December 2021. The score considered the following four pre-operative parameters: the neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, serum albumin, and total cholesterol. The Kaplan-Meier method and Cox regression analysis were performed to evaluate the relationship between the score and disease-free survival, overall survival, and cancer-related survival. A total of 260 patients were selected for the study, though this was reduced to 154 after propensity score matching. Post-propensity Kaplan-Meier analysis showed a significant correlation between the Naples Prognostic Score, overall survival (p = 0.018), and cancer-related survival (p = 0.007). Multivariate Cox regression analysis further validated the score as an independent prognostic indicator for both types of survival (p = 0.007 and p = 0.010, respectively). The Naples Prognostic Score proved to be an easily achievable prognostic factor of long-term survival in patients with non-small cell lung cancer after surgical treatment.

The utility of quantitative computed tomography in cohort studies of chronic obstructive pulmonary disease: a narrative review.

Background and Objective: Chronic obstructive pulmonary disease (COPD) is a significant contributor to global morbidity and mortality. Quantitative computed tomography (QCT), a non-invasive imaging modality, offers the potential to assess lung structure and function in COPD patients. Amidst the coronavirus disease 2019 (COVID-19) pandemic, chest computed tomography (CT) scans have emerged as a viable alternative for assessing pulmonary function (e.g., spirometry), minimizing the risk of aerosolized virus transmission. However, the clinical application of QCT measurements is not yet widespread enough, necessitating broader validation to determine its usefulness in COPD management. Methods: We conducted a search in the PubMed database in English from January 1, 2013 to April 20, 2023, using keywords and controlled vocabulary related to QCT, COPD, and cohort studies. Key Content and Findings: Existing studies have demonstrated the potential of QCT in providing valuable information on lung volume, airway geometry, airway wall thickness, emphysema, and lung tissue density in COPD patients. Moreover, QCT values have shown robust correlations with pulmonary function tests, and can predict exacerbation risk and mortality in patients with COPD. QCT can even discern COPD subtypes based on phenotypic characteristics such as emphysema predominance, supporting targeted management and interventions. Conclusions: QCT has shown promise in cohort studies related to COPD, since it can provide critical insights into the pathogenesis and progression of the disease. Further research is necessary to determine the clinical significance of QCT measurements for COPD management.

Radiomics and Artificial Intelligence Can Predict Malignancy of Solitary Pulmonary Nodules in the Elderly.

Solitary pulmonary nodules (SPNs) are a diagnostic and therapeutic challenge for thoracic surgeons. Although such lesions are usually benign, the risk of malignancy remains significant, particularly in elderly patients, who represent a large segment of the affected population. Surgical treatment in this subset, which usually presents several comorbidities, requires careful evaluation, especially when pre-operative biopsy is not feasible and comorbidities may jeopardize the outcome. Radiomics and artificial intelligence (AI) are progressively being applied in predicting malignancy in suspicious nodules and assisting the decision-making process. In this study, we analyzed features of the radiomic images of 71 patients with SPN aged more than 75 years (median 79, IQR 76-81) who had undergone upfront pulmonary resection based on CT and PET-CT findings. Three different machine learning algorithms were applied-functional tree, Rep Tree and J48. Histology was malignant in 64.8% of nodules and the best predictive value was achieved by the J48 model (AUC 0.9). The use of AI analysis of radiomic features may be applied to the decision-making process in elderly frail patients with suspicious SPNs to minimize the false positive rate and reduce the incidence of unnecessary surgery.

Nonintubated versus intubated thoracoscopic bullectomy for primary spontaneous pneumothorax: A multicenter propensity-matched analysis.

BACKGROUND: We aimed at comparing in a multicenter propensity-matched analysis, results of nonintubated versus intubated video-assisted thoracic surgery (VATS) bullectomy/blebectomy for primary spontaneous pneumothorax (PSP). METHODS: Eleven Institutions participated in the study. A total of 208 patients underwent VATS bullectomy by intubated (IVATS) (N = 138) or nonintubated (NIVATS) (N = 70) anesthesia during 60 months. After propensity matching, 70 pairs of patients were compared. Anesthesia in NIVATS included intercostal (N = 61), paravertebral (N = 5) or thoracic epidural (N = 4) block and sedation with (N = 24) or without (N = 46) laryngeal mask under spontaneous ventilation. In the IVATS group, all patients underwent double-lumen-intubation and mechanical ventilation. Primary outcomes were morbidity and recurrence rates. RESULTS: There was no difference in age (26.7 ± 8 vs 27.4 ± 9 years), body mass index (19.7 ± 2.6 vs 20.6 ± 2.5), and American Society of Anesthesiology score (2 vs 2). Main results show no difference both in morbidity (11.4% vs 12.8%; p = 0.79) and recurrence free rates (92.3% vs 91.4%; p = 0.49) between NIVATS and IVATS, respectively, whereas a difference favoring the NIVATS group was found in anesthesia time (p < 0.0001) and operative time (p < 0.0001), drainage time (p = 0.001), and hospital stay (p < 0.0001). There was no conversion to thoracotomy and no hospital mortality. One patient in the NIVATS group needed reoperation due to chest wall bleeding. CONCLUSION: Results of this multicenter propensity-matched study have shown no intergroup difference in morbidity and recurrence rates whereas shorter operation room time and hospital stay favored the NIVATS group, suggesting a potential increase in the role of NIVATS in surgical management of PSP. Further prospective studies are warranted.

Expert consensus on indocyanine green fluorescence imaging for thoracoscopic lung resection (The Version 2022).

The use of the white-light thoracoscopy is hampered by the low contrast between oncologic margins and surrounding normal parenchyma. As a result, many patients with in situ or micro-infiltrating adenocarcinoma have to undergo lobectomy due to a lack of tactile and visual feedback in the resection of solitary pulmonary nodules. Near-infrared (NIR) guided indocyanine green (ICG) fluorescence imaging technique has been widely investigated due to its unique capability in addressing the current challenges; however, there is no special consensus on the evidence and recommendations for its preoperative and intraoperative applications. This manuscript will describe the development process of a consensus on ICG fluorescence-guided thoracoscopic resection of pulmonary lesions and make recommendations that can be applied in a greater number of centers. Specifically, an expert panel of thoracic surgeons and radiographers was formed. Based on the quality of evidence and strength of recommendations, the consensus was developed in conjunction with the Chinese Guidelines on Video-assisted Thoracoscopy, and the National Comprehensive Cancer Network (NCCN) guidelines on the management of pulmonary lesions. Each of the statements was discussed and agreed upon with a unanimous consensus amongst the panel. A total of 6 consensus statements were developed. Fluorescence-guided thoracoscopy has unique advantages in the visualization of pulmonary nodules, and recognition and resection of the anterior plane of the pulmonary segment. The expert panel agrees that fluorescence-guided thoracoscopic surgery has the potential to become a routine operation for the treatment of pulmonary lesions.

Variations of inflammatory mediators and alpha1-antitrypsin levels after lung volume reduction surgery for emphysema.

RATIONALE: In emphysema, chronic inflammation, including protease-antiprotease imbalance, is responsible for declining pulmonary function and progressive cachexia. OBJECTIVES: To evaluate variations of inflammatory mediators and alpha(1)-antitrypsin levels after lung volume reduction surgery (LVRS) compared with respiratory rehabilitation. METHODS: A total of 28 patients with moderate to severe emphysema, who underwent video-assisted thoracoscopic LVRS, were compared with 26 similar patients, who refused operation and followed a standardized rehabilitation program, and to a matched healthy group. Respiratory function, body composition, circulating inflammatory mediators, and alpha(1)-antitrypsin levels were evaluated before and 12 months after treatment. Gene expression levels of inflammatory mediators and protease-antiprotease were assessed in emphysematous specimens from 17 operated patients by matching to normal tissue from resection margins. MEASUREMENTS AND MAIN RESULTS: Significant improvements were only obtained after surgery in respiratory function (FEV(1), +25.2%, P < 0.0001; residual volume [RV], -19.5%, P < 0.0001; diffusing lung capacity for carbon monoxide, +3.3%, P < 0.05) and body composition (fat-free mass, +6.5%, P < 0.01; fat mass, +11.9%, P < 0.01), with decrement of circulating inflammatory mediators (TNF-alpha, -22.2%, P < 0.001; IL-6, -24.5%, P < 0.001; IL-8, -20.0%, P < 0.001) and increment of antiprotease levels (alpha(1)-antitrypsin, +27.0%, P < 0.001). Supportive gene expression analysis demonstrated active inflammation and protease hyperactivity in the resected emphysematous tissue. Reduction of TNF-alpha and IL-6 and increment of alpha(1)-antitrypsin levels significantly correlated with reduction of RV (P = 0.03, P = 0.009, and P = 0.001, respectively), and partially with increment of fat-free mass (P = 0.03, P = 0.02, and P = 0.09, respectively). CONCLUSIONS: LVRS significantly reduced circulating inflammatory mediators and increased antiprotease levels over respiratory rehabilitation, also improving respiratory function and nutritional status. Correlations of inflammatory mediators and antiprotease levels with RV and, partly, with body composition suggest that elimination of inflammatory emphysematous tissue may explain clinical improvements after surgery.

Quasilobar minimalist lung volume reduction surgery.

OBJECTIVES: Our goal was to assess the results and the costs of the quasilobar minimalist (QLM) thoracoscopic lung volume reduction (LVR) surgical method developed to minimize the trauma from the operation and the anaesthesia and to maximize the effect of the lobar volume reduction. METHODS: Forty patients with severe emphysema underwent QLM-LVR that entailed adoption of sole intercostal block analgesia and lobar plication through a single thoracoscopic incision. Results were compared after propensity matching with 2 control groups undergoing non-awake resectional LVR with double-lumen tracheal intubation or awake non-resectional LVR by plication with thoracic epidural anaesthesia. As a result, we had 3 matched groups of 30 patients each. RESULTS: Baseline forced expiratory volume in 1 s, residual volume, the 6-min walking test and the modified Medical Research Council dyspnoea index were 0.77 ± 0.18, 4.97 ± 0.6, 328 ± 65 and 3.3 ± 0.7, respectively, with no intergroup difference after propensity score matching. The visual pain score was better (P < 0.007), the hospital stay was shorter (P < 0.04) and overall costs were lower (P < 0.04) in the QLM-LVR group than in the control groups. The morbidity rate was lower with QLM-LVR than with non-awake resectional-LVR (P = 0.006). Significant improvements (P < 0.001) occurred in all study groups during the follow-up period. At 24 months, improvements in residual volume and dyspnoea index were significantly better with QLM-LVR (P < 0.04). CONCLUSIONS: QLM-LVR proved safe and showed better perioperative outcomes and lower procedure-related costs than the control groups. Similar clinical benefit occurred at 12 months, but absolute improvements in residual volume and dyspnoea index were better in the QLM-LVR group at 24 months.

Thoracic surgery in the COVID-19 era: an Italian university hospital experience.

Background: Aims of this study were to assess the results of anti-COVID19 measures applied to maintain thoracic surgery activity at an Italian University institution through a 12-month period and to assess the results as compared with an equivalent non-pandemic time span. Methods: Data and results of 646 patients operated on at the department of Thoracic Surgery of the Tor Vergata University Policlinic in Rome between February 2019 and March 2021 were retrospectively analyzed. Patients were divided in 2 groups: one operated on during the COVID-19 pandemic (pandemic group) and another during the previous non-pandemic 12 months (non-pandemic group). Primary outcome measure was COVID-19 infection-free rate. Results: Three patients developed mild COVID-19 infection early after surgery resulting in an estimated COVID-19 infection-free rate of 98%. At intergroup comparisons (non-pandemic vs. pandemic group), a greater number of patients was operated before the pandemic (352 vs. 294, p = 0.0013). In addition, a significant greater thoracoscopy/thoracotomy procedures rate was found in the pandemic group (97/151 vs. 82/81, p = 0.02) and the total number of chest drainages (104 vs. 131, p = 0.0001) was higher in the same group. At surgery, tumor size was larger (19.5 ± 13 vs. 28.2 ± 21; p < 0.001) and T3-T4/T1-T2 ratio was higher (16/97 vs. 30/56; p < 0.001) during the pandemic with no difference in mortality and morbidity. In addition, the number of patients lost before treatment was higher in the pandemic group (8 vs. 15; p = 0.01). Finally, in 7 patients admitted for COVID-19 pneumonia, incidental lung (N = 5) or mediastinal (N = 2) tumors were discovered at the chest computed tomography. Conclusions: Estimated COVID-19 infection free rate was 98% in the COVID-19 pandemic group; there were less surgical procedures, and operated lung tumors had larger size and more advanced stages than in the non-pandemic group. Nonetheless, hospital stay was reduced with comparable mortality and morbidity. Our study results may help implement efficacy of the everyday surgical care.

Extended videothoracoscopic thymectomy in nonthymomatous myasthenia gravis.

Myasthenia gravis (MG) is an uncommon, organ-specific, autoimmune chronic neuromuscular disorder involving the production of autoantibodies directed against the nicotinic acetylcholine receptors (anti-AchRab). It is characterized by weakness and rapid fatigability of voluntary muscles. Thymectomy is performed early in the course of the disease and is indicated for adults less than 70 years old. For many years, the clinical efficacy of thymectomy has been questioned and so far, its benefits in nonthymomatous MG have not been firmly established. Furthermore, the precise mechanisms of action of thymectomy are unknown although possible explanations include removal of the source of continued antigen stimulation and of the AchRab-recruiting B-lymphocytes as well as immunomodulation. However, thymectomy remains indicated in patients with MG and is widely applied to increase the probability of improvement or remission. This article presents the evolution of technical and surgical advances achieved within the authors' program of extended endoscopically assisted thymectomy since 1995. The use of video-assisted thoracic surgery and its variants for performing thymectomy in MG patients is now well established and will continue to evolve for further improvement in the results.

Awake video-assisted thoracoscopic biopsy in complex anterior mediastinal masses.

Anterior mediastinal masses can develop from a wide spectrum of pathologic conditions, most of which are malignant in nature and require prompt diagnosis for immediate initiation of the appropriate treatment. Clinical pictures can be variable and complicated by associated intrathoracic conditions requiring surgical management such as pleural and pericardial effusions or nodules (complex anterior mediastinal masses). We have used a single-trocar video-assisted thoracoscopic surgery (VATS) approach using thoracic epidural or sole local anesthesia in awake patients. Advantages of awake VATS biopsy include avoidance of all potential adverse effects related to the use of general anesthesia, wide visual control of mediastinal sampling, and accurate assessment of the disease extent with the possibility of obtaining multiple biopsy specimens from different sites of the mass and a diagnostic yield of 100%. This novel and less invasive surgical option might thus be included within the framework of most reliable methods currently available to manage patients with undetermined anterior mediastinal masses.

Videothoracoscopic approach to the spine in idiopathic scoliosis.

Surgical treatment of idiopathic scoliosis has classically included posterior, anterior, or combined open surgical techniques. In recent years, a videothoracoscopic approach to the spine has been increasingly employed either in combination with the posterior open approach or as a stand-alone treatment including anterior release and fusion. Proponents of videothoracoscopic approaches believe that they allow clinical outcomes comparable to those of open surgery with minimized surgical trauma and postoperative pain, superior cosmetic effects, and less impairment of respiratory function. Periodic technological refinements continue to be proposed and are likely to render these surgical options simpler, safer, and more effective. This article reports on the current state of the art of the videothoracoscopic approaches most commonly employed for the surgical treatment of thoracic idiopathic scoliosis.

Ergonomical Assessment of Three-Dimensional Versus Two-Dimensional Thoracoscopic Lobectomy.

In this study. we compared ergonomical domains characteristics of three-dimensional (3D) versus two-dimensional (2D) video-systems in thoracoscopic lobectomy using a scoring-scale-based assessment. Seventy patients (mean age, 69 ± 6.9 years, 43 males and 27 females) with early stage lung cancer were randomized to undergo thoracoscopic lobectomy by either 3D (N = 35) or 2D (N = 35) video-systems. All operations were divided into 5 standardized surgical steps (vein, artery, bronchus, fissure, and lymph nodes), which were evaluated by 4 thoracic surgeons using a scoring scale (score range from 1, unsatisfactory to 3,excellent) entailing assessment of 3 ergonomical domains: exposure, instrumentation and maneuvering. Primary outcome was a difference ≥10% in the maneuvering domain steps. At intergroup comparisons, there was no difference in demographics. The 3D system results were better for maneuvering domain total score and particularly for the artery and bronchus steps scores (score ≥10%, P ≤ 0.006). Other significant differences included exposure of the vein, artery and bronchus (P ≤ 0.03). Results favoring the 2D system included maneuvering, exposure and instrumentation of the fissure (P = 0.001). Inter-rater concordance of ergonomics scoring was satisfactory (Cronbach's α range, 0.85-0.88). Operative time was significantly shorter in the 3D group (127 ± 19 min vs 143±18 min, P = 0.001) whereas there was no difference in hospital stay (3.4 ± 1.2 vs 4.1 ± 1.6 days, P = 0.07). In this study comparison of ergonomic domains scoring in 3D versus 2D thoracoscopic lobectomy favored the 3D system for the maneuvering total score, which proved inversely correlated with operative times possibly due to a better perception of depth and more precise surgical maneuvering.

Symptomatic and quality of life changes after extrapleural pneumonectomy for malignant pleural mesothelioma.

BACKGROUND: Extrapleural pneumonectomy for malignant pleural mesothelioma is considered an aggressive procedure, but symptomatic and quality of life changes are unknown. METHODS: Between 1997 and 2004, 16 consecutive patients underwent extrapleural pneumonectomy for mesothelioma followed by chemo-radiotherapy. Tumor-related symptoms and quality of life (Short-Form-36 and St. George's questionnaires) were assessed pre, 3, 6, 12, and 24 months postoperatively. RESULTS: Thirty-day postoperative major morbidity was 31% with no mortality. At 3 months postoperatively, dyspnea improved in 10 patients (62%), pain in 12 (75%), cough in 10 (62%), fever in 11 (68%), Karnofsky-index in 10 (62%), Short-Form-36 physical-component-summary in 8, mental-component-summary in 5 and total St. George score in 8 (50%). At 1 year 10 (62%) patients were alive and majority of improved parameters were still stable. Thereafter they usually started to decline. Survival was influenced by nonepithelial histology (P < 0.01) and N2-disease (P < 0.01), which showed to be the only prognosticator at Cox regression (P < 0.0001, Odd ratio 5.4). Among symptomatic variables, a 3-month postoperative Short-Form-36 physical-component-summary above the median value correlated significantly with a better prognosis (P < 0.02). CONCLUSIONS: Extrapleural pneumonectomy may rapidly improve symptoms as well as quality of life, especially in physical domains. Other than biological factors, postoperative Short-Form-36 physical component as well, significantly influenced the prognosis.

Nonintubated surgical biopsy of undetermined interstitial lung disease: a multicentre outcome analysis.

OBJECTIVES: Nonintubated surgical biopsy (NISB) of interstitial lung disease (ILD) has shown promise in unicentre reports as a reliable method to achieve pathological diagnosis with low morbidity. The aim of this study was to investigate for the first time early outcomes of NISB of ILD using a multicentre retrospective analysis. METHODS: Seven European and extra-European institutions participated in the study. Overall, 112 procedures were included. The mean age was 60 ± 12 years (65 men and 47 women). Preoperative total lung capacity and diffusion capacity of carbon monoxide were 74 ± 16% predicted and 57 ± 18% predicted, respectively. Forty-five patients had 1 or more associated comorbidities. NISB of ILD were performed under spontaneous ventilation by intercostal block (n = 84) or epidural anaesthesia (n = 28) with (n = 58) or without (n = 54) sedation and by thoracoscopic surgery (n = 88) or minithoracotomy (n = 24). RESULTS: Mean anaesthesia time, operative time and global time spent in the operating room were 31 ± 31 min, 29 ± 15 min and 89 ± 156 min, respectively. Feasibility was scored as excellent, good, satisfactory or unsatisfactory requiring conversion to general anaesthesia with intubation in 92, 12, 2 and 6 instances, respectively. There were no deaths. Morbidity was 7.1% and included prolonged air leaks in 4 patients and pneumonia, atelectasis, anaemia and gastric bleeding in 1 patient each. A precise pathological diagnosis was achieved in 108 patients (96%). The mean hospital stay was 2.5 ± 2.7 days. Comparisons of results achieved in the largest single-centre series (group A, 60 patients operated on) versus those resulting from the sum of the patients operated on in the other centres (group B, 52 patients operated on) showed no differences in feasibility (P = 0.10) and morbidity (P = 0.10) whereas hospital stay was shorter in group A (1.3 ± 0.5 days vs 3.9 ± 3.4 days, P < 0.001). CONCLUSIONS: Results of this multicentre study confirm the satisfactory feasibility of NISB of ILD in 82% of patients with no deaths and a low morbidity rate. Intergroup comparisons indicated that the hospital stay was shorter in group A whereas there were no differences in feasibility and morbidity rates.