Coronary artery bypass surgery for acute coronary syndrome: A network meta-analysis of on-pump cardioplegic arrest, off-pump, and on-pump beating heart strategies.

BACKGROUND: Coronary artery bypass grafting (CABG) in the setting of an acute coronary syndrome is a high-risk procedure, and the best strategy for myocardial revascularisation remains debated. This study compares the 30-day mortality benefit of on-pump CABG (ONCAB), off-pump CABG (OPCAB), and on-pump beating heart CABG (OnBHCAB) strategies. METHODS: A systematic search of three electronic databases was conducted for studies comparing ONCAB with OPCAB or OnBHCAB in patients with acute coronary syndrome (ACS). The primary outcome, 30-day mortality, was compared using a Bayesian hierarchical network meta-analysis (NMA). A random effects consistency model was applied, and direct and indirect comparisons were made to determine the relative effectiveness of each strategy on postoperative outcomes. RESULTS: One randomised controlled trial and eighteen observational studies fulfilling the inclusion criteria were identified. A total of 4320, 5559, and 1962 patients underwent ONCAB, OPCAB, and OnBHCAB respectively. NMA showed that OPCAB had the highest probability of ranking as the most effective treatment in terms of 30-day mortality (odds ratio [OR], 0.50; 95% credible interval [CrI], 0.23-1.00), followed by OnBHCAB (OR, 0.62; 95% CrI, 0.20-1.57), however the 95% CrI crossed or included unity. A subgroup NMA of nine studies assessing only acute myocardial infarction (AMI) patients demonstrated a 72% reduction in likelihood of 30-day mortality after OPCAB (CrI, 0.07-0.83). No significant increase in rate of stroke, renal dysfunction or length of intensive care unit stay was found for either strategy. CONCLUSIONS: Although no single best surgical revascularisation approach in ACS patients was identified, the significant mortality benefit with OPCAB seen with AMI suggests high acuity patients may benefit most from avoiding further myocardial injury associated with cardiopulmonary bypass and cardioplegic arrest.

Unilateral Versus Bilateral Antegrade Cerebral Perfusion: A Meta-Analysis of Comparative Studies.

BACKGROUND: Antegrade cerebral perfusion (ACP) is an essential adjunct for prolonged hypothermic circulatory arrest (HCA) during aortic arch surgery. However, it has yet to be established whether ACP should be delivered unilaterally or bilaterally. The aim of the present meta-analysis is to investigate outcomes of unilateral ACP (uACP) compared to bilateral ACP (bACP) in comparative studies. METHODS: Electronic searches were performed using four databases from their inception to February 2017. Relevant comparative studies with adult patients who underwent aortic arch surgery using unilateral or bilateral ACP were included. Data was extracted by two independent researchers and analysed according to predefined endpoints using a random-effects model. Meta-regression was used to identify predictors of primary outcomes. RESULTS: Nine comparative studies were identified, comprising 967 uACP patients and 879 bACP patients. No significant differences in age, sex, or proportion of total arch replacements were identified. The uACP cohort had a greater proportion of acute dissections (86% vs 75%, p = 0.04). Hypothermic circulatory arrest and cerebral perfusion times were similar between both groups. No significant differences were seen between unilateral and bilateral groups in terms of mortality (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.64-1.48; p = 0.90; I2 = 0%), permanent neurological deficit (PND) (OR 1.04; 95% CI 0.74-1.45; p = 0.85; I2 = 0%), temporary neurological deficit (p = 0.74), acute kidney injury (p = 0.36) or reoperation for bleeding (p = 0.65). No factors affecting mortality or PND were identified on meta-regression. CONCLUSION: For patients undergoing aortic arch surgery, the available evidence supports either uACP or bACP as an adjunct to HCA. However, there is insufficient comparative evidence available to determine the benefit of either modalities in patients with longer durations of circulatory arrest.

Neurologic Complications of Extracorporeal Membrane Oxygenation: A Review.

OBJECTIVE: To review the evidence on neurologic complications in adult extracorporeal membrane oxygenation (ECMO) patients with regard to incidence, pathophysiology, risk factors, diagnosis, monitoring techniques, prevention, and management. DESIGN: Literature review. SETTING: Observational studies and case reports from a variety of institutions. PARTICIPANTS: Adult ECMO patients. INTERVENTIONS: Six electronic databases were searched from their dates of inception to October 2016. MEASUREMENTS AND MAIN RESULTS: The range of neurologic complications reported in adult ECMO patients included stroke, intracranial hemorrhage, and brain death. Due to a lack of standardized reporting, their true incidence may have been underestimated significantly. A variety of pathophysiologic mechanisms and risk factors have been proposed. Some of these are specific to venoarterial ECMO, whereas others may be more relevant to venovenous ECMO (eg, rapid correction of hypercarbia). With regard to diagnosis and monitoring, clinical examination alone can be challenging and insufficiently sensitive, particularly for the confirmation of brain death. Computed tomography is the main imaging modality for acute neurologic assessment because magnetic resonance imaging is not feasible in these patients. Options for neuromonitoring are limited, although cerebral near-infrared spectroscopy may be useful. There are very limited data to guide the management of specific complications such as intracranial hemorrhage, which remains a leading cause of mortality in ECMO patients. CONCLUSIONS: ECMO can be lifesaving and is being used increasingly for severe respiratory and/or cardiac failure. However, it remains associated with significant neurologic morbidity and mortality. Greater research clearly is needed to determine the best approach to the assessment and management of neurologic complications in this rapidly growing patient population.

Biatrial ablation vs. left atrial concomitant surgical ablation for treatment of atrial fibrillation: a meta-analysis.

AIMS: Surgical ablation performed concomitantly with cardiac surgery has emerged as an effective curative strategy for atrial fibrillation (AF). Left atrial (LA) lesion sets for ablation have been suggested to reduce procedural times and post-surgical bradycardia compared with biatrial (BA) lesions. Given the inconclusive literature regarding BA vs. LA ablation, the present meta-analysis sought to assess the current evidence. METHODS AND RESULTS: Electronic searches were performed using six databases from their inception to December 2013, identifying all relevant randomized trials and observational studies comparing BA vs. LA surgical ablation AF patients undertaking cardiac surgery. In 10 included studies, 2225 patient results were available for analysis to compare BA (n = 888) vs. LA (n = 1337) ablation. Sinus rhythm prevalence was higher in the BA cohort compared with the LA cohort at 6-month and 12-month follow-up, but similar beyond 1 year. Permanent pacemaker implantations were higher in the BA cohort, but 30-day and late mortality, neurological events, and reoperation for bleeding were similar between BA and LA groups. CONCLUSIONS: Biatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates. Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year, but this difference was not maintained beyond 1 year. Trends appear to be driven by the preferential selection of long-standing and persistent AF patients for the BA approach. Future randomized studies of adequate follow-up are required to validate risks and benefits of BA vs. LA surgical ablation.

Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest: a meta-analysis.

OBJECTIVE: To evaluate the effect of extracorporeal membrane oxygenation (ECMO) on survival and complication rates in adults with refractory cardiogenic shock or cardiac arrest. DESIGN: Meta-analysis. SETTING: University hospitals. PARTICIPANTS: One thousand one hundred ninety-nine patients from 22 observational studies. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Observational studies published from the year 2000 onwards, examining at least 10 adult patients who received ECMO for refractory cardiogenic shock or cardiac arrest were included. Pooled estimates with 95% confidence intervals were calculated based on the Freeman-Tukey double-arcsine transformation and DerSimonian-Laird random-effect model. Survival to discharge was 40.2% (95% confidence intervals [CI], 33.9-46.7), while survival at 3, 6, and 12 months was 55.9% (95% CI, 41.5-69.8), 47.6% (95% CI, 25.4-70.2), and 54.4% (95% CI, 36.6-71.7), respectively. Survival up to 30 days was higher in cardiogenic shock patients (52.5%, 95% CI, 43.7%-61.2%) compared to cardiac arrest (36.2%, 95% CI, 23.1%-50.4%). Concurrently, complication rates were particularly substantial for neurologic deficits (13.3%, 95% CI, 8.3-19.3), infection (25.1%, 95%CI, 15.9-35.5), and renal impairment (47.4%, 95% CI, 30.2-64.9). Significant heterogeneity was detected, although its levels were similar to previous meta-analyses that only examined short-term survival to discharge. CONCLUSIONS: Venoarterial ECMO can improve short-term survival in adults with refractory cardiogenic shock or cardiac arrest. It also may provide favorable long-term survival at up to 3 years postdischarge. However, ECMO also is associated with significant complication rates, which must be incorporated into the risk-benefit analysis when considering treatment. These findings require confirmation by large, adequately controlled and standardized trials with long-term follow-up.

Transcatheter Aortic Valve Implantation (TAVI) in Patients With Bicuspid Aortic Valve Stenosis--Systematic Review and Meta-Analysis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a feasible interventional technique for severe aortic stenosis in patients who are deemed inoperable or at high surgical risk. There is limited evidence for the safety and efficacy of TAVI in patients with bicuspid aortic valves (BAV), the most common congenital valve abnormality. In many TAVI trials, patients with BAV have been contraindicated due to concerns surrounding abnormal valve geometry, leading to malfunction or malpositioning. A systematic review and meta-analysis was conducted in order to assess the current evidence and relative merits of TAVI in aortic stenosis patients with BAV. METHOD: From six electronic databases, seven articles including 149 BAV and 2096 non-BAV patients undergoing TAVI were analysed. RESULTS: Between the BAV and no-BAV cohorts, there was no difference in 30-day mortality (8.3% vs 9.0%; P=0.68), post-TAVI mean peak gradients (weighted mean difference, 0.36 mmHg; P=0.55), moderate or severe paravalvular leak (25.7% vs 19.9%; P=0.29), pacemaker implantations (18.5% vs 27.9%; P=0.52), life-threatening bleeding (8.2% vs 13.9%; P=0.33), major bleeding (20% vs 16.8%; P=0.88), conversion to conventional surgery (1.9% vs 1.2%; P=0.18) and vascular complications (8.6% vs 10.1%; P=0.32). CONCLUSIONS: Preliminary short and mid-term pooled data from observation studies suggest that TAVI is feasible and safe in older patients with BAV. While future randomised trials are not likely, larger adequately-powered multi-institutional studies are warranted to assess the long-term durability and complications associated with TAVI in older BAV patients with severe aortic stenosis.

Robot-assisted Hybrid Coronary Revascularisation: Systematic Review.

BACKGROUND: Hybrid coronary revascularisation (HCR) for multi-vessel coronary artery disease combines surgical bypass grafting for the left anterior descending (LAD) coronary artery and percutaneous coronary intervention (PCI) for non-LAD coronary arteries. The present systematic review was conducted to assess the available evidence on robotic-assisted HCR and explore the potential advantages and disadvantages it proposes. METHODS: A comprehensive search from six electronic databases was performed for studies reporting outcomes for robotic-assisted hybrid coronary revascularisation. Eight studies were identified from six electronic databases amenable for qualitative assessment and pooled quantitative analysis. RESULTS: There were no in-hospital deaths reported. Pooled myocardial infarction rates was 1.2% (range 0-3.7%), pooled strokes was 0.8% (range: 0-1.7%), freedom from reintervention was 92.5% (range 70.4-100%), and freedom from angina was 92.9% (range 74.3-100%). LITA patency ranged from 89-100%, while hospital stay ranged from 4-8.1 days. CONCLUSIONS: The current data suggests potentially acceptable mortality and complication rates, when patients are carefully selected and operated on by expert cardiovascular teams. However, due to the heterogeneous nature of the evidence and lack of long-term outcomes, this promising technique warrants future comparative and randomised studies before becoming a part of mainstay coronary interventions.

Outcomes of surgical aortic valve replacement in octogenarians.

BACKGROUND: In the era of TAVI, there has been renewed interest in the outcomes of conventional AVR for high-risk patients. This study evaluates the short- and long-term outcomes of AVR in octogenarians. METHODS: A retrospective review was performed of all 117 patients aged ≥ 80 years who underwent AVR, (isolated AVR (n = 60) or AVR+CABG (n = 57),) from August 2005 to February 2011 at Royal Prince Alfred Hospital and Strathfield Hospital. Univariate analysis was used to compare pre- and post-operative variables between younger and older subgroups (age 80-84, n = 82; age 85-89, n = 35 respectively). Long-term survival data was obtained from the National Death Index at the Australian Institute of Health and Welfare and survival curves were constructed using the Kaplan-Meier method. RESULTS: The median age was 83 years (interquartile range, 81-85 years), 46.2% were females, the median EuroSCORE was 10.89% (interquartile range, 8.20-16.45%) and 16.2% of patients had a EuroSCORE ≥ 20%. The difference between subgroups for history of stroke was significant (p = .042). Post-operative complications included pleural effusion (12.8%), new renal failure (4.3%) and respiratory failure (4.3%). The rate of major adverse events was extremely low, with no cases of stroke. The 30-day mortality rate was 3.4%. There was a significant difference between subgroups for 30-day mortality (p = .007). 38.9% of patients were discharged home, 11.5% were transferred to another hospital and 38.9% spent a period of time in a rehabilitation institution post discharge. In terms of long-term survival, the six-month, one-year and three-year survival was 95.6%, 87.6% and 58.4% respectively. CONCLUSIONS: Surgical AVR yields excellent short- and long-term outcomes for potentially high-risk, elderly patients.

The learning curve of the robotic-assisted lobectomy-a systematic review and meta-analysis.

Background: Early studies have illustrated the robotic lobectomy to be safe, oncologically effective, and economically feasible as a therapeutic modality in the treatment of thoracic malignancies. The 'challenging' learning curve seemingly associated with the robotic approach, however, continues to be an often-cited factor to its ongoing uptake, with the overwhelming volume of these surgeries being performed in centers of excellence where extensive experience with minimal access surgery is the norm. An exact quantification of this learning curve challenge, however, has not been made, begging the question of whether this is an outdated assumption, versus fact. This systematic review and meta-analysis sort to clarify the learning curve for robotic-assisted lobectomy based on the existing literature. Methods: An electronic search of four databases was performed to identify relevant studies outlining the learning curve of robotic lobectomy. The primary endpoint was a clear definition of operator learning (e.g., cumulative sum chart, linear regression, outcome-specific analysis, etc.) which could be subsequently aggregated or reported. Secondary endpoints of interest included post-operative outcomes and complication rates. A meta-analysis using a random effects model of proportions or means was applied, as appropriate. Results: The search strategy identified twenty-two studies relevant for inclusion. A total of 3,246 patients (30% male) receiving robotic-assisted thoracic surgery (RATS) were identified. The mean age of the cohort was 65.3±5.0 years. Mean operative, console and dock time was 190.5±53.8, 125.8±33.9 and 10.2±4.0 minutes, respectively. Length of hospital stay was 6.1±4.6 days. Technical proficiency with the robotic-assisted lobectomy was achieved at a mean of 25.3±12.6 cases. Conclusions: The robotic-assisted lobectomy has been illustrated to have a reasonable learning curve profile based on the existing literature. Current evidence on the oncologic efficacy and purported benefits of the robotic approach will be bolstered by the results of upcoming randomized trials, which will be critical in supporting RATS uptake.

del Nido versus blood cardioplegia in adult cardiac surgery: a meta-analysis.

AIMS: Initially developed for myocardial protection in immature cardiomyocytes, del Nido cardioplegia has been increasingly used over the past decade in adult patients. Our aim is to analyse the results from randomized controlled trials and observational studies comparing early mortality and postoperative troponin release in patients who underwent cardiac surgery using del Nido solution and blood cardioplegia. METHODS: A literature search was performed through three online databases between January 2010 and August 2022. Clinical studies providing early mortality and/or postoperative troponin evaluation were included. A random-effects meta-analysis with a generalized linear mixed model, incorporating random study effects, was implemented to compare the two groups. RESULTS: Forty-two articles were included in the final analysis for a total of 11 832 patients, 5926 of whom received del Nido solution and 5906 received blood cardioplegia. del Nido and blood cardioplegia populations had comparable age, gender distribution, history of hypertension and diabetes mellitus. There was no difference in early mortality between the two groups. There was a trend towards lower 24 h [mean difference -0.20; 95% confidence interval (CI) -0.40 to 0.00; I2 = 89%; P = 0.056] and lower peak postoperative troponin levels (mean difference -0.10; 95% CI -0.21 to 0.01; I2 = 0.87; P = 0.087) in the del Nido group. CONCLUSION: del Nido cardioplegia can be safely used in adult cardiac surgery. The use of del Nido solution was associated with similar results in terms of early mortality and postoperative troponin release when compared with blood cardioplegia myocardial protection.

The perioperative outcomes of uniportal robotic-assisted thoracic surgeries-a systematic review and meta-analysis of surgical cohort studies and case reports.

Background: Early results have illustrated the multiportal robotic approach to be safe and oncologically efficacious in the treatment of thoracic malignancies. Industry leaders have improved upon the lessons learned during the early multiportal studies and have now come to establish the feasibility of the biportal, and subsequently the uniportal robotic-assisted approach, all in an effort to offer patients equivalent or better outcomes with less surgical trauma. No current, coherent body of evidence currently exists outlining the early-term outcomes of patients undergoing uniportal robotic-assisted thoracic surgery. This systematic review and meta-analysis sought to clarify the early-phase outcomes of these patients. Methods: An electronic search of four databases was performed to identify relevant studies outlining the immediate post-operative outcomes of patients undergoing uniportal robotic-assisted thoracic surgeries. The primary endpoint was defined as technical success (i.e., no conversion to secondary robotic, video-assisted thoracoscopic, or open approaches). Secondary endpoints of interest included post-operative outcomes and complication rates. A meta-analysis using a random effects model of proportions or means was applied, as appropriate. Results: The search strategy ultimately yielded 12 relevant studies for inclusion. A total of 240 patients (52% male) split across cohort studies and case reports were identified. The mean age of the two groups was 59.7±3.0 and 58.1±6.8 years, respectively. The mean operative time was 133.8±38.2 and 150.0±52.2 minutes, respectively. Length of hospital stay was 4.4±1.6 and 4.3±1.1 days, respectively. The mean blood loss was 80.0±25.1 mL The majority of identified procedures were lobectomies, segmentectomies, and wedge resections, though complex sleeve resections and anterior mediastinal mass resections were also completed. Cumulative technical success was 99.9%. Conclusions: The uniportal robotic-assisted approach, when completed in expert hands, has been illustrated to have exceedingly low rates of conversion to secondary procedures, along with short length of stay (LOS), minimal blood loss, and short procedural times (variable depending on operation type). Current evidence on the feasibility of this approach will be bolstered by upcoming multi-institutional series.

Surgical management of melanoma lung metastasis: an analysis of survival outcomes in 292 consecutive patients.

BACKGROUND: The role of surgical resection of melanoma lung metastases (MLM) remains controversial. Some authorities advocate an aggressive surgical approach, while others recommend a conservative strategy. This study sought to identify the clinicopathologic and predictors of outcome after surgical management of MLM in a large series of melanoma patients from a single institution. METHODS: All patients undergoing surgical management of MLM between November 1984 and April 2010 were identified and predictors of outcome analyzed. RESULTS: Of the 292 patients eligible for the study, 112 (38%) had previously undergone surgery for nonpulmonary recurrences. Four patients (1%) died within 30 days of surgery for MLM. The median progression-free survival time was 10 months. The median overall survival and 3- and 5-year survival were 23 months [95% confidence interval (CI) 17­30], 41 and 34%, respectively. Metastasis size >2 cm [hazard ratio (HR) 1.4, 95% CI 1.0­1.8, P = 0.03, HR 1.6, 95% CI 1.2­2.2; P = 0.002] and positive surgical margin (HR 1.5, 95% CI 1.2­1.9, P < 0.001; HR 1.4, 95% CI 1.1­1.7, P = 0.003) were independently associated with poorer progression-free survival and overall survival, respectively. The presence of more than one metastasis (HR 1.4, 95% CI 1.1­1.7, P = 0.013) was independently associated with poorer overall survival. CONCLUSIONS: The results support the role of pulmonary metastasectomy in selected patients with MLM. Patients with small (<2 cm) and solitary tumors that can be completely resected with a negative margin are most likely to experience prolonged survival.

Robotically assisted mitral valve repair-the string, ruler, and bulldog technique.

Robotic mitral valve repair presents its own unique set of challenges. Neochordae implantation is one of the techniques used to achieve adequate repair of the mitral valve. Precise securing of neochordae is vital in achieving a meticulous repair. This article describes how to perform an efficient, reproducible robotic mitral valve repair using a string, a ruler, and a bulldog.

Robotic versus conventional sternotomy mitral valve surgery: a systematic review and meta-analysis.

Background: Robotic-assisted mitral valve surgery (RMVS) is becoming an increasingly performed procedure in cardiac surgery, however, its true safety and efficacy compared to the gold standard conventional sternotomy approach [conventional sternotomy mitral valve surgery (CSMVS)] remains debated. The aim of this meta-analysis was to provide a comprehensive analysis of all available literature comparing RMVS to CSMVS. Methods: An electronic search of five databases was performed to identify all relevant studies comparing RMVS to CSMVS. Pre-defined primary outcomes of interest included all-cause mortality, cerebrovascular accidents (CVA) and re-operation for bleeding. Secondary outcomes of interest included cross clamp time, cardiopulmonary bypass (CPB) time, intensive care unit (ICU) and hospital length of stay (LOS), post-operative atrial fibrillation (POAF) and red blood cell (RBC) transfusion. Results: The search strategy identified fourteen studies qualifying for inclusion in this meta-analysis comparing RMVS to CSMVS. The outcomes of 6,341 patients (2,804 RMVS and 3,537 CSMVS) were included. RMVS had significantly lower mortality when compared to CSMVS group in both the unmatched [odds ratio (OR) 0.33; 95% confidence interval (CI): 0.19-0.57; P<0.001] and matched cohorts (OR 0.35; 95% CI: 0.15-0.80; P=0.01). There was no significant difference in rates of CVA or re-operation for bleeding between the two groups in either the entire included cohort or matched patients. CSMVS had significantly shorter cross clamp time by 28 minutes (95% CI: 19.30-37.32; P<0.001) and CPB time by 49 minutes (95% CI: 36.16-61.01; P<0.001) which remained significantly shorter in the matched cohorts. RMVS had shorter ICU [mean difference (MD) 26 hours; 95% CI: -34.31 to -18.52; P<0.001] and hospital LOS (MD 2 days; 95% CI: -2.66 to -1.37; P<0.001), which were again both significantly shorter in the matched cohort. RMVS group also had fewer RBC transfusions (OR 0.44; 95% CI: 0.28-0.70; P<0.001). Conclusions: Current evidence on comparative outcomes of RMVS and CSMVS is limited with only low-quality studies currently available. This present meta-analysis suggests that RMVS may have lower mortality and shorter ICU and hospital LOS, however CSMVS may be associated with significantly shorter cross clamp and CPB times. Further analysis of high-quality studies with randomized data is required to verify these results.

Summary of prognostic factors and patient selection for extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma.

BACKGROUND: Extrapleural pneumonectomy (EPP) has been shown to improve long-term survival outcomes in selected patients with malignant pleural mesothelioma (MPM). The present study aimed to evaluate potential prognostic factors on overall survival for patients who underwent EPP for MPM and to examine the patient selection process in major referral centers that perform EPP. METHODS: A systematic review of the current literature was performed using 5 electronic databases. Relevant studies with prognostic data on overall survival for patients with MPM treated by EPP were included for review. Two reviewers independently assessed each included study. RESULTS: A total of 17 studies from 13 institutions containing the most updated and complete data on prognostic factors for patients with MPM who underwent EPP were included for review. A number of quantitative, clinical, and treatment-related factors were identified to have significant impact on overall survival. CONCLUSIONS: Patients with nonepithelial MPM and nodal involvement have consistently demonstrated to have a worse prognosis after EPP. Their eligibility as candidates for EPP should be questioned. The preoperative patient selection process currently differs greatly between institutions and should focus on identifying patients with nonepithelial histologic subtypes and nodal involvement to exclude them as EPP surgical candidates in the future.

Prognostic impact of MMP-2 and MMP-9 expression in pathologic stage IA non-small cell lung cancer.

BACKGROUND: The purpose of the present study was to assess the value of matrix metalloproteinase (MMP)-2 and MMP-9 expression and other potential prognostic factors in predicting the clinical outcome of patients after definitive surgery for pathologic stage IA non-small cell lung cancer (NSCLC). METHODS: One hundred and forty-six consecutive and non-selected patients who underwent definitive surgery for stage IA NSCLC were included in this study. Formalin-fixed paraffin-embedded specimens were stained for MMP-2 and MMP-9, which were statistically evaluated for their prognostic value and other clinicopathological parameters. RESULTS: Of the 146 patients studied, 102 (69.9%) cases were classified as having high expression for MMP-2. A total of 89 carcinomas (61.0%) had high expression for MMP-9. MMP-9 expression correlated with Eastern Cooperative Oncology Group (ECOG) performance status, pT stage, and differentiation (P = 0.005, <0.001, and <0.001, respectively). Vessel invasion, pT stage, and MMP-9 expression maintained their independent prognostic influence on overall survival (P = 0.037, <0.001, and <0.001, respectively). CONCLUSIONS: From results of our relatively large database, MMP-9 may be considered as a viable biomarker that can be used in conjunction with other prognostic factors such as vessel invasion and pT stage to predict the prognosis of patients with completely resected pathologic stage IA NSCLC.

Long-term outcome of hybrid surgical approach of video-assisted minithoracotomy sleeve lobectomy for non-small-cell lung cancer.

BACKGROUND: The aim of this study was to evaluate the technical feasibility and safety of a hybrid surgical approach of video-assisted minithoracotomy (hybrid VATS) sleeve lobectomy for non-small-cell lung cancer (NSCLC), using success rate as the primary end point. METHODS: Between February 1996 and December 2006, patients with bronchogenic tumors were prospectively registered to undergo hybrid VATS sleeve resection in a single institution. Hybrid VATS involved performing the main procedures via rib spreading and minithoracotomy using a monitor and direct vision. A successful procedure was defined as a patient who had a sleeve lobectomy via hybrid VATS without conversion to thoracotomy and without significant perioperative morbidity or mortality. RESULTS: A total of 148 patients (108 men and 40 women; median age = 58 years) who underwent hybrid VATS sleeve lobectomy for NSCLC were identified in our database. The median duration of the successfully completed procedures was 190 min (range = 145-305 min). The median length of time of chest tube in place was 3 days (range = 1-12 days). Hybrid VATS sleeve lobectomy was performed successfully in 134 of 148 patients for a success rate of 90.5%. The median follow-up period was 65.1 months (range = 34.5-154.8 months). The overall 5-year disease-free survival and overall survival of all patients were 36.7% (95% CI = 27.9-45.5%) and 54.2% (95% CI = 44.8-63.6%), respectively. CONCLUSION: Hybrid VATS sleeve lobectomy is feasible for selected patients with NSCLC in specialized centers.