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Background A surgical fellowship allows both additional training as well as maintenance of surgical skills while searching for a steady job. As the presence of fellows usually does not results in a measurably higher productivity, fellowshipsmay be considered a form of disguised unemployment. The aim of this study is to evaluate the career flow of a surgical trainee to a staff position and to determine the number of surgeons working on temporary basis within the general surgery workforce in Flanders.Methods All surgeons graduated in Flanders between 2000 and 2022 were invited to fill out a web-based survey concerning their current and past employment. Reminders were sent out after 2 and 4 weeks. Statistical analysis was performed with SPSS version 27.0 (IBM Inc., Chicago, IL, USA.)Results Response rate was 64% (292/457) with 76% of respondents currently working as surgeons, 14% (38) as fellows and 10% working outside the surgical domain. Eighty-two percent of current fellows graduated in 2019 or later. Thirty-one percent of surgeons graduated in 2019 are still working as fellows. For surgeons graduated in 2020, 2021 and 2022 this is 45%, 80% and 90% respectively. Compared to staff surgeons the number of additional training years (2,8 ± 1,0 vs 2,2 ± 1,3; p = 0,009). and the number of applications (6,6 ± 5 vs 3,3 ± 3; p < 0,001) is significantly higher for current fellowsConclusion This study shows that disguised unemployment is present in the general surgical community in Flanders. The status of "fellow" should be incorporated in calculations concerning future needs of the surgical workforce in order to prevent open unemployment.
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OBJECTIVE: To describe our experience with lung transplantation (LTx) from donors ≥70 years and compare short and long-term outcomes to a propensity-matched cohort of donors <70 years. BACKGROUND: Although extended-criteria donors have been widely used to enlarge the donor pool, the experience with LTx from older donors (≥70 years) remains limited. METHODS: All single-center bilateral LTx between 2010 and 2020 were retrospectively analyzed. Matching (1:1) was performed for the donor (type, sex, smoking history, x-ray abnormalities, partial pressure of oxygen/fraction of inspired oxygen ratio, and time on ventilator) and recipient characteristics (age, sex, LTx indication, perioperative extracorporeal life support, and cytomegalovirus mismatch). Primary graft dysfunction grade-3, 5-year patient, and chronic lung allograft dysfunction-free survival were analyzed. RESULTS: Out of 647 bilateral LTx, 69 were performed from donors ≥70 years. The mean age in the older donor cohort was 74 years (range: 70-84 years) versus 49 years (range: 12-69 years) in the matched younger group. No significant differences were observed in the length of ventilatory support, intensive care unit, or hospital stay. Primary graft dysfunction-3 was 26% in the older group versus 29% in younger donor recipients ( P = 0.85). Reintervention rate was comparable (29% vs 16%; P = 0.10). Follow-up bronchoscopy revealed no difference in bronchial anastomotic complications ( P = 1.00). Five-year patient and chronic lung allograft dysfunction-free survivals were 73.6% versus 73.1% ( P = 0.72) and 51.5% versus 59.2% ( P = 0.41), respectively. CONCLUSIONS: LTx from selected donors ≥70 years is feasible and safe, yielding comparable short and long-term outcomes in a propensity-matched analysis with younger donors (<70 years).
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Trasplante de Pulmón , Disfunción Primaria del Injerto , Humanos , Anciano , Anciano de 80 o más Años , Estudios Retrospectivos , Resultado del Tratamiento , Donantes de Tejidos , OxígenoRESUMEN
BACKGROUND: The COVID-19 pandemic has tremendously impacted the healthcare system and residency programs worldwide. Surgical residents were redeployed to COVID-19 units, whereas education and scientific didactics were reduced. The aim of this study is to identify the impact of COVID-19 on Flemish surgical residents' education, personal life and volume of performed surgeries. METHODS: A cross-sectional retrospective survey on educational and personal impact during the first COVID-19 wave was administered anonymously to all surgical residents in Flanders. A quantitative comparison of performed surgeries during this period and the same period a year earlier was conducted. RESULTS: A total of 193 surgical residents (46%) completed the survey. 63% of residents were no longer admitted to multidisciplinary oncologic meetings and 107 (55%) residents had no longer any scientific theoretical meetings at all. Almost one in two residents (46%) indicated more than 50% reduction in time in the operating theater and one in three (31%) residents were involved in care for COVID-19 positive surgical patients. Seventy-eight percent of the residents experienced a negative impact on their surgical training and 41% experienced a negative influence on their private situation. Performed surgical cases during the COVID-19 period were on average 40% less for second, third- and fourth-year residents. CONCLUSION: Surgical residents perceived a high negative impact on personal and professional lives during the start of the COVID-19 pandemic in Flanders. Education and training programs were cancelled and volume of performed surgeries decreased tremendously. Policymakers and surgical program coordinators should ensure surgical education during further evolution of this and future pandemics.
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COVID-19 , Internado y Residencia , Humanos , COVID-19/epidemiología , SARS-CoV-2 , Pandemias , Estudios Transversales , Estudios Retrospectivos , Encuestas y CuestionariosRESUMEN
Primary graft dysfunction (PGD) is a major obstacle after lung transplantation (LTx), associated with increased early morbidity and mortality. Studies in liver and kidney transplantation revealed prolonged anastomosis time (AT) as an independent risk factor for impaired short- and long-term outcomes. We investigated if AT during LTx is a risk factor for PGD. In this retrospective single-center cohort study, we included all first double lung transplantations between 2008 and 2016. The association of AT with any PGD grade 3 (PGD3) within the first 72 h post-transplant was analyzed by univariable and multivariable logistic regression analysis. Data on AT and PGD was available for 427 patients of which 130 (30.2%) developed PGD3. AT was independently associated with the development of any PGD3 ≤72 h in uni- (odds ratio [OR] per 10 min 1.293, 95% confidence interval [CI 1.136-1.471], p < .0001) and multivariable (OR 1.205, 95% CI [1.022-1.421], p = .03) logistic regression analysis. There was no evidence that the relation between AT and PGD3 differed between lung recipients from donation after brain death versus donation after circulatory death donors. This study identified AT as an independent risk factor for the development of PGD3 post-LTx. We suggest that the implantation time should be kept short and the lung cooled to decrease PGD-related morbidity and mortality post-LTx.
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Trasplante de Pulmón , Disfunción Primaria del Injerto , Anastomosis Quirúrgica/efectos adversos , Estudios de Cohortes , Humanos , Trasplante de Pulmón/efectos adversos , Disfunción Primaria del Injerto/etiología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
The technique for bronchial stump suturing following lung resection which is currently applied in the Department of Thoracic Surgery at the University Hospitals Leuven, Belgium owes its name to the Dutch surgeon Dr. Klinkenbergh (1891-1985). A true pioneer of cardiothoracic surgery in Europe, Dr. Klinkenbergh dedicated himself to the surgical treatment of pulmonary tuberculosis. His work was praised by his peers for his precision and the reasoning behind every gesture. The Klinkenbergh technique consists in performing two running sutures which cross each other 'in the same manner as the laces of a shoe' to close the bronchus, limiting the occurrence of broncho-pleural fistulas. In our experience with more than 100 patients in the last 5 years (2016-2020) who underwent open pneumonectomy for benign or malignant disease, less than 2% developed post-operative broncho-pleural fistulas.
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Fístula Bronquial , Neoplasias Pulmonares , Bronquios/cirugía , Fístula Bronquial/cirugía , Epónimos , Humanos , Neoplasias Pulmonares/cirugía , Neumonectomía , Complicaciones Posoperatorias , SuturasRESUMEN
Transplant type for end-stage pulmonary vascular disease remains debatable. We compared recipient outcome after heart-lung (HLT) versus double-lung (DLT) transplantation. Single-center analysis (38 HLT-30 DLT; 1991-2014) for different causes of precapillary pulmonary hypertension (PH): idiopathic (22); heritable (two); drug-induced (nine); hepato-portal (one); connective tissue disease (four); congenital heart disease (CHD) (24); chronic thromboembolic PH (six). HLT decreased from 91.7% [1991-1995] to 21.4% [2010-2014]. Re-intervention for bleeding was higher after HLT; (P = 0.06) while primary graft dysfunction grades 2 and 3 occurred more after DLT; (P < 0.0001). Graft survival at 90 days, 1, 5, 10, and 15 years was 93%, 83%, 70%, 47%, and 35% for DLT vs. 82%, 74%, 61%, 48%, and 30% for HLT, respectively (log-rank P = 0.89). Graft survival improved over time: 100%, 93%, 87%, 72%, and 72% in [2010-2014] vs. 75%, 58%, 42%, 33%, and 33% in [1991-1995], respectively; P = 0.03. No difference in chronic lung allograft dysfunction (CLAD)-free survival was observed: 80% & 28% for DLT vs. 75% & 28% for HLT after 5 and 10 years, respectively; P = 0.49. Primary graft dysfunction in PH patients was lower after HLT compared to DLT. Nonetheless, overall graft and CLAD-free survival were comparable and improved over time with growing experience. DLT remains our preferred procedure for all forms of precapillary PH, except in patients with complex CHD.
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Trasplante de Corazón-Pulmón/métodos , Trasplante de Pulmón/métodos , Hipertensión Arterial Pulmonar/cirugía , Adolescente , Adulto , Niño , Preescolar , Enfermedades del Tejido Conjuntivo/cirugía , Supervivencia sin Enfermedad , Femenino , Supervivencia de Injerto , Cardiopatías Congénitas/cirugía , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Periodo Preoperatorio , Disfunción Primaria del Injerto , Estudios Retrospectivos , Tromboembolia/cirugía , Adulto JovenRESUMEN
Recent animal studies and intraoperative studies in humans suggested that phrenic nerve stimulation could attenuate ventilator-induced diaphragm dysfunction. The purpose of the present study is to examine the safety and feasibility of diaphragm pacing during the weaning process after bilateral lung transplantation. Four patients, suffering from chronic pulmonary disease, were included, and diaphragm pacing was evaluated after lung transplantation. Implantation of electrodes at the end of the lung transplant procedure was possible in three of the four patients. In all implanted patients, stimulation of the diaphragm could trigger the ventilator. Implanted electrodes were completely removed by percutaneous retraction after up to 7 days of pacing. Adverse events related to pacing included occurrence of pain. Diaphragm pacing with temporary electrodes, inserted during surgery, is feasible and is able to trigger the ventilator in patients after bilateral lung transplantation. The use of intradiaphragmatic electrodes creates the additional opportunity to monitor the evolution of diaphragm electromyography during the postoperative weaning process.
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Terapia por Estimulación Eléctrica , Electrodos Implantados , Trasplante de Pulmón/métodos , Insuficiencia Respiratoria/terapia , Desconexión del Ventilador/métodos , Diafragma , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios ProspectivosRESUMEN
Combined liver/thoracic transplantation (cLiThTx) is a complex procedure for end-stage/advanced liver and heart(H)/lung(Lu) disease. To avoid futile use of multiple organs in single recipients, results should be scrutinously analyzed. Single-center cLiThTx (04/2000-12/2015) were reviewed for the following: demographics, indications, surgical technique, complications, rejection, and five-year patient survival. Results are reported as median (range). Fourteen consecutive patients underwent cLiThTx: 3 cLiHTx, 10 cLiLuTx, and 1 cLiHLuTx. Recipient age was 42 years (17-63 years). Most frequent indications were cystic fibrosis (n = 5), hepatopulmonary fibrosis (n = 2), amyloidosis (n = 2), and epithelioid hemangio-endothelioma (n = 2). Thoracic organs were transplanted first, except in three where LiTx preceded LuTx. In the latter, lungs were preserved by normothermic ex vivo lung perfusion. Stenting was performed for stenosis of bile duct (n = 4), hepatic artery (n = 2), and bronchus (n = 2). Abdominal interventions were required for bleeding (n = 3), evisceration (n = 1), and adhesiolysis (n = 1). One liver (cLiLuTx) was lost to hepatic artery thrombosis 3 months post-transplant and successfully retransplanted. One patient (cLiHTx) died 4 months post-transplant (myocardial infarction). Follow-up was 4 years (2 months-16 years). One liver and 5 pulmonary rejections occurred, all mild and reversible. Two patients developed bronchiolitis obliterans, one is clinically well 16 years post-transplant, and the other successfully retransplanted. Estimated 5-year patient survival is 90%. CLiThTx is safe with excellent short-/long-term surgical and immunological results.
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Trasplante de Corazón/métodos , Fallo Hepático/cirugía , Trasplante de Hígado/métodos , Trasplante de Pulmón/métodos , Adolescente , Adulto , Anciano , Bronquiolitis Obliterante/etiología , Fibrosis Quística/cirugía , Femenino , Estudios de Seguimiento , Rechazo de Injerto/etiología , Insuficiencia Cardíaca/cirugía , Humanos , Terapia de Inmunosupresión , Isquemia , Hepatopatías/cirugía , Enfermedades Pulmonares/cirugía , Masculino , Persona de Mediana Edad , Preservación de Órganos , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
Third Mediterranean Symposium on Thoracic Surgical Oncology, Catania, Italy, 21-22 April 2016 The primary justification for mediastinal lymphadenectomy is that it provides more complete nodal staging to help select best adjuvant treatments. There is a secondary argument that dissection of nodes might remove otherwise unrecognized nodal disease to increase the chance of cure. They have to be thought through again as patients look for less invasive treatments for their cancers such as videothoracoscopy and stereotactic radiotherapy. Evidence from analysis of Surveillance, Epidemiology and End Results data indicated that sampling or dissection can be performed adequately by surgeons using videothoracoscopy but stereotactic radiotherapy of its nature precludes intraoperative lymph node dissection and yet is being promoted as equivalent treatment. Consideration of these issues requires re-examination of the evidence that lymphadenectomy influences survival.
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Neoplasias Pulmonares/patología , Neoplasias Pulmonares/cirugía , Escisión del Ganglio Linfático/métodos , Mediastino/patología , Cirugía Torácica Asistida por Video/métodos , Terapia Combinada , Femenino , Humanos , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/terapia , Ganglios Linfáticos/patología , Metástasis Linfática , Masculino , Terapia Neoadyuvante , Estadificación de NeoplasiasRESUMEN
Esophageal wall rupture after EUS-FNA for mediastinal staging is a severe complication. Here we describe the management of two patients with esophageal wall rupture and the presence of empyema. Management was in both cases surgical and consisted of a decortication via thoracotomy. Postoperative IV antibiotics and parenteral nutrition were continued until the first negative X-ray with gastrografin. Both patients recovered and left the hospital in good condition and with oral intake.
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Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico/efectos adversos , Esófago/lesiones , Neoplasias del Mediastino/patología , Rotura/etiología , Anciano de 80 o más Años , Servicio de Urgencia en Hospital , Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico/métodos , Resultado Fatal , Estudios de Seguimiento , Humanos , Enfermedad Iatrogénica , Metástasis Linfática , Masculino , Neoplasias del Mediastino/cirugía , Estadificación de Neoplasias , Reoperación/métodos , Medición de Riesgo , Rotura/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVE: The current pathological lymph node (pN) staging is based on the number of positive lymph nodes but does not take into consideration characteristics of the involved lymph nodes itself. The current study aims to examine the prognostic value of extracapsular lymph node involvement (EC-LNI) and intracapsular lymph node involvement (IC-LNI) for esophageal adenocarcinoma treated by primary surgery. METHODS: From the databases of five European high volume centers, 1639 adenocarcinoma patients with primary R0-resection were withheld after excluding 90-day mortality. Oncologic variables, including number of resected lymph nodes, number of resected positive lymph nodes, and EC-LNI/IC-LNI were examined. The Union Internationale contre le Cancer (UICC) 7th edition prognostic staging was used as baseline staging system. Statistical analysis was performed by Cox proportional hazards modeling and verified using the Random Survival Forest technique. RESULTS: EC-LNI showed significantly worse overall 5-year survival compared with IC-LNI overall (13.4% vs 37.2%, Pâ<â0.0001), including in each pN-category [16.4% vs 45.6% in pN1 (Pâ<â0.0001), 16.1% vs 23.8% (Pâ=â0.047) in pN2 (Pâ=â0.065), and 8.7% vs 26.3% in pN3 categories, respectively]. pN1 IC-LNI patients show a 5-year overall survival comparable (Pâ=â0.92) with stage IIB (ie, pT3N0). Reclassifying the UICC prognostic stages according to these findings into an adapted staging model showed a significant (Pâ<â0.0001) increase in homogeneity, discriminatory ability, and monotonicity compared with the original UICC TNM 7th edition prognostic staging. CONCLUSIONS: These data suggest that lymph node capsular status is an important prognostic factor and should be considered for the future edition of the TNM staging system for esophageal cancer.
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Adenocarcinoma/secundario , Neoplasias Esofágicas/secundario , Esofagectomía/métodos , Ganglios Linfáticos/patología , Estadificación de Neoplasias , Adenocarcinoma/mortalidad , Adenocarcinoma/cirugía , Anciano , Neoplasias Esofágicas/mortalidad , Neoplasias Esofágicas/cirugía , Europa (Continente)/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Escisión del Ganglio Linfático , Metástasis Linfática , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de TiempoRESUMEN
INTRODUCTION: Non-small cell lung cancer (NSCLC) is a heterogeneous disorder consisting of distinct molecular subtypes each characterised by specific genetic and epigenetic profiles. Here, we aimed to identify novel NSCLC subtypes based on genome-wide methylation data, assess their relationship with smoking behaviour, age, COPD, emphysema and tumour histopathology, and identify the molecular pathways underlying each subtype. METHODS: Methylation profiling was performed on 49 pairs of tumour and adjacent lung tissue using Illumina 450 K arrays. Transcriptome sequencing was performed using Illumina HiSeq2000 and validated using expression data from The Cancer Genome Atlas (TCGA). Tumour immune cell infiltration was investigated by immunohistochemistry. RESULTS: Unsupervised hierarchical clustering of tumour methylation data revealed two subgroups characterised by a significant association between cluster membership and presence of COPD (p=0.024). Ontology analysis of genes containing differentially methylated CpGs (false discovery rate, FDR-adjusted p<0.05) revealed that immune genes were strongly enriched in COPD tumours, but not in non-COPD tumours. This COPD-specific immune signature was attributable to methylation changes in immune genes expressed either by tumour cells or tumour-infiltrating immune cells. No such differences were observed in adjacent tissue. Transcriptome profiling similarly revealed that genes involved in the immune response were differentially expressed in COPD tumours (FDR-adjusted p<0.05), an observation that was independently replicated using TCGA data. Immunohistochemistry validated these findings, revealing fewer CD4-positive T lymphocytes in tumours derived from patients with COPD. CONCLUSIONS: Lung tumours of patients with COPD differ from those of patients without COPD, with differentially methylated and expressed genes being mainly involved in the immune response.
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Carcinoma de Pulmón de Células no Pequeñas/epidemiología , Carcinoma de Pulmón de Células no Pequeñas/inmunología , Metilación de ADN/inmunología , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/inmunología , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/inmunología , Comorbilidad , HumanosRESUMEN
PURPOSE: To evaluate the diagnostic accuracy of the visual assessment of malignant pleural mesothelioma (MPM) on magnetic resonance (MR) images by using two known visual markers (mediastinal pleural thickness and shrinking of the lung) and a newly introduced one (pleural pointillism). MATERIALS AND METHODS: With the approval of the local ethics committee, 100 consecutive patients (mean age, 61.4 years; age range, 18-87 years; 75 men, 25 women) suspected of having MPM pleural abnormalities underwent positron emission tomography/computed tomography and MR imaging, including diffusion-weighted (DW) MR imaging, followed by explorative thoracoscopy or guided biopsy with histopathologic confirmation. Because visual assessment is still the preferred method of image interpretation, the diagnostic accuracy of mediastinal pleural thickening, shrinking lung (hemithorax volume decrease due to fibrosis), and pleural pointillism were examined. Pleural pointillism was denoted by the presence of multiple, hyperintense pleural spots on high-b-value DW images. Histopathologic findings in the surgical specimen served as the reference standard. McNemar tests with Bonferroni correction were used to assess differences in accuracy among the three examined markers. RESULTS: Of 100 patients, 33 had benign pleural alterations, and 67 had malignant pleural diseases (MPDs); 57 of 67 had MPM. A total of 78 patients received a correct diagnosis (benign vs malignant) on the basis of mediastinal pleural thickening (sensitivity, 81%; specificity, 73%; accuracy, 78%); and 66 patients, on the basis of shrinking lung (sensitivity, 60%; specificity, 79%; accuracy, 66%). The correct diagnosis was indicated on the basis of pleural pointillism in 88 patients (sensitivity, 93%; specificity, 79%; accuracy, 88%). CONCLUSION: Visual assessment of pleural pointillism on high-b-value DW images is useful to differentiate MPD from benign alterations, performing substantially better than mediastinal pleural thickness and shrinking lung, and might obviate unnecessary invasive procedures for MPM.
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Imagen de Difusión por Resonancia Magnética/métodos , Neoplasias Pulmonares/patología , Mesotelioma/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Interpretación de Imagen Asistida por Computador , Masculino , Mesotelioma Maligno , Persona de Mediana Edad , Estudios Prospectivos , Reproducibilidad de los Resultados , Adulto JovenRESUMEN
This is an official guideline of the European Society of Gastrointestinal Endoscopy (ESGE), produced in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). It addresses the benefit and burden associated with combined endobronchial and esophageal mediastinal nodal staging of lung cancer. The Scottish Intercollegiate Guidelines Network (SIGN) approach was adopted to define the strength of recommendations and the quality of evidence.The article has been co-published with permission in the European Journal of Cardio-Thoracic Surgery and the European Respiratory Journal. Recommendations 1 For mediastinal nodal staging in patients with suspected or proven non-small-cell lung cancer (NSCLC) with abnormal mediastinal and/or hilar nodes at computed tomography (CT) and/or positron emission tomography (PET), endosonography is recommended over surgical staging as the initial procedure (Recommendation grade A). The combination of endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic (esophageal) ultrasound with fine needle aspiration, with use of a gastrointestinal (EUS-FNA) or EBUS (EUS-B-FNA) scope, is preferred over either test alone (Recommendation grade C). If the combination of EBUS and EUS-(B) is not available, we suggest that EBUS alone is acceptable (Recommendation grade C).Subsequent surgical staging is recommended, when endosonography does not show malignant nodal involvement (Recommendation grade B). 2 For mediastinal nodal staging in patients with suspected or proven non-small-cell peripheral lung cancer without mediastinal involvement at CT or CT-PET, we suggest that EBUS-TBNA and/or EUS-(B)-FNA should be performed before therapy, provided that one or more of the following conditions is present: (i) enlarged or fluorodeoxyglucose (FDG)-PET-avid ipsilateral hilar nodes; (ii) primary tumor without FDG uptake; (iii) tumor size ≥â3âcm (Fig.â3aâ-âc) (Recommendation grade C). If endosonography does not show malignant nodal involvement, we suggest that mediastinoscopy is considered, especially in suspected N1 disease (Recommendation grade C).If PET is not available and CT does not reveal enlarged hilar or mediastinal lymph nodes, we suggest performance of EBUS-TBNA and/or EUS-(B)-FNA and/or surgical staging (Recommendation grade C). 3 In patients with suspected or provenâ<â3âcm peripheral NSCLC with normal mediastinal and hilar nodes at CT and/or PET, we suggest initiation of therapy without further mediastinal staging (Recommendation grade C). 4 For mediastinal staging in patients with centrally located suspected or proven NSCLC without mediastinal or hilar involvement at CT and/or CT-PET, we suggest performance of EBUS-TBNA, with or without EUS-(B)-FNA, in preference to surgical staging (Fig.â4) (Recommendation grade D). If endosonography does not show malignant nodal involvement, mediastinoscopy may be considered (Recommendation grade D). 5 For mediastinal nodal restaging following neoadjuvant therapy, EBUS-TBNA and/or EUS-(B)-FNA is suggested for detection of persistent nodal disease, but, if this is negative, subsequent surgical staging is indicated (Recommendation grade C). 6 A complete assessment of mediastinal and hilar nodal stations, and sampling of at least three different mediastinal nodal stations (4âR, 4âL, 7) (Fig.â1, Fig.â5) is suggested in patients with NSCLC and an abnormal mediastinum by CT or CT-PET (Recommendation grade D). 7 For diagnostic purposes, in patients with a centrally located lung tumor that is not visible at conventional bronchoscopy, endosonography is suggested, provided the tumor is located immediately adjacent to the larger airways (EBUS) or esophagus (EUS-(B)) (Recommendation grade D). 8 In patients with a left adrenal gland suspected for distant metastasis we suggest performance of endoscopic ultrasound fine needle aspiration (EUS-FNA) (Recommendation grade C), while the use of EUS-B with a transgastric approach is at present experimental (Recommendation grade D). 9 For optimal endosonographic staging of lung cancer, we suggest that individual endoscopists should be trained in both EBUS and EUS-B in order to perform complete endoscopic staging in one session (Recommendation grade D). 10 We suggest that new trainees in endosonography should follow a structured training curriculum consisting of simulation-based training followed by supervised practice on patients (Recommendation grade D). 11 We suggest that competency in EBUS-TBNA and EUS-(B)-FNA for staging lung cancer be assessed using available validated assessment tools (Recommendation Grade D).
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Broncoscopía/métodos , Carcinoma de Pulmón de Células no Pequeñas/patología , Endosonografía/métodos , Esofagoscopía/métodos , Neoplasias Pulmonares/patología , Carcinoma de Pulmón de Células no Pequeñas/diagnóstico por imagen , Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico , Humanos , Neoplasias Pulmonares/diagnóstico por imagen , Metástasis Linfática , Mediastino , Estadificación de NeoplasiasRESUMEN
Despite a worldwide need to expand the lung donor pool, approximately 75% of lung offers are not accepted for transplantation. We investigated the impact of liberalizing lung donor acceptance criteria during the last decade on the number of effective transplants and early and late outcomes in our center. All 514 consecutive lung transplants (LTx) performed between Jan 2000 and Oct 2011 were included. Donors were classified as matching standard criteria (SCD; n = 159) or extended criteria (ECD; n = 272) in case they fulfilled at least one of the following criteria: age >55 years, PaO2 /FiO2 at PEEP 5 cmH2 O < 300 mmHg at time of offer, presence of abnormalities on chest X-ray, smoking history, presence of aspiration, presence of chest trauma, or donation after circulatory death. Outcome parameters were primary graft dysfunction (PGD) grade at 0, 12, 24, and 48 h after LTx, time to extubation, stay in intensive care unit (ICU), early and late infection, acute rejection and bronchiolitis obliterans syndrome (BOS), and survival. Two hundred and seventy-two recipients (63.1%) received ECD lungs. PGD grade at T0 was similar between groups, while at T12 (<0.01), T24 (<0.01), and T48 (<0.05), PGD3 was observed more often in ECDs. ICU stay (P < 0.05) was longer in ECDs compared with SCDs. Time to extubation, respiratory infections, acute rejection, lymphocytic bronchiolitis, BOS, and survival were not different between groups. Accepting ECDs contributed in increasing the number of lung transplants performed in our center. Although this lung donor strategy has an impact on early postoperative outcome, liberalizing criteria did not influence long-term outcome after LTx.
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Trasplante de Pulmón , Donantes de Tejidos , Adulto , Muerte , Femenino , Humanos , Tiempo de Internación , Trasplante de Pulmón/efectos adversos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
OBJECTIVE: To clarify the biologic behavior of esophageal signet ring cell (SRC) carcinomas of the esophagus and gastroesophageal junction (GEJ). To evaluate the accuracy of pretreatment biopsies in diagnosing true SRC carcinoma. BACKGROUND: In contrast with gastric cancer, little is known about the biologic behavior and prognosis of SRC. METHODS: All adenocarcinomas (ADC) of the esophagus and GEJ-patients undergoing primary resection between 1990 and 2009 were included (n = 920). Specimens containing SRCs (n = 114) were classified according to World Health Organization criteria (>50% SRC or <50% SRC). RESULTS: Thirty-two patients showed more than 50% SRC and 71 patients showed less than 50% SRC. Overall cancer-specific 5-year survival was worse for SRC (22.4%, P < 0.0001) and for SRC > 50% (13.6%, P = 0.0001) compared with ADC. Complete resection was achieved in 86.5% of patients (n = 697) in ADC, 69.5% (n = 57) in SRC < 50%, and 78.1% (n = 25) in SRC > 50% (vs ADC, respectively, P < 0.0001 and P = 0.1801). In 379 pN + R0 patients, the median number of positive lymph nodes was comparable between ADC and SRC < 50% (4 vs 5, P = 0.207) or SRC > 50% (4 vs 8, P = 0.077). Compared with ADC, SRC > 50% showed more pN3's (30% vs 61%, P = 0.006), higher recurrence (56% vs 42% for ADC, P = 0.003), and local-regional recurrences (29% vs 16%, P = 0.002). Pretreatment biopsies were unreliable to define the presence of SRC > 50% (sensitivity = 56.3%, positive predictive value = 43.9%). CONCLUSIONS: SRCs are aggressive neoplasms associated with poorer prognosis than other ADCs after primary esophagectomy. Because our data suggest that pretreatment biopsies failed to reliably define presence of SRC > 50%, presence of SRCs in pretreatment biopsies seems to be of no use to define treatment strategy or prognosis.
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Carcinoma de Células en Anillo de Sello/secundario , Neoplasias Esofágicas/patología , Unión Esofagogástrica/patología , Estadificación de Neoplasias , Bélgica/epidemiología , Biopsia , Carcinoma de Células en Anillo de Sello/diagnóstico , Carcinoma de Células en Anillo de Sello/cirugía , Progresión de la Enfermedad , Neoplasias Esofágicas/mortalidad , Neoplasias Esofágicas/cirugía , Esofagectomía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Metástasis de la Neoplasia , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de TiempoRESUMEN
A persistent post-operative pulmonary expiratory air leak after an anatomical pulmonary resection is usually managed conservatively, but can be associated with significant morbidity and increased costs. The use of bronchial valves is a minimally invasive method that may be an effective and safe treatment in this setting. In a prospective study, the clinical efficacy of intrabronchial valve treatment in patients with a prolonged persistent pulmonary air leak after anatomical surgical resection for cancer was investigated. 10 out of 277 patients with anatomical pulmonary resection for cancer were included, and 90% were scheduled for valve treatment. We demonstrated an air leak cessation at a median of 2 days after valve placement, which resulted in chest tube removal at a median of 4 days after valve placement. Elective removal of the intrabronchial valves could be safely planned 3 weeks after valve implantation. Lung function alteration associated with airway occlusion by valves was limited. Intrabronchial valve treatment with the aid of a digital thoracic drainage system is an effective and safe therapy for patients with a prolonged pulmonary air leak after anatomical lung resection for cancer.
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Bronquios/patología , Neoplasias Pulmonares/cirugía , Pulmón/cirugía , Neumonectomía/efectos adversos , Neumotórax/cirugía , Adulto , Anciano , Tubos Torácicos , Drenaje , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neumonectomía/métodos , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate the diagnostic accuracy of dynamic contrast-enhanced (DCE) magnetic resonance (MR) and diffusion-weighted imaging (DWI) sequences for defining benignity or malignancy of solitary pulmonary lesions (SPL). METHODS: First, 54 consecutive patients with SPL, clinically staged (CT and PET or integrated PET-CT) as N0M0, were included in this prospective study. An additional 3-Tesla MR examination including DCE and DWI was performed 1 day before the surgical procedure. Histopathology of the surgical specimen served as the standard of reference. Subsequently, this functional method of SPL characterisation was validated with a second cohort of 54 patients. RESULTS: In the feasibility group, 11 benign and 43 malignant SPL were included. Using the combination of conventional MR sequences with visual interpretation of DCE-MR curves resulted in a sensitivity, specificity and accuracy of 100%, 55% and 91%, respectively. These results can be improved by DWI (with a cut-off value of 1.52 × 10(-3) mm(2)/s for ADChigh) leading to a sensitivity, specificity and accuracy of 98%, 82% and 94%, respectively. In the validation group these results were confirmed. CONCLUSION: Visual DCE-MR-based curve interpretation can be used for initial differentiation of benign from malignant SPL, while additional quantitative DWI-based interpretation can further improve the specificity. KEY POINTS: ⢠Magnetic resonance imaging is increasingly being used to help differentiate lung lesions. ⢠Solitary pulmonary lesions (SPL) are accurately characterised by combining DCE-MRI and DWI. ⢠Visual DCE-MRI assessment facilitates the diagnostic throughput in patients with SPL. ⢠DWI provides additional information in inconclusive DCE-MRI (type B pattern).
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Imagen de Difusión por Resonancia Magnética/métodos , Imagen de Perfusión/métodos , Tomografía de Emisión de Positrones/métodos , Nódulo Pulmonar Solitario/diagnóstico , Tomografía Computarizada por Rayos X/métodos , Anciano , Medios de Contraste , Diagnóstico Diferencial , Imagen de Difusión por Resonancia Magnética/normas , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Background: To identify intersegmental planes (ISPs) in video/robot-assisted thoracoscopic segmentectomies, indocyanine green (ICG) is commonly used. The aim of this systematic review is to evaluate the efficacy of intravenous ICG in the identification of ISP. Methods: A systematic search was performed. Studies evaluating patients who underwent a video/robot-assisted thoracoscopic segmentectomy using intravenous ICG were included. The primary outcome measure was the frequency and percentage of patients in whom the ISP was adequately visualized. Secondary outcomes encompassed the ICG dose, time to visualization, time to maximum ICG visualization, time to disappearance of ICG effect and adverse reactions to ICG. Results: Eighteen studies were included for systematic review, enrolling a total of 1,090 patients. Irrespective of the injected dose, intravenous ICG identified the ISP in 94% of the cases (range, 30-100%). Overall, there was a considerable amount of heterogeneity regarding the injected dose of ICG (range, 5-25 mg or 0.05-0.5 mg/kg). The mean time before first effect of ICG was visible ranged from 10 to 40 seconds. The mean total time of ICG visibility ranged from 90 to 140 seconds after a bolus injection and was 170 seconds after continuous infusion. No adverse reactions were reported. Conclusions: After administration of intravenous ICG, visualization of the ISP is successful in up to 94% of cases, even after administration of a low dose (0.05 mg/kg) of ICG. The use of intravenous ICG is safe with no reported adverse effects in the immediate peri-operative period.
RESUMEN
OBJECTIVE: Harmonized European NSCLC incidence, treatment approach, and survival based on national tumor registries are unclear. SUMMARY BACKGROUND DATA: Surgery has the potential to cure NSCLC and significantly prolong survival. This large-scale international study aimed to investigate treatment variations in Europe and the USA, as well as the determinants for its utilization. METHODS: The retrospective cohort study analyzed data from six European national population-based cancer registries (Belgium, Denmark, Estonia, Germany, the Netherlands, and Slovenia) and the US SEER database from 2010-2015. RESULTS: The study computed cancer incidence, survival, and age-standardized proportions of the use of various therapies. Multivariable logistic regression models were used to assess associations between resection and demographic and clinical parameters. A total of 428,107 records were analyzed. Among all countries, Estonia had the highest surgical resection rate (79.3 %) and the lowest radiation rate (7.3 %) for stage I patients. The Netherlands had the highest rate of radiotherapy across all years of investigation and the lowest surgery rate between 2012 and 2015. The primary treatment for early-stage NSCLC showed significant international variation, with the USA having a decrease in surgical rates from 67.6 % to 59.5 %. Resection was less frequently performed as tumor stage increased, patients aged, other lung cancer besides adenocarcinoma was present, and when the tumor site overlapped multiple lobes. CONCLUSIONS: Resection rates have declined in some studied European countries and the USA and resection rates vary substantially among countries. Interpretation of current scientific lung cancer evidence and international guidelines results in wide variations in patient treatment.