Lung volume reduction surgery versus endobronchial valves: a randomised controlled trial.

BACKGROUND: Lung volume reduction surgery (LVRS) and bronchoscopic lung volume reduction (BLVR) with endobronchial valves can improve outcomes in appropriately selected patients with emphysema. However, no direct comparison data exist to inform clinical decision making in people who appear suitable for both procedures. Our aim was to investigate whether LVRS produces superior health outcomes when compared with BLVR at 12 months. METHODS: This multicentre, single-blind, parallel-group trial randomised patients from five UK hospitals, who were suitable for a targeted lung volume reduction procedure, to either LVRS or BLVR and compared outcomes at 1 year using the i-BODE score. This composite disease severity measure includes body mass index, airflow obstruction, dyspnoea and exercise capacity (incremental shuttle walk test). The researchers responsible for collecting outcomes were masked to treatment allocation. All outcomes were assessed in the intention-to-treat population. RESULTS: 88 participants (48% female, mean±sd age 64.6±7.7 years, forced expiratory volume in 1 s percent predicted 31.0±7.9%) were recruited at five specialist centres across the UK and randomised to either LVRS (n=41) or BLVR (n=47). At 12 months follow-up, the complete i-BODE was available in 49 participants (21 LVRS/28 BLVR). Neither improvement in the i-BODE score (LVRS -1.10±1.44 versus BLVR -0.82±1.61; p=0.54) nor in its individual components differed between groups. Both treatments produced similar improvements in gas trapping (residual volume percent predicted: LVRS -36.1% (95% CI -54.6- -10%) versus BLVR -30.1% (95% CI -53.7- -9%); p=0.81). There was one death in each treatment arm. CONCLUSION: Our findings do not support the hypothesis that LVRS is a substantially superior treatment to BLVR in individuals who are suitable for both treatments.

The progression of non-small cell lung cancer from diagnosis to surgery.

OBJECTIVES: The IASLC 8th TNM Staging 8th differentiates between a greater number of T-stages. Resection remains the mainstay of curative treatment with often significant waiting times. This study aims to quantify the T-stage progression and growth of non-small cell lung cancers (NSCLCs) between radiological diagnosis and resection, and its impact on disease recurrence and survival. MATERIALS AND METHODS: A retrospective analysis of NSCLC resections (289) in a high-volume centre between July 01, 2015 and June 30, 2016. Baseline demographics, time from diagnostic CT to surgery, tumour size (cm) and T-stage from diagnostic CT, PET-CT and post-operative histopathology reports were recorded. The primary outcome was increase in T-stage from diagnostic CT to resection. Kaplan-Meier and cox proportional hazard analyses were used to determine recurrence-free survival and survival. RESULTS: Median increase in tumour size between diagnosis and resection was 0.3 cm (p < 0.0001). Median percentage increase in size was 13%. T-stage increased in 133 (46.0%) patients. N stage increased in 51 patients (17.7%), 32 (11.1%) to N2 disease. Mean survival in those upstaged was 43.5 (39.9-47.1) months versus 53.4 (50.0-56.8) months in patients not upstaged (p = 0.025). Mean recurrence-free survival in those upstaged was 39.1 (35.2-43.0) months versus 47.7 (43.9-51.4) months in patients not upstaged (p = 0.117). Upstaging was independently associated with inferior survival (HR 1.674, p = 0.006) and inferior recurrence-free survival (HR 1.423, p = 0.038). CONCLUSIONS: A significant number of patients are upstaged between diagnostic and resection resulting in reduced survival and recurrence-free survival. A change in management pathways are required to improve outcomes in NSCLC.

A case series of pulmonary resection for metastatic colorectal cancer in a UK regional thoracic center.

Pulmonary metastasectomy has become an established mode of therapy in the management of certain patients with metastatic colorectal cancer. All patients undergoing pulmonary resection for metastatic colorectal cancer between March 2008 and February 2014 were studied. 190 patients were identified. Most had a single metastasis (83%); 17% had multiple lesions (maximum: 4). The approach was thoracotomy in 92 and VATS in 98. 67% underwent wedge resection and 33% lobectomy. The size of the resected lesions was 8-110 mm (median: 24). 13% of patients underwent more than one procedure (maximum: 4); 8% had prior hepatic metastasectomy. There was no operative mortality. The 1-, 3- and 5-year survival was 92, 87 and 82%, respectively. Guidelines for referral and follow-up of these patients should be developed.

Is it safe not to drain the pneumonectomy space?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether it is safe not to position any chest drain into the pneumonectomy space at the conclusion of the procedure. Altogether 381 relevant studies were identified of which 11 represented the best evidence to answer the question. The author, journal, date, country of publication, alternative methods of postpneumonectomy space (PPS) management, complications and relevant outcomes are tabulated. The majority of studies are on the basis of expert opinion or small cohorts. Major cohorts, by which the pneumonectomy outcomes have been examined, demonstrated that the rates of complications related to pneumonectomy space management such as empyema, bronchopleural fistula, mediastinal shift and major bleeding requiring reopening are very low. In a large cohort where 408 patients underwent pneumonectomy the rate of relevant complications was low and also it was concluded that the PPS drainage is not necessary. Two separate expert opinions were in agreement that needle aspiration in the absence of a drainage system is adequate for the management of PPS and avoiding a mediastinal shift. One small cohort and one institutional audit directly examined the impact of a drainage versus no drainage approach in the management of PPS. Although neither study could show a significant superiority of one method over another, they recommended adopting a unified institutional protocol for current departmental practice. They also emphasized that larger cohorts are required to examine the superiority of different strategies for PPS management. In a cohort of 291 patients, it was demonstrated that patients with drainage with underwater seal are more at risk of postpneumonectomy oedema. A recent review published as a book chapter appraised the relevant literature in both humans and animals. The authors concluded that the simplicity of a no-drainage system is notable; however, a balanced drainage might be recommended for local protocols. We conclude that although the current evidence is not adequate to examine the different aforementioned approaches, not draining the pneumonectomy space can be performed safely.

An audit of pain control pathways following video-assisted thoracoscopic surgery.

OBJECTIVE: To compare different modes of pain management following video-assisted thoracoscopic surgery (VATS) to our national standard. METHODS: This is an audit based on patient's experiences. One hundred consecutive patients who underwent VATS with or without pleurodesis were managed by one of the following pain relief pathways: (A) thoracic paravertebral block + morphine patient-controlled analgesia (PCA), (B) percutaneous thoracic paravertebral catheter +/- morphine PCA, (C) thoracic epidural +/- morphine PCA, (D) morphine PCA alone, and (E) intravenous or subcutaneous morphine as required. Pain score was documented up to four times per day for each patient. The incidence of severe pain was defined as visual analog scale ≥ 7. The results were compared with the standard set by the audit commission for postoperative pain relief in the UK. The mean daily pain scores were calculated retrospectively for all patients. RESULTS: There were no statistically significant differences in mean daily pain scores irrespective of having a pleurodesis. The percentage of patients experiencing severe pain was 34% [mean visual analog scale = 8 (standard deviation = 1.0)]. This was almost seven times the standard. Among these pathways, B had the least percentage incidence of severe pain (16.7%) followed by A (25.0%) D (33.3%), C (35.7%), and E (52.4%). CONCLUSIONS: We are not compliant with the standards set by the audit commission. Pain management in theater recovery needs to be targeted. In the light of these results, we recommend the use of percutaneous thoracic paravertebral catheter +/- morphine PCA for postoperative VATS pain relief.

Are bronchoscopic approaches to post-pneumonectomy bronchopleural fistula an effective alternative to repeat thoracotomy?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether bronchoscopic or other minimal access approaches to the closure of bronchopleural fistulae (BPFs) were effective compared to a conventional re-thoracotomy. Our search identified 1052 abstracts, from which we identified six case series of greater than two post-pneumonectomy bronchopleural fistula patients. These series included reports of bronchial stenting, glue occlusion and scar obliteration of fistulae. No thoracoscopic techniques were reported except in case report form. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We identified 85 post-pneumonectomy bronchopleural fistulae reported in the literature who underwent bronchoscopic procedures to attempt repair. There was a 30% cure rate using a range of bronchoscopic techniques in these series. Bronchoscopic techniques included cyanoacrylate or fibrin glue application, YAG laser therapy, injection of the vein sclerosant polidocanol and tracheo-bronchial stenting. The mortality was 40% in these patients reflecting the very high mortality with this complication. Many patients required multiple bronchoscopic procedures and also further drainage procedures of their empyemas. Bronchoscopic treatment has so far only been reported in small case series but may offer further treatment options in patients too unwell to undergo re-thoracotomy.

Bronchopleural fistula treated with a covered wallstent.

Bronchopleural fistula is a well-recognized complication of pneumonectomy, which presents a difficult challenge to the thoracic surgeon. We report the successful treatment of a bronchopleural fistula after right pneumonectomy for lung cancer, using a covered esophageal stent.

Chemotherapy following complete resection of non-small-cell lung cancer is of small but significant benefit in terms of survival.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether patients benefit in terms of survival from chemotherapy following complete resection of non-small-cell lung cancer. Altogether 681 papers were found using the reported search, of which 14 represented the best evidence on this topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that post-operative adjuvant chemotherapy carries a small survival benefit in those patients with complete resection of their lung cancer. This survival benefit is in the region of a 4% absolute survival advantage at 5 years. Thus, 25 patients require chemotherapy to save one life at 5 years. This should be discussed with all the patients following complete resection of non-small-cell lung cancer.