Comparison of Quality of Life after Robotic, Video-Assisted, and Open Surgery for Lung Cancer.

Post-operative quality of life (QOL) has become crucial in choosing operative approaches in thoracic surgery. However, compared to VATS and thoracotomy, QOL results post-RATS are limited. We compared QOL before and after RATS and between RATS, VATS, and thoracotomy. We conducted a retrospective review of lung cancer surgical patients from 2015 to 2020. Patients completed validated EORTC QOL questionnaires (QLQ-C30 and QLQ-LC13). Results were analysed using the EORTC Scoring Guide, with statistical analysis. A total of 47 (94%) pre- and post-RATS questionnaires were returned. Forty-two patients underwent anatomical lung resections. In addition, 80% of patients experienced uncomplicated recovery. All global and functional QOL domains improved post-operatively, as did most symptoms (13/19). Only four symptoms worsened, including dyspnoea (p = 0.017), with two symptoms unchanged. Of the 148 returned questionnaires for all approaches (open-22/VATS-79/RATS-47), over 70% showed a high pre-operative performance status. Most patients underwent anatomical lung resection, with only VATS patients requiring conversion (n = 6). Complications were slightly higher in RATS, with one patient requiring re-intubation. RATS patients demonstrated the highest global and functional QOL. Physical QOL was lowest after thoracotomy (p = 0.002). RATS patients reported the fewest symptoms, including dyspnoea (p = 0.046), fatigue (p < 0.001), and pain (p = 0.264). Overall, RATS results in a significantly better post-operative QOL and should be considered the preferred surgical approach for lung cancer patients.

Quality of Life in Octogenarians After Lung Resection Compared to Younger Patients.

INTRODUCTION: To evaluate postoperative outcome and quality of life (QOL), comparing patients <80 years old to patients ≥ 80. PATIENTS AND METHODS: EORTC questionnaires, QLQ-C30 and QLQ-LC13 was used to assess QOL, in patients after surgery. Results were evaluated according to 3 age groups: <70, 70 to 79, and ≥80. RESULTS: 106 patients were enrolled with 33 (<70), 25 (70-79), and 48 (≥80) patients per group. The median age was 74 years. 79% of patients had minimally invasive procedures, including 91% of those ≥80. Fifteen patients underwent wedge resections. Complication rates (18%, 32%, and 29%, P = .4) and median length of stay (4, 6, and 5 days, P = .2) were similar in all age groups, with no hospital mortality. One hundred one patients completed the questionnaires. Global QOL was highest among octogenarians. Overall functional and role QOL was higher among octogenarians than 70- to 79-year-olds, with emotional QOL higher than those <70 (P < .05). Social QOL in octogenarians was marginally lower than younger patients. Lung-specific symptom scores were at least 1.5 times lower than those <80 (P = .052). Patients aged 70 to 79 had the worst symptomatic and emotional effect on QOL. Surgical access and preoperative performance status did not affect final QOL across all age groups (P = .9 and P = .065). Among anatomical lung resections, QOL was higher in octogenarians than those 70 to 79 in all domains, and similar or higher than those <70 in most domains. CONCLUSION: Quality of life among octogenarians after surgery remains similar to younger patients even after anatomical lung resection. Surgery in octogenarians is safe, with minimal impact on postoperative QOL.

Maintaining safe lung cancer surgery during the COVID-19 pandemic in a global city.

BACKGROUND: SARS-CoV-2 has challenged health service provision worldwide. This work evaluates safe surgical pathways and standard operating procedures implemented in the high volume, global city of London during the first wave of SARS-CoV-2 infection. We also assess the safety of minimally invasive surgery(MIS) for anatomical lung resection. METHODS: This multicentre cohort study was conducted across all London thoracic surgical units, covering a catchment area of approximately 14.8 Million. A Pan-London Collaborative was created for data sharing and dissemination of protocols. All patients undergoing anatomical lung resection 1st March-1st June 2020 were included. Primary outcomes were SARS-CoV-2 infection, access to minimally invasive surgery, post-operative complication, length of intensive care and hospital stay (LOS), and death during follow up. FINDINGS: 352 patients underwent anatomical lung resection with a median age of 69 (IQR: 35-86) years. Self-isolation and pre-operative screening were implemented following the UK national lockdown. Pre-operative SARS-CoV-2 swabs were performed in 63.1% and CT imaging in 54.8%. 61.7% of cases were performed minimally invasively (MIS), compared to 59.9% pre pandemic. Median LOS was 6 days with a 30-day survival of 98.3% (comparable to a median LOS of 6 days and 30-day survival of 98.4% pre-pandemic). Significant complications developed in 7.3% of patients (Clavien-Dindo Grade 3-4) and 12 there were re-admissions(3.4%). Seven patients(2.0%) were diagnosed with SARS-CoV-2 infection, two of whom died (28.5%). INTERPRETATION: SARS-CoV-2 infection significantly increases morbidity and mortality in patients undergoing elective anatomical pulmonary resection. However, surgery can be safely undertaken via open and MIS approaches at the peak of a viral pandemic if precautionary measures are implemented. High volume surgery should continue during further viral peaks to minimise health service burden and potential harm to cancer patients. FUNDING: This work did not receive funding.

Risks and rewards of the surgical treatment of lung cancer in octogenarians.

OBJECTIVES: Surgeons will face an increasing number of octogenarians with lung cancer potentially curable by surgery. The goal of this study was to evaluate short- and long-term outcomes after lung resection. METHODS: We performed a single-centre study of consecutive patients ≥80 years old, surgically treated for suspected lung cancer between 2009 and 2016. Age, sex, performance status, lung function, surgical approach, type of lung resection, complications, in-hospital and 30- and 90-day deaths and long-term survival were analysed. RESULTS: Two hundred and fifty-seven patients were enrolled. The median age was 82 years (range 80-97). One hundred and thirty-four patients were treated by thoracotomy and 123 by video-assisted thoracic surgery [10 (8.1%) converted]. Two hundred and thirty-two underwent lobar resection and 25 underwent sublobar resection. There were no intraoperative deaths and 9 admissions to the intensive therapy unit; 112 (43.6%) patients suffered complications: More complications occurred after lobar versus after sublobar resections [45.7% vs 24% (P = 0.037)] and in those with chronic obstructive pulmonary disease (COPD) [57.4% vs 40% (P = 0.02)]. The 30-day mortality was 3.9% (n = 10) and the 90-day mortality was 6.22% (n = 16). One hundred and sixty-seven patients died during the study period; patients with non-small-cell lung cancer (n = 233) had a median survival of 46.5 months with 67.2% alive at 2 years and 40.8% at 5 years. Pathological stage and R status were independent prognostic factors for survival. CONCLUSIONS: Surgery for malignancies in octogenarians is feasible and safe with good long-term outcomes. The risk of postoperative complications, especially in those with COPD, is high but can be minimized with sublobar resection. Postoperative mortality is acceptable, and long-term survival is primarily governed by lung cancer stage. Age is no reason to deny patients surgery for early-stage disease.

Impact of the TNM staging system for thymoma.

BACKGROUND: Masaoka-Koga staging system remains the most frequently applied clinical staging system for thymic malignancy. However, the International Association for the Study of Lung Cancer (IASLC)/International Thymic Malignancy Interest Group (ITMIG) proposed a tumor-node-metastasis (TNM) staging system in 2014. This study aims to evaluate its impact on stage distribution, clinical implementation, and prognosis for thymomas. METHODS: We performed a single institution, retrospective analysis of 245 consecutive patients who underwent surgical resection for thymoma. 9 patients with thymic carcinoma were excluded. No patients were lost to follow up. Kaplan-Meier survival analysis was used to calculate overall survival. RESULTS: Median age was 62 years; 129 patients (53%) were female. The median overall survival was 158 months (range, 108-208 months), and disease-free survival 194 months (range, 170-218 months). At the end of follow up 63 patients were dead. Early Masaoka-Koga stages I (n=74) and II (n=129) shifted to the IASLC/ITMIG stage I (n=203). 8 patients were down staged from Masaoka-Koga stage III to IASLC/ITMIG stage II because of pericardial involvement. Advanced stages III (Masaoka-Koga: n=30; IASLC/ITMIG: n=22) and IV (Masaoka-Koga: n=12; IASLC/ITMIG: n=12) remained similar and were associated with more aggressive WHO thymoma histotypes (B2/B3). Masaoka-Koga (P=0.004), IASLC/ITMIG staging (P<0.0001) and complete surgical resection (P<0.0001) were statistically associated with survival. At multivariate analysis only R status was an independent prognostic factor for survival. CONCLUSIONS: The proportion of patients with stage I disease increased significantly when IASLC/ITMIG system used, whilst the proportion with stages III and IV were similar in both systems. Completeness of resection, Masaoka-Koga and the IASLC/ITMIG staging system are strong predictors of survival. The TNM staging system is useful in disease management and a strong predictor of overall survival.

New N1/N2 classification and lobe specific lymphatic drainage: Impact on survival in patients with non-small cell lung cancer treated with surgery.

OBJECTIVE: to validate the proposed N descriptor revision on a large cohort of patients and assess the impact of tumour location on the distribution pattern of lymph node metastases for patients with NSCLC. METHODS: This is a retrospective review of a consecutive series of patients who had anatomical lung resections. Systematic lymph node dissection was done for all patients. RESULTS: Between January 2009 and December 2019 2566 patients had surgical resection for NSCLC. 448 patients (17.5%) had histologically confirmed lymph node metastases: 257 (57.4 %) had pN1 and 191 pN2. Median age of the study population was 69.1 years. Overall survival (OS) for study population was 37.3 months with 5-year survival rate of 35.7 %. The survival analysis of the N subgroups showed the pN2 patients had a median OS of 27.9 months vs. 41.7 months for pN1 patients (p = 0.013). Analysis as per the new proposal of the N subgroups N1a vs N1b vs N2a1 vs N2a2 vs N2b showed that median survival OS was 41.7 vs. 39.2 mo vs. 33.3 mo vs. 28.9 mo vs. 24.6 mo (p = 0.099). There was statistically significant difference in survival between N2 patients with skip metastasis and N2 patients without skip metastases: OS 32.2 (95 % CI: 16.8-47.6) months vs. 24.2 months (p = 0.024). On multivariate analysis only pathological N (p = 0.011) and the new proposed N classification (p = 0.006) were independent prognostic factors for survival. CONCLUSIONS: N1 and N2 disease are heterogeneous groups and require further stratification. The number of N2 lymph node stations involved and the presence or not of N1 disease translated to significant differences in survival and therefore have to be included in N staging.

Retrospective Observational Study into the Early Causes of Death Following Surgery for NSCLC.

INTRODUCTION: Respiratory failure has historically been the major cause of mortality after elective lung resections. With improved intubation using fiber-optic scopes, better preoperative respiratory risk assessment, more advanced anesthetic single lung ventilation, and minimally invasive surgical technique, this may have changed. Our objective was to assess the main causes of mortality over the past 10 years in patients undergoing elective lung surgery in a major UK center. MATERIALS AND METHODS: A retrospective unit data search was made for all deaths during the 10-year period between January 2007 and December 2016 inclusive. All inpatient deaths within 30 days of an elective anatomical lung resection for lung malignancies were included. RESULTS: Three-thousand three-hundred sixteen lung resections for malignancy were performed in the 10-year period. There were 44 (1.3%) deaths during this period, 27 (61.4%) after open lobectomies, 8 (18.2%) after video-assisted thoracoscopic surgery lobectomies, 5 (11.4%) after sleeve lobectomies, and 4 (9%) after pneumonectomies. Causes of death included 24 (54.5%) respiratory failure, 10 (22.7%) ischemic bowel, 4 (9%) coronary events, 2 (4.5%) strokes, 2 (4.5%) on table hemorrhage, 1 (2.3%) massive pulmonary embolus, and 1 (2.3%) postoperative hemorrhage. CONCLUSION: Although respiratory failure is still a major cause of mortality in the postoperative patient, bowel ischemia has been found to be the second greatest cause of death. This study highlights the need to identify those at risk of this fatal complication during preoperative assessment and their postoperative management.

Prognostic factors including lymphovascular invasion on survival for resected non-small cell lung cancer.

OBJECTIVES: The aim of this study was to report on the influence of tumor lymphovascular invasion on overall survival and in patients with resected non-small cell lung cancer and identify prognostic factors for survival. METHODS: This is a retrospective observational study of a consecutive series of patients who had surgical resection of non-small cell lung cancer in a single institution. The study covers a 3-year period. Overall survival was estimated by Kaplan-Meier method and multivariate Cox regression analysis was used to evaluate the relationship of lymphovascular invasion and other clinicopathologic variables. A multivariate regression was used to assess the relationship between tumor lymphovascular invasion and other clinical and pathologic characteristics. RESULTS: A total of 524 patients were identified and included in the study. Two hundred twenty-five patients (43%) had tumors with lymphovascular invasion. Patients with tumor lymphovascular invasion had a lower overall survival (P < .0001). Tumor lymphovascular invasion was independently associated with visceral pleural involvement (P < .0001). In a multivariable model, lymphovascular invasion (hazard ratio [HR], 2.58; 95% confidence interval [CI], 1.63-4.09; P < .0001), parietal pleural invasion (HR, 45.4; 95% CI, 2.08-990; P = .015), advanced age (HR, 1.028; 95% CI, 1.009-1.048; P = .004), and N2 lymph node involvement (HR, 1.837; 95% CI, 1.257-2.690; P = .002) were independent prognostic factors for lower overall survival. CONCLUSIONS: Lymphovascular invasion is associated with a worse overall survival in patients with resected non-small cell lung cancer regardless of tumor stage. Parietal pleural involvement, N2 nodal disease, and advanced age independently predict poor overall survival.

A lateral costal artery complicating video-assisted thorascopic surgery (VATS) pleurectomy.

The lateral costal artery is a rare variant arising from the internal thoracic artery (ITA). It has been associated with steel syndrome after coronary artery bypass using the ITA as a conduit. Clinically, it is under-reported in the literature. We report the presence of a prominent lateral costal artery, coursing below the diaphragm, discovered during video-assisted thorascopic surgery pneumothorax surgery and preventing parietal pleurectomy.

New-onset atrial fibrillation after anatomic lung resection: predictive factors, treatment and follow-up in a UK thoracic centre.

Objectives: Postoperative atrial fibrillation (POAF) increases morbidity, hospital stay and healthcare expenditure. This study aims to determine the perioperative factors correlating with POAF as well as to evaluate both treatment strategies and AF persistence beyond discharge. Methods: The records of all patients undergoing anatomical lung resection over a 1-year period were retrospectively reviewed. Patients with a history of arrhythmia were excluded. POAF was defined by clinical diagnosis and electrocardiography. Pre- and postoperative demographic and clinical data were collected, and uni- and multivariable regression were performed to determine the factors associated with POAF. Results: POAF occurred in 11.4% (43/377) of patients with a mean of 3.55 days postoperatively and significantly increased hospital stay (6.78 ± 4.42 vs 10.8 ± 5.8 days (P = 0.0014)). No correlation was found with gender, hypertension, ischaemic heart disease, beta-blocker use, alcohol consumption or thyroid dysfunction. However, older age (P = 0.001) and postoperative infection (P < 0.0001; χ2 = 26.03) were found to be significant uni- and multivariable predictors of POAF. Open surgery rather than video assisted thoracoscopic surgery (VATS) (open 26/189 (13.8%); VATS 17/188 (9.0%); P = 0.150) demonstrated a tendency towards increased postoperative AF; however, this was not statistically significant. Four (9.3%) patients remained in AF on discharge, and three required long-term anticoagulation. Three (7%) patients were found to have ongoing AF at 1-month follow-up. Conclusions: Increasing age and postoperative infection are most strongly associated with POAF. Adoption of enhanced recovery protocols, along with more rigorous monitoring and early treatment of postoperative infection may help reduce POAF and its associated morbidity. Rhythm assessment is crucial to identify persistent AF after discharge, and clinicians should be vigilant for recurrence of AF at follow-up.

Are there recognized prognostic factors for patients undergoing pulmonary metastasectomy for colorectal carcinoma?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether there is a specific subgroup of patients that would benefit from pulmonary metastasectomy for colorectal carcinoma (CRC). A total of 524 papers were identified using the reported search, of which 1 meta-analysis, 1 systematic review and 17 retrospective studies represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. Single pulmonary metastasis (PM) was identified as an independent prognostic favourable factor of survival in 5 of the studies (P = 0.059-0.001), whereas in 2 of the retrospective studies there was linear inverse correlation between the number of PMs and survival (P = 0.005-0.001). The presence of involved hilar and/or mediastinal lymph nodes was reported as a significant negative prognostic factor on multivariate analysis in 7 of the studies (P = 0.042 to <0.001), whereas the level and number of lymph node stations affected were not statistically significant. Seven studies showed an elevated pre-thoracotomy carcinoembrionic antigen (CEA) level (>5 ng/ml) to be a significant predictor of poor survival (P = 0.047-0.0008). In one of the studies, sublobar resection (wedge or segmentectomy) was associated with better survival compared with anatomic resection (P = 0.04). The size of the tumour (maximum diameter >3.75 cm) was associated with worse survival in 1 of the studies (P = 0.04), while another one reported size as a continuous variable to be a prognostic factor of poor survival. Synchronous chemotherapy (P = 0.027) on one study and neo-adjuvant chemotherapy prior to pulmonary metastasectomy (P = 0.0001) on another were found to be favourable prognostic factors, while disease progression during chemotherapy was associated with poor outcome in another paper (P < 0.0001). Patients older than 70 years were shown to have a worse prognosis in one of the studies. Rectal position of the tumour was associated with worse survival in one of the studies and worse disease-free interval in another one. Finally, one report showed no significant difference in terms of overall survival between thoracotomy and video-assisted thoracoscopic surgery groups. In conclusion, the prognostic factors for patients undergoing pulmonary metastasectomy for CRC include the size and number of metastases, intra-thoracic lymph node involvement, pre-thoracotomy CEA levels and the response to induction chemotherapy.

A case of pulmonary placental transmogrification.

Pulmonary placental transmogrification is a rare lung lesion that microscopically resembles placenta with cystic spaces filled with papillary structures. Considered a histological variant of bullous emphysema, only 30 reported cases have been published in the world's literature. We report a rare case of pulmonary placental transmogrification in a 72-year-old man, in whom the clinical presentation of the disease mimicked lung carcinoma. Histopathology of the surgically resected segment showed a complex bulla with squamous metaplasia and placental transmogrification. Whilst rare, pulmonary placental transmogrification must be ruled out in all patients presenting with unilateral bullous emphysema, without known risk factors.

Thoracotomy and decortication: impact of culture-positive empyema on the outcome of surgery.

OBJECTIVES: This study aimed to assess the efficacy of thoracotomy and decortication (T/D) in achieving lung re-expansion in patients with Stage III empyema and assess the impact of culture-positive empyema on the outcome of decortication. METHODS: This is a retrospective observational study of consecutive patients treated with T/D over a 6-year period. RESULTS: A total of 107 consecutive patients were identified. The median age was 55 (range 16-86) years; of which, 86% were male. The median length of hospital stay was 9 (range 2-45) days. Full lung re-expansion was achieved in 86% of cases. There were no postoperative deaths. Pleural cultures were positive in 56 (52%) cases. Patients with culture-positive empyema had a longer duration of pleural drainage (median of 11 days, range 3-112 versus median of 5 days, range 3-29 days for negative culture; P = 0.0004), longer length of hospital stay (median of 11 days, range 4-45 versus median of 7 days, range 2-34 days; P = 0.0002) and more complications (P = 0.0008), respectively. There was no statistically significant difference in the outcome of surgery, i.e. lung re-expansion versus trapped lung (P = 0.08) between the two groups. CONCLUSIONS: T/D is safe and achieved lung re-expansion in the majority of patients. Culture-positive empyema was associated with worse outcomes.

Aortic pseudoaneurysm: a rare complication of mediastinoscopy.

Mediastinoscopy still represents the gold standard in mediastinal lymph node staging in patients with lung cancer. It is an invasive procedure, where complications are unusual. This case report shows an uncommon complication after mediastinoscopy: pseudoaneurysm of the aortic arch and its minimally invasive endovascular stenting treatment in order to facilitate the recovery and to allow minimal delay to oncological treatment.

Endobronchial pulmonary angiomatoid fibrous histiocytoma: two cases with EWSR1-CREB1 and EWSR1-ATF1 fusions.

Angiomatoid fibrous histiocytoma (AFH) is a rare soft tissue neoplasm of intermediate biological potential, predominantly occurring in the extremities of children and young adults. It has only recently been reported as a primary lung tumor. We describe 2 cases arising endobronchially harboring EWSR1 gene rearrangements by fluorescence in situ hybridization and, respectively, EWSR1-CREB1 and EWSR1-ATF1 gene fusions by reverse transcription polymerase chain reaction. Histologically, both tumors showed classical features of AFH, comprising multiple nodules of bland spindle to epithelioid cells surrounded by lymphoplasmacytic inflammation and at least a partial fibrous capsule. Both tumors showed focal but strong desmin immunoreactivity, with focal pancytokeratin and epithelial membrane antigen in 1 case. The lung is now a recognized site of AFH occurrence, but tumors arising here can be associated with different gene fusions. It is important to recognize AFH in the pulmonary region, as its behavior at other sites is generally relatively indolent; however, it may be mistaken for metastatic or more aggressive primary lung tumors. It is likely that cases of AFH in the lung may have been previously missed because of their morphologic and genetic overlap with other pulmonary lesions.

Which stages of thymoma benefit from adjuvant chemotherapy post-thymectomy?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Which stages of thymoma benefit from adjuvant chemotherapy post thymectomy?' Altogether more than 150 papers were found using the reported search, of which only eight represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated; these studies have mainly reported the survival and recurrence rates of post-thymectomy patients who received adjuvant radiotherapy or chemoradiotherapy, and adjuvant radiotherapy alone was only used in a small group of patients in these studies. We did not find any randomized controlled trials comparing adjuvant chemotherapy with chemo/radiotherapy and, due to a very small incidence of this tumour, it is unlikely to see any trials in future. Studies were mainly retrospective or institutional reports and showed that, despite the high sensitivity of this tumour to chemotherapy agents and the use of chemotherapy as one of the main treatment modalities in the advanced stages of thymoma, current data are not supporting postoperative chemotherapy as a sole adjuvant treatment in advanced stages of thymoma. We conclude that, in patients with thymoma, surgical resection with or without radiation therapy is the gold standard treatment for early-stage disease (I and II). Adjuvant radiotherapy/chemoradiotherapy should be considered for Masaoka stage III (A and B) or above, and it is also advised to add adjuvant therapy for all patients with cortical fenestration, even in stages I and II. But there is no evidence that chemotherapy alone improves the survival in patients with completely resected stage III and IV thymomas and thymic carcinoma. In patients with extra-radiation field disease, however, the use of chemotherapy can potentially improve survival but no follow-up data on this group of patients are available.

What is the optimum strategy for thromboembolic prophylaxis following extrapleural pneumonectomy in patients with malignant pleural mesothelioma?

Malignant pleural mesothelioma (MPM) increases the risk of venous thromboembolic (VTE) events. This risk is higher following extrapleural pneumonectomy (EPP) as part of trimodality therapy, where VTE can be catastrophic. In our series, the impact of warfarin in preventing a pulmonary embolus (PE) after neoadjuvant chemotherapy and EPP for MPM was analysed. A retrospective analysis of 21 consecutive patients undergoing EPP for MPM was conducted. The first 10 patients (Group A) had VTE prophylaxis by subcutaneous enoxaparin and compression stockings commenced a day prior to surgery, intraoperative pneumatic calf compression and early post-operative mobilization. Enoxaparin was continued for 30 days postoperatively. The following 11 patients (Group B) had the same VTE prophylaxis, together with warfarin, started prior to hospital discharge and continued for 6 months postoperatively. All patients had a computed tomography pulmonary angiogram within 8 weeks after surgery and a full examination at 1, 3, 6 and 12 months. Both groups were comparable for characteristics. Three patients in Group A suffered a PE at 4, 6 and 16 weeks postoperatively. One PE was fatal. No patient in Group B suffered VTE (P = 0.05, χ(2) test) or haemorrhagic complications. Warfarin anticoagulation following EPP is feasible and safe, and is associated with a significant reduction in VTE complications.

A prospective randomized controlled study to assess the effectiveness of CoSeal® to seal air leaks in lung surgery.

OBJECTIVES: Prolonged alveolar air leak is the most common complication after pulmonary surgery. We conducted an investigator-led randomized trial to evaluate the effectiveness of CoSeal® surgical sealant (Cohesion Technologies Inc.; manufactured and distributed by Baxter Healthcare) for the closure of alveolar air leak after anatomical pulmonary resection. METHODS: Patients undergoing primary open lobectomy, bilobectomy, or sublobar resection with a demonstrable air leak on intra-operative testing were randomized to either standard care or standard care plus application of CoSeal® surgical sealant to areas of air leak. A second application of CoSeal® was used in the treatment group if air leak persisted. Patients were allocated at the point of entry to the trial by unbiased allocation with minimization to ensure balance between the two arms with respect to age, sex, surgeon, number of segments resected, preoperative forced expiratory volume in 1s (FEV1), and grade of air leak. Kaplan-Meier analysis of air-leak duration and a log rank test were performed on an intention-to-treat basis, with observations censored at death, transfer to the intensive care unit, or discharge. RESULTS: Of the 200 patients, who entered the trial over a 24-month period, 121 with demonstrable intra-operative air leak were randomly allocated to the two groups. Data were missing for one patient in the CoSeal® group. In 57%, the air leak was stopped at the first application; a quarter continued to leak after the second. At 24h, there was no difference in air leak and fewer patients in the control group were leaking at 48 h postoperatively. By log rank test, the difference was not significant (p=0.09). CONCLUSIONS: Patients treated with CoSeal® in this study had, as a group, a longer duration of air leak and hence we cannot recommend its routine use.

Prognostic factors for survival after surgical palliation of malignant pleural effusion.

INTRODUCTION: To investigate prognostic factors for patient survival after surgical palliation of malignant pleural effusion (MPE). METHOD: We reviewed 278 consecutive nonoverseas patients (108 men, median age: 60 years [range 26-89]) undergoing 310 surgical procedures for palliation of MPE over a 72-month period. There were 195 thoracoscopic talc pleurodesis, 39 pleuroperitoneal shunts, 38 pleurodesis by an intercostal drain, 29 pleural biopsies alone, and nine long-term drains. Referring physicians provided survival data. The significance of prognostic factors was examined with the log-rank test (Kaplan-Meier), those significant entered a Cox logistic multivariate regression analysis. RESULTS: Follow-up was complete until death (following 264 procedures) and for a median 648 days (range 173-2135) for surviving patients. Overall median postoperative survival was 211 days (95% confidence interval: 169-253). Survival was not significantly different for tumor type or method of palliation. In univarate analysis, preoperative leucocytosis, hypoxemia, raised alanine transaminase, body mass index below 18 and hypoalbuminemia were associated with a significantly reduced postoperative survival. In multivariate analysis, leucocytosis (p < 0.0001), hypoxemia (p = 0.014), and hypoalbuminemia (p < 0.0001) maintained significance. CONCLUSIONS: The survival reported demonstrates the necessity of an active approach to palliation of MPE. The identification of prognostic factors will assist the choice of palliative technique. In addition, an appreciation of the influence of selection on survival after surgical palliation of malignant pleural mesothelioma, especially that of unforeseen prognostic factors, is useful when evaluating the results of aggressive treatment such as chemoradiotherapy and radical surgery for these diseases.