Ángel Salvatierra

Predicting pulmonary complications after pneumonectomy for lung cancer

OBJECTIVES Patients undergoing pneumonectomy for lung cancer are thought to be at high risk for the development of postoperative pulmonary complications (PC) and these complications are associated with high mortality rates. The purpose of this study was to identify independent factors associated with increased risk for the development of postoperative PC after pneumonectomy for lung cancer, and to assess the usefulness of predicted pulmonary function to identify high risk patients and other adverse outcomes. PATIENTS AND METHODS We reviewed retrospectively 242 patients undergoing pneumonectomy for lung cancer during a 12-year period. Perioperative data (clinical, pulmonary function test, and surgical) were recorded to identify risk factors of PC by univariate and multivariate analyses. RESULTS Overall mortality and morbidity rates were 5.4 and 59%, respectively. Thirty-four patients (14%) developed PC (acute respiratory failure, ARF = 8.7%, reintubation = 5.4%, pneumonia = 3.3%, atelectasis = 2.9%, postpneumonectomy pulmonary edema = 2.5%, mechanical ventilation more than 24 h = 1.2%, pneumothorax = 0.8%). Patients with surgical (P < 0.001), cardiac (P < 0.001) and other complications (P < 0.01) had higher incidence of PC than those without postoperative complications. Intensive care unit stay (53 +/- 39 h vs. 35 +/- 19 h; P < 0.001) and hospital stay (18 +/- 11 days vs. 12 +/- 7 days; P < 0.001) was significantly longer in patients with PC. The mortality rate associated with PC was 35.5% (P < 0.001). By univariate analysis, it was found that older patients (P = 0.007), chronic obstructive pulmonary disease (COPD) (P = 0.023), heart disease (P = 0.019), no previous record of chest physiotherapy (P = 0.008), poor predicted postoperative forced expiratory volume in 1s (ppo-FEV1) (P = 0.001), and prolonged anesthetic time (P < 0.001) were related with higher risk of PC. In the multiple logistic regression model, the anesthetic time (minutes; odds ratio, OR = 1.012), ppo-FEV1 (ml/s; OR = 0.998), heart disease (OR = 2.703), no previous record of previous chest physiotherapy (OR = 2.639), and COPD (OR = 2.277) were independent risk factors of PC. CONCLUSIONS PC after pneumonectomy are associated with high mortality rates. Careful attention must be paid to patients with COPD and heart disease. Our results confirm the relevance of previous chest physiotherapy and the importance of the length of the surgical procedure to minimize the incidence of PC. The predicted pulmonary function (ppo-FEV1) may be useful to identify high risk patients for PC development and adverse outcomes.

Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis

BACKGROUND The aim of this study was to determine independent risk factors for early bronchopleural fistula (BPF) after pneumonectomy and to assess the efficacy of bronchial coverage in preventing this complication. METHODS We reviewed 242 consecutive patients undergoing pneumonectomy for lung cancer. The bronchial stump was covered with autologous tissue in 178 patients (74%). Perioperative data were recorded to identify risk factors of BPF by univariate and multivariate analyses. RESULTS Overall morbidity and mortality rates were 59% and 5.4%, respectively. The incidence of BPF was 5.4%. By univariate analysis, patients with chronic obstructive pulmonary disease (COPD; p = 0.017), hyperglycemia (p = 0.003), hypoalbuminemia (p = 0.017), previous steroid therapy (p < 0.001), poor predicted postpneumonectomy forced expiratory volume in 1 second (FEV1; p = 0.012), long bronchial stumps (p < 0.001), and mechanical ventilation (p = 0.015), were related with higher risk of BPF. In the multiple logistic regression model, the independent risk factors of BPF were the bronchial stump coverage and length, side of pneumonectomy, predicted postpneumonectomy FEV1, COPD, and mechanical ventilation. CONCLUSIONS Bronchial stump coverage is highly recommended in all cases to minimize the risks of BPF. A shorter length of the bronchial stump and early extubation may prevent the development of BPF. Careful attention must be paid to those patients with COPD and poor predicted postpneumonectomy FEV1.

Extended cervical mediastinoscopy: Prospective study of fifty cases☆

To assess the usefulness of extended cervical mediastinoscopy (ECM) in the staging of bronchogenic carcinoma, an ECM was performed prospectively in 50 patients with bronchogenic carcinoma of the left lung. The ECM was used after evaluation of disease operability and computed tomographic findings, and was performed simultaneously with standard cervical mediastinoscopy. In ECM, using the same cervical incision as in a standard cervical mediastinoscopy, dissection is performed behind the anterior face of the sternum. The aortic arch is reached at the level of the origin of the innominate artery. The mediastinoscope is then passed by sliding it along the left anterolateral face of the aortic arch until it reaches the aortopulmonary window. Extended cervical mediastinoscopy was considered positive when a nodal biopsy result consistent with a neoformative process or direct invasion of the mediastinal structures was found. Four patients with positive standard cervical mediastinoscopy and negative ECM were excluded. A false negative ECM was defined as the presence of infiltrated adenopathies at the paraaortic level detected on postoperative histologic study. The ECM was positive in 5 patients in whom operation was contraindicated. Resectability in the remaining 41 patients was 97.6%. Postoperative pathologic study showed infiltrated adenopathy in 3 patients (2 subcarinal, 1 subaortic) accounting for 40 true negatives (the subcarinal group is inaccessible by ECM). This study suggests that ECM has outstanding specificity (100%), sensitivity of 83.3%, and a diagnostic accuracy of 97.8%. A positive predictive value of 100% and a negative predictive value of 97.5% were also identified by this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence, management and clinical outcomes of patients with airway complications following lung transplantation

OBJECTIVE Airway complications (AC) remain a significant contributing factor of morbidity after lung transplantation (LT). The aim of this study was to identify risk factors for AC, and to review the outcomes after endoscopic and surgical treatment. METHODS From 1993 to 2006, 255 patients underwent LT. Seven retransplants and 34 patients not surviving beyond 7 days were excluded. The remaining patients were: 124 double LT (DLT), 85 single LT (SLT), 3 lobar LT and 2 liver-DLT, comprising 343 bronchial anastomoses at risk. Donor lungs were flushed with either modified Eurocollins or Perfadex. Bronchial anastomoses were telescoped when needed. Donor and recipient variables were recorded and analyzed by univariate and multivariate tests to identify risk factors for AC, and to assess differences between both complicated and non-complicated groups. RESULTS Among 343 bronchial anastomoses, 31 presented AC (9%) in 27 patients (12.6%): 22 stenoses, 5 dehiscences, and 4 malacias, at 2.6+/-1.7 months post-transplant. Indications were 7 emphysema, 3 Alpha-1-antitrypsin deficiency, 12 cystic fibrosis (p=0.007), 4 pulmonary fibrosis, and 1 bronchiectasis. AC were observed in 4 SLT and 23 DLT (p=0.005). Incidence of AC did not differ between telescoped and non-telescoped anastomoses. By univariate analysis, AC were more frequent in grafts preserved with modified Eurocollins (p=0.033), CMV infection/disease (p=0.027) and airway colonizations post-transplant (p=0.021). Other donor and recipient variables did not differ between groups. By multivariate analysis, intubation longer than 72 h, DLT, and airway colonizations post-transplant remained independently associated with AC. Survival did not differ between groups. Most patients were successfully treated with endoscopic procedures; three required reoperation (lobectomy, pneumonectomy, retransplantation). AC related mortality was 1%. CONCLUSIONS The incidence of AC after LT is 12.6% with a related mortality of 1%, irrespective of the technique of bronchial anastomosis performed. DLT, airway colonizations, and prolonged intubation post-transplant are associated with AC. Either endoscopic procedures or surgical therapy resolve these complications in most cases.

Registro Español de Trasplante Pulmonar: primer informe de resultados (2006-2010)

The Spanish Lung Transplant Registry (SLTR) began its activities in 2006 with the participation of all the lung transplantation (LT) groups with active programs in Spain. This report presents for the first time an overall description and results of the patients who received lung transplants in Spain from 2006 to 2010. LT activity has grown progressively, and in this time period 951 adults and 31 children underwent lung transplantation. The mean age of the recipients was 48.2, while the mean age among the lung donors was 41.7. In adult LT, the most frequent cause for lung transplantation was emphysema/COPD, followed by idiopathic pulmonary fibrosis, both representing more than 60% the total number of indications. The probability for survival after adult LT to one and three years was 72% and 60%, respectively, although in patients who survived until the third month post-transplantation, these survival rates reached 89.7% and 75.2%. The factors that most clearly influenced patient survival were the age of the recipient and the diagnosis that indicated the transplantation. Among the pediatric transplantations, cystic fibrosis was the main cause for transplantation (68%), with a one-year survival of 80% and a three-year survival of 70%. In adult as well as pediatric transplantations, the most frequent cause of death was infection. These data confirm the consolidated situation of LT in Spain as a therapeutic option for advanced chronic respiratory disease, both in children as well as in adults.

Normativa para la selección de pacientes candidatos a trasplante pulmonar

The present guidelines have been prepared with the consensus of at least one representative of each of the hospitals with lung transplantation programs in Spain. In addition, prior to their publication, these guidelines have been reviewed by a group of prominent reviewers who are recognized for their professional experience in the field of lung transplantation. Within the following pages, the reader will find the selection criteria for lung transplantation candidates, when and how to remit a patient to a transplantation center and, lastly, when to add the patient to the waiting list. A level of evidence has been identified for the most relevant questions. Our intention is for this document to be a practical guide for pulmonologists who do not directly participate in lung transplantations but who should consider this treatment for their patients. Finally, these guidelines also propose an information form in order to compile in an organized manner the patient data of the potential candidate for lung transplantation, which are relevant in order to be able to make the best decisions possible.

New technique for pulmonary artery reconstruction

Bronchial and vascular reconstructive procedures are a technically feasible alternative to pneumonectomy in lung cancer and have the advantage of preserving lung parenchyma function. Sleeve resection and prosthetic reconstruction of the pulmonary artery (PA) have progressively gained acceptance as an alternative to pneumonectomy in lung cancer surgery. To spare the lung parenchyma, angioplastic procedures involving removal of a portion of the arterial wall or a circumferential resection with arterial reconstruction have been used. Several techniques of pulmonary arterioplasty have been documented, such as patch reconstruction, end-to-end anastomosis, synthetic prosthesis, biological prosthesis, prosthetic or pericardial conduit. We present the first case reported in the literature of PA reconstruction with a pulmonary vein graft.

Assessment of lungs for transplantation: a stepwise analysis of 476 donors.

OBJECTIVE This study aims to assess the suitability rates and the causes of lung-donor refusal, to determine which factors could be improved to expand the donor pool available for transplantation (LTx). METHODS Lung donors offered to our Lung Transplantation Unit from October 1993 to December 2007 were reviewed to assess the causes of unsuitability. The donor-lung evaluation was divided into three stages: stage 1 (PaO(2)/FiO(2) ratio, chest X-ray, bronchoscopic findings), stage 2 (donor-lung inspection and palpation) and stage 3 (assessment of grafts after harvesting). Variables from donors and recipients were analysed and compared between 1993-2001 (group A) and 2002-2007 (group B). An additional subgroup of extended donors was analysed to assess the recipient outcomes. RESULTS A total of 476 lung donors were assessed (278 men and 198 women; mean age 29+/-13 years). Causes of death were trauma in 255, intracranial bleeding in 202 and others in 19. As many as 273 donors were suitable for LTx (57%; 162 double LTx and 111 single LTx). Acceptability rates were 68%, 58% and 57% at stages 1, 2 and 3, respectively, and were significantly higher in group B than in group A (overall: 64% vs 54%; stage 2: 91% vs 79%), with no changes in stages 1 and 3. Abnormal bronchoscopy precluded LTx in 79 cases (16%). Group B donors were older (p=0.000), ventilated longer (p=0.07) and with shorter ischaemic times (p=0.000) than group A. In the recipients, primary graft dysfunction (PGD) (17% vs 15%) and 30-day mortality (11% vs 6%) did not differ between both the groups. No differences were observed between extended and ideal donors in terms of recipient 30-day mortality (extended 6% vs ideal 9%; p=0.315) and development of PGD (extended 21% vs ideal 15%; p=0.342). CONCLUSIONS Despite the high rate of organ donation in Spain, the acceptability rate remains low (57%), mainly due to failure to meet the criteria for acceptance at the early stages of donor-lung assessment. Improvements in multi-organ donor care must be made to expand the lung-donor pool. The use of extended donors does not seem to have a negative impact on recipient outcomes.

Surgical Treatment of Stage III Non-Small Cell Bronchogenic Carcinoma Involving the Chest Wall

Thirty-five patients who had undergone surgery for non-small cell bronchogenic carcinoma with isolated involvement of the chest wall were reviewed. The diagnosis was preoperatively suspected in 80% of cases. En-bloc resection of the invaded chest wall was performed in 25 cases and parietal pleurectomy in ten in which the pleura was easily dissectable from the costal plane. Of the eight patients with major complications in the early postoperative period, six, including the two who died perioperatively, had undergone en-block resection. The 5-year actuarial survival rate was 22% overall and 36% in the patients without lymph node involvement. No significant relationship between survival and type of operation or degree of chest wall invasion was found. Isolated involvement of the chest wall by non-small cell bronchogenic carcinoma does not necessarily contraindicate surgery with curative intent. Parietal pleurectomy is valid in selected cases. Long-term survival depends basically on node involvement.

The Expression of the Ubiquitin Ligase SIAH2 (Seven In Absentia Homolog 2) Is Increased in Human Lung Cancer

Objectives Lung cancer is the leading cause of cancer-related deaths worldwide. Overall 5-year survival has shown little improvement over the last decades. Seven in absentia homolog (SIAH) proteins are E3 ubiquitin ligases that mediate proteasomal protein degradation by poly-ubiquitination. Even though SIAH proteins play a key role in several biological processes, their role in human cancer remains controversial. The aim of the study was to document SIAH2 expression pattern at different levels (mRNA, protein level and immunohistochemistry) in human non-small cell lung cancer (NSCLC) samples compared to surrounding healthy tissue from the same patient, and to analyse the association with clinicopathological features. Materials and Methods One hundred and fifty-two samples from a patient cohort treated surgically for primary lung cancer were obtained for the study. Genic and protein expression levels of SIAH2 were analysed and compared with clinic-pathologic variables. Results The present study is the first to analyze the SIAH2 expression pattern at different levels (RNA, protein expression and immunohistochemistry) in non-small cell lung cancer (NSCLC). We found that SIAH2 protein expression is significantly enhanced in human lung adenocarcinoma (ADC) and squamous cell lung cancer (SCC). Paradoxically, non-significant changes at RNA level were found, suggesting a post-traductional regulatory mechanism. More importantly, an increased correlation between SIAH2 expression and tumor grade was detected, suggesting that this protein could be used as a prognostic biomarker to predict lung cancer progression. Likewise, SIAH2 protein expression showed a strong positive correlation with fluorodeoxyglucose (2-deoxy-2(18F)fluoro-D-glucose) uptake in primary NSCLC, which may assist clinicians in stratifying patients at increased overall risk of poor survival. Additionally, we described an inverse correlation between the expression of SIAH2 and the levels of one of its substrates, the serine/threonine kinase DYRK2. Conclusions Our results provide insight into the potential use of SIAH2 as a novel target for lung cancer treatment.