John Pilling

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.

Salvage intensive care following initial recovery from pulmonary resection: is it justified?

BACKGROUND There is little objective evidence concerning the outcome of thoracic surgical patients who suffer postoperative complications. We assessed the outcome and cost of care for patients admitted to the intensive care unit after initial recovery from pulmonary resection in a high dependency unit. METHODS In a single surgeons practice, over a 3-year period, 28 patients [22 male, median age 66 years old (range 48-80 years old)] required intensive care admission. Preoperative pulmonary function, reason for initial operation, cause of intensive care admission, interventions, and outcome in hospital and at 6 months was studied. The cost of care provided was estimated. RESULTS The major reason for intensive care admission was respiratory failure; 61% of patients required mechanical ventilation and 54% renal support. All 4 patients who required both mechanical ventilation and hemofiltration died. Intensive care and 6-month survival were 54% and 36%, respectively. On univarate analysis mechanical ventilation and renal support predicted both hospital mortality (p < 0.001 and p = 0.003) and 6-month mortality (p = 0.003 and p = 0.01). Patients who died in intensive care stayed longer (median stay 9 vs 3 days; p = 0.04) at a higher cost per patient (median cost

Malignant Triton Tumor of the Brachial Plexus Invading the Left Thoracic Inlet: A Rare Differential Diagnosis of Pancoast Tumor

6975 vs

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

19,375; p = 0.04) than those who survived. CONCLUSIONS Patients who suffer complications after lung resection and require salvage intensive care, particularly mechanical ventilation, have a poor prognosis. In the light of this data the onset of two-organ failure should prompt an informed discussion as to whether escalation of treatment is in the patients best interest.

PD6-2-6: Predictors of early mortality and morbidity following surgical palliation of malignant pleural effusion

Malignant triton tumor is a divergent malignant peripheral nerve sheath tumor with rhabdomyoblastic differentiation. We report a case of malignant triton tumor arising in the brachial plexus of a 28-year-old women with neurofibromatosis type 1. Fluorodeoxyglucose-positron emission tomography-computed tomography before excision demonstrated a tumor with a maximum standard uptake value of 21 at 4 hours postinjection. The patient underwent complete excision of the tumor through median sternotomy and left supraclavicular approach. Adjuvant radiotherapy and chemotherapy were planned but the patient died of metastatic disease within 3 months of surgical resection.

A case-matched study of anatomical segmentectomy versus lobectomy for stage I lung cancer in high-risk patients

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.

The Effect of Extent of Local Resection on Patterns of Disease Progression in Malignant Pleural Mesothelioma

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