Levon Toufektzian

In minor and major thoracic procedures is uniport superior to multiport video-assisted thoracoscopic surgery?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Are there differences in outcomes in uniport compared with multiport video-assisted thoracoscopic surgery? Altogether, 45 papers were found using the reported search, of which 8 papers represent the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type and level of evidence of publication, relevant outcomes and results of these papers are tabulated. Two studies (272 patients) compared outcomes for lobectomy. One study found pain control was significantly better in uniportal (P < 0.01) with earlier mobilization (P < 0.05), and decreased hospital stay by half a day (P < 0.05). The chest drain volume was less, and consequently the number of days the chest drain remained in situ decreased by 1 day (P < 0.05). The second study looking at lobectomies failed to find any differences between the two techniques. For minor thoracic procedures (pneumothorax, peripheral lung nodules, thymic tumours, lung biopsies, sympathectomies and mediastinal cystectomies), 3 papers (117 patients) showed a statistically significant reduction in pain score during inpatient stay, and 1 paper showed a reduction in pain score day 0 postoperatively, however, no difference in pain score days 1 and 3 postoperatively. Two papers (n = 91) showed no difference in the reported pain scores; however, the patients in the uniportal group experienced less paraesthesia postoperatively. Patients in the uniportal group in this study also had reduced in-hospital stay (P = 0.03), and this led to a reduction in inpatient costs (P = 0.03). Four other studies, however, did not find any significant difference in duration of hospital stay. Pain scores are lower in uniportal VATS, most studies however do not demonstrate differences in other outcomes including analgesic use, duration of chest tube drainage, length of hospital stay or other thoracic complications. We conclude that, although uniport access may offer improved pain scores, the current evidence reveals no differences in most postoperative outcomes between uniport and multiport approaches to VATS in either minor or major thoracic procedures.

Pleural lavage cytology: Where do we stand?

Although a malignant pleural effusion is considered a manifestation of an advanced stage disease not amenable to curative resection in patients with non-small cell lung cancer, the same is not true in the case of the presence of malignant cells in the pleural cavity without an accompanying effusion, discovered incidentally during the operation with pleural lavage cytology (PLC). PLC is a diagnostic technique used to detect tumor cells and translate this finding to a prognostic index. Various reports have attempted to utilize the results of PLC and draw inferences regarding the origins of malignant cells in the pleural cavity, the association of these results with various disease characteristics and, most importantly, their impact on disease recurrence and survival. However, due to non-consistent techniques and protocols used to acquire the samples for cytological evaluation and assess their significance, results are inhomogeneous. Nevertheless, the entrance of malignant cells in the pleural cavity follows the rules posed by the natural disease process when discovered before pulmonary resection takes place, while surgical manipulations certainly play an important role in the case malignant cells are checked over after pulmonary resection. In addition, although the prognostic significance of a positive PLC result is indisputable and significantly decreases long-term survival in the majority of studies, this factor has not yet been incorporated into the TNM staging system. Lastly, some authors have advocated the use of some form of adjuvant treatment for those patients found with positive PLC results, based on the assumption that a curative resection followed by multiple pleural washings will not remove the entirety of the population of malignant cells present in the pleural space.

Is the learning curve for video-assisted thoracoscopic lobectomy affected by prior experience in open lobectomy?

A best evidence topic was written according to a structured protocol. The question addressed is the learning curve for video-assisted thoracoscopic (VATS) lobectomy affected by prior experience in open lobectomy? Two hundred and two studies were identified of which seven presented the best evidence on the topic. The authors, date, journal, country of publication, study type, participating surgeon and relevant outcomes are tabulated. The studies presented discuss the learning experiences of surgeons with a range of proficiency in open lobectomy in performing VATS lobectomy. Four of the studies made direct comparisons between the outcomes achieved by trainees and fully qualified surgeons. Trainees performed a total of 154 VATS lobectomies and the consultants performed 714. The reported number of open lobectomies performed by trainees ranged 14-50. In one study, a qualified surgeon who had performed 100 open lobectomies achieved a statistically significant progression in his learning curve and was able to safely perform VATS lobectomies after 6 months. A trainee who had performed only 14 open lobectomies achieved a similar blood loss to his experienced supervisors (P = 0.79). Two trainee surgeons who had each performed at least 20 open lobectomies achieved similar mean intraoperative blood loss (P = 0.2) and complication rate (P = 0.4) to their experienced consultant when performing VATS lobectomy. Average duration of chest drainage was similar between consultant and trainee groups (P = 0.34) and was improved in favour of trainees in one group (P < 0.001); this might be due to the fact that they operated on more technically straightforward cases. Four trainee surgeons who had performed at least 50 open pulmonary resections each managed to achieve a similar mean operative time to their consultant in their first 46 cases, and a lower morbidity (26 vs 34.7%). There was no increase in mortality in the trainee groups. Surgeons with limited experience in open lobectomy can achieve good outcomes in VATS lobectomy comparable with their more experienced seniors.

Effectiveness of brain natriuretic peptide in predicting postoperative atrial fibrillation in patients undergoing non-cardiac thoracic surgery.

A best evidence topic was written according to a structured protocol. The question addressed was whether plasma brain natriuretic peptide (BNP) levels could effectively predict the occurrence of postoperative atrial fibrillation (AF) in patients undergoing non-cardiac thoracic surgery. A total of 14 papers were identified using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. All studies were prospective observational, and all reported a significant association between BNP and N-terminal (NT)-proBNP plasma levels measured in the immediate preoperative period and the incidence of postoperative AF in patients undergoing either anatomical lung resections or oesophagectomy. One study reported a cut-off value of 30 pg/ml above which significantly more patients suffered from postoperative AF (P < 0.0001), while another one reported that this value could predict postoperative AF with a sensitivity of 77% and a specificity of 93%. Another study reported that patients with NT-proBNP levels of 113 pg/ml or above had an 8-fold increased risk of developing postoperative AF. These findings support that BNP or NT-proBNP levels, especially when determined during the preoperative period, if increased, are able to identify patients at risk for the development of postoperative AF after anatomical major lung resection or oesophagectomy. The same does not seem to be true for lesser lung resections. These high-risk patients might have a particular benefit from the administration of prophylactic antiarrhythmic therapy.

Does postoperative mechanical ventilation predispose to bronchopleural fistula formation in patients undergoing pneumonectomy

A best evidence topic was written according to a structured protocol. The question addressed was whether postoperative mechanical ventilation has any effect on the incidence of development of bronchopleural fistulas (BPFs) in patients undergoing pneumonectomy. A total of 40 papers were identified using the reported search, of which 8, all retrospective, represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. Of the eight identified papers, six of them reported a statistically significant relationship between postoperative mechanical ventilation and the occurrence of bronchopleural fistula in patients undergoing pneumonectomy (P = 0.027-0.0001). In two of these studies, postoperative mechanical ventilation was identified during multivariate analysis as an independent predictor for the development of BPF after pneumonectomy (odds ratio 15.57 and 33.1), indicating a causal relationship whereas, in the other four reports, statistical significance was the result of univariate analysis. In another study, the difference between these two groups approached but did not reach statistical significance (P = 0.057). Finally, one study reported no association between postoperative mechanical ventilation and the development of post-pneumonectomy BPF (0.16). Apart from mechanical ventilation, pre-existing pleuropulmonary infection was reported by one study as an independent predictor for the development of post-pneumonectomy BPF whereas, in two other studies, its impact approached but did not reach statistical significance. Another study did not find any association between preoperative infection and postoperative BPF occurrence. In conclusion, the majority of the reported studies report a significant relationship between mechanical ventilation after pneumonectomy and the occurrence of BPF. Every effort should be made to achieve extubation at the earliest possible time to withdraw the effects of the continuous barotrauma on the bronchial stump, although its impact cannot be quantified. Performing pneumonectomy in the presence of infectious conditions may contribute to the development of postoperative BPF, but its role is less well defined.

Is silver nitrate an effective means of pleurodesis

A best evidence topic was written according to a structured protocol. The question addressed was whether silver nitrate (SN) is an effective means of pleurodesis. A total of 42 papers were identified using the reported search, of which 8 represented the best evidence to address 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. Three studies assessed the efficacy of SN in inducing pleurodesis in patients with malignant pleural effusion (MPE). Using intrapleural injections of SN in concentrations of 0.5-1%, they reported success rates of 89-96% at 30 days. One of these studies compared SN with talc slurry and found equally effective pleurodesis at monthly intervals up to 4 months (P = 0.349-1). Another two studies retrospectively reviewed the efficacy of thoracosopic SN instillation (1 or 10%) in patients with primary spontaneous pneumothorax (PSP). Recurrence rates were 0-1.1% during long-term follow-up. One of these compared SN with simple drainage and reported a therapeutic gain of 45 ± 30% (95% CI) with SN, at the cost of increased analgesia consumption, chest drainage and hospital stay. Finally, three studies reported the results of the comparison of intrapleural injections of SN, talc or tetracycline in inducing pleurodesis in rabbits. SN was equally effective with tetracycline and superior to talc at producing pleurodesis, with lower concentrations of SN (0.1%) resulting in significantly attenuated systemic inflammatory response when compared with either higher SN concentrations (0.5%) or talc. Although not commonly used, available evidence suggests that SN is an effective agent in inducing pleurodesis in patients with either MPE or PSP. Compared with universally employed talc, it seems to result in at least similar short-term recurrence rates for MPE, with a demonstrably good side-effect profile; the longer-term efficacy is, as yet, undetermined. In cases of PSP, evidence suggests that thoracoscopic SN instillation is at least as effective as talc, with potentially fewer systemic side effects.

Is axillary superior to femoral artery cannulation for acute type A aortic dissection surgery

A best evidence topic was written according to a structured protocol. The question addressed was whether axillary artery cannulation (AXC) is superior to femoral artery cannulation (FAC) in patients undergoing surgical repair of acute type A aortic dissection. A total of 90 studies were identified using the reported search, of which 10 represented the best evidence to answer the clinical question. There were nine retrospective studies and one meta-analysis. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. Four papers, including the meta-analysis, reported significantly increased mortality in patients undergoing surgery with FAC. From these, two papers, again including the meta-analysis, reported also significantly increased neurological dysfunction, and another one demonstrated significantly increased incidence of postoperative bleeding and sternal infections in this same group of patients. Two more studies reported decreased mortality, malperfusion and neurological complications in patients undergoing surgical repair with AXC, but no statistical analysis was performed. Three reports comparing AXC and FAC found no difference between the two groups in terms of operative mortality and major complications, while another one demonstrated increased incidence of postoperative mortality in patients undergoing surgery with AXC, most likely due to the presence of malperfusion of one or more organs preoperatively in those who died. Patients undergoing repair of type A aortic dissection may benefit from AXC, whenever this is technically feasible. Most reports show that inflow perfusion through the axillary artery will reduce overall mortality, and neurological and malperfusion complications when compared with FAC. However, it needs to be stressed that, in three reports, the superiority of AXC over FAC might be attributed to the fact that patients in the latter group were critically ill in haemodynamic collapse. Nevertheless, this indicates that the femoral artery remains a bailout option in the emergency situation when institution of cardiopulmonary bypass is required rapidly.

Is it safe and worthwhile to perform pulmonary resection after contralateral pneumonectomy

A best evidence topic was written according to a structured protocol. The question addressed was whether pulmonary resection is safe and worthwhile in patients who have undergone previous pneumonectomy. A total of 141 studies were identified using the reported search, of which 8 represented the best evidence to answer the clinical question. Studies on multiple lung cancers with patients undergoing subsequent pulmonary resection after previous pneumonectomy, without outcome data specifically for this group of patients and case reports, were not included in this analysis. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. All studies were retrospective. In total, 102 patients underwent pulmonary resection after contralateral pneumonectomy, of which 96 had sublobar resections and 6 had lobectomies. Postoperative complications, reported in four of the eight studies, ranged from 21 to 44% (mean from four studies 36.8%). Four of the eight studies reported no mortality after pulmonary resection following pneumonectomy, whereas the other four reported mortality rates from 6.7 to 43%. For patients undergoing sublobar resections, the postoperative mortality was 6.2% (6/96), while for those submitted to lobectomy, mortality was 33.3% (2/6). Five-year survival rates ranged from 14% for metastatic disease to 50% for metachronous lung cancer. Due to the infrequent situation of a patient being considered for a pulmonary resection after contralateral pneumonectomy, this analysis was based on a limited number of patients from eight reports. Nevertheless, analysis of the data suggests that pulmonary resection for metastatic or metachronous disease can be performed with acceptable morbidity and low mortality in appropriately selected patients who have previously undergone a pneumonectomy. Sublobar resection is the treatment of choice whenever possible, for which long-term results are rewarding especially for patients with metachronous lung cancer.

Does the extent of resection affect survival in patients with synchronous multiple primary lung cancers undergoing curative surgery

A best evidence topic was written according to a structured protocol. The question addressed was whether the extent of pulmonary resection affects survival in patients with synchronous multiple primary lung cancers undergoing curative surgery. A total of 724 papers were identified using the reported searches, of which 14 represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. All studies were retrospective. Eight of 14 studies found no difference in terms of median, overall or progression-free survival when a sublobar resection in the form of a wedge resection or segmentectomy was performed for at least one of the synchronous lesions. Two studies demonstrated a negative impact on survival when lobectomy or bilobectomy was not performed for each lesion. Five papers reviewed the role of pneumonectomy in this category of patients and four of them demonstrated that such an extended resection has a significantly negative impact on survival, while, in one study, although pneumonectomy when compared with sublobar resections and photodynamic therapy had decreased long-term survival, this difference did not reach statistical significance. The use of lung-sparing resections (wedge resection or segmentectomy) of at least one lesion (if technically feasible) is advised for patients with synchronous multiple primary lung cancers. Most studies do not demonstrate any differences in immediate or long-term survival with two anatomical resections. Embarking for anatomical lung resections in the form of lobectomies should be done only in those cases where there are no concerns about postoperative pulmonary reserve. The performance of a pneumonectomy should be avoided, especially for bilateral synchronous lesions, unless it is absolutely necessary.

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.