Lieven Depypere

Central tumour location should be considered when comparing N1 upstaging between thoracoscopic and open surgery for clinical stage I non-small-cell lung cancer

OBJECTIVES Nodal upstaging is a quality indicator for oncological thoracic surgery and is found in up to 25% of patients with clinical stage I (cStage-I) non-small-cell lung cancer (NSCLC). In large retrospective series, lower N1 upstaging was reported after video-assisted thoracic surgery (VATS) resections. We studied the impact of central primary tumour location on nodal upstaging in cStage-I NSCLC. METHODS Consecutive patients operated for cStage-I NSCLC were selected from a prospectively managed surgical database. Tumour location was classified as central if the lesion was visible during standard video bronchoscopy. A nodal station mapping was drawn for each patient based on final pathological examination. Univariable and additive multivariable binary logistic regression analyses were performed. RESULTS Between 2007-2014, 334 patients underwent anatomical resection for cStage-I NSCLC, either by open thoracotomy (n = 158) or by VATS (n = 176; conversion rate 1.7%). All patients underwent imaging with [(18)F]-fluorodeoxyglucose positron emission tomography and computer tomography. Invasive mediastinal staging was performed in 24.6% of patients. There were more central tumours in the open group (24.1%, n = 38) compared with the VATS group (4.5%, n = 8). There was no significant difference between the number (mean ± standard deviation) of nodal stations examined (open 5 ± 1.9 vs VATS 5 ± 1.7, P = 0.99). Pathological nodal upstaging was found in 15.9% (n = 53) of cStage-I patients. Nodal pN1 and pN2 upstaging were 13.3 and 8.2%, respectively, for the open group, and 6.3 and 4.5%, respectively, for the VATS group. In 32.6% (n = 15/46) of patients with a central cStage-I tumour pN1, upstaging was found. A binary logistic regression model (including tumour location, technique, tumour size, gender and histology) showed that only tumour location had a significant impact on pN1 upstaging [peripheral versus central; odds ratio (OR) 5.07 (confidence interval, CI: 1.89-13.60), P = 0.001], while surgical technique had no significant impact [VATS versus open; OR 0.74 (CI: 0.31-1.78), P = 0.50]. CONCLUSIONS The number of lymph node stations examined during VATS resections is similar to open resections for cStage-I NSCLC. Almost one-third of the patients with a central cStage-I NSCLC were upstaged to pN1. Tumour location was the only independent variable for pN1 upstaging in logistic regression analysis. It is a potential bias in retrospective studies and should therefore be accounted for when comparing different surgical resection techniques for cStage-I NSCLC.

Fluorine-18-fluorodeoxyglucose uptake in a benign oesophageal leiomyoma: a potential pitfall in diagnosis

Positron-emission tomography scans (PET) with fluorine-18-fluorodeoxyglucose ((18)F- FDG) are usually negative in leiomyomas. Two patients underwent a PET that showed an increased (18)F- FDG uptake of the distal oesophagus suggestive for malignancy. Both patients were operated on and histologic examination revealed a benign leiomyoma in both cases. We conclude that oesophageal leiomyomas are a potential cause of a false-positive PET. A high level of caution is needed in these diagnostically challenging cases to prevent unnecessary surgical procedures.

White light, autofluorescence and narrow-band imaging bronchoscopy for diagnosing airway pre-cancerous and early cancer lesions: a systematic review and meta-analysis

BACKGROUND We aimed to summarize the diagnostic accuracy of white light bronchoscopy (WLB) and advanced techniques for airway pre-cancerous lesions and early cancer, such as autofluorescence bronchoscopy (AFB), AFB combined with WLB (AFB + WLB) and narrow-band imaging (NBI) bronchoscopy. METHODS We searched for eligible studies in seven electronic databases from their date of inception to Mar 20, 2015. In eligible studies, detected lesions should be confirmed by histopathology. We extracted and calculated the 2×2 data based on the pathological criteria of lung tumor, including high-grade lesions from moderate dysplasia (MOD) to invasive carcinoma (INV). Random-effect model was used to pool sensitivity, specificity, diagnostic odds ratio (DOR) and the area under the receiver-operating characteristic curve (AUC). RESULTS In 53 eligible studies (39 WLB, 39 AFB, 17 AFB + WLB, 6 NBI), diagnostic performance for high-grade lesions was analyzed based on twelve studies (10 WLB, 7 AFB, 7 AFB + WLB, 1 NBI), involving with totally 2,880 patients and 8,830 biopsy specimens. The sensitivity, specificity, DOR and AUC of WLB were 51% (95% CI, 34-68%), 86% (95% CI, 73-84%), 6 (95% CI, 3-13) and 77% (95% CI, 73-81%). Those of AFB and AFB + WLB were 93% (95% CI, 77-98%) and 86% (95% CI, 75-97%), 52% (95% CI, 37-67%) and 71% (95% CI, 56-87%), 15 (95% CI, 4-57) and 16 (95% CI, 6-41), and 76% (95% CI, 72-79%) and 82% (95% CI, 78-85%), respectively. NBI presented 100% sensitivity and 43% specificity. CONCLUSIONS With higher sensitivity, advanced bronchoscopy could be valuable to avoid missed diagnosis. Combining strategy of AFB and WLB may contribute preferable diagnosis rather than their alone use for high-grade lesions. Studies of NBI warrants further investigation for precancerous lesions.

Does the Implementation of European Working Time Directive (EWTD) Have an Effect on Surgical Training in a Flemish Teaching Hospital Network

Abstract Background: Surgical residents used to work many hours. The European working time directive (EWTD) 2003/88/EG was created to protect young doctors from working too many hours. EWTD was implemented in Belgium on February 1st 2011. A decrease in working hours and improvement of surgical education was expected. Methods: Every resident was requested by the Faculty of Medicine to answer an ACC (Activities Coaching Context) questionnaire about his/her teaching hospital. The answers of surgical residents in all teaching hospitals, during the academic years before, during and after the implementation of the EWTD were used. Statistical analysis was performed with SPSS 20. Results: Since implementation we noted a significant decrease in mean daily working time (MDWT) (p < 0,001). However, this MDWT stayed significantly longer in university hospitals (UH), even after implementation of EWTD (p = 0,024). Non-medical administrative workload (AW) did not change significantly (p = 0,531), but medical AW increased significantly after implementation (p = 0,050). Non-medical and medical AW were significantly higher in UH after implementation (p = 0,002 and p < 0,001). The opportunity to practice skills and also the perception of a good balance between working and learning did not change significantly after implementation (p = 0,200 and p = 0,819), but both were scored significantly better in non-UH (p < 0,001 and p = 0,052) regardless implementation of EWTD. Conclusions: Since implementation of EWTD there is a significant decrease in MDWT. However, AW has not decreased and is higher in UH. The main challenge for future surgical education will be to reduce AW in order to give surgical residents enough opportunities to practice their surgical skills without prolonging training time.

Is central lung tumour location really predictive for occult mediastinal nodal disease in (suspected) non-small-cell lung cancer staged cN0 on 18F-fluorodeoxyglucose positron emission tomography–computed tomography?

OBJECTIVES Current guidelines recommend preoperative invasive mediastinal staging in centrally located tumours with negative mediastinum on positron emission tomography-computed tomography, based on a 20-30% prevalence of occult mediastinal disease (pN2-3). However, a uniform definition of central tumour location is lacking. Our objective was to determine the best definition in predicting occult pN2-3. METHODS A single-institution database was queried for patients with (suspected) non-small-cell lung cancer staged cN0 after positron emission tomography-computed tomography and referred to invasive staging and/or primary surgery. We evaluated 5 definitions: inner 1/3, inner 2/3, contact with bronchovascular structures, ≤2 cm from bronchus or endobronchial visualization. RESULTS Between 2005 and 2015, 813 patients were eligible (cT1: 42%, cT2: 28%, cT3: 17% and cT4: 11%). Invasive mediastinal staging and resection were performed in 30% and 97% of patients, respectively. Any nodal upstaging (pN+) was found in 21% of patients, of whom pN2-3 was found in 8%. Central tumour location demonstrated 4 times higher odds for any pN+ [for inner 1/3 vs outer 2/3, odds ratio 3.90 (95% confidence interval 2.24-6.77), P < 0.001], whereas no significantly different odds was observed for pN2-3. The discriminative ability for pN+ was not significantly different between the several definitions. CONCLUSIONS The prevalence of occult pN2-3 was only 8% when modern fusion positron emission tomography-computed tomography imaging pointed at clinical N0 non-small-cell lung cancer. None of the 5 verified definitions of centrality was predictive for occult pN2-3. However, each definition of centrality was related to any pN+ at a prevalence of 21%, without significant differences in discriminative ability between definitions. These data question whether indication for preoperative invasive mediastinal staging should be based on centrality alone.

Spontaneous ventilation thoracoscopic thymectomy without muscle relaxant for Myasthenia Gravis: comparison with “standard” thoracoscopic thymectomy

Objectives: Myasthenia gravis (MG) benefits from thymectomy. However, its unpredictable response to muscle relaxants and volatile anesthetic agents may result in muscle weakness and subsequently in postoperative myasthenic crisis. The aim of this study was to determine the surgical outcomes after spontaneous ventilation compared with conventional intubated video‐assisted thoracoscopic thymectomy (spontaneous‐ventilation video‐assisted thoracic thymectomy [SV‐VATT] vs intubated video‐assisted thoracic thymectomy) in patients with MG. Methods: Data from all minimally invasive thymectomy procedures performed at our institute between January 2009 and June 2016 were collected. Patient characteristics, perioperative results, and treatment outcomes between SV‐VATT (group 1) and the intubated video‐assisted thoracic thymectomy (group 2) groups were compared. Furthermore, a propensity score‐matching analysis was generated to control for selection bias due to nonrandom group assignment in a 1:1 manner. Results: Thirty‐six patients were included in group 1 and 68 in group 2. Matching of patients according to propensity score resulted in a cohort that consisted of 27 patients in both groups. Patients had similar clinical characteristics in both groups. Operating time (P = .07) and lowest pulse oxygen saturation (P = .09) between the procedures were comparable after matching, but peak CO2 level at the end of expiration was significantly greater in group 1 both before and after matching (P < .01). Moreover, the incidence of postoperative myasthenic crisis and postoperative prolonged tracheal intubation was lower in group 1. The postoperative pain visual analog scale score (P < .01) and the length of hospital stay (P = .03) were shorter in group 1. Conclusions: SV‐VATT is a feasible procedure in patients with MG. It might be beneficial by reducing postoperative myasthenic crisis and postoperative prolonged tracheal intubation. Further prospective research is needed.

Reflection on the 1st ESTS-AME prize-the experience of one month clinical fellowship in the 1st Affiliated Hospital of the Medical University of Guangzhou

General thoracic surgery has evolved towards a highly specialized technically demanding surgical specialty. Fellowship positions in leading units are therefore becoming more and more important (1). As a European ESTS trainee member from Belgium, I had just finished my training and was also looking for fellowships to add to my postgraduate training.

Options for Esophageal Replacement

Abstract Esophagectomy followed by reconstruction is considered one of the most challenging interventions on the alimentary tract. Today most esophagectomies are performed for cancer of the esophagus and gastroesophageal junction. Other indications are decompensated achalasic megaeesophagus, sequelae of caustic burns, after multiple redo surgeries for reflux. The stomach, shaped into a narrow gastric tube, is the most commonly used conduit for reconstruction due to its favorable length, reliable vascular supply, the need for only one single anastomosis, and, in general, good to excellent sustainable quality of deglutition and life. However, dependent on each individual patients particularities, reconstruction may require to choose another conduit. Colon and jejunum—sometimes to be used as an isolated loop with free vascular anastomosis or as composite grafts—are the available alternatives. Tubular skin flaps in an extremely rare situation may become the last resort option. Combined with a multitude of different access routes, including the recent minimally invasive techniques, as well as different levels of anastomosis, it is clear that there are myriad options available when planning an esophagectomy and reconstruction. A tailored approach for each individual patient guided by an experienced surgical team that is familiar with all conduits available and able to adapt to every situation in order to offer the patient the best possible type of reconstruction is the key to success. This chapter provides an in-depth description of the techniques and results of the whole spectrum of options for esophageal replacement.

Video-assisted thoracoscopic surgery and open chest surgery in esophageal cancer treatment: present and future

Surgical esophageal cancer treatment has, like other solid organ cancer treatments, evolved from a monospeciality treatment towards a multidisciplinary treatment. In an increasing number of centers around the world minimally invasive esophagectomy (MIE) is now proposed as the preferred surgical approach although there is still a place for open surgery in selected cases. Careful assessment of oncologic and medical operability and adequate pre-operative preparation are the first and foremost important steps to guarantee optimal oncological and functional results. This article serves as a practical guide to MIE for esophageal cancer with figures, equipment preference cards and videos explaining and illustrating a MIE procedure in prone position as one example of the present state of the art. Some future perspectives will also be discussed.