Mohamed Kamel

Anatomical Segmentectomy and Wedge Resections Are Associated with Comparable Outcomes for Patients with Small cT1N0 Non–Small Cell Lung Cancer

Objectives Sublobar resection is advocated for patients with NSCLC and compromised cardiopulmonary reserve, and for selected patients with early stage disease. Anatomic segmentectomy (AS) has traditionally been considered superior to wedge resection (WR), but well‐balanced comparative studies are lacking. We hypothesize that WR and AS are associated with comparable oncologic outcomes for patients with cT1N0 NSCLC. Methods A retrospective review of a prospective database was performed (2000–2014) for cT1N0 patients, excluding patients with multiple primary tumors, carcinoid tumors, adenocarcinoma in situ, and minimally invasive adenocarcinoma. Demographic, clinical, and pathological data were reviewed. Overall survival (OS) and disease‐free survival (DFS) were estimated using the Kaplan‐Meier method and differences compared using log‐rank test. Multivariable analysis (MVA) of factors affecting DFS was performed by Cox regression analysis. For further comparison of the effect of resection type on survival, propensity score matching (i.e., by age, sex, Charlson comorbidity index, percent forced expiratory volume in 1 second (FEV1%), clinical tumor size, and tumor maximum standardized uptake value) was performed to obtain balanced cohorts of patients undergoing WR and AS (n = 76 per group). Results Two hundred eighty‐nine patients met our selection criteria, including WR in 160 and AS in 129. Poor performance status and limited cardiopulmonary reserve were the primary indications for sublobar resection in 76% of WR patients and in 62% of AS patients (p = 0.011). Thirteen patients (4.5%) had pN1/2 disease. Patients undergoing AS were more likely to have nodal sampling/dissection [123 (95%) versus 112 (70%); p < 0.001], more stations sampled (3 versus 2; p < 0.001), and more total nodes resected (7 versus 4; p = 0.001). However, there was no difference between patients undergoing WR versus AS in local recurrence [15 versus 14; p = 0.68] or 5‐year DFS (51% versus 53%; p = 0.7; median follow‐up 34 months). Univariate analysis showed no effect of extent of resection on DFS [hazard ratio 1.07 (95% confidence interval 0.74–1.56); p = 0.696]. MVA showed that only tumor maximum standardized uptake value was associated with worse DFS [hazard ratio 1.07 (95% confidence interval 1.01–1.13); p = 0.016]. In the propensity‐matched analysis of balanced subgroups, there was also no difference (p = 0.950) in 3‐ or 5‐year DFS in cT1N0 patients undergoing WR (65% and 49%) or AS (68% and 49%). Conclusions Our data show that WR and AS are comparable oncologic procedures for carefully staged cT1N0 NSCLC patients. Although AS is associated with a more thorough lymph node dissection, this did not translate to a survival benefit in this patient population with a low rate of nodal metastases.

The importance of lymph node dissection accompanying wedge resection for clinical stage IA lung cancer

Objectives For patients undergoing lobectomy for non-small cell lung cancer (NSCLC), a survival benefit exists with increased number of lymph nodes (LNs) resected. We sought to evaluate the associations of LN removal with outcomes in clinical stage I lung cancer patients undergoing wedge resection. Methods We evaluated all patients undergoing wedge resection for peripheral, clinical stage IA NSCLC and grouped patients into those with and without LN assessment. Data were compared and survival analysed using Kaplan-Meier, with differences compared using log-rank. Propensity score matching controlling for age, gender, Charlson comorbidity index, patient tolerability of lobectomy, surgery year, tumour size and surgical approach was done (51 patients in each group, caliper 0.2). Results We identified196 patients undergoing wedge resection, of whom 138 patients (70%) had LNs resected (median = 4 nodes), while the remaining 58 patients (30%) had none. There were no significant differences in the clinical or pathologic characteristics between the two groups. There was no difference in terms of OR time, estimated blood loss, chest tube duration or length of stay. Median pT size was 1.5 cm in each group ( P  = 0.73). Among patients with LNs removed, 6 (4.3%) had positive nodes Patients in the LN assessed group had higher probability of freedom from loco-regional recurrence compared to the no lymph node (NLN) group (5-year: 92 vs 74%, P  = 0.025).In propensity matched groups, patients who underwent LN dissection also had higher probability of freedom from local recurrence ( P  = 0.024). Conclusions Accompanying wedge resection for lung cancer, LN sampling adds no morbidity and does not increase length of stay. Positive nodes are identified in 4.3% of patients thought eligible for wedge resection. LN removal appears to decrease locoregional recurrence and may be associated with a survival benefit.

Endoscopic versus open radial artery harvesting: A meta‐analysis of randomized controlled and propensity matched studies

We sought to investigate the impact of radial artery harvesting techniques on clinical outcomes using a meta‐analytic approach limited to randomized controlled trials and propensity‐matched studies for clinical outcomes, in which graft patency was analyzed.

T1N0 oesophageal cancer: patterns of care and outcomes over 25 years

OBJECTIVES Historically, surgical resection has been the mainstay of treatment for T1N0 oesophageal cancer (OC). More recently, oesophageal sparing endoscopic techniques have shown value for local control in a large institutional series. However, the effect of their utilization upon survival rates in large population series is largely unknown. METHODS The surveillance, epidemiology, and end results (SEER) database was queried for T1N0M0-OC patients (1988-2013). Patients with multiple treatment types were excluded. Time periods were divided by 5-year increments. Overall survival and cancer-specific survival (CSS) were compared in the group as a whole and in propensity-matched subgroups. Independent predictors of cancer-specific mortality were studied by the Cox proportional hazard models. RESULTS We identified 5497 patients with cT1N0M0 OC. Treatment modalities used were changed significantly over time. The ratio of oesophagectomy when compared with local therapy decreased from 15:1 in 1998-92 to 1.4:1 in 2008-13. The proportion of patients treated with radiation slightly increased (35% vs 41%) between 1988-92 and 2008-13. In the propensity-matched groups, 5-year CSS was similar in patients treated with oesophagectomy and local therapy (81% vs 89%; P = 0.257) (n = 216 in each group), whereas oesophagectomy had superior 5-year CSS compared with radiation alone (73% vs 38%; P < 0.001) (n = 497 in each group). In multivariable analysis, significant predictors of cancer-specific mortality included age [hazard ratio (HR) 1.022], tumour size (HR 1.005), radiation therapy (HR 3.67), tumour Grade III/IV (HR 1.25) and early time period of diagnosis (HR 1.75). CONCLUSIONS Oesophageal sparing endoscopic techniques have been increasingly utilized in the treatment of cT1N0-OC but without compromising CSS. Local therapy, either endoscopic techniques or surgery, remains superior to radiation therapy.

Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis

Background: Cerebrospinal‐fluid (CSF) drainage is recommended by current guidelines for spinal protection during open and endovascular repairs of thoracic and thoraco‐abdominal aortic aneurysms. In the published literature, great variability exists in the rate of CSF‐related complications and morbidity. Herein, we perform a systematic review and meta‐analysis on the incidence of CSF drainage‐related complications, and compare the complication rates between open and endovascular repairs. Methods: The systematic review was conducted according to the Meta‐Analysis of Observational Studies in Epidemiology guidelines. Thirty‐four studies (4714 patients) were included in the quantitative analysis. The CSF drainage‐related complications were categorised as mild, moderate, and severe. Pooled event rates for each complication category were estimated using a random‐effect model. Random‐effect uni‐ and multivariable meta‐regression analyses were used to assess the effect of aortic‐repair approach (open vs endovascular) and the CSF drainage criteria on CSF drainage‐related complications. Results: The pooled event rates were 6.5% [95% confidence interval (CI): 4.3–9.8%] for overall complications, 2% (95% CI: 1.1–3.4%) for minor complications, 3.7% (95% CI: 2.5–5.6%) for moderate complications, and 2.5% (95% CI: 1.6–3.8%) for severe complications. The drainage‐related‐mortality pooled event rate was 0.9% (95% CI: 0.6–1.4%). The uni‐ and multivariable meta‐regression analyses showed no difference in complication rates between the open and endovascular approaches, or between the different CSF drainage protocols. Conclusion: The complication rate for CSF drainage is not negligible. Our results help define a more accurate risk–benefit ratio for CSF drain placement at the time of repair of thoracic and thoraco‐abdominal aneurysms.

Robotic Thymectomy: Learning Curve and Associated Perioperative Outcomes

INTRODUCTION Recently, robotic-assisted thymectomy (RAT) has emerged as an alternative to either, an open transsternal approach or to a video-assisted thoracoscopic approach, for both thymic tumors and benign lesions. We have reviewed our early experience with RAT to assess the associated learning curve as well as the short-term perioperative outcomes. METHODS A prospectively collected database was reviewed for patients who underwent RAT for all causes in the period 2012-2016. Robotic thymectomy cases were stratified and compared according to the number of cases performed by each surgeon (≤15 versus >15 cases). A propensity score matching was done to compare perioperative outcomes in patients undergoing robotic and transsternal resection of thymomas. RESULTS Seventy patients (47 females) with a median age of 52, underwent RAT. The median operative time was 102 min with 5 conversions to an open approach for local invasion (n = 3) or for complete pleural symphysis (n = 2). There were 2 rib fractures and 1 recurrent laryngeal nerve palsy. Median length of chest tube drainage and length of stay were 1 and 3 days, respectively. Operative time and estimated blood loss plateaued after surgeons initial 15-20 cases, which may reflect the initial learning curve. A comparison between early and late robotic cases showed that with the growing experience, the operative time becomes shorter (94 versus 107 min, P = .018). Propensity score analysis between robotic and transsternal resection of thymoma (n = 22 in each group) showed no significant differences in operative time (P = .79), intraoperative complications (P = .99), or postoperative complications (P = .99). CONCLUSIONS Robotic thymectomy is feasible and safe, and is associated with comparable perioperative outcomes to the traditional transsternal approach in patients undergoing thymomectomy. An initial learning curve of 15-20 robotic thymectomy cases may be required by the surgeons to adequately perform this relatively novel technique.

PS01.45: Intraoperative Blood Loss is an Independent Predictor of Poor Disease Free Survival for Patients Undergoing VATS Lobectomy for Lung Cancer: Topic: Surgery

Conversion to a thoracotomy was encountered in 66 patients(6.5%). 3 patients (0.3%) had 30-days postoperative mortality. On MVA, only advanced pathological stage[(pStage II, HR: 1.69, 95%CI: 1.15-2.48),(pStage III, HR: 2.94, 95%CI: 2.09-4.14)], grade 2/3 tumors(HR: 1.53, 95% CI: 1.092.16),and longer LOS(HR: 1.05, 95% CI: 1.01-1.09) independently predicted poor DFS. A subgroup analyses on 150 patients(14.9%)80 years old or older(octogenarians),showed comparable complications rate with their younger counterparts(<80 years old) (Clavien Dindo 3, 22.7% vs 17.2%, p1⁄40.110), despite having significantly higher Charlson comorbidity index(CCI>1; 46.7% vs 34.9%, p1⁄40.006). Also, there were no differences between patients older and young than 80 years old regarding probability of freedom from recurrence(p1⁄40.457)or cancer specific survival(p1⁄40.305). Conclusion: The current study reports a large number of lobectomies performed using VATS approach in a high volume academic center. These data came in accordance with previous reports affirming the feasibility, safety,and improved perioperative outcomes associated with this approach, even in the frail octogenarians.

New-generation stents compared with coronary bypass surgery for unprotected left main disease: A word of caution

Background: With the advent of bare metal stents and drug‐eluting stents, percutaneous coronary intervention has emerged as an alternative to coronary artery bypass grafting surgery for unprotected left main disease. However, whether the evolution of stents technology has translated into better results after percutaneous coronary intervention remains unclear. We aimed to compare coronary artery bypass grafting with stents of different generations for left main disease by performing a Bayesian network meta‐analysis of available randomized controlled trials. Methods: All randomized controlled trials with at least 1 arm randomized to percutaneous coronary intervention with stents or coronary artery bypass grafting for left main disease were included. Bare metal stents and drug‐eluting stents of first‐ and second‐generation were compared with coronary artery bypass grafting. Poisson methods and Bayesian framework were used to compute the head‐to‐head incidence rate ratio and 95% credible intervals. Primary end points were the composite of death/myocardial infarction/stroke and repeat revascularization. Results: Nine randomized controlled trials were included in the final analysis. Six trials compared percutaneous coronary intervention with coronary artery bypass grafting (n = 4654), and 3 trials compared different types of stents (n = 1360). Follow‐up ranged from 6 months to 5 years. Second‐generation drug‐eluting stents (incidence rate ratio, 1.3; 95% credible interval, 1.1–1.6), but not bare metal stents (incidence rate ratio, 0.63; 95% credible interval, 0.27–1.4), and first‐generation drug‐eluting stents (incidence rate ratio, 0.85; 95% credible interval, 0.65–1.1) were associated with a significantly increased risk of death/myocardial infarction/stroke when compared with coronary artery bypass grafting. When compared with coronary artery bypass grafting, the highest risk of repeat revascularization was observed for bare metal stents (hazard ratio, 5.1; 95% confidence interval, 2.1–14), whereas first‐generation drug‐eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4–2.4) and second‐generation drug‐eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4–2.4) were comparable. Conclusions: The introduction of new‐generation drug‐eluting stents did not translate into better outcomes for percutaneous coronary intervention when compared with coronary artery bypass grafting.

Plenary presentations and public citations from The American Association for Thoracic Surgery

OBJECTIVE We examined the impact of work presented in the plenary sessions at the meeting of The American Association for Thoracic Surgery (AATS), by determining how frequently the published papers corresponding to the session presentations during the past 20 years, were cited; those that were most cited were identified. METHODS We reviewed the AATS meeting programs from the 20-year period from 1994 to 2014 and identified the corresponding publications in the Journal of Thoracic and Cardiovascular Surgery (JTCVS) from all abstracts presented at the plenary sessions. Papers were categorized as cardiac, thoracic, or congenital. References were evaluated for subsequent citation in the Web of Science (WoS), and Google Scholar (GS). We determined both the median number of citations overall, and per year. For comparison, we evaluated numbers of citations in WoS from current JTCVS papers in issues containing the 3 most-cited plenary session papers. RESULTS Among 195 published plenary papers, the median number of citations in WoS and GS was 49 and 76, respectively. The median total number of citations in WoS was as follows: 51 for cardiac-category papers (n = 105); 61 for thoracic (n = 55), and 41 for congenital (n = 35). These values were higher than the median total number of citations for contemporary nonplenary JTCVS papers: cardiac (22, n = 55; P < .001); thoracic (31.5, n = 8; P = .183); and congenital (15.5, n = 24; P = .002) papers published in JTCVS. The median number of citations per year since publication for plenary publications was 5.9 (cardiac), 6 (thoracic), and 3.7 (congenital), respectively. CONCLUSIONS Publications corresponding to the plenary sessions of the AATS are highly cited and include some of the seminal studies in our field in the past 20 years.

Surgery is the Optimum Local Therapeutic Modality for Second Primary Lung Cancer

Recent advances in lung cancer screening have encouraged many clinicians to apply computed tomography screening principles to their resected patients. These patients represent a high-risk cohort for the development of either recurrent disease or a metachronous second lung primary. 1,2 Often with current imaging, cytology, and genetic analysis the distinction can be challenging and the surgeon would offer definitive local therapy for patients who clinically present with local disease. The exact incidence of second primaries and which local therapy is superior is not well understood. Taioli et al. 3 performed an analysis of the Surveillance, Epidemiology, and End Results database for patients with second primary lung cancers discovered 6 months or more after potentially curative resection of stage-one disease. Despite the non-randomized nature and the dearth of information on how treatment was assigned, the study highlights several important points. Overall, 5.4% of patients who undergo curative resection for stage I disease would develop a second cancer, the most of which are apparent before 3 years. This represents a significant risk and supports close monitoring of our resected patients. In addition, only 58.5% of these second primaries were stage I. The improvements in radiation therapy, particularly stereotactic body radiation therapy (SBRT), have encouraged radiation oncologists to offer definitive radiation to early-stage lung cancer patients who are deemed medically inoperable. SBRT has achieved good local control for this high-risk group and has encouraged some to question whether it should be offered to the medically operable as well. Unfortunately, 2 randomized trials comparing SBRT to lobectomy, closed due to the slow accrual. 4 So, what should be the optimum therapy offered for second lung primaries? Perhaps, the best therapy is the same as for first primaries. We performed a retrospective, propensity-matched,