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Extended pleurectomy-decortication is a cytoreductive surgical treatment for malignant pleural mesothelioma. Prolonged air leak remains a major postoperative challenge, lengthening hospital stay and increasing morbidity. In this video report, we present a stepwise approach for visceral decortication and introduce the concept of aerostasis by construction of an artificial neopleura. Our results suggest that improved aerostasis results in shortened air leak duration., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Lung volume reduction surgery (LVRS) is an established therapeutic option for advanced emphysema. To improve patients' safety and reduce complications, an enhanced recovery protocol (ERP) was implemented. This study aims to describe and evaluate the short-term outcome of this ERP., Methods: This retrospective single-centre study included all consecutive LVRS patients (1 January 2017 until 15 September 2020). An ERP for LVRS was implemented and stepwise optimised from 1 August 2019, it consisted of changes in pre-, peri- and postoperative care pathways. Patients were compared before and after implementation of ERP. Primary outcome was incidence of postoperative complications (Clavien-Dindo), and secondary outcomes included chest tube duration, incidence of prolonged air leak (PAL), length of stay (LOS) and 90-day mortality. Lung function and exercise capacity were evaluated at 3 and 6 months post-LVRS., Results: Seventy-six LVRS patients were included (pre-ERP: n=41, ERP: n=35). The ERP cohort presented with lower incidence of postoperative complications (42% vs 83%, P=0.0002), shorter chest tube duration (4 vs 12 days, P<0.0001) with a lower incidence of PAL (21% vs 61%, P=0.0005) and shorter LOS (6 vs 14 days, P<0.0001). No in-hospital mortality occurred in the ERP cohort versus 4 pre-ERP. Postoperative forced expiratory volume in 1 s was higher in the ERP cohort compared to pre-ERP at 3 months (1.35 vs 1.02 l) and at 6 months (1.31 vs 1.01 l)., Conclusions: Implementation of ERP as part of a comprehensive reconceptualisation towards LVRS, demonstrated fewer postoperative complications, including PAL, resulting in reduced LOS. Improved short-term functional outcomes were observed at 3 and 6 months., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Hiatal hernias (HH) after oesophagectomy are rare, and their surgical management is not well standardized. Our goal was to report on the management of HH after oesophagectomy in high-volume tertiary European French-speaking centres., Methods: We conducted a retrospective multicentre study among 19 European French-speaking departments of upper gastrointestinal and/or thoracic surgery. All patients scheduled or operated on for the repair of an HH after oesophagectomy were collected between 2000 and 2016. Demographics, details of the initial procedure, surgical management and long-term outcome were analysed., Results: Seventy-nine of 6608 (1.2%) patients who had oesophagectomies were included in the study. The postoesophagectomy diagnostic interval of an HH after oesophagectomy was ≤90 days (n = 17; 21%), 13 were emergency cases; between 91 days and 1 year, n = 21 (27%), 13 in emergency; ≥1 year, n = 41 (52%), 17 in emergency. The time to occurrence of HH after oesophagectomy was shorter after laparoscopy (median 308 days; interquartile range 150-693) compared to that after laparotomy (median 562 days, interquartile range 138-1768; P = 0.01). The incidence of HH after oesophagectomy was 0.73% (22/3010) after open surgery and 1.4% (26/1761) after laparoscopy (P = 0.03). Among the 79 patients, 78 were operated on: 35 had laparotomies (45%), 19 had laparoscopies (24%) and 24 (31%) had transthoracic approaches. Among the 43 urgent surgeries, 35 were open (25 laparotomies and 10 transthoracic approaches) and 8 were laparoscopies (conversion rate, 25%). Nine patients required bowel resections. Morbidity occurred in 36 (46%) patients with 1 postoperative death (1.2%). During the follow-up period, recurrent HH after oesophagectomy requiring revisional surgery developed in 8 (6 days-26 months) patients., Conclusions: Surgical management of HH after oesophagectomy could be done by laparoscopy in patients with scheduled surgery but laparotomy or thoracotomy was preferred in urgent situations. The incidence of HH after oesophagectomy is higher and its onset earlier when laparoscopy is used at the initial oesophagectomy., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Combined modality treatment (CMT) for malignant pleural mesothelioma (MPM) remains a matter of debate regarding the choice of surgical procedure: extrapleural pneumonectomy (EPP) or pleurectomy/decortication., Methods: We performed a prospective interventional cohort study between 2003 and 2014. All consecutive patients with any histological MPM subtype, ≤70 years old, World Health Organization performance status ≤1, medically fit for pneumonectomy and stage cT1-2cN0-2cM0 (TNM7) or lower were included. Eligibility for CMT was discussed by the multidisciplinary tumour board. Our local CMT protocol consisted of induction chemotherapy, followed by EPP and hemithoracic radiotherapy. Induction chemotherapy consisted of 3 cycles of cisplatin (75 mg/m2 day 1) and pemetrexed (500 mg/m2 day 1), each administered once every 3 weeks. If non-progressive, EPP was performed followed by hemithoracic radiotherapy (most frequently, intensity-modulated radiotherapy; dose 54 Gy/1.8 Gy ± boost). Feasibility and long-term survival analyses were performed. Overall survival and disease-free survival (DFS) were calculated from histological confirmation of a diagnosis of MPM., Results: Out of 197 patients, 97 started with CMT (79 epithelioid, 15 mixed and 3 sarcomatoid tumours, based on histological analysis). Clinical TNM was IA (n = 9)/IB (n = 8)/II (n = 57)/III (n = 23). A total of 76 patients underwent surgery (EPP: n = 56; exploratory thoracotomy: n = 20). The in-hospital mortality rate was 3.6%. Out of 56 patients who underwent surgery, 47 completed the entire CMT protocol. The intent-to-treat median and 5-year OS were 22.4 [95% confidence interval (CI) = 15.5-27.9] months and 11.2% (95% CI = 6.9-23.4). In patients who completed the CMT protocol (n = 47), these values were 33.2 (95% CI = 23.0-45.0) months and 24.2% (95% CI = 13.4-43.8). The intent-to-treat median and 5-year DFS were 15.6 (95% CI = 14.0-17.3) months and 9.9% (95% CI = 5.1-19.2), 19.8 (95% CI = 16.8-27.7) months and 17.2% (95% CI = 8.6-34.1) in those who had the full CMT. The Cox proportional hazards model showed a significantly lower DFS in positive lymph nodes (HR 2.79, 95% CI=1.35-5.78; P=0.006). In 30 (64%) patients with epithelioid type MPM without positive lymph nodes (pN0) after EPP, the 5-year DFS was 27.0% (95% CI=14.1-51.7)., Conclusions: CMT with EPP for MPM is feasible, with an acceptable surgical mortality rate, and results in a 5-year survival rate of 24%. Careful patient selection (staging and physical performance) is extremely important., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: We developed a new algorithm to identify high-risk patients for underweight after oesophagectomy for cancer. Patients were assigned to an age-gender-specific body mass index percentile (AG-BMI) which is then used in a survival analysis. This model was able to identify patients more at risk for being underweight in comparison with the classically used BMI. It shows a worse overall survival (OS) in patients with a preoperative AG-BMI < 10th percentile. The aim of this study is to validate this new model based on a cohort of patients from an external high-volume institution specialized in oesophageal cancer surgery., Methods: The validation cohort consists of 407 patients operated on between 1999 and 2012 with the prerequisite data to calculate AG-BMI and OS. The base cohort consisted of 642 consecutive patients, operated on in our institution between 2005 and 2010. Age, gender, height and weight on the day before surgery were used to calculate the BMI and the AG-BMI. OS was analysed and a multivariate analysis was performed., Results: Incidence rates of the AG-BMI < 10th percentile risk-patients in the validation cohort showed similar results to our original results (17.8 vs 17.2% for the base cohort) with a similar significant OS difference between at-risk patients and not-at-risk patients (P < 0.001). Multivariate analysis found the same five independent prognosticators for OS in both datasets: age, early versus advanced disease, resection status, number of positive lymph nodes and the AG-BMI 10th percentile, but not BMI itself. In the validation cohort, gender was identified as an additional independent prognosticator. The worse OS survival in AG-BMI < 10th percentile in both patient populations was related to a significantly higher number of deaths without oesophageal cancer recurrence., Conclusions: This study validates the newly developed AG-BMI model to predict more accurately a subgroup of patients at risk for worse survival after oesophagectomy. Improved perioperative identification of risk factors for poorer OS could help to develop perioperative strategies to reduce these risks., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Donor to recipient (D/R) matching in lung transplantation (LTx) is usually directed by blood group (identity or compatibility) and predicted total lung capacity (pTLC) based on height and age. Other donor (D) and recipient (R) characteristics such as cytomegalovirus (CMV) serology (±), gender [male (M)/ female (F)] and age are often ignored, but the impact of D/R mismatch for these variables and their combinations on outcome is less investigated., Methods: The early and late outcomes in 461 lung recipients (149 single-lung and 312 double-lung) transplanted between July 1991 and December 2009 were explored, comparing different D/R combinations for gender (M/F), age (<20/21 to 45/≥ 45 years), CMV (±), blood group (identical/compatible) and pTLC (-9%Δ, +11%Δ)., Results: Overall 5-, 10-, 15- and 20-year survival rates were 69, 50, 37 and 37%, respectively, and were significantly better in females {HR [95% confidence interval (CI)]: 0.5 (0.3-0.9); P = 0.023} and worse in older recipients [HR (95% CI): 1.6 (1.2-2.2); P = 0.003]. On univariate analysis, survival was significantly worse in recipients with gender opposite to that of the donor (39% for mismatch vs 51% for match at 10 years; P = 0.04), but not for other D/R matching variables: age (P = 0.89), pTLC (P = 0.14), CMV (P = 0.15), blood group (P = 0.82) and their combinations. The best survival at 5 years was seen in female donor (DF)/female recipient (RF) (80%), the worst in DF/male recipient (RM) (47%), and intermediate in male donor (DM)/RF (72%) and DM/RM (63%); P = 0.0001. On multivariate analysis, D/R gender mismatch was found to be the sole negative predictive factor for survival with an 80% increased risk of mortality [HR (95% CI): 1.8 (1.1-2.8); P = 0.01]., Conclusions: In our patient cohort, survival after LTx was superior in female and younger recipients. D/R gender mismatch may be an important prognostic factor for long-term outcome. A gender combination of DF/RM should be avoided. The exact reasons for these differences remain speculative., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The current (7th) International Union Against Cancer (UICC) pN staging system is based on the number of positive lymph nodes but does not take into consideration the characteristics of the metastatic lymph nodes itself. In particular, it has been suggested that tumour penetration beyond the lymph node capsule in metastatic lymph nodes, which is also called extracapsular lymph node involvement, has a prognostic impact. The aim of the current study was to assess the prognostic value of extracapsular (EC) and intracapsular (IC) lymph node involvement (LNI) in adenocarcinoma of the oesophagus and gastro-oesophageal junction (GOJ) and to assess its potential impact on the 7th edition of the UICC TNM manual., Methods: From 2000 to 2010, all consecutive adenocarcinoma patients with primary R0-resection (n = 499) were prospectively included for analysis. The number of resected lymph nodes, number of positive lymph nodes and number of EC-LNI/IC-LNI were determined. Extracapsular spread was defined as infiltration of cancer cells beyond the capsule of the positive lymph node., Results: Two hundred and eighteen (43%) patients had positive lymph nodes. Cancer-specific 5-year survival in lymph node-positive patients was significantly (P < 0.0001) worse compared with lymph node-negative patients, being 88.3 vs 28.7%, respectively. In 128 (58.7%) cases EC-LNI was detected. EC-LNI showed significantly worse cancer-specific 5-year survival compared with IC-LNI, 19.6 vs 44.0% (P < 0.0001). In the pN1 category (1 or 2 positive LN's-UICC stages IIB and IIIA), this was 30.4% vs 58%; (P = 0.029). In higher pN categories, this effect was no longer noticed. Integrating these findings into an adapted TNM classification resulted in improved homogeneity, monotonicity of gradients and discriminatory ability indicating an improved performance of the staging system., Conclusions: EC-LNI is associated with worse survival compared with IC-LNI. EC-LNI patients show survival rates that are more closely associated with the current TNM stage IIIB, while IC-LNI patients have a survival more similar to TNM stage IIB. Incorporating the EC-IC factor in the TNM classification results in an increased performance of the TNM model. Further confirmation from other centres is required within the context of future adaptations of the UICC/AJCC (American Joint Committee on Cancer) staging system for oesophageal cancer., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Oesophagal perforation after foreign body ingestion may result in an arterio-oesophageal fistula. We present a case of a man who presented with haematemesis and hypovolemic shock after ingestion of a chicken bone. Imaging revealed an infected fistula between the oesophagus and the left subclavian artery. Haemorrhage stopped after endovascular deployment of a stent graft in the subclavian artery. Aftercare consisted of intravenous antibiotics and parenteral feeding. The patient was discharged after 3 weeks and he encountered no infectious or vascular problems on follow-up. This unique case deals with a patient in whom an infected arterio-oesophageal fistula was successfully treated with a vascular stent-graft, thereby avoiding open surgical repair.

Objectives: To evaluate baseline health-related quality of life (HRQL) factors that influence short-term outcome after oesophagectomy for cancer of the oesophagus and gastro-oesophageal junction and the effects of postoperative length of hospital stay on postoperative HRQL, as perceived by the patients themselves., Methods: Four hundred and fifty-five patients operated on with curative intent between January 2005 and December 2009 were analysed. HRQL scores were obtained by European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ)-C30 and oesophageal-specific symptoms (OES-18) questionnaires at baseline (=day before surgery) and 3-monthly post-surgery for the first year., Results: There were 372 males and 83 females, with a mean age of 63.1 years. Hospital mortality was 3.7% (17 patients). When analysing postoperative length of stay (LOS), a median of 10 days was found. In a multivariable analysis, using a binary logistic regression model, independent prognosticators for a longer LOS (>10 days) were: medical [hazard ratio, HR, 6.2 (3.62-10.56); P < 0.0001] and surgical [HR 2.79 (1.70-4.59); P < 0.0001] morbidity, readmittance to intensive care unit [HR 33.82 (4.55-251.21); P = 0.001] and poor physical functioning [HR 1.89 (1.14-3.14); P = 0.014]. Postoperatively, patients with early discharge (LOS <10 days) indicated, at 3 and 12 months postoperatively, significant better HRQL scores in the functional scales (physical, emotional, social and role functioning) and in symptoms scales (fatigue, nausea, dyspnoea appetite loss and dry mouth) when compared with LOS >10 days. Return to the level of the reference population scores was achieved at 1 year in the LOS ≤10 days for almost all the scales, but not in the LOS >10 days group., Conclusions: A better perception of preoperative physical functioning might have a beneficial effect on LOS. Our data, furthermore, suggest that early discharge correlates with improved postoperative HRQL outcomes. A clear decrease of the HRQL is seen at 3 months after the surgery, particularly in the LOS >10 days group. Generally, return to the level of the reference population scores is achieved at 1 year in the LOS ≤10 days, but not in the LOS >10 days group.

Objectives: Preventive antireflux surgery (ARS) at the moment of congenital diaphragmatic hernia (CDH) repair has been suggested by some authors, particularly in subgroups with a liver herniated in the chest or patch requirement. We evaluated the incidence and associated factors of gastro-oesophageal reflux disease (GERD) and the need for subsequent ARS in our CDH patients., Methods: We retrospectively reviewed our CDH database. Demographics, prenatal assessment of severity, prenatal treatment, type of repair, intraoperative findings and incidences of gastro-oesophageal reflux and ARS were recorded., Results: CDH repair was performed in 77 infants between July 1993 and November 2009. Eight died after repair. Seven were lost to follow-up. The median follow-up was 4.0 (0.16-14.88) years. Fourteen of these 62 patients were prenatally treated with fetoscopic endoluminal tracheal occlusion (FETO) because of severe pulmonary hypoplasia. After CDH repair, GERD was diagnosed in 31 patients. In all of them, medical antireflux treatment was started. Thirteen (42%) patients needed ARS at a median age of 64 (37-264) days. One year after starting medical treatment, 14 (45%) patients were completely off antireflux medication. In CDH subgroups with patch repair, liver herniated in the chest or previous FETO, the incidences of gastro-oesophageal reflux and ARS were 61 and 32%, 73 and 38% and 71 and 43%, respectively. Univariable analysis of associated potentially predisposing factors shows that patch repair, liver herniated in the chest, pulmonary hypertension, high-frequency oscillatory ventilation and FETO are associated with subsequent ARS. On multivariable analysis, liver herniated in the chest was the only independent predictor for both gastro-oesophageal reflux and ARS., Conclusions: Of all CDH patients, 50% developed gastro-oesophageal reflux and 21% required ARS. For both, liver in the chest was the only independent predictor. Routine ARS in certain subgroups at the time of CDH repair seems not to be justified. Foetal endoluminal tracheal occlusion creates a new cohort of survivors with an increased risk for undergoing ARS. The surgical group, in particular, reflects a more complex gastro-oesophageal reflux physiopathology.

Objective: The aim was to conduct a comparative analysis of outcome after minimally invasive oesophagectomy (MIO) versus open oesophagectomy (OO) for early oesophageal and gastro-oesophageal junction (GOJ) carcinoma., Methods: Inclusion criteria for MIO and a matched group of OO were pT<2 and N0. Surgical outcome, complications, survival and health-related quality of life (HRQL) were assessed., Results: Between January 2005 and January 2010, 175 patients (101 OOs, 65 MIOs and nine MIOs converted to OO) fulfilled the abovementioned criteria. Histology was predominantly adenocarcinoma (75%), equally distributed between both groups as were preoperative co-morbidities (p = 0.43), pathologic staging (pT: p = 0.56) and mean number of resected lymph nodes in pTIS/1a (p = 0.23) and pT1b (p = 0.13). Blood loss was less (p = 0.01) and duration of operation longer (p = 0.001) in MIO. Hospital mortality (p = 0.66) and postoperative complications (p = 0.34) were comparable. However, respiratory complications (p = 0.008) and intensive care unit (ICU) admission (p = 0.02) were higher in OO. Gastrointestinal complications (p = 0.005), that is, gastroparesis (p = 0.004) were more frequent in MIO. At 3 months, postoperative fatigue, pain (general) and gastrointestinal pain were less in MIO (p = 0.09, 0.05 and 0.01, respectively). Five-year cancer-specific and recurrence-free survival stratified to the pathologic T-stage were not statistically different between MIO and OO., Conclusion: MIO is a valuable alternative to OO for the treatment of early oesophageal and GOJ carcinoma. This study underscores the need for large-scale, preferably multicentric studies to assess the real value of MIO versus OO., (Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: Single-lung transplantation (SLTx) is a valid treatment option for patients with non-suppurative end-stage pulmonary disease. This strategy helps to overcome current organ shortage. Side is usually chosen based on pre-transplant quantitative perfusion scan, unless specific recipient considerations or contralateral lung offer dictates opposite side. It remains largely unknown whether outcome differs between left (L) versus right (R) SLTx., Methods: Between July 1991 and July 2009, 142 first SLTx (M/F=87/55; age=59 (29-69) years) were performed from 142 deceased donors (M/F=81/61; age=40 (14-66) years) with a median follow-up of 32 (0-202) months. Indications for SLTx were emphysema (55.6%), pulmonary fibrosis (36.6%), primary pulmonary hypertension (0.7%), and others (7.0%). Recipients of L-SLTx (n=72) and R-SLTx (n=70) were compared for donor and recipient characteristics and for early and late outcome., Results: Donors of L-SLTx were younger (37 (14-65) vs 43 (16-66) years; p=0.033). R-SLTx recipients had more often emphysema (67.1% vs 44.4%; p=0.046) and replacement of native lung with ≥ 50% perfusion (47.1% vs 23.6%; p=0.003). The need for bypass, time to extubation, intensive care unit (ICU) and hospital stay, and 30-day mortality did not differ between groups. Overall survival at 1, 3, and 5 years was 78.4%, 60.5%, and 49.4%, respectively, with a median survival of 60 months, with no significant differences between sides. Forced expiratory volume in 1s (FEV₁) improved (p<0.01) in both groups to comparable values up to 36 months. Complications overall (44.4% vs 50.0%) or in allograft (25.0% vs 24.3.0%) as well as time to bronchiolitis obliterans syndrome (BOS) (35 months) and 5-year freedom from BOS (68.9% vs 75.0%) were comparable after L-SLTx versus R-SLTx, respectively. There were no differences in all causes of death (p=0.766). On multivariate analysis, BOS was a strong negative predictor for survival (hazard ratio (HR) 6.78; p<0.001), whereas side and mismatch for perfusion were not., Conclusion: The preferred side for SLTx differed between fibrotic versus emphysema recipients. Transplant side does not influence recipient survival, freedom from BOS, complications, or pulmonary function after SLTx. Besides surgical considerations in the recipient, offer of a donor lung opposite to the preferred side should not be a reason to postpone the transplantation until a better-matched donor is found., (Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: It remains uncertain whether donor cause of brain death (DCBD) affects survival and freedom from bronchiolitis obliterans syndrome (BOS) after lung transplantation (LTx). In addition, it is unknown whether the length of time interval from brain insult to brain death [BI-BD] and from brain death to cold preservation [BD-CP] has an impact on outcome., Methods: Medical charts of isolated lung transplant recipients from 400 consecutive donors were reviewed and classified according to DCBD: 190 vascular [V], 185 traumatic [T], 25 others [O]. Demographics were compared between donor groups. Hospital outcome, survival, and freedom from BOS in recipients were analyzed in relation to DCBD and related time intervals., Results: Donor age, gender, and weight differed between donor groups (p<0.001, p<0.001, p<0.05; respectively). No differences in recipient hospital outcome, survival, and freedom from BOS were found between groups. [BD-CP] longer than 10h resulted in a survival advantage (69% vs 58% and 51% vs 42% at 5 and 10 years, respectively; p<0.05) and a reduced hazard risk (0.952) of dying after LTx; (p<0.05). Multivariable analysis failed to show a significant correlation between DCBD and [BI-BD] versus survival and BOS., Conclusion: DCBD and [BI-BD] do not affect survival and freedom from BOS after LTx. Lung recipients from donors certified brain dead with a time interval longer than 10h prior to organ preservation showed improved survival unrelated to BOS. This may result from longer and better donor management with reduced lung injury., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: Analysis of single centre results and identification of prognostic factors of surgical combined modality treatment in pathological proven stage IIIA-N2 non-small cell lung cancer (NSCLC)., Methods: Out of a total of 996 resections for NSCLC between 2000 and 2006, 92 patients with radiological response or stable disease after induction chemotherapy for pathologically proven ipsilateral positive lymph nodes (N2-disease) underwent surgical exploration with the aim of complete resection. Adenocarcinoma and squamous cell carcinomas were equally present (48% vs 43%). Median follow-up of surviving patients (n=36) was 51 (10-94) months., Results: Complete resection (i.e., tumour with free margins and negative highest mediastinal lymph nodes, R0) was achieved in 68% (n=63), resection was uncertain or incomplete in 24% (n=22), while surgery was explorative in 8% (n=7). Pneumonectomy was performed in 24%, (bi)lobectomy in 62%, and sleeve lobectomy in 13% of patients. In-hospital mortality was 2.3%. Overall need for ICU stay was 18% (30% after pneumonectomy). Median hospital stay was 10 days (6-157). Downstaging of mediastinal lymph nodes (ypN0-1) was found in 43% (n=40). Overall survival at 5 years (5YS) was 33% (n=92), and after complete resection 43% (n=63). Detection of multilevel compared to single level positive nodes at initial mediastinoscopy was related to lower 5YS (17% vs 39%; p<0.005), and this was identified as an independent prognostic factor in a multivariate analysis of the examined presurgical variables. We found a trend for a better 5YS in patients with mediastinal nodal downstaging compared to patients with persistent N2 disease (49% vs 27%; p=0.095). In the subgroup with persistent N2 disease, single level disease has a significantly better survival (37% vs 7% 5YS, p<0.005). Multivariate survival analysis of the examined surgical variables identified completeness of resection and classification of ypN category (ypN0-1 and ypN2-single level vs multilevel-ypN2 and ypN3) as independent prognostic factors., Conclusions: Surgery after induction chemotherapy for stage IIIA-N2 NSCLC can be performed with an acceptable mortality and morbidity. Baseline single level N2 disease is an independent prognostic factor for long-term survival. Patients with mediastinal downstaging, but also a subgroup of patients with single level persistent N2 disease, after induction therapy have a rewarding survival.

Since 1992, various combinations of thoracoscopy (VATS), laparoscopy or hand-assisted thoracolaparoscopy have been used for 'minimally invasive' cancer esophagectomy (MIE). Despite widespread current use, indications and potential benefits of the many technical approaches remain controversial. A systematic literature search was conducted until June 2007. Out of 128 publications, 46 original series (1932 patients) met the inclusion criteria and were analyzed for surgical and oncological outcome. No prospective controlled study has compared any MIE technique to another or to open surgery. Most publications are retrospective series of highly selected patients, mostly excluding high-risk patients and locally advanced (T3) tumors. Altogether, the overall conversion rate was 5.9%, mortality 2.9% and morbidity 46%, many papers reporting only major complications. Overall, rates for pulmonary complications were 22%, leakage 8.8% and vocal cord palsy 7.1%. Fifteen tracheo-bronchial injuries or fistulas (1% of all VATS cases) were reported. Laparoscopy and VATS were combined in 11 series (609 patients, 4.7% conversions, 2.4% mortality). VATS combined with (mini)-laparotomy was reported in 14 papers (743 patients, 6.3% conversions, 2.4% mortality). Laparoscopy combined with right thoracotomy was reported in four papers (147 patients, 5.4% conversions, 2% mortality). Laparoscopic transhiatal resections were reported in 17 papers (433 patients, 7% conversions, 4.6% mortality). Overall morbidity rates for these four approaches were 43%, 47.6%, 51.6% and 46%, respectively. Data on oncological outcome are scarce. Lymph node retrieval (median of all series: 14 nodes, range 5-62) was mostly inferior to open surgery standards and follow-up too short to draw definitive conclusions regarding long-term survival. Based on the available literature, the morbidity and mortality of MIE is substantial and not inferior to radical open esophagectomy in experienced centers. Many different operative techniques for MIE have been reported without obvious superiority for any of them. The term 'minimally invasive' is not supported by hitherto reported results. Selection bias and huge variability in extent of resection and lymphadenectomy impair comparisons of different MIE techniques. Oncological outcome of MIE remains largely unknown by lack of good quality data and selection bias. MIE remains an investigational and still evolving treatment for invasive cancer.

Objective: Due to recent advances in imaging, the incidence of patients presenting with bilateral lung lesions is increasing. A single contralateral lung lesion can be an isolated metastasis or a synchronous second primary lung cancer. For the revision of the TNM in 2009, the International Association for the Study of Lung Cancer Staging Committee proposes that patients with contralateral lung nodules remain classified as M1 disease. In this retrospective study, the survival after resection of synchronous bilateral lung cancer is evaluated., Methods: From our database of bronchial carcinoma, all patients with bilateral synchronous lung lesions between 1990 and 2007 were retrieved. We analysed 57 patients in which, after functional assessment and thorough staging, the decision was taken to treat the disease with bilateral resection. All these files were retrospectively reviewed. Twenty-one patients were excluded from this analysis because only one side was resected (n=15) or one of the lesions was non-neoplastic on final pathology (n=6)., Results: Thirty-six patients underwent bilateral resection for synchronous multiple primary lung cancer. All resections were performed as sequential procedures. In 23 patients, one side was anatomically resected (2 pneumonectomies) and the contralateral side was resected by limited resection. In 10 patients a bilateral lobectomy was performed, and 3 patients had bilateral limited resections. Postoperative mortality was 2.8%. Eighteen patients had a tumour with a different histological pattern, confirmed by comparing both specimens by an experienced senior pathologist. The median survival after resection of synchronous bilateral lung cancer in our series was 25.4 months with a 5-year survival rate of 38%. There was no significant difference in survival between patients with different versus same histology. This survival is much higher compared to the survival of assumed stage IV disease., Conclusions: Our study shows that selected patients with bilateral lung cancer may benefit from an aggressive approach, with acceptable morbidity and mortality, and rewarding long-term survival. Patients with a single contralateral lung lesion should not be treated as disseminated disease (stage IV). After extensive searching for metastatic spread, bilateral surgical resection should be considered in fit patients.

Objective: Though the surgical treatment of esophageal cancer is increasingly accepted for elderly people defined as aged over 70 years, less is reported about the results in patients over 75. This study is a single institution retrospective analysis of outcome after esophagectomy for cancer of the esophagus and GEJ in patients aged over 75 years., Methods: All consecutive patients 76 years old and over undergoing curative esophagectomy for cancer in the period 1991-2006 were analyzed as to comorbidities, outcome and long-term survival. All the data had been prospectively collected in a database. Postoperative mortality risk was assessed by P-POSSUM and O-POSSUM score for in-hospital mortality and by the recently published Steyerberg's score system [Steyerberg EW, Neville BA, Koppert LB, Lemmens VEPP, Tilanus HW, Coebergh JWW, Weeks JC, Earle CC. Surgical mortality in patients with esophageal cancer: development and validation of a simple risk score. J Clin Oncol 2006;24:4277-84.] for 30-day mortality. Five-year survival was compared to the standardized survival in the general population., Results: One hundred and eight patients fulfilling the abovementioned criteria were found (76 males and 32 females, mean age 79.5 years, mean standardized life-expectancy: 7.36 years). Among them, 69% had esophageal tumors and 31% GEJ tumors. The predominant histology was adenocarcinoma (74%). Eighty-six (79.6%) presented with one or more major comorbidities or a history of previous major upper-GI surgery, potentially affecting the surgical outcome. All underwent resection with curative intent (R(0) 83.3%, R(1) 12%, R(2) 4.6%). The overall postoperative morbidity rate was 51.9%, pulmonary complications (37%) being the most frequent. Postoperative mortality, mainly due to cardiopulmonary complications, was 7.4%, which was consistent with that predicted by P-POSSUM score (7.2%) and lower than that predicted by O-POSSUM score (15.1%). Thirty-day mortality was 5.5%, being consistent with that predicted by the Steyerberg's score (6.8%). Overall 5-year survival was 35.7%, while R(0) overall survival 42% and cancer specific R(0) survival 51.7%., Conclusions: Patients 76 years old and over with esophageal or GEJ cancer should not be denied surgery solely on the basis of age. Outcome and long-term results in the selected elderly are not differing from those reported for younger patients. However, despite thorough preoperative assessment being applied in the selection of the candidates for surgery, a practical and reliable individual risk-analysis stratification is still lacking.

Objective: Lung transplantation (LTx) has enjoyed increasing success with better survival in recent years. Nevertheless, airway anastomotic complications (AC) are still a potential cause of early morbidity and mortality. In this retrospective cohort study we looked at possible predictors of AC within the first year after LTx., Methods: Between July 1991 and December 2004, 232 consecutive single (n=102) and bilateral (n=130) LTx were performed (142 males and 90 females; mean age: 48 years [range 15-66 years]). Indications for LTx were emphysema (n=113), pulmonary fibrosis (n=45), cystic fibrosis (n=35), pulmonary hypertension (n=10), sarcoidosis (n=7) and miscellaneous (n=22). Donor variables (age, gender, PaO(2)/FiO(2), mechanical ventilation, ischemic time and preservation solution) and recipient variables (age, diagnosis, length, gender, pre-operative steroids, smoking, cytomegalovirus matching, LTx type, anastomotic type, wrapping and bypass) were evaluated in an univariate and multivariate model., Results: Fifty-seven complications occurred in 362 airway anastomoses (15.7%) of which 55 (15.2%) within the first year after transplantation. Six patients died as a result of AC (mortality 2.6%) during the first year after LTx. In a univariate analysis (321 airway anastomoses at risk), anastomotic type (7/17 [Telescoping] vs 48/304 [End-to-end]; p=0.011), recipient length (p=0.0012), donor ventilation (>50-70h<; p=0.0015) and recipient male gender (43/191 [M] vs 12/130 [F]; p=0.0092) were significant predictors of AC. Three factors remained significant predictors in the multivariate analysis: telescoping technique (p=0.0495), recipient length (p=0.0029) and donor ventilation (p=0.003)., Conclusions: Tall recipients and those receiving lungs from donors with prolonged ventilation have an increased risk to develop bronchial anastomotic problems. An end-to-end anastomosis should be preferred. Airway complications remain a matter of concern after lung transplantation.

Objective: Very few studies have examined post-operative morbidity after resection of oesophageal carcinoma, especially in patients treated with induction chemo- and radiotherapy for locally advanced stages. This study assessed the effects of induction chemoradiotherapy on post-operative course after resection of locally advanced oesophageal carcinoma (cT3-4 + cM1lymph)., Methods: Induction therapy consisted of 5-fluorouracil days 1-5 and days 21-25, cisplatin day 1 + day 21 and concomitant radiotherapy 18-20 fractions of 2Gy (total dose 36-40Gy). Induction chemoradiotherapy was completed in 109 patients. Surgery was performed in 90 patients (operability: 90/109 = 83%): 85 patients underwent resection with curative intent (resectability: 85/109 = 78%), bypass operation was performed in five patients. Nineteen patients could not be operated on. Results were compared to a matched group of pT3M1LYM/pT4 patients (n = 86) who underwent primary surgery in the same period., Results: Resection was complete (R0) in 68 patients (68/90 = 76%). Mean duration of surgery was 428 min (range: 240-690). Peroperative complications were haemorrhage in three patients (3/90 = 3.3%), tracheobronchial perforation in three patients (3/90 = 3.3%). Median total hospital stay was 20.5 days (range: 8-355). Mean duration of intubation was 7 days (range: 1-190); 67 patients (67/90 = 74.4%) were intubated for less than 24 h. Non-tumour related hospital mortality after resection was 8.3% (7/84 patients). Mortality after two-field lymphadenectomy was 5.2 versus 11.7% after three-field lymphadenectomy. After primary surgery (n = 86) overall mortality was 2.3% (P = 0.015) and nil after two- and three-field lymphadenectomy (P = 0.011). Medical morbidity consisted of pneumonia in 43 patients (43/90 = 48%), atelectasis in ten patients (10/90 = 11%), dysrhythmia in 21 patients (21/90 = 23%), sepsis in 11 patients (11/90 = 12%) and adult respiratory distress syndrome in ten patients (10/90 = 11%). Surgical morbidity included pleural effusion in 16 patients (16/90 = 18%), tracheal fistula in two patients (2/90 = 2%), chylothorax in two patients (2/90 = 2%) and acute pancreatitis in one patient (1/90 = 1%). Ten patients (10/90 = 11%) had a radiologically confirmed anastomotic leak; however only in four out of them with clinical manifestation; treatment was conservative in all four patients. Major morbidity occurred in 27 patients (27/90 = 30%). Overall rate of morbidity was significantly higher after three-field lymphadenectomy (85%) as compared to two-field lymphadenectomy (68.7%; P = 0.023)., Conclusions: Chemoradiotherapy followed by resection of cT3-4 +/- cM1lymph oesophageal carcinoma is feasible with acceptable mortality. Mortality, however, seems to be significantly higher when compared to a group of pT3M1LYM/pT4 patients who underwent primary surgery (8.3 versus 2.3%; P = 0.015) in the same period in our department.