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Purpose Respiratory complications are the leading causes of morbidity and mortality after lung cancer surgery. We hypothesized that oropharyngeal and nasopharyngeal decontamination with chlorhexidine gluconate (CHG) would be an effective method to reduce these complications as reported in cardiac surgery. Methods In this multicenter parallel-group randomized double-blind placebo-controlled trial, we enrolled consecutive adults scheduled for anatomical pulmonary resection for lung cancer. Perioperative decontamination consisted in oropharyngeal rinse solution (0.12% CHG) and nasopharyngeal soap (4% CHG) or a placebo. The primary outcome measure was the proportion of patients requiring postoperative invasive and/or noninvasive mechanical ventilation (MV). Secondary outcome measures included occurrence of respiratory and non-respiratory healthcare-associated infections (HAIs) and outcomes within 90 days. Results Between July 2012 and April 2015, 474 patients were randomized. Of them, 24 had their surgical procedure cancelled or withdrew consent. The remaining 450 patients were included in a modified intention-to-treat analysis: 226 were allocated to CHG and 224 to the placebo. Proportions of patients requiring postoperative MV were not significantly different [CHG 14.2%; placebo 15.2%; relative risks (RRs) 0.93; 95% confidence interval (CI) 0.59-1.45; P = 0.76]. Neither of the proportions of patients with respiratory HAIs were different (CHG 13.7%; placebo 12.9%; RRs 1.06; 95% CI 0.66-1.69; P = 0.81). The CHG group had significantly decreased incidence of bacteremia, surgical-site infection and overall Staphylococcus aureus infections. However, there were no significant between-group differences for hospital stay length, change in tracheal microbiota, postoperative antibiotic utilization and outcomes by day 90. Conclusions CHG decontamination decreased neither MV requirements nor respiratory infections after lung cancer surgery. Additionally, CHG did not change tracheal microbiota or postoperative antibiotic utilization. Trial Registration This study is registered on ClinicalTrials.gov, number NCT01613365., Author(s): Xavier Benoit D'Journo [sup.1] [sup.6], Pierre-Emmanuel Falcoz [sup.2], Marco Alifano [sup.3], Jean-Philippe Le Rochais [sup.4], Thomas D'Annoville [sup.5], Gilbert Massard [sup.2], Jean Francois Regnard [sup.3], Philippe Icard [sup.4], Charles [...]

Byline: Aurelie Lefebvre (1), Christine Lorut (1), Marco Alifano (2), Herve Dermine (3), Nicolas Roche (1), Remy Gauzit (3), Jean-Francois Regnard (2), Gerard Huchon (1), Antoine Rabbat (1,4) Keywords: Noninvasive ventilation; Acute respiratory failure; Postoperative thoracic surgery; Lung resection; COPD; Outcomes Abstract: Background A single prospective randomized study found that, in selected patients with acute respiratory failure (ARF) following lung resection, noninvasive ventilation (NIV) decreases the need for endotracheal mechanical ventilation and improves clinical outcome. Method We prospectively evaluated early NIV use for ARF after lung resection during a 4-year period in the setting of a medical and a surgical ICU of a university hospital. We documented demographics, initial clinical characteristics and clinical outcomes. NIV failure was defined as the need for tracheal intubation. Results Among 690 patients at risk of severe complications following lung resection, 113 (16.3%) experienced ARF, which was initially supported by NIV in 89 (78.7%), including 59 with hypoxemic ARF (66.3%) and 30 with hypercapnic ARF (33.7%). The overall success rate of NIV was 85.3% (76/89). In-ICU mortality was 6.7% (6/89). The mortality rate following NIV failure was 46.1%. Predictive factors of NIV failure in univariate analysis were age (P = 0.046), previous cardiac comorbidities (P = 0.0075), postoperative pneumonia (P = 0.0016), admission in the surgical ICU (P = 0.034), no initial response to NIV (P < 0.0001) and occurrence of noninfectious complications (P = 0.037). Only two independent factors were significantly associated with NIV failure in multivariate analysis: cardiac comorbidities (odds ratio, 11.5 95% confidence interval, 1.9--68.3 P = 0.007) and no initial response to NIV (odds ratio, 117.6 95% confidence interval, 10.6--1305.8 P = 0.0001). Conclusion This prospective survey confirms the feasibility and efficacy of NIV in ARF following lung resection. Author Affiliation: (1) Department of Respiratory and Intensive Care Medicine, Hotel-Dieu Hospital, AP-HP, Universite Paris 5, Rene Descartes, Paris, France (2) Department of Thoracic Surgery, Hotel-Dieu Hospital, AP-HP, Universite Paris 5, Rene Descartes, Paris, France (3) Department of Anesthesiology and Surgical Intensive Care, Hotel-Dieu Hospital, AP-HP, Universite Paris 5, Rene Descartes, Paris, France (4) Pneumologie et Reanimation, Hotel-Dieu, 1, place du parvis de Notre-Dame, 75181, Paris Cedex 04, France Article History: Registration Date: 01/10/2008 Received Date: 08/04/2008 Accepted Date: 26/09/2008 Online Date: 14/10/2008 Article note: This work was presented during the September 2008 ESICM congress in Lisbon international meeting and published as an abstract. Electronic supplementary material The online version of this article (doi: 10.1007/s00134-008-1317-z) contains supplementary material, which is available to authorized users.

Author(s): Marco Alifano [sup.1] [sup.4], Christine Lorut [sup.2] [sup.4], Aurelie Lefebvre [sup.2] [sup.4], Lyna Khattar [sup.2] [sup.4], Diane Damotte [sup.3] [sup.4], Gerard Huchon [sup.2] [sup.4], Jean-Francois Regnard [sup.1] [sup.4], Antoine [...]

Aims: The benefits of superior vena cava (SVC) resection for lung cancer remain controversial. Data obtained in four international centers were analyzed in order to identify prognostic factors and thus guide in future patient selection. Materials and methods: Retrospective study. Prognostic factors were examined by logistic regression for postoperative morbidity/mortality using the Kaplan–Meier method (log rank test) and the Cox proportional-hazard model for survival. Results: From 1963 to 2000, 109 patients underwent SVC resection. Induction treatment was given to 23 (21%) patients. The SVC was resected for T involvement in 78 (72%) cases and for N involvement in 31 (28%) cases. Fifty-five (50.5%) patients underwent pneumonectomy (20 with carinal resection), while the remaining underwent lobar resections. Prosthetic SVC replacement was performed in 28 (26%) patients; partial resection with running suture (53%), vascular stapler (13%), or patch (7%) was performed in 80 patients; 1 patient did not undergo reconstruction. Pathological examination identified direct involvement (T4) in 66 (60%) patients and N2 disease in 55 (50%) patients. Major postoperative morbidity and mortality were 30 and 12%, respectively. Median intensive care unit stay was 3 days, while median hospital stay was 16 days. Five-year survival was at 21%, with median survival at 11 months. In multiple regression analysis, induction treatment was associated with an increased risk of major complications (P=0.016). None of the factors assessed demonstrated an association with postoperative death. In multivariate survival analysis, both pneumonectomy and complete resection of the SVC with prosthetic replacement were associated with a significant increased risk of death (P=0.0013 and 0.014, respectively). Conclusions: The radical resection of lung cancer involving the SVC may result in a permanent cure in carefully selected patients. The type of pulmonary resection (i.e., pneumonectomy) and the type of SVC resection (i.e., complete resection with prosthetic replacement) are the prognostic factors with the greatest adverse effect on survival. [Copyright &y& Elsevier]

Objectives: Superior vena cava (SVC) resection with prosthetic replacement for non-small cell lung cancer (NSCLC) is infrequently performed and oncological results are unclear. To establish a historical benchmark for this extended surgery, we have updated and reviewed data from four international centers. Methods: Data were obtained through retrospective chart review. Prognostic factors were analyzed using first univariate techniques and subsequently multiple regression (logistic regression). Kaplan–Meier overall survival was calculated and prognostic factors examined by log–rank test and the estimation of hazard ratios using Cox regression. Results: From 1985 to 2000, 28 patients underwent SVC resection with prosthetic replacement for NSCLC. During the same period, 65 patients underwent partial SVC resection. Induction treatment was performed in 25% of patients. The resection was done for T involvement in 22 patients (79%), and for N2 involvement in the remaining. There were 12 tracheal sleeve resections, four pneumonectomies, and 12 lobar or sublobar resections with or without bronchoplasty. The median clamping time was 40 min. The median diameter of the prosthesis used was No. 14. Pathological examination showed direct SVC invasion (T4) in 79% of patients, whereas N2 disease was present in 50% of patients. Median intensive care unit and hospital stay were 3 and 20 days, respectively. The postoperative morbidity and mortality were 39 and 14%, respectively. The overall 5-year probability of survival was 15% (median of 9 months, range 0–105 months). Patients who underwent partial SVC resection during the same period had a significantly higher probability of survival (P=0.03). Induction chemotherapy was associated with a significant increase of postoperative morbidity in multivariate analysis. None of the potential prognostic factors analyzed in multivariate analysis were associated with survival, but the type of resection (sleeve pneumonectomy/pneumonectomy) were borderline significant. Conclusions: SVC resection with prosthetic replacement should not be considered an absolute contraindication in patients with NSCLC; however, the poor oncological results suggest more restrictive and severe criteria of patient selection (mediastinoscopy, induction treatment, no pneumonectomy, no N2 disease). [Copyright &y& Elsevier]