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Open in new tab Download slide Open in new tab Download slide OBJECTIVES Unplanned readmission is defined as the return to inpatient hospitalization within 30 days after discharge. Worldwide, its incidence after lung resection ranges between 8% and 50%, and it has been shown to impact both patient recovery and healthcare resources. Our goal was to identify the risk factors to prioritize early follow-ups. METHODS We analysed data from the database of the Grupo Español de Cirugía Torácica Video-Asistida from 33 thoracic surgery departments over 15 months. Standard tests were used to compare the different risk groups. Our goal was to present the most relevant explanatory variables for readmission. RESULTS A total of 174 of 2808 patients (6%) underwent unplanned readmission after a lobectomy. Of all the preoperative individual characteristics, only lung function was found to be a risk factor for readmission [forced expiratory volume in 1 s < 80%, risk ratio (RR) 1.78, P  < 0.001; diffusing capacity of carbon monoxide <60%, RR 1.6, P  = 0.02; and VO2 < 20 ml/kg/min, RR 1.59, P  = 0.02]. The tumour's characteristics and the stage of the disease did not have an influence on the readmission rates. In the readmitted cohort, an open approach or thoracotomy was associated with more frequent readmissions (RR 1.77; P  < 0.001). Strong adhesions (RR 1.81; P  < 0.001) or adhesions occupying more than half of the hemithorax (RR 1.73, P  < 0.001) were also found to be risk factors for readmission and for longer operative times. A length of stay of >10 days after a lobectomy was found to be a risk factor for readmission (RR 1.9). CONCLUSIONS We identified preoperative, intraoperative and postoperative risk factors for readmission. This information can be a useful tool to help with the prioritization of early follow-ups, especially in centres with high workloads. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Paravertebral block (PVB) with infusion of local anaesthetic (LA) through a paravertebral catheter is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. PVB can be done in two ways: either through administration of a bolus dose of the LA or continuous infusion via an infusion pump; currently, there is no consensus on which route is best. Our objective was to compare the efficacy of the PVB for post-thoracotomy pain control using bolus doses versus a continuous infusion pump. METHODS: We performed a prospective randomized study of 80 patients submitted to thoracotomy. Patients were divided into two independent groups (anterior thoracotomy-ANT-and posterolateral thoracotomy-POST). At the conclusion of the surgery, a catheter was inserted under direct vision in the thoracic paravertebral space at the level of the incision. In each group, patients were randomized to receive levobupivacaine 0.5% every 6 h ('Bolus' group) or levobupivacaine 0.25% in continuous infusion at 5 ml/h through an elastomeric pump ('Continuous infusion' group). Patients in both groups received the same dosage of LA: 300 mg/day. Metamizole (every 6 h) was administered as an adjunct. Subcutaneous meperidine was employed as a rescue medication. Pain scores were measured using the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. RESULTS: Thirteen (16.2%) patients required meperidine for rescue (8 in continuous infusion and 5 in the bolus group). Mean VAS scores were the following: all the cases (n = 80): 5.0 ± 1.6, ANT (n = 36): 4.4 ± 1.8, POST (n = 44): 5.4 ± 1.6, Bolus (n = 40): 4.7 ± 1.7, Continuous infusion (n = 40): 5.2 ± 1.8, ANT with bolus (n = 18): 4.1 ± 1.7, ANT with continuous infusion (n = 18): 4.7 ± 1.8, POST with bolus (n = 22): 5.2 ± 1.5, POST with continuous infusion (n = 22): 5.6 ± 1.6. CONCLUSIONS: Post-thoracotomy pain control using a combination of PVB and a non-steroidal anti-inflammatory drug is a safe and effective approach. Patients submitted to ANT experienced less pain than those with POST 4.4 vs 5.4 (P = 0.02). Since no statistical differences were observed, it was not possible to confirm differences between the LA administered in a bolus versus continuous infusion. [ABSTRACT FROM AUTHOR]

OBJECTIVES A new revision of the international lung cancer staging system has been recently introduced. The revisions are largely focussed on the T descriptor. We sought to test the validity of this new system on a separate prospectively collected cohort of patients from a recent multicentre trial of early-stage lung cancer. METHODS We reviewed the prospectively collected data from 1012 patients undergoing pulmonary resection for early-stage lung cancer in the ACOSOG Z0030 trial. TNM descriptors and overall staging were assessed using both the sixth and seventh editions of the American Joint Committee on Cancer and the Union Internationale Contre le Cancer (AJCC/UICC) lung cancer staging system. Survival results were analysed according to both staging allocations. RESULTS Using the proposed criteria, the number of patients by stage in the sixth and seventh edition allocations, respectively, were as follows: IA (432, 431); IB (402, 303); IIA (39, 167); IIB (94, 70); IIIA (26, 40); IIIB (19,0); there were no stage IV patients by either version. Overall, 180 (18%) patients had a change in the stage group from the sixth to seventh edition versions with 76 (8%) being downstaged and 104 (10%) being upstaged. In the sixth edition staging system based on pathological stages, median survivals in years were as follows: IA, NA; IB, 7.7; IIA, 4.0; IIB, 3.6; IIIA, 2.6 and IIIB, 2.4. Five-year survivals were: IA, 76.4%; IB, 62.0%; IIA, 47.8%; IIB, 40.4%; IIIA, 31.3% and IIIB, 44.4%. In the new system, median survivals in years were as follows: IA, NA; IB, 8.2; IIA, 4.4; IIB, 3.6 and IIIA, 1.8. Five-year survivals were: IA, 76.9%; IB, 65.0%; IIA, 48.5%; IIB, 42.9% and IIIA, 30.6%. Survival analysis and Kaplan–Meier survival curves showed more monotonic progression, distinction and homogeneity within groups in the seventh edition. CONCLUSIONS This study provides an external validation of the recently revised lung cancer staging system using a large multicentre database. The seventh edition of the AJCC/UICC lung cancer staging system appears to be an improvement over the preceding system. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate clinical aspects, results and the economic impact of the outpatient thoracic surgery programme (OTSP) developed in our Department. Methods: Prospective study of 300 patients who entered in the OTSP from April 2001 to March 2005. The procedures performed were videomediastinoscopy (MC), videothoracoscopic lung biopsy (LB) and videothoracoscopic bilateral thoracic sympathectomy (TS). All procedures were performed under general anaesthesia and patients were discharged in 4–6h. We analyse demographic data, the substitution index (SI), the admission rate (AR) and readmission rate (RR) after the procedure. We calculate the economic impact of stay expenses on our hospital and on other Spanish hospitals. Results: The female/male ratio of the 300 patients was 83/217, with a mean age of 58.1 years (range: 15–85 years). There were no deaths. Mediastinoscopy was performed as outpatient procedure in 210 patients (mean age: 65.6 years) out of 244 total MC (SI=86.1%). Two patients were admitted (AR=0.95%) to observe a minimal pneumothorax and because of late night end. There were no readmissions after MC (RR=0%). We included 32 ambulatory patients for lung biopsy (mean age: 61.5 years) out of 64 total LB (SI=50.0%). One patient was admitted because of air leak (AR=3.1%) and there were no readmissions after LB (RR=0%). Fifty-eight patients were included in the OTSP for bilateral sympathectomy (mean age: 27.1 years) out of 83 total TS (SI=69.9%); there were no admissions (AR=0%) and one patient was readmitted after 9 days because of a hemothorax (RR=1.7%). Sixty-four patients out of the 91 not included in the OTSP were included in an ‘afternoon surgical programme’ and dismissed the morning after surgery, without contraindication for their inclusion in the OTSP. The hospital's total stay saving was €12,668 (€88,226 if performed elsewhere), €42 per patient (€294 per patient if performed elsewhere). Conclusion: Video-assisted mediastinoscopy, lung biopsy and bilateral sympathectomy can be included safely in outpatient thoracic surgical programmes. The impact of the economic benefit of OTSP over the conventional hospitalisation depends on the Department's previous policy on hospital stays. Further experience is needed to increase the substitution index and expand the OTSP to other procedures. [Copyright &y& Elsevier]

OBJECTIVES In efforts to obtain complete results, current practice in surgical lung biopsy (LB) for interstitial lung disease (ILD) recommends sending lung tissue samples for bacterial, mycobacterial, fungal, and viral cultures. This study assesses the value of this practice by evaluating the microbiology findings obtained from LB for ILD and their associated costs. METHODS A total of 296 consecutive patients (140 women, 156 men, median age = 61 years) underwent LB for ILD from 2002 to 2009. All had lung tissue sent for microbiology examination. Microbiology results and resultant changes in patient management were analyzed retrospectively. A cost analysis was performed based upon nominal hospital charges adjusted on current inflation rates. Cost data included cultures, stains, smears, direct fluorescent antibody studies, and microbiologist consulting fees. RESULTS As many as 25 patients (8.4%) underwent open LB and 271 (91.6%) underwent thoracoscopic LB. A total of 592 specimens were assessed (range 1–4 per patient). The most common pathologic diagnoses were idiopathic pulmonary fibrosis in 122 (41.2%), cryptogenic organizing pneumonia in 31 (10.5%), and respiratory bronchiolitis ILD in 16 (5.4%). Microbiology testing was negative in 174 patients (58.8%). A total of 118 of 122 (96.7%) positive results were clinically considered to be contaminants and resulted in no change in clinical management. The most common contaminants were Propionibacterium acnes (38 patients; 31%) and Penicillium fungus (16 patients; 13%). In only four patients (1.4%), the organism cultured (Nocardia one, Histoplasma one, and Aspergillus fumigatus two) resulted in a change in clinical management. The cost of microbiology studies per specimen was $984 (€709), with a total cost for the study cohort being $582 000 (€420 000). CONCLUSIONS The yield and impact on clinical management of microbiology specimens from LB for ILD is very low. Its routine use in LB is questionable. We suggest it should be limited to those cases of ILD with a high suspicion of infection. Substantial cost savings are possible with this change in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Patients with pulmonary metastases from colorectal cancer (CRC) may benefit from aggressive surgical therapy. The objective of this study was to determine the role of major anatomic resection for pulmonary metastasectomy to improve survival when compared with limited pulmonary resection. Patients and methods: Data of 522 patients (64.2% men, mean age 64.5 years) who underwent pulmonary resections with curative intent for CRC metastases over a 2-year period were reviewed. All patients were followed for a minimum of 3 years. Disease-specific survival (DSS) and disease-free survival (DFS) were assessed with the Kaplan-Meier method. Factors associated with DSS and DFS were analyzed using a Cox proportional hazards regression model. Results: A total of 394 (75.6%) patients underwent wedge resection, 19 (3.6%) anatomic segmentectomy, 5 (0.9%) lesser resections not described, 100 (19.3%) lobectomy, and 4 (0.8%) pneumonectomy. Accordingly, 104 (19.9%) patients were treated with major anatomic resection and 418 (80.1%) with lesser resection. Operations were carried out with video-assisted thoracoscopic surgery (VATS) in 93 patients. The overall DSS and DFS were 55 and 28.3 months, respectively. Significant differences in DSS and DFS in favor of major resection versus lesser resection (DSS median not reached versus 52.2 months, P = 0.03; DFS median not reached versus 23.9 months, P < 0.001) were found. In the multivariate analysis, major resection appeared to be a protective factor in DSS [hazard ratio (HR) 0.6, 95% confidence interval (CI) 0.41-0.96, P = 0.031] and DFS (HR 0.5, 95% CI 0.36-0.75, P < 0.001). The surgical approach (VATS versus open surgical resection) had no effect on outcome. Conclusion: Major anatomic resection with lymphadenectomy for pulmonary metastasectomy can be considered in selected CRC patient with sufficient functional reserve to improve the DSS and DFS. Further prospective randomized studies are needed to confirm the present results. [ABSTRACT FROM AUTHOR]

Background: To assess possible differences in the perioperative profile between men and women in lung cancer surgery., Methods: A prospective cohort multicenter study was design, in which consecutive patients undergoing curative intent surgery for lung cancer in 24 Thoracic Services throughout Spain were included. Clinical features, tumor- and surgery-related data, postoperative complications, and mortality were recorded., Results: There were 2,566 men and 741 women. Women were younger than men [mean (SD) age, 61.8 (10.8) vs. 66.5 (9.1) years, P<0.0001] and showed a more favorable preoperative characteristics, with significantly higher percentages of ECOG grade 0 and lower percentages of active smokers (28.4% vs. 33.9%; pack-years 18.8 vs. 26.9) and comorbidities [chronic obstructive pulmonary disease (COPD), diabetes, hypertension, cardiac disorders]. There were significant differences (P<0.001) in histological types and TNM stages with adenocarcinoma (70.1% vs. 46.4%) and IA stage (41.5% vs. 33.6%) more frequent in women. The use of VATS or thoracotomy was similar. The rate of pneumonectomy was higher in men (10.9%) than in women (5.1%) (P<0.001) but the distributions of other procedures were similar. Postoperative complications (pneumonitis, atelectasis, air leak, hemorrhage, fistula, empyema, wound dehiscence, and need of reintubation) were lower in women. Significant differences (P<0.0001) in the severity of postoperative complications (Clavien-Dindo classification) were also found, with higher percentages of grades I (51.6% vs. 43%) and II (37.5% vs. 33%) and lower percentages of grades III and IV among women. The mean length of hospital stay was 7.8 (7.1) days in men versus 6.3 (5.0) days in women, and the 30-day mortality rate 0.3% in women versus 2.9% in men (P<0.0001). The percentage of readmissions within 30 days after surgery was also higher in men (8.6% vs. 2.8%)., Conclusions: This multicenter nationwide study of lung cancer surgery with curative intent shows that the perioperative profile is better in women than in men., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Pectus excavatum (PE) is the most common congenital chest wall deformity. It consists of a concavity of the sternum, and the costal cartilages derived from an unbalanced growth of the costochondral regions of the anterior chest wall. The standard operative treatment for PE has been the Ravitch procedure. This technique requires a long incision in the anterior chest wall and bilateral resection of the affected costal cartilages, needing in most cases a posterior metal bar support. The belief that the treatment of PE is basically esthetic led Donald Nuss to develop in 1998 a minimally invasive surgical treatment based on the skeletal frame plasticity and reshape capacity applied to the thorax. Thereby he deviced a technique involving a retrosternal steel bar modifying the sternum´s concavity and supporting the shape of the amended thorax, all performed through two small incisions at each side of the thorax with the help of a thoracoscope. The bar is maintained from 2 to 3 years, and removed after this period. This procedure obtains >90% of positive results with significant esthetic improvement and patient satisfaction. This minimally surgical approach for PE is to be discussed in this review.