Search

BACKGROUND: Postsurgical pleural infection is a life-threatening complication after implantation of artificial devices such as ventricular assist devices (VADs). The treatment can be challenging and the evidence in the literature is very limited. Here we report our multidisciplinary approach of the management of pleural infection after VAD implantation. METHODS: Between March 2014 and December 2019, 33 patients developed postoperative pleural infection after VAD implantation and underwent thoracic surgical intervention at our institution. All patients were prospectively enrolled in this analysis. Data were retrospectively analyzed. Primary outcome was the 90-day mortality rate. Length of ICU stay related to pleural infection, chest tube duration, re-thoracotomy rate and length of ventilatory support represented secondary outcomes. RESULTS: The 90-day mortality rate was 6% (2 patients). The mean ICU stay related to the pleural infection was 6 days (2–24 days). Video-assisted thoracoscopic surgery (VATS) was performed in all patients. Conversion to thoracotomy was necessary in 12 cases. Decortication and parietal pleurectomy in addition to hematoma and empyema removal was performed in all patients. Due to diffuse bleeding, packing of the thoracic cavity with temporary thoracic closure was necessary in 10 patients. Depacking was performed after a mean of 3 days (3–7 days). Recurrent empyema or bleeding after definitive chest closure was not observed. Lung resection was performed in 3 patients. CONCLUSIONS: Thoracic surgical management of pleural infection in patients after VAD implantation is challenging and complicated due to the inevitable anticoagulative therapy. A perioperative multidisciplinary management which includes the early involvement of thoracic surgical expertise helps to improve survival in this very complex patient cohort.

Despite their considerable organ size, the lungs rarely give rise to malignant tumors during childhood and adolescence. If they do, these tumors may present with embryonal structures resembling immature stages of pulmonary development ­(pleuropulmonary blastoma). On the other hand, tumors may present with organ-specific bronchial or ­neuroendocrine differentiation, while classic ­adeno-, squamous cell, or small cell carcinomas are ­exceedingly rare.

Extracorporeal lung support (ECLS) represents an essential support tool especially for critically ill patients undergoing thoracic surgical procedures. Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we report the efficacy of veno-venous ECLS (VV ECLS) as a bridge to or through LVRS in patients with end-stage lung emphysema and severe hypercapnia. Between January 2016 and May 2017, 125 patients with end-stage lung emphysema undergoing LVRS were prospectively enrolled into this study. Patients with severe hypercapnia caused by chronic respiratory failure were bridged to or through LVRS with low-flow VV ECLS (65 patients, group 1). Patients with preoperative normocapnia served as a control group (60 patients, group 2). In group 1, VV ECLS was implemented preoperatively in five patients and in 60 patients intraoperatively. Extracorporeal lung support was continued postoperatively in all 65 patients. Mean length of postoperative VV ECLS support was 3 ± 1 day. The 90 day mortality rate was 7.8% in group 1 compared with 5% in group 2 (p = 0.5). Postoperatively, a significant improvement was observed in quality of life, exercise capacity, and dyspnea symptoms in both groups. VV ECLS in patients with severe hypercapnia undergoing LVRS is an effective and well-tolerated treatment option. In particular, it increases the intraoperative safety, supports de-escalation of ventilatory strategies, and reduces the rate of postoperative complications in a cohort of patients considered "high risk" for LVRS in the current literature.

Background High morbidity and mortality are frequently reported in intensive care patients suffering from severe sepsis with systemic inflammation. With the development of severe respiratory failure, extracorporeal membrane oxygenation (ECMO) is often required. In this study, cytokine adsorption therapy in combination with ECMO is applied in patients with acute respiratory distress syndrome (ARDS) due to severe pneumogenic sepsis. The efficacy of this therapy is evaluated compared with a historical cohort without hemoadsorption therapy. Methods Between January and May 2018, combined high-flow venovenous ECMO and CytoSorb therapy (CytoSorb filter connected to ECMO circuit) was applied in patients (n = 13) with pneumogenic sepsis and ARDS. These patients were prospectively included (CytoSorb group). Data from patients (n = 7) with pneumogenic sepsis and ECMO therapy were retrospectively analyzed (control group). Results All patients survived in the CytoSorb group, where the 30-day mortality rate reached 57% in the control group. After CytoSorb therapy, we instantly observed a significant reduction in procalcitonin (PCT) and C-reactive protein (CRP) levels compared with the control group. Within 48 hours, the initial high doses of catecholamine could be weaned off only in the CytoSorb group. Conclusions Our results indicate that CytoSorb in combination with ECMO is an effective therapy to prevent escalation of sepsis with rapid weaning off high-dose catecholamine infusions and quick reduction in PCT and CRP levels. Optimal timing of immunomodulatory therapy and impact on ECMO-related inflammation still need to be furtherly investigated.

Zusammenfassung Hintergrund Die chirurgische Therapie persistierender bronchopleuraler Fisteln (BPF) kann sich insbesondere aufgrund von rezidivierenden Infekten langwierig gestalten. Als Alternative zur chirurgischen Versorgung steht die intrabronchiale Ventilimplantation zur Verfügung. Hier werden unsere Erfahrungen mit dem Einsatz intrabronchialer Ventilen bei Hochrisikopatienten mit persistierender BPF dargestellt. Material und Methoden Von April 2015 bis März 2017 wurden bei insgesamt 8 Patienten (n = 4 weiblich) mit komplikativem Pleuraempyem und begleitender Lungendestruktion, die eine persistierende BPF entwickelt hatten, intrabronchiale Ventile eingebracht. Die persistierende BPF konnte sowohl bronchoskopisch als auch CT-grafisch dargestellt werden. Die Ventile wurden via flexibler Bronchoskopie eingebracht. Bei n = 6 Patienten wurde aufgrund wiederholter Keimnachweise und persistierenden Infekten ein temporäres Thorakostoma angelegt. Ergebnisse Das mittlere Alter betrug 61 Jahre (45 – 85 Jahre). In allen Fällen konnte die BPF mit intrabronchialen Ventilen okkludiert werden. Nach erfolgreicher Infektsanierung wurden alle Thorakostomata verschlossen. Bei 1 Patientin musste eine Thorakoplastik durchgeführt werden. Zur Therapie der persistierenden BPFs wurden durchschnittlich n = 3 Ventile platziert (1 – 4 Ventile). Bei allen Patienten verlief die Ventilplatzierung komplikationsfrei. Thoraxdrainagen konnten bei ausbleibender Luftfistelung und radiologisch kompletter Entfaltung der Lunge nach durchschnittlich 7 Tagen (3 – 15 Tagen) entfernt werden. Der mittlere Krankenhausaufenthalt nach Ventilimplantation lag bei 10 Tagen (5 – 20 Tagen). Komplikationen traten auch in der Nachbeobachtung nicht auf. Bei 2 Patienten wurden die Ventile bereits nach 6 Monaten entfernt. Die nachfolgenden Kontrollen zeigten weiterhin eine komplette Entfaltung der Lunge. Alle Patienten leben bis dato. Schlussfolgerung Die intrabronchiale Ventilimplantation ist ein sicheres und wirksames Verfahren zur Behandlung von Patienten mit persistierender BPF auf dem Boden von rezidivierenden thorakalen Infekten mit begleitender Lungendestruktion. Insbesondere bei Patienten mit hohem operativem Risiko kann diese Therapie als Alternative zur chirurgischen Intervention mehr in Betracht gezogen werden.

Introduction: Small cell lung cancer makes up about 15 percent of all lung cancers. Extensive stage small cell lung cancer (ES-SCLC) carries a poor prognosis, and the thoracic progression is common. It is usually an aggressive cancer that tends to grow and spread quickly. Because of this, surgery is useful for very few patients with small cell lung cancer. Most people with limited-stage small cell lung cancer are treated with chemotherapy in combination with radiation therapy. Method: From 2010 to 2018 9 patients with SCLC very limited Disease was studied. From those there were 5 male with 67 and 4 female with 68 average years. In 3 patients we found stage IA1, one patient with stage IA2, one with IB, two with IIA and 2 patients with stage IIB. From 27 patients from 2010 to 2018 with limited disease there were 12 female (59 average years), 15 male with (68 average years). From those we found 7 patients with stage IIIA, 18 with stage IIIB and two with stage IIIC. The median survival time of patients with SCLC limited disease without OP was 29 months. The median survival time of 6 studied patients with SCLC limited disease with neoadjuvant chemotherapy with carboplatin and etoposide with and without combined radiotherapy and Follow up staging was 103 months. Discussion: Neoadjuvant chemotherapy with and without radiotherapy can significantly expand the median survival time of patients with SCLC limited disease. Further studies are needed with larger patient collective.

Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we first describe the application of low-flow venovenous extracorporeal CO2 removal (LFVV-ECCO2R) as bridge to LVRS in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute failure of the breathing pump. Between March and October 2015, n = 4 patients received single-site LFVV-ECCO2R as bridge to LVRS. Indication for extracorporeal lung support was severe hypercapnia with respiratory acidosis and acute breathing pump failure. Two patients required continuous mechanical ventilation over a temporary tracheostomy and were bed ridden. The other two patients were nearly immobile because of severe dyspnea at rest. Length of preoperative ECCO2R was 14 (1-42) days. All patients underwent unilateral LVRS. Anatomical resection of the right (n = 3) or left (n = 1) upper lobe was performed. Postoperatively, both patients with previous mechanical ventilatory support were successfully weaned. ECCO2R in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute breathing pump failure is a safe and effective bridging tool to LVRS. In such patients, radical surgery leads to a significant improvement of the performance status and furthermore facilitates respiratory weaning from mechanical ventilation.

Background Video-assisted thoracoscopic surgery (VATS) clipping of the sympathetic branch has become the standard approach for the treatment of essential hyperhidrosis when conservative treatment failed. However, this is associated with relevant potential complications such as postoperative compensatory sweating and recurrent sweating. We report the outcome after selective sympathectomy (ramicotomy) through a miniuniportal VATS approach in patients with therapy-refractory palmar and/or axillary hyperhidrosis. Methods A total of 51 consecutive patients (37 females, mean age: 30 years, range: 12–64 years) who suffered from therapy-refractory palmar and/or axillary severe hyperhidrosis were included. Data were prospectively collected and retrospectively analyzed. All patients underwent bilateral miniuniportal VATS ramicotomy. Duration of surgery, hospital stay, recurrent, and compensatory sweating were documented. Results All patients had palmar sweating, where 51% had additional axillary sweating and 57% had additional plantar sweating. In all patients, selective division of the rami communicantes of the thoracic sympathetic ganglions Th2 to Th5 was performed. The mean duration of bilateral surgery for both sides was 67 ± 2.5 minutes. The mean postoperative hospital stay was 2 ± 1 days. After surgery and at further follow-up (mean: 12 ± 2.5 months), all patients presented dry and warm hands and axillae, without any evidence of compensatory or recurrent sweating. All patients described a remarkable increase in quality of life. Conclusion Miniuniportal VATS ramicotomy represents a feasible surgical technique with a very high success and satisfaction rate. Therefore, this approach should be considered as the method of choice for the treatment of patients with severe therapy-refractory palmar and axillary hyperhidrosis.

Persistent air leak or bronchopleural fistula (BPF) is a challenging and frequently observed problem after pulmonary resection and may lead to prolonged chest tube therapy. One efficient nonsurgical approach to manage such a fistula is the application of intrabronchial valves. This may support earlier chest tube removal and hospital discharge.Between 04/2015 and 03/2017, n = 8 patients (n = 4 female) with severe pleural empyema and necrotising lung tissue defects developed prolonged air leak and persistent BPF after surgery. Radiological and bronchoscopical investigations revealed the presence of a BPF. For closure, intrabronchial valves were endoscopically inserted into the affected bronchi. In patients with repeat development of empyema, a chest wall window was required (n = 6 patients).The mean age was 61 years (45 - 85 years). After repeated surgical debridement, the space was sterile and the chest wall window was closed. After valve placement, air leaks were no longer detectable. In all patients, the procedures were well tolerated without any negative events. After successful valve placement, chest tubes could be removed in all n = 8 patients within 7 days (3 - 15 days) and patients were discharged thereafter.Placement of intrabronchial valves presents an alternative option to conventional surgical and non-surgical methods for the treatment of postoperative persistent air leak or BPF. Particularly in high risk patients, this procedure is safe and effective.Die chirurgische Therapie persistierender bronchopleuraler Fisteln (BPF) kann sich insbesondere aufgrund von rezidivierenden Infekten langwierig gestalten. Als Alternative zur chirurgischen Versorgung steht die intrabronchiale Ventilimplantation zur Verfügung. Hier werden unsere Erfahrungen mit dem Einsatz intrabronchialer Ventilen bei Hochrisikopatienten mit persistierender BPF dargestellt.Von April 2015 bis März 2017 wurden bei insgesamt 8 Patienten (n = 4 weiblich) mit komplikativem Pleuraempyem und begleitender Lungendestruktion, die eine persistierende BPF entwickelt hatten, intrabronchiale Ventile eingebracht. Die persistierende BPF konnte sowohl bronchoskopisch als auch CT-grafisch dargestellt werden. Die Ventile wurden via flexibler Bronchoskopie eingebracht. Bei n = 6 Patienten wurde aufgrund wiederholter Keimnachweise und persistierenden Infekten ein temporäres Thorakostoma angelegt.Das mittlere Alter betrug 61 Jahre (45 – 85 Jahre). In allen Fällen konnte die BPF mit intrabronchialen Ventilen okkludiert werden. Nach erfolgreicher Infektsanierung wurden alle Thorakostomata verschlossen. Bei 1 Patientin musste eine Thorakoplastik durchgeführt werden. Zur Therapie der persistierenden BPFs wurden durchschnittlich n = 3 Ventile platziert (1 – 4 Ventile). Bei allen Patienten verlief die Ventilplatzierung komplikationsfrei. Thoraxdrainagen konnten bei ausbleibender Luftfistelung und radiologisch kompletter Entfaltung der Lunge nach durchschnittlich 7 Tagen (3 – 15 Tagen) entfernt werden. Der mittlere Krankenhausaufenthalt nach Ventilimplantation lag bei 10 Tagen (5 – 20 Tagen). Komplikationen traten auch in der Nachbeobachtung nicht auf. Bei 2 Patienten wurden die Ventile bereits nach 6 Monaten entfernt. Die nachfolgenden Kontrollen zeigten weiterhin eine komplette Entfaltung der Lunge. Alle Patienten leben bis dato.Die intrabronchiale Ventilimplantation ist ein sicheres und wirksames Verfahren zur Behandlung von Patienten mit persistierender BPF auf dem Boden von rezidivierenden thorakalen Infekten mit begleitender Lungendestruktion. Insbesondere bei Patienten mit hohem operativem Risiko kann diese Therapie als Alternative zur chirurgischen Intervention mehr in Betracht gezogen werden.

The application of extracorporeal lung support (ECLS) in patients with acute respiratory distress syndrome is a well-established concept. In patients receiving ECLS therapy, hemodynamic monitoring is often required. However, less is known about the effect of ECLS on hemodynamic measurements. In the present work, the influence of single-site low-flow veno-venous ECLS (LFVV-ECLS) on hemodynamic monitoring by transpulmonary thermodilution (TPTD) was prospectively investigated. Five consecutive patients undergoing single-site LFVV-ECLS for severe hypercapnic respiratory failure were included in this study. For single-site LFVV-ECLS, a 22 Fr twin-port double-lumen cannula was inserted percutaneously into the right jugular vein. Hemodynamic monitoring was performed using the Pulse index Continuous Cardiac Output system. Before ECLS initiation, baseline measurements of cardiac index, systemic vascular resistance, mean arterial pressure, and extravascular lung water (EVLW) were performed. During the first 3 days of ECLS therapy, repeated hemodynamic measurements at different ECLS flow rates were performed. No significant differences were seen in hemodynamic measurements. With respect to EVLW, a significant decrease over the duration of ECLS therapy was observed. This study demonstrates that LFVV-ECLS does not interfere with TPTD. It needs to be further studied if these findings also apply to other ECLS modes.

Preoperative chemotherapy improves survival in patients with stage III non-small-cell lung cancer (NSCLC) amenable to resection. We aimed to assess the additional effect of preoperative chemoradiation on tumour resection, pathological response, and survival in these patients.Between Oct 1, 1995, and July 1, 2003, patients with stage IIIA-IIIB NSCLC and invasive mediastinal assessment from 26 participating institutions of the German Lung Cancer Cooperative Group (GLCCG) were randomly assigned to one of two treatment groups. The intervention group were scheduled to receive three cycles of cisplatin and etoposide, followed by twice-daily radiation with concurrent carboplatin and vindesine, and then surgical resection (those with positive resection margins or unresectable disease were offered further twice-daily radiotherapy). The control group were scheduled to receive three cycles of cisplatin and etoposide, followed by surgery, and then further radiotherapy. The primary endpoint was median progression-free survival (PFS) in patients eligible for treatment after randomisation. Secondary endpoints in patients eligible for treatment after randomisation were overall survival (OS) and the proportion of patients undergoing surgery. Secondary endpoints in patients with tumour resection were the proportion with negative resection margins, the proportion with complete resection, the proportion with histopathological response, and the proportion with mediastinal downstaging. Additionally, exploratory (not prespecified) post-hoc analyses in terms of PFS and OS were done on patients not amenable to resection and on further subgroups of patients undergoing resection. Analyses were by intention to treat. This trial is registered on the ClinicalTrials.gov website, number NCT 00176137.558 patients were randomly assigned. 34 patients did not meet inclusion criteria and were excluded. Of 524 eligible patients, 142 of 264 (54%) in the interventional group and 154 of 260 (59%) in the control group underwent surgery; 98 of 264 (37%) and 84 of 260 (32%) underwent complete resection. In patients with complete resection, the proportion of those with mediastinal downstaging (45 of 98 [46%] and 24 of 84 [29%], p=0.02) and pathological response (59 of 98 [60%] and 17 of 84 [20%], p0.0001) favoured the interventional group. However, there was no difference in PFS (primary endpoint) between treatment groups-either in eligible patients (median PFS 9.5 months, range 1.0-117.0 [95% CI 8.3-11.2] vs 10.0 months, range 1.0-111.0 [8.9-11.5], 5-year PFS 16% [11-21] vs 14% [10-19], hazard ratio (HR) 0.99 [0.81-1.19], p=0.87), in those undergoing tumour resection, or in patients with complete resection. In both groups, 35% of patients undergoing surgery received a pneumonectomy (50/142 vs 54/154). In patients receiving a pneumonectomy, treatment-related mortality increased in the interventional group compared with the control group (7/50 [14%] vs 3/54 [6%]).In patients with stage III NSCLC amenable to surgery, preoperative chemoradiation in addition to chemotherapy increases pathological response and mediastinal downstaging, but does not improve survival. After induction with chemoradiation, pneumonectomy should be avoided.German Cancer Aid (Bonn, Germany).

BACKGROUND AND OBJECTIVE The overall prognosis of patients with stage IIIA non-small-cell lung cancer is unfavourable (median survival time 12 months). Tolerance to and efficacity of a multimodal neoadjuvant treatment was assessed in a prospective study. PATIENTS AND METHODS 25 patients (median age 59 [37-69] years), with histologically confirmed mediastinal lymph node metastases, underwent chemotherapy. Immediately after two cycles with carboplatin/Ifosfamid (dimethoate)/etoposide they received hyperfractionated accelerated radiotherapy (45 Gy; 2 x 1.5 Gy daily) with simultaneous administration of carboplatin and vindesine. This was followed by tumour resection. RESULTS After conclusion of the neoadjuvant treatment 19 of 25 patients (76%) had a remission. Of the 20 operated patients complete resection (R0) was possible in 17 (85%) and 14 of the 20 patients with resection (70%) had histologically demonstrated marked tumour regression. Critical toxicity consisted of pneumonitis and bronchial stump problems. Median survival time of all patients was 24.8 months and for patients with R0 resection 35.9 months. CONCLUSION Neoadjuvant multimodal treatment of stage IIIA non-small-cell lung cancer can achieve prolongation in survival time. The place of radiotherapy or radiotherapy with chemotherapy in such a treatment concept will need to be defined in a randomized study.

Objectives Cytokine-based immunotherapy (IMT) is a first-line treatment for metastatic renal cell carcinoma (mRCC). Radical nephrectomy and interferon monotherapy were shown to prolong survival of patients with mRCC compared with interferon treatment alone. We prospectively compared the outcome of patients with mRCC who achieved partial remission (PR) under IMT with patients achieving PR under IMT, followed by complete resection of tumor residues. Methods From January 1997 to June 2003, 34 patients with mRCC were treated with IMT and achieved PR. Of these patients, 18 continued IMT until disease progression (group A). In 16 patients with PR, residual tumor tissue was surgically resected (group B). Surgical complications in group B and survival time were evaluated. Results All patients from group B achieved a surgical complete remission (sCR), which is ongoing in 6 of 16 patients. Tumor-related death has occurred in all patients from group A and in 9 of 16 patients from group B. Surgery post-IMT was not associated with intraoperative complications, wound infections, or prolonged postoperative stay. Median overall survival was 50 mo (range: 18–104) versus 58 mo (range: 9–104) for patients in groups A and B, respectively. Conclusions Median survival benefit after IMT and surgery compared with IMT alone was 8 mo for patients who achieved PR. The resection of tumor residues after PR under IMT seems to extend the long-term survival of patients with mRCC and should be attempted when surgically feasible.

Objectives Intraoperative extracorporeal lung support (ECLS) during thoracic surgical procedures is a modern concept that is gaining increasing acceptance. So far, cardiopulmonary bypass (CPB), veno-arterial extracorporeal membrane oxygenation (v-a-ECMO) or pumpless arterio-venous interventional lung assist (iLA) were utilized for intraoperative support. Only a few case reports have described the use of veno-venous ECMO for intraoperative ECLS. Here, we report our experience with intraoperative ECLS using different veno-venous low-flow and high-flow settings adapted to the individual patient requirements. Methods Between April 2014 and April 2015, 9 patients underwent pulmonary resections under ECLS. In 6 patients, a twin-port double-lumen cannula was inserted percutaneously into the right femoral vein for low-flow ECLS. In 3 patients, high-flow ECLS was achieved either by femoro-atrial (n = 1) or femoro-jugular cannulation. Results Indications for ECLS were severely impaired lung function (n = 3), previous pulmonary resections including contralateral pneumonectomy (n = 4), previous single-lung transplantation (sLTX) (n = 1) and extended carinal pneumonectomy (n = 1). Procedures included segmentectomy (n = 3), extended lobectomy with bronchial and vascular anastomoses (n = 1), VATS lobectomy (n = 2), extended left-sided carinal pneumonectomy (n = 1) as well as extended metastasectomy (n = 2). Low-flow ECLS allowed for apnoea up to 45 min in patients with previous pneumonectomy (n = 3) and facilitated protective single-lung ventilation in patients (n = 3) with severely impaired pulmonary function. During trans-sternal carinal pneumonectomy (n = 1), high-flow ECLS achieved by femoro-atrial cannulation allowed for apnoea for 40 min, avoiding cross-field ventilation. In 2 patients requiring extended metastasectomy after previous lobectomy of the contralateral lower lobe (n = 1) or pulmonary metastases in the graft after sLTX for end-stage fibrosis (n = 1), high-flow ECLS by percutaneous femoro-jugular cannulation allowed for extensive metastasectomy under optimal atelectasis of the lung. Conclusions For intraoperative ECLS, different modes may be applied depending on the intended procedures and required mechanical ventilation. In our experience, different settings of veno-venous ECLS provide sufficient partial or complete lung support, avoiding possible complications associated with other forms of extracorporeal support such as CPB or v-a-ECMO.

Objective: Multi-modality approaches are increasingly employed to improve prognosis in surgically treated stage III non-small cell lung cancer (NSCLC). Risk and benefit of the preoperative therapeutic chemotherapy or combined radiochemotherapy on surgical morbidity and mortality are still a matter of debate. Methods: In 1995, a national phase III trial was started to compare (arm A) preoperative chemotherapy followed by twice-daily chemoradiation and consecutive surgery, with (arm B) preoperative chemotherapy alone followed by surgery and consecutive radiotherapy. An interim analysis with 277 patients was performed to assess surgical risk and complication rates. Results: Of the 385 patients, 273 (71%) underwent thoracotomy, 130 (73%) in arm A and 143 (69%) in arm B. Of the 273 patients undergoing thoracotomy, 168 had stage IIIB disease. Complete resection (R0) was achieved in 212 patients (78%), 104 in arm A (80%) and 108 in arm B (76%) (PZ n.s.). There was no difference in the proportion of complex resections between treatment arms (41% in arm A; 48% in arm B). Whilst bronchial stump insufficiency (3.8 vs 2.1%) and bleeding requiring re-thoracotomy (1.5 vs 0.7%) prevailed slightly in arm A, the occurrence of pneumonia divided similar on both treatment arms (4.6 vs 4.9%). Surgical mortality reached 6.1% in arm A (8/130) and 5.6% in arm B (6/143) (PZn.s.). Conclusions: In both treatment arms, a similar percentage of patients could be forwarded to surgery, even in stage IIIB disease. Bimodality induction seems to be superior with regard to resection rates (R0) (n.s.), but was associated with a higher complication rate, especially bronchial stump insufficiency. q 2004 Elsevier B.V. All rights reserved.