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Abstract: Objective: To report on the experience with radical surgery, with emphasis on the long-term outcome, for malignant pleural mesothelioma (MPM) at a single institution. Methods: From our prospective database over a 17-year period, we reviewed 83 consecutive patients undergoing radical surgery for MPM in a multimodality programme. The long-term overall survival was analysed using the Kaplan–Meier method. Results: A total of 83 patients (65 males, median age: 60 years) underwent an extra-pleural pneumonectomy (EPP) with a curative intent. Epitheliod MPM was the most frequent (82%) cause. A right-sided disease was present in half of the cases (n =42). The International Mesothelioma Interest Group (IMIG) stage of the disease was 2 in 36%, 3 in 45% and 4 in 9% of the cases. Preoperative chemotherapy consisting of a doublet cisplatin–pemetrexed (mean of three cycles) was offered to 10 patients (12%). Postoperative therapies, either chemotherapy or radiotherapy, were given in 25 patients (30%). The 30-day and 90-day mortality rates were 4.8% and 10.8%, respectively. Postoperative complications occurred in 39.8% and were major in 23 patients (27.7%). Re-operation was necessary in 12 cases (14.5%) for one of the following reasons: broncho-pleural fistula (n =4), bleeding (n =3), diaphragmatic patch rupture (n =3), oesophago-pleural fistula (n =1) and empyaema (n =1). The mean hospital stay was 43 days. The median survival was 14.5 months, while the overall 1-, 2- and 5-year survival rates were 62.4%, 32.2% and 14.3%, respectively. Conclusions: These results concur with the published data of the most experienced centre with regards to the mortality and morbidity after EPP for MPM. In line with the biggest series reported in the past, the observed 5-year survival rate of almost 15% is disappointing. [Copyright &y& Elsevier]

Abstract: Objective: To identify the optimal debulking procedure in patients with malignant pleural mesothelioma who are not suitable for extrapleural pneumonectomy (EPP). Methods: We reviewed 102 consecutive patients (93 male; 9 female, mean age 63 years) who were not suitable for EPP because of either advanced tumour stage or suboptimal fitness. Patients underwent either a non-radical tumour decortication to obtain lung expansion (group NR) or latterly a radical pleurectomy/decortication to obtain macroscopic tumour clearance (group R). We analysed the comparative perioperative courses and long-term survival. Results: The two groups were similar for age and gender distribution but epithelioid type was more predominant in group R: 78% compared to 55% epithelioid in group NR. Thirty-day mortality was similar (5.9% in group R and 9.8% in the group NR, p =0.36) but 90-day mortality was significantly higher in the group NR (29.4% vs 9.8% in group R, p =0.012). More patients in group R received adjuvant chemotherapy (65% vs 28%, p =0.000) and radiotherapy (65% vs 26%, p =0.000). Median survival for all cell types was significantly higher in group R (15.3 months vs 7.1 months, p <0.000). Group R survival rates at 1, 2, 3 and 4 years were 53, 41, 25 and 13%, respectively while for group NR they were 32, 9.6, 2 and 0%, respectively. For epithelioid cell type there was still a significant median survival advantage in group R (25.4 months vs 10.2 months, p <0.000), but there was no difference for sarcomatoid (9.3 months vs 3.2 months, p =0.16) or biphasic cell types (9.4 months vs 7 months, p =0.38). Conclusion: If a patient with epithelioid MPM is fit enough to tolerate a thoracotomy then macroscopic clearance of the tumour is the preferred option as part of a multimodality regime including chemotherapy. [Copyright &y& Elsevier]

Abstract: Objective: T4-disease for non-small cell lung cancer (NSCLC) includes different conditions: mediastinal invasion, neoplastic pleural cytology, and multifocal disease in the same lobe; regarding the last category, no strict criteria allow to differentiate satellite nodules from synchronous multiple primary tumours. Methods: Retrospective study of 56 patients who underwent a complete resection from 1985 to 2006 of a NSCLC graded pT4N0 due to multifocal disease. A small nodule (<1cm) closed to the primary tumour, in a same pulmonary segment with an identical histology was considered as a satellite nodule (pT4sn). Multiple tumours, sized more than 1cm, with an identical histology, located in the same lobe but in different segment were considered as synchronous cancers (pT4sc). Results: There were 44 males and 12 females: 35 patients were graded T4sn and 21 patients T4sc. The median age was 62.5 years. The two groups were similar for sex, age, tobacco consumption, ASA score, NYHA, Charlson''s index, spirometric parameters, cardiovascular comorbidity and history of previous extra-thoracic malignancies. All had a complete anatomic resection with mediastinal lymphadenectomy. Thirty-day mortality rate was 3.6%. Overall 5-year and 10-year survival rates were 48.2% and 29.9%, respectively. There was a non-significant trend for a worse survival in T4sn group patients when compared to that of T4sc group patients: 42.9% vs 52.3% at 5 years, and 25% vs 34.9% at 10 years (p =0.62). Conclusions: Multifocal T4 stage IIIB disease is a heterogeneous category where overall prognosis is far better than those of other T4 subgroups. Survival rates associated with pT4sn and pT4sc look roughly similar because of the small size of the subgroups usually submitted to comparison in most series. In the present experience, respective survival figures diverge, suggesting different biological behaviours. [Copyright &y& Elsevier]

Although pain and dyspnoea are common symptoms in pleural diseases, there are few studies on the sensory innervation of the pleura. Using rabbits, after removal of all muscles in the intercostal space to be studied, we investigated the afferents of the internal intercostal nerve by applying to the internal thoracic wall pieces of gauze soaked in warmed (37°C), buffered saline (mechanical stimulation) or solutions containing lactic acid, inflammatory mediators or capsaicin (chemical stimulation). The afferent conduction velocity ranged from 0.5 to 14 m s−1. Most units (97%) were activated by mechanical stimulation of the pleura (local positive pressure range = 4.5–8.5 cmH2O) and we found a linear relationship between the discharge rate of afferents and the force applied to the thoracic wall. The majority of mechanosensitive units (70%) also responded to one or several chemical agents. Thus, the afferents were activated by lactic acid (49%) and/or a mixture of inflammatory mediators (50%). Local application of capsaicin elicited an initial increased or decreased background afferent activity in 57% of the afferents, a delayed decrease in firing rate being noted in some units initially activated by capsaicin. Capsaicin blocked the afferent response to a further application of inflammatory mediators but did not affect the mechanosensitive units. Thus, sensory endings connected with thin myelinated and unmyelinated fibres in the internal intercostal nerve detect the mechanical and chemical events of pleural diseases. [ABSTRACT FROM AUTHOR]

Background Acquired Tracheo-broncho-esophageal fistulae of the adult are uncommon, severe and require a complex management associating medical, endoscopic and surgical treatment. Methods From January 2013 to December 2017, we conducted a monocentric, retrospective study on the etiology, the diagnosis and the management of acquired tracheo-broncho-esophageal fistulae. Results During the last 5 years, 29 consecutive acquired tracheo-broncho-esophageal fistulae were diagnosed in our department (23 men and 6 women), of which 2 malignant fistulae. Sixteen appeared in the early postoperative period after esophagectomy (From 7 to 63 days), and two more later at post-operative day 150 and 154 days. The other 10 tracheo-broncho-esophageal fistulae had variable etiologies: post-radiation (5), traumatic (4), severe reflux. Clinical presentation were of variable severity as well. Six patients were asymptomatic, the fistula diagnosed on systematic radiological or endoscopic examinations. The other patients had respiratory and infectious symptoms, going from iterative pneumopathy to acute respiratory distress with septic shock. The management was complex and specific to each patient, but 3 situations can be described: 1. Endoscopic treatment (7) 2. Surgical treatment, more or less followed by an endoscopic treatment (7) 3. Multiple endoscopic treatment, followed by surgery (13). Regardless of the treatment, the mortality rate was extremely high, 12 patients out of 27 dying in the early follow-up (44,4%). Conclusion The incidence of acquired tracheo-broncho-esophageal fistulae seems to be increasing, especially after esophagectomy. Their treatment is different than from the usual anastomotic fistula. Multimodal management is associated with patient death in about half of the cases. Endoscopic treatment allows the stabilisation of patients in a precarious clinical situation, but where the immediate results can be satisfactory it can later on lead to chronic and harmful situations. Surgery remains the cornerstone of the treatment. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Despite an improvement in surgical abilities, the need for an intraoperative switch from a minimally invasive procedure towards an open surgery (conversion) still remains. To anticipate this risk, the Epithor conversion score (ECS) has been described for video-assisted thoracoscopic surgery (VATS). Our objective was to determine if this score, developed for VATS, is applicable in robotic-assisted thoracoscopic surgery (RATS). METHODS This was a retrospective monocentric study from January 2006 to June 2022, and data were obtained from the EPITHOR database. Patients included were those who underwent anatomic lung resection either by VATS or RATS. The ECS was calculated for all patients studied. Discrimination and calibration of the test were measured by the area under the curve and Hosmer–Lemeshow test. RESULTS A total of 1685 were included. There were 183/1299 conversions in the VATS group (14.1%) and 27/386 conversions in the RATS group (6.9%). Patients in the RATS group had fewer antiplatelet therapy and peripheral arterial disease. There were more segmentectomies in the VATS group. As for test discrimination, the area under the curve was 0.66 [0.56–0.78] in the RATS group and 0.64 [0.60–0.69] in the VATS group. Regarding the calibration, the Hosmer–Lemeshow test was not significant for both groups but more positive (better calibrated) for the VATS group (P  = 0.12) compared to the RATS group (P  = 0.08). CONCLUSIONS The ECS seems applicable for patients operated with RATS, with a correct discrimination but a lower calibration performance for patients operated with VATS. A new score could be developed to specifically anticipate conversion in patients operated on by RATS. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The aim of this study was to describe the epidemiology of patients undergoing diagnostic and/or curative surgical pulmonary resections for lung opacities suspected of being localized primary lung cancers without preoperative tissue confirmation. METHODS We performed a single-centre retrospective study of a prospectively implemented institutional database of all patients who underwent pulmonary resection between January 2010 and December 2020. Patients were selected when surgery complied with the Fleischner society guidelines. We performed a multivariable logistic regression to determine the preoperative variables associated with malignancy. RESULTS Among 1392 patients, 213 (15.3%) had a final diagnosis of benignancy. We quantified futile parenchymal resections in 29 (2.1%) patients defined by an anatomical resection of >2 lung segments for benign lesions that did not modified the clinical management. Compared with patients with malignancies, patients with benignancies were younger (57.5 vs 63.9 years, P  < 0.001), had lower preoperative risk profile (thoracoscore 0.4 vs 2.1, P  < 0.001), had a higher proportion of wedge resection (50.7% vs 12.2%, P  < 0.01) and experienced a lower burden of postoperative complication (Clavien–Dindo IV or V, 0.4% vs 5.6%, P  < 0.001). Preoperative independent variables associated with malignancy were (adjusted odd ratio [95% confident interval]) age 1.02 [1.00; 1.04], smoking (year-pack) 1.005 (1.00; 1.01), history of cardiovascular disease 2.06 [1.30; 3.30], history of controlled cancer 2.74 [1.30; 6.88] and clinical N involvement 4.20 [1.11; 37.44]. CONCLUSIONS Futile parenchymal lung resection for suspicious opacities without preoperative tissue diagnosis is rare (2.1%) while surgery for benign lesions represented 15.3% and has a satisfactory safety profile with very low postoperative morbi-mortality. [ABSTRACT FROM AUTHOR]

Objective: Despite recent advances in imaging and core or endoscopic biopsies, a percentage of patients have a major lung resection without diagnosis. We aimed to assess the feasibility of a rapid tissue preparation/analysis to discriminate cancerous from non-cancerous lung tissue. Methods: Fresh sample preparations were analyzed with the Microflex LTTM MALDI-TOF analyzer. Each main reference spectra (MSP) was consecutively included in a database. After definitive pathological diagnosis, each MSP was labeled as either cancerous or non-cancerous (normal, inflammatory, infectious nodules). A strategy was constructed based on the number of concordant responses of a mass spectrometry scoring algorithm. A 3-step evaluation included an internal and blind validation of a preliminary database (n = 182 reference spectra from the 100 first patients), followed by validation on a whole cohort database (n = 300 reference spectra from 159 patients). Diagnostic performance indicators were calculated. Results: 127 cancerous and 173 non-cancerous samples (144 peripheral biopsies and 29 inflammatory or infectious lesions) were processed within 30 minutes after biopsy sampling. At the most discriminatory level, the samples were correctly classified with a sensitivity, specificity and global accuracy of 92.1%, 97.1% and 95%, respectively. Conclusions: The feasibility of rapid MALDI-TOF analysis, coupled with a very simple lung preparation procedure, appears promising and should be tested in several surgical settings where rapid on-site evaluation of abnormal tissue is required. In the operating room, it appears promising in case of tumors with an uncertain preoperative diagnosis and should be tested as a complementary approach to frozen-biopsy analysis. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To review the long-term results of redo gastro-esophageal reflux disease (GERD) surgery with special emphasis on residual acid-suppressing medications, pH monitoring results, and quality of life. Methods: Retrospective analysis of 52 patients (24 males) who underwent redo GERD surgery between 1986 and 2006 through a transthoracic (n =14), or a transabdominal (n =38) approach. Indications were recurrent GERD in 41 patients, and complication of the initial surgery in 11. Quality of life was evaluated by telephone enquiry using a validated French questionnaire (reflux quality score, RQS). Results: Postoperative complications occurred in 18 patients (35%), resulting in one death (2%). Reoperation was required in seven patients. At 1 year, 26 patients (51%) had 24h pH monitoring, among whom 2 (8%) were proved to have recurrence of GERD. RQS values were calculated in 38 patients with a mean follow-up of 113 months. Fifty percent of this subgroup had a RQS value beyond 26/32, indicating an excellent quality of life. Among these 38 patients, 20 (53%) had acid-suppressing medications whatever their RQS values. Patients who underwent transthoracic GERD surgery had the highest RQS values (p =0.02), a lower rate of complications (p =0.06) and a lower rate of reoperation (p =0.04). Conclusion: Our experience confirms that selection of candidates for redo GERD surgery is a challenging issue. A transthoracic approach seems to produce better results and lower rates of complications. [Copyright &y& Elsevier]

• The number of octogenarians with an early-stage NSCLC almost doubled each 5-year interval of the study period. • The implementation of a dedicated geriatric pathway and the use of minimally invasive approaches were both associated with improved outcomes. • Overall survival was influenced by lower co-morbidity index, highest predicted postoperative DLCO values, and absence of diabetes mellitus. We investigated on the benefit/risk ratio of surgery in octogenarians with early-stage non-small cell lung cancer (NSCLC). From 2005–2020, 100 octogenarians were operated on for a clinical stage IA to IIA NSCLC. All patients had undergone whole body PET -scan and brain imaging. Operability was assessed according to current guidelines regarding the cardiopulmonary function. Since 2015, patients followed a dedicated geriatric evaluation pathway. Minimally invasive approaches were used in 66 patients, and a thoracotomy in 34. Clavien-Dindo grade ≥ 4 complications occurred in 15 patients within 90 days, including 7 fatalities. At multivariable analysis, the number of co-morbidities was their single independent prognosticator. Following resection, 24 patients met pathological criteria for adjuvant therapy among whom 3 (12.5 %) received platinum-based chemotherapy. Five-year survival rates were overall (OS) 47 ± 6.3 %, disease-free (DFS) 77.6 ± 5.1 %, and lung cancer-specific (CSS) 74.7 ± 6.3 %. Diabetes mellitus impaired significantly long-term outcomes in these 3 dimensions. OS was improved since the introduction of a dedicated geriatric assessment pathway (72.3 % vs. 6.4 %, P = 0.00002), and when minimally invasive techniques were used (42.3 % vs. 11.3 %; P = 0.02). CSS was improved by the performance of systematic lymphadenectomy (55.3 % vs. 26.9 %; P = 0.04). Multivariable and recursive partitioning analyses showed that a decision tree could be built to predict overall survival on the basis of diabetes mellitus, high co-morbidity index and low ppoDLCO values. The introduction of a dedicated geriatric assessment pathway to select octogenarians for lung cancer surgery was associated with OS values that are similar to outcomes in younger patients. The use of minimally invasive surgery and the performance of systematic lymphadenectomy were also associated with improved long-term survival. Octogenarians with multiple co-morbid conditions, diabetes mellitus, or low ppo DLCO values may be more appropriately treated with SBRT. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

OBJECTIVES: It has been suggested that laparoscopic Ivor Lewis (IL) oesophagectomy reduces postoperative morbidity and mortality rates. However, data related to the long-term outcomes of this hybrid minimally invasive procedure are scarce. METHODS: All of the patients who had an IL oesophagectomy for cancer were extracted from a prospective database. Patients were matched one to one according to the surgical approach (laparoscopy versus laparotomy) and on the basis of a propensity score including eight variables: age, gender, American Society of Anaesthesiologists score, forced expiratory volume in 1 s, surgery (first-line treatment, after neoadjuvant treatment and salvage surgery), histology, location and pathological stage. The first end point was the assessment of the 5-year survival and disease-free survival rates. The secondary end points were R0 resection rate, number of resected lymph nodes (LNs) and patterns of recurrence. RESULTS: Over a 12-year period, 272 IL oesophagectomies were performed. A total of 140 patients were matched in two homogeneous groups: laparotomy (n = 70) and laparoscopy (n = 70). The 5-year overall survival and disease-free survival rates were 65% and 48% in laparotomy group and 73% and 51% in the laparoscopy group (P = 0.891; P = 0.912). R0 resection rates were, respectively, 93% vs 97% (P = 0.441). The number and distribution of resected LNs were similar between the groups except at the level of the celiac axis (P < 0.001). Depending on the surgical approach, the patterns of recurrence were similar in both groups. CONCLUSIONS: Laparoscopic IL oesophagectomy does not compromise the long-term oncological outcome compared to open IL oesophagectomy. The quality of the operations is similar for both techniques except for the number of resected LNs at the level of the celiac trunk. Further randomized controlled trials are necessary to confirm these results. [ABSTRACT FROM AUTHOR]

Background: Pre-therapeutic pathological diagnosis is a crucial step of the management of pulmonary nodules suspected of being non small cell lung cancer (NSCLC), especially in the frame of currently implemented lung cancer screening programs in high-risk patients. Based on a human ex vivo model, we hypothesized that an embedded device measuring endogenous fluorescence would be able to distinguish pulmonary malignant lesions from the perilesional lung tissue. Methods: Consecutive patients who underwent surgical resection of pulmonary lesions were included in this prospective and observational study over an 8-month period. Measurements were performed back table on surgical specimens in the operative room, both on suspicious lesions and the perilesional healthy parenchyma. Endogenous fluorescence signal was characterized according to three criteria: maximal intensity (Imax), wavelength, and shape of the signal (missing, stable, instable, photobleaching). Results: Ninety-six patients with 111 suspicious lesions were included. Final pathological diagnoses were: primary lung cancers (n = 60), lung metastases of extra-thoracic malignancies (n = 27) and non-tumoral lesions (n = 24). Mean Imax was significantly higher in NSCLC targeted lesions when compared to the perilesional lung parenchyma (p<0,0001) or non-tumoral lesions (p<0,0001). Similarly, photobleaching was more frequently found in NSCLC than in perilesional lung (p<0,0001), or in non-tumoral lesions (p<0,001). Respective associated wavelengths were not statistically different between perilesional lung and either primary lung cancers or non-tumoral lesions. Considering lung metastases, both mean Imax and wavelength of the targeted lesions were not different from those of the perilesional lung tissue. In contrast, photobleaching was significantly more frequently observed in the targeted lesions than in the perilesional lung (p≤0,01). Conclusion: Our results demonstrate that endogenous fluorescence applied to the diagnosis of lung nodules allows distinguishing NSCLC from the surrounding healthy parenchyma and from non-tumoral lesions. Inconclusive results were found for lung metastases due to the heterogeneity of this population. [ABSTRACT FROM AUTHOR]

Purpose: A specific biomarker of post-ARDS fibroproliferation could be useful in the identification of patients who could benefit from therapies aiming to modulate fibroproliferation such as corticosteroids.The aim of this prospective study was to determine the best threshold of the N-terminal-peptidetype III procollagen (NT-PCP-III) in non-resolving ARDS to validate this threshold according to the outcome. Methods: Concerning the best threshold of NT-PCP-III, all consecutive patients with a non-resolving ARDS were included if all the following criteria were fulfilled: moderate to severe ARDS lasting for at least 5 days, lung biopsy performed, serum and alveolar NT-PCP-III obtained within 1 week prior to biopsy, and no documented infection contra-indicating the corticosteroids. In the validation cohort part of the study, patients were included at day 7 if they presented a persistent moderate to severe ARDS. Results: Nineteen of 32 patients had fibroproliferatio nonbiopsy. Serum and alveolar NT-PCP-III were higher in patients with fibroproliferation. Using a threshold of 9 µg/L, alveolar NT-PCP-III had the highest accuracy for diagnosing fibroproliferation (sensitivity = 89.5 % and specificity = 92.3 %). Regarding the 51 patients included in the validation cohort, the mortality rate at day 60 was increased in patients presenting an alveolar NT-PCP-III level higher than 9 µg/L (69 vs. 17 %, p < 0.001). The mean alveolar level of NT-PCP-III on day 7 was 8.1-fold higher in nonsurvivors ( p = 0.03). Conclusions: The determination of NT-PCP-III on BAL done at day 7 in persistent ARDS is able to identify patients with fibroproliferation who could be included in a trial of corticosteroids or any other treatment that might help resolve lung fibroproliferation. [ABSTRACT FROM AUTHOR]

OBJECTIVES Recent studies have suggested that postoperative complications could have a potential negative effect on long-term outcome after oesophagectomy for cancer. Because respiratory failures represent the most frequent postoperative complication, we have investigated the prognostic impact of these complications on disease-free survival (DFS). METHODS From a prospective single-institution database of 405 consecutive patients who underwent transthoracic oesophagectomy for cancer, we retrospectively analysed medical charts of all patients with microscopically complete resection (R0, n = 384 patients). Complications were graded according to the modified Clavien classification. Respiratory complications were defined as atelectasis, pneumonia or acute respiratory distress syndrome in the absence of early surgical complications. Patients with grade 5 (postoperative mortality, n = 43, 11%) were excluded from the analysis. The remaining 341 patients were analysed for estimation of DFS according to the Kaplan–Meier method. Logistic regression analysis was conducted to discriminate predictive factors affecting DFS. RESULTS According to the modified Clavien classification, postoperative complications rates were grade 0: 147 (44%), grade 1: 7 (2%), grade 2: 56 (16%), grade 3: 69 (20%) and grade 4: 62 (18%). Five-year DFS rates were not significantly different between grade 0 (no complication, 38%, n = 147) and other grades (grade 1, 2, 3 and 4 (64, 45, 56 and 48%, respectively)). Respiratory complications occurred in 107 patients (31%) and the 5-year DFS in this subgroup was 47% compared with 38% observed in grade 0 patients (P = 0.75). Clavien classification and respiratory complications did not come out in the univariate analysis of factors affecting DFS. On logistic regression, only two variables affected DFS: c-N stage and extracapular lymph node involvement. CONCLUSIONS When postoperative mortality is excluded, postoperative complications do not affect DFS in patients with complete resection. This deserves substantial information regarding the prognosis of subgroup of patients in critical situations where incrementing intensive care is debated. [ABSTRACT FROM AUTHOR]

OBJECTIVE Malnutrition is common after oesophageal cancer surgery. This study aims to investigate body mass index (BMI) kinetics and the risk factors of malnutrition among 1-year disease-free survivors after radical transthoracic oesophagectomy for cancer. METHODS From a prospective single-institution database, 118 1-year disease-free survivors having undergone a R0 transthoracic oesophagectomy with gastric tubulization between 2000 and 2008 were identified retrospectively. BMI values were collected at the onset of the disease (pre-treatment BMI), at the time of surgery (preoperative BMI), at postoperative 6 months and 1 year after oesophagectomy (1-year BMI). Logistic regression was performed with adjustment for confounders to estimate odds ratios of the factors associated with a 1-year weight loss (WL) of at least 15% of the pre-treatment body weight (BW). RESULTS At the onset of the disease, 5 patients (4%) were underweighted (BMI < 8.5 kg/m²), 65 (55%) were normal (BMI = 18.5–24.9 kg/m²), 36 (31%) were overweighted (BMI > 25 kg/m²) and 12 (10%) were obese (BMI > 30 kg/m²). Mean pre-treatment, preoperative, postoperative 6-month and 1-year BMI values were 24.64 ± 4 kg/m², 23.55 ± 3.8 kg/m², 21.7 ± 3 kg/m² and 21.97 ± 4 kg/m², respectively. One-year WL ≥ 15% of the pre-treatment BW was present in 29 patients (25%): 18 among the 48 patients (37%) with a pre-treatment BMI ≥ 25 and 11 among the 70 patients (15%) with pre-treatment BMI < 25 (P = 0.006). On logistic regression, initial overweighting was the sole independent prognosticator of 1-year postoperative WL of at least 15% of the pre-treatment BW (P = 0.039; OR: 2.96, [1.06–8.32]). CONCLUSIONS Postoperative malnutrition remains a severe problem after oesophageal cancer resection, even in long-term disease-free survivors. Overweight and obese patients are the segment population most exposed to this postoperative malnutrition, suggesting that such surgery could have substantial bariatric effect. A special vigilance programme on the nutritional status of this sub-group of patients should be the rule. [ABSTRACT FROM AUTHOR]

Background: Hypertonic saline may be administered in the setting of lung transplantation but may affect the development of ischemia–reperfusion lung injury. This study investigated the effects of the pre-treatment by intravenous hypertonic saline in a pig model of single lung ischemia–reperfusion. Methods: Forty-three pigs (34 ± 4 kg) under mechanical ventilation were randomly assigned to a left lung ischemia–reperfusion alone or preceded by 4-ml/kg 7.5% hypertonic saline, 33-ml/kg normal saline, or by the infusion of the vasodilator nicardipine. Animals without ischemia served as controls. After euthanasia, the left lung was sampled for histologic analysis and measurement of lung water and alveolar–capillary permeability. Results: Ischemia–reperfusion resulted in high-permeability pulmonary edema, hypoxemia, and increased interleukin-6 serum level. Hypertonic saline pre-treatment worsened pulmonary edema of the left lung (6.6 ± 0.7 vs 4.8 ± 0.8 ml/kg of body weight, p < 0.05) and resulted in a higher ratio of the protein level in the alveolar fluid to the serum protein level (0.41 ± 0.04 vs 0.21 ± 0.09, p < 0.05) and in a higher histologic damage score (11 [range, 9–11.75] vs 6.5 [range, 4.5–7.5], p < 0.05) without promoting pulmonary or systemic inflammation. Lung injury was affected neither by normal saline nor by nicardipine pre-treatment. Nicardipine did not influence the deleterious effect of hypertonic saline. Conclusions: Pre-treatment by intravenous hypertonic saline worsened ischemia–reperfusion lung injury independently of its effects on the cardiac index or pulmonary circulation but probably through a direct effect of hyperosmolarity on endothelial permeability. [Copyright &y& Elsevier]

Abstract: Objective: Controversy continues over the optimal extent of lymphadenectomy for the surgical treatment of Adenocarcinoma of the oesophagus. Methods: From 1996 to 2003, 102 transthoracic en-bloc esophagectomy were performed for adenocarcinoma. Based on the 1994 consensus conference of the International Society of Disease of Esophagus, 35 patients underwent standard lymphadenectomy whereas 67 underwent extended lymphadenectomy. Mortality, morbidity and long-term survival were reviewed in each group. Results: Extended lymphadenectomy increased the number of resected lymph nodes and improved the healthy/invaded lymph node ratio. It allowed to detect skip nodal metastasis in 36.4% of the N+ patients. Morbidity was higher following extended lymphadenectomy, with respect to pulmonary complications, and blood transfusions requirement (P=0.04). However, operative mortality was similar in both groups (9 vs. 11%). Overall disease-free survival was 28% at 5 years. Median of survival was higher in N0 than in N+ patients (55 months vs. 20 months; P=0.02). Extended lymphadenectomy was associated with an improving of disease-free survival when compared to standard lymphadenectomy (41 vs. 10% at 5 years; P&#60;0.05), especially in the subgroup of patients with a N0 disease (median of survival 44 months vs. 17 months; P=0.001). Based on multivariable analyses, predictive factors of recurrence affecting disease free-survival were the pT status (P=0.02), standard lymphadenectomy (P=0.05) and extracapsular lymph node involvement (0.04). Conclusions: These results indicate that extended 2-field lymphadenectomy is an important component of the surgical treatment of patients with adenocarcinoma of the oesophagus. It increases the likelihood of proper staging and affects patient outcome, while it does not enhance the operative mortality. However, extended lymphadenectomy increases non-fatal morbidity, especially the incidence of pulmonary complications and the need for blood transfusion. [Copyright &y& Elsevier]

OBJECTIVES The high mortality rate observed on the regular waiting list (RWL) before lung transplantation (LTx) prompted the French organ transplantation authorities to set up in 2007 a dedicated graft allocation strategy, the so-called ‘high-emergency waiting list’ (HEWL), for patients with an abrupt worsening of their respiratory function. This study reports on the early results of this new allocation system. METHODS Among 11 active French LTx programmes, 7 were able to provide full outcome data by 31 December 2011. The medical records of 101 patients who were listed on the HEWL from July 2007 to December 2011 were reviewed for an intention-to-treat analysis. RESULTS Ninety-five patients received LTx within a median waiting time on the HEWL of 4 days (range 1–26), and 6 died before transplantation. Conditions were cystic fibrosis (65.2%), pulmonary fibrosis (24.8%), emphysema (5%) and miscellaneous (5%). The median age of the recipient was 30 years (range 16–66). Patients listed on the HEWL came from the RWL in 48.5% of the cases and were new patients in 51.5%. Forty-nine were placed under invasive ventilation and, in 26 cases, extracorporeal membrane oxygenation (ECMO) prior to transplantation was necessary as a complementary treatment. ECMO for non-intubated patients was performed in 6 cases. Eighty-one bilateral and 14 single LTx were performed, with an overall in-hospital mortality rate of 29.4%. One- and 3-year survival rates were 67.5 and 59%, respectively. Multivariate analysis shows that the use of ECMO prior to transplantation was the sole independent mortality risk factor (hazard ratio = 2.77 [95% CI 1.26–6.11]). CONCLUSIONS The new allocation system aimed at lowering mortality on the RWL, but also offered an access to LTx for new patients with end-stage respiratory failure. The HEWL increased the likelihood of mortality after LTx, but permitted acceptable mid-term survival rates. The high mortality associated with the use of ECMO should be interpreted cautiously. [ABSTRACT FROM AUTHOR]

OBJECTIVES The 7th edition of American Joint Committee on Cancer (AJCC) staging system of oesophageal cancer and gastro-oesophageal junction has re-staged positive nodes into N1–3 according to the number of invaded lymph nodes (LNs). However, this new classification does not consider the potential negative impact of the extracapsular breakthrough on survival. This study aims at assessing prognosis according to whether LN involvement is intracapsular (ICLNI) or extracapsular (ECLNI) on disease-free survival (DFS) among the three sub-groups of LN-positive patients. METHODS Four hundred and sixteen consecutive R0 patients who underwent transthoracic oesophagectomy for cancer between 1996 and 2011 were retrospectively re-classified using the latest AJCC TNM classification. Among them, 230 (55%) patients have received a neoadjuvant chemoradiotherapy. Prognostic impact of ICLNI and ECLNI on DFS was assessed according to their new LN status. Multivariate analysis was drawn to determine factors affecting DFS. RESULTS Among the 416 patients, there were 138 (33%) patients with positive LN: 79 (57%) with ICLNI and 59 (43%) with ECLNI. The proportion of ECLNI was 21 of 73 (28%), 21 of 41 (51%) and 17 of 24 (70%) in N1, N2 and N3 patients, respectively. In N1 patients, median DFS was 48 months in ICLNI and 13 months in ECLNI (P = 0.068). In N2 patients, median DFS was 19 months in ICLNI and 9 months in ECLNI (P = 0.07). In N3 patients, median DFS was not reached in ICLNI and was 6 months in ECLNI (P = 0.002). On multivariate analysis, the ECLNI (P < 0.001, hazard ratio, HR: 2.51) and the post-T stage (P = 0.03, HR: 1.62) were the two independent factors affecting DFS. CONCLUSIONS Based on our limited study population, the existence of an ECLNI seems to have an additive negative impact on DFS, regardless of the pN stage. This suggests that extracapsular breakthrough status should be added to the new TNM staging system. This information has to be validated by further investigations. [ABSTRACT FROM AUTHOR]