Video assisted thoracoscopic thyroidectomy for retrosternal goitre

INTRODUCTION

Thyroidectomy for retrosternal goitre is usually carried out through a cervical incision. Around 4-12% of patients, however, require an extracervical approach, usually by sternotomy. Anatomically, the thyroid extends deep behind the great vessels in the pretracheal fascia. A sternotomy is therefore not only a substantial incision but this anterior approach is also not ideal for exposure. We report the use of video assisted thoracoscopic surgery (VATS) instead of a sternotomy or thoracotomy in conjunction with a transverse cervical incision for these patients.

METHODS

A retrospective descriptive study was carried out of seven patients with retrosternal goitre who underwent a VATS thyroidectomy.

RESULTS

Twenty-one patients with retrosternal goitre were referred to our institution for surgical excision with the anticipation of requiring an extracervical incision. Of these, seven (median age: 68 years, range: 58-73 years) underwent a VATS thyroidectomy. The median operating time was 218 minutes (range: 120-240 minutes). The median diameter of the retrosternal goitre was 70 mm (range: 40-145 mm). Only one patient required conversion to a manubriotomy to deliver the bulky thyroid and one patient suffered a transient right recurrent laryngeal nerve palsy. The median postoperative pain scores for days 0 and 1 were 1 (range: 0-5) and 0 (range: 0-3) respectively. The median length of stay was 5 days (range: 3-7 days).

CONCLUSIONS

The use of VATS in thyroidectomy for retrosternal goitre offers a minimally invasive approach resulting in less morbidity while affording excellent exposure. </sec>

The need for thoracic surgery in adult patients receiving extracorporeal membrane oxygenation: a 16-year experience

Objectives:

Patients on extracorporeal membrane oxygenation (ECMO) are at risk from thoracic complications such as bleeding or pneumothorax, which may subsequently necessitate thoracic surgical intervention. We aimed to: 1) analyse the indication and nature of thoracic surgical intervention in these patients and 2) analyse the effect of a change in the ECMO circuit from roller pump to centrifugal pump on transfusion requirements pre and post thoracotomy.

Methods:

We retrospectively reviewed a prospectively collected database of 569 adults put on ECMO between 1995 and 2011. Patients undergoing thoracotomy were identified and outcomes were statistically analysed.

Results:

Forty thoracotomies were performed in 18 patients [61% male, median age 31 (14-56) years, one bilateral procedure]. The indications for ECMO included: pneumonia 14/18 (78%), trauma 2/18 (11%) and other 2/18 (11%). Median duration on ECMO was 13 (1–257) days and the time to initial thoracotomy was 10 (1-183) days. The indications for thoracotomy were: excessive bleeding post chest drain insertion (11/19, 58%), uncontrolled air leak (9/19, 47%) and pleural effusion (4/19, 21%). The primary operations were 12/19 (63%) evacuation of haemothorax, 3/19 (16%) lung repair, 2/19 (11%) diagnostic lung biopsy and 2/19 (11%) other. Ten patients needed a further 21 thoracotomies (3 lobectomies); average 2 (1-5) per patient. In total, 30/40 (75%) thoracotomies were performed for bleeding complication. The change from roller to centrifugal pump trended towards a reduction in mean transfusion requirements in these patients following thoracotomy (11.5 versus 4 units, p=0.14). The in-hospital mortality was 7/18 (39%) patients. There were no statistically significant predictors of poor outcome.

Conclusions:

The need for thoracotomy whilst on ECMO is 3.2% in this large series. Intervention may be complicated, thus, either ECMO specialists should have thoracic training or thoracic surgeons should be on-site. Potential mortality is high and, although not statistically significant, a difference in transfusion requirements was observed following the change of circuit.

Macrophages within NSCLC tumour islets are predominantly of a cytotoxic M1 phenotype associated with extended survival

There is a marked survival advantage for patients with nonsmall cell lung cancer (NSCLC) expressing high numbers of macrophages in their tumour islets. The primary aim of the present study was to determine the immunological phenotype of NSCLC-associated macrophages. CD68(+) macrophages expressing markers of a cytotoxic M1 phenotype or a noncytotoxic M2 phenotype were identified in the islets and stroma of surgically resected tumours from 20 patients with extended survival (median 92.7 months) and 20 with poor survival (median 7.7 months), using immunohistochemistry. The islet density of both M1 and M2 macrophages was markedly increased in extended compared with poor survival patients. In the extended survival group, M1 islet density was significantly increased compared with M2 density, 70% of islet macrophages were positive for M1 markers versus 38% for M2, and the islet:stromal ratio of M1 macrophages was markedly increased compared with M2. The 5-yr survival for patients with above and below median expression of M1 macrophages in the islets was >75 and <5%, respectively. Macrophages infiltrating the tumour islets in nonsmall cell lung cancer were predominantly of the M1 phenotype in patients with extended survival. The survival advantage conferred by islet macrophage infiltration may be related to their cytotoxic antitumour activity.

EGFR expression: associations with outcome and clinicopathological variables in malignant pleural mesothelioma

Malignant mesothelioma (MM) is a fatal tumour of increasing incidence which is related to asbestos exposure. This work evaluated expression in MM of Epidermal Growth Factor Receptor (EGFR) by immunohistochemistry in 168 tumour sections and its correlations with clinicopathological and biological factors. The microvessel density (MVD) was derived from CD34 immunostained sections. Hematoxylin and eosin stained sections were examined for intratumoural necrosis. COX-2 protein expression was evaluated with semi-quantitative Western blotting of homogenised tumour supernatants (n=45). EGFR expression was correlated with survival by Kaplan-Meier and log rank analysis. Univariate and multivariate Cox proportional hazards models were used to compare the effects of EGFR with clinicopathological and biological prognostic factors and prognostic scoring systems. EGFR expression was identified in 74 cases (44%) and correlated with epithelioid cell type (p<0.0001), good performance status (p<0.0001), the absence of chest pain (p<0.0001) and the presence of TN (p=0.004), but not MVD or COX-2. EGFR expression was a good prognostic factor in univariate analysis (p=0.01). Independent indicators of poor prognosis in multivariate analysis were non-epithelioid cell type (p=0.0001), weight loss, performance status and WBC>8.3x10(9)L(-1). EGFR status was not an independent prognostic factor. EGFR expression in MM correlates with epithelioid histology and TN. EGFR may be a target for selective therapies in MM.

Chemotherapy versus supportive care in advanced non-small cell lung cancer: improved survival without detriment to quality of life

BACKGROUND

In 1995 a meta-analysis of randomised trials investigating the value of adding chemotherapy to primary treatment for non-small cell lung cancer (NSCLC) suggested a small survival benefit for cisplatin-based chemotherapy in each of the primary treatment settings. However, the meta-analysis included many small trials and trials with differing eligibility criteria and chemotherapy regimens.

METHODS

The aim of the Big Lung Trial was to confirm the survival benefits seen in the meta-analysis and to assess quality of life and cost in the supportive care setting. A total of 725 patients were randomised to receive supportive care alone (n = 361) or supportive care plus cisplatin-based chemotherapy (n = 364).

RESULTS

65% of patients allocated chemotherapy (C) received all three cycles of treatment and a further 27% received one or two cycles. 74% of patients allocated no chemotherapy (NoC) received thoracic radiotherapy compared with 47% of the C group. Patients allocated C had a significantly better survival than those allocated NoC: HR 0.77 (95% CI 0.66 to 0.89, p = 0.0006), median survival 8.0 months for the C group v 5.7 months for the NoC group, a difference of 9 weeks. There were 19 (5%) treatment related deaths in the C group. There was no evidence that any subgroup benefited more or less from chemotherapy. No significant differences were observed between the two groups in terms of the pre-defined primary and secondary quality of life end points, although large negative effects of chemotherapy were ruled out. The regimens used proved to be cost effective, the extra cost of chemotherapy being offset by longer survival.

CONCLUSIONS

The survival benefit seen in this trial was entirely consistent with the NSCLC meta-analysis and subsequent similarly designed large trials. The information on quality of life and cost should enable patients and their clinicians to make more informed treatment choices.

Experience with video-assisted surgery for suspected mediastinal tumours

AIM

To assess the therapeutic feasibility of video-assisted thoracoscopic surgery (VATS) in the excision of suspected mediastinal tumours.

METHODS

The case notes of 24 consecutive patients referred to a single surgeon between 1997 and 2002 for excision of suspected mediastinal tumours were reviewed. The operative, post-operative and pathological characteristics of patients treated thoracoscopically and by open procedure were analysed.

RESULTS

Thirteen of 24 patients underwent thoracoscopic excision. The mean age of the two groups was similar as was the mean operating time and duration of chest drainage. However, patients in the thoracoscopic group had less chest drainage, less pain and a shorter hospital stay.

CONCLUSIONS

Video-assisted thoracoscopic excision of mediastinal tumours is a safe and technically feasible procedure and may offer significant post-operative advantages over open procedures.

A prospective audit evaluating the role of video-assisted cervical mediastinoscopy (VAM) as a training tool☆

OBJECTIVE

Cervical mediastinoscopy is an important diagnostic and staging technique. Limited operative field and visibility have traditionally made it a difficult procedure to learn and supervise. Video-assisted techniques can aid training in the procedure. We designed a prospective study to assess the usefulness of video-assisted mediastinoscopy (VAM) as a training tool.

METHODS

43 patients were operated upon by two trainees during their initial formation in general thoracic surgery (25 patients in 15 months, and 18 patients in 9 months, respectively).

INDICATIONS

staging (n = 23), diagnosis of enlarged mediastinal nodes (n = 14) and diagnosis/staging (n = 6). End-points of the study: operative time, need of consultant assistance during procedures, and ability of the trainee to identify all nodal stations independently.

RESULTS

There were no complications. The mean operative time was 29 (range 18-51) min. Valid histological samples were obtained in all cases. There were no false negative results in the 13 patients who underwent subsequent lung resection (sensitivity 100%). Operative time (R2 = 0.83 and 0.77), need for consultant assistance (R2 = 0.98 and 0.94), and failure to independently reach all nodal stations (R2 = 0.95 and 0.94) significantly decreased with experience in both trainees' cases (cubic curve fit; P < 0.001 throughout).

DISCUSSION

VAM permits a rapid learning and adequate supervision of the technique without compromising safety, operative time or completeness of the procedure. The main advantages are: increased visual field, image magnification, adequate light source and the ability to use two instruments simultaneously. VAM should be the technique of choice in thoracic surgical teaching units.

The case for routine cervical mediastinoscopy prior to radical surgery for malignant pleural mesothelioma

OBJECTIVES

To assess whether cervical mediastinoscopy is necessary before radical resection of malignant pleural mesothelioma (MPM).

METHODS

Patients who underwent radical excision of MPM in a 48-month period were prospectively followed for evidence of disease recurrence and death. Histological evidence of extra pleural lymph node metastases was correlated with survival. Lymph node size at intraoperative lymphadenectomy was correlated with the presence of metastatic tumour.

RESULTS

The 55 patients who underwent radical resection (51 extra pleural pneumonectomies and 4 radical pleurectomies) comprised 50 men and 5 women with a median age of 58 years, range 41-70. Histological examination revealed 50 epithelioid, four biphasic and one sarcomatoid histology. Postoperative IMIG T stage was stage I 4, II 11, III 30 and IV 10. Postoperatively the 17 patients with metastases to the extra pleural lymph nodes had significantly shorter survival (median 4.4 months, 95% CI 3.2-5.4) than those without (median survival 16.3 months, 95% CI 11.6-21.0) P=0.012 Kaplan-Meier analysis. Seventy-seven extra pleural lymph nodes without metastases were measured with a mean long axis diameter of 16.9 mm (range 4-55); 22 positive nodes had a mean long axis diameter of 15.2 mm (range 6-30). In 15 of the 17 patients with positive extra pleural nodes, the nodes could have been biopsied at cervical mediastinoscopy.

CONCLUSIONS

This study confirms that extra pleural nodal metastases are related to poor survival. Pathological nodal involvement cannot be predicted from nodal dimensions. These data suggest that all patients being considered for radical resection of MPM should preferentially undergo preoperative cervical mediastinoscopy irrespective of radiological findings.

Postoperative pain detracts from early health status improvement seen after video-assisted thoracoscopic lung volume reduction surgery☆

OBJECTIVES

To assess the impact of lung volume reduction surgery (LVRS) on postoperative pain.

METHODS

Fifty-two patients, 34 male/18 female, median age 59 (46-70) years, underwent unilateral video-assisted thoracoscopic (VAT) LVRS. FEV(1), TLC, RV and RV/TLC ratio were assessed preoperatively and at 3, 6, 12 and 24 months post surgery. At the same time interval health status was assessed by Euroquol and SF 36 questionnaires.

RESULTS

Significant improvements in health status, as assessed by SF 36, persisted from 3 months to 1 year. However, in the pain domain there was a worsening of the mean score from 74 preoperatively to 64 at 3 months, 68 at 6 months, 73 at 12 months and 65 at 24 months. The improvements in Euroquol score were not statistically significant. However, they became significant for at least 2 years postoperatively, when those patients who had a worsening pain score postoperatively were excluded. While the percentage of patients with a worsening of pain scores measured with SF 36 remained between 40 and 45% even 2 years after LVRS, when using Euroquol this percentage did decrease from 30% at 3 months to 14% at 2 years. There was no significant correlation between the change of scores and length of operation, hospital stay or air leak. It was also not statistically significant whether these patients had an extra procedure (redo thoracotomy or insertion of extra drain postoperatively). There were some significant correlations between changes in hyperinflation and changes in pain scores but this was not consistent for Euroquol and SF 36.

CONCLUSION

Postoperative pain detracts from global improvement in health status after LVRS even after unilateral VATS. There may be an influence of alterations in chest mechanics after surgery on the development of pain.

En-bloc chest wall and lung resection for non-small cell lung cancer. Predictors of 60-day non-cancer related mortality

OBJECTIVE

Predictors for early mortality after isolated pulmonary resection have been identified and clear guidelines regarding fitness for surgery have been produced. However, the additional risk of en-bloc chest wall resection has not been extensively studied.

AIM

We analyzed our total experience of combined chest wall and lung resection for non-small-cell lung cancer (NSCLC) to identify additional risk factors for early non-tumour related mortality.

PATIENTS AND METHODS

A retrospective review of 41 consecutive patients, with median age of 69 (range 37-84) years, operated by a single surgeon over a 4-year period. Univariate analysis was performed to assess the relationship of selected preoperative and operative variables on mortality within 2 months from surgery.

RESULTS

Low preoperative body mass index, age over 75 years, and preoperative FEV(1) of less than 70% of predicted were associated with a significantly increased 60-day mortality. In those patients with any of these risk factors 60-day mortality was 47% (8 of 17). In those with none of the above there was no mortality (of 24 patients) (P=0.0004).

DISCUSSION

En-bloc pulmonary and chest wall resection for NSCLC should be avoided in the elderly, those with limited respiratory reserve or significant weight loss. These factors render the patient highly susceptible to chest complications leading to increased mortality.

Matrix metalloproteinases 2 and 9 (gelatinases A and B) expression in malignant mesothelioma and benign pleura

Matrix metalloproteinases (MMPs), in particular the gelatinases (MMP-2 and -9), play a significant role in tumour invasion and angiogenesis. The expression and activities of MMPs have not been characterised in malignant mesothelioma (MM) tumour samples. In a prospective study, gelatinase activity was evaluated in homogenised supernatants of snap frozen MM (n=35), inflamed pleura (IP, n=12) and uninflammed pleura (UP, n=14) tissue specimens by semiquantitative gelatin zymography. Matrix metalloproteinases were correlated with clinicopathological factors and with survival using Kaplan-Meier and Cox proportional hazard models. In MM, pro- and active MMP-2 levels were significantly greater than for MMP-9 (P=0.006, P<0.001). Active MMP-2 was significantly greater in MM than in UP (P=0.04). MMP-2 activity was equivalent between IP and MM, but both pro- and active MMP-9 activities were greater in IP (P=0.02, P=0.009). While there were trends towards poor survival with increasing total and pro-MMP-2 activity (P=0.08) in univariate analysis, they were both independent poor prognostic factors in multivariate analysis in conjunction with weight loss (pro-MMP-2 P=0.03, total MMP-2 P=0.04). Total and pro-MMP-2 also contributed to the Cancer and Leukemia Group B prognostic groups. MMP-9 activities were not prognostic. Matrix metalloproteinases, and in particular MMP-2, the most abundant gelatinase, may play an important role in MM tumour growth and metastasis. Agents that reduce MMP synthesis and/or activity may have a role to play in the management of MM.

Lung volume reduction surgery – a comparison of the long term outcome of unilateral vs. bilateral approaches

OBJECTIVE

Bilateral lung volume reduction surgery (LVRS) is thought to be preferable to unilateral surgery due to greater initial benefit but the subsequent rate of decline may also be greater. We compared the long term physiological and health status outcome of LVRS performed on one or simultaneously on both lungs.

METHODS

Prospective data were collected on a consecutive series of 65 patients undergoing LVRS who were all suitable for bilateral surgery. Twenty-six patients: age 59 (8) years underwent bilateral LVRS by video-assisted thoracoscopy (VAT) or sternotomy and 39 patients: age 60 (6) years underwent unilateral VAT. The perioperative effects of LVRS on spirometry were prospectively recorded at 3, 6, 12 and 24 months.

RESULTS

The unilateral group had similar preoperative lung volumes to the bilateral patients: forced expiratory volume in 1s (FEV(1)) 26 vs. 30% predicted, RV 275 vs. 246% predicted and total lung capacity (TLC) 148 vs. 142% predicted. Unilateral LVRS was associated with significantly lower weight of lung resected: 80 (31) vs. 118 (46) g; hospital stay: 16 (10) days vs. 28 (22) days. Thirty-day mortality was 3% in the unilateral and 8% in the bilateral group (P=0.34). Postoperative ventilation occurred in 5% in the unilateral and in 42% in the bilateral group (P=0.0002). The decline of FEV(1) during the first postoperative year was significant in the bilateral group (-313 ml/y, P=0.04) but not significant in the unilateral group (-50 ml/y, P=0.18). SF 36 scores in all eight domains were similar in both groups preoperatively and at any postoperative interval.

CONCLUSION

We have found no benefit from bilateral simultaneous LVRS and prefer unilateral LVRS because of the lower morbidity, resulting in earlier discharge, and slower decline in physiological benefit.

Can pneumonectomy for non-small cell lung cancer be avoided? An audit of parenchymal sparing lung surgery

BACKGROUND

Lung cancer resection rates are suboptimal in the UK. Pneumonectomy has a higher perioperative mortality risk than lobectomy. To increase resection rates and improve outcomes we have implemented a policy of parenchymal sparing surgery for tumours involving a main stem bronchus.

METHODS

In a prospective 4 year study of 119 consecutive patients operated upon by a single surgeon the perioperative course, pathology and survival were compared for 81 patients undergoing pneumonectomy and 38 patients in whom pneumonectomy was avoided by bronchoplastic+/-angioplastic procedures.

RESULTS

The rate of pneumonectomy decreased significantly with increasing experience with parenchymal sparing surgery (R(2)=0.98, P<0.001) with 21 of the last 30 patients (70%) avoiding pneumonectomy. There were no significant inter-group differences in patient characteristics, perioperative course or outcome. One-year survival was 64% after pneumonectomy and 73% after sleeve lobectomy. However the perioperative loss of respiratory function was significantly lower in the patients in whom pneumonectomy was avoided (P=0.0003).

CONCLUSIONS

Pneumonectomy can be avoided in a large proportion of patients with non-small cell lung cancer of a main stem bronchus without adversely affecting outcome but with preservation of lung function

Surgery for non-small cell lung cancer--new trends

New trends in lung cancer surgery focus on new approaches to the management of the primary tumour, combined modality approaches to both local and distant control of the tumour, new approaches to ensure resectability by staging and techniques to expand the limits of operability. With new screening methods for NSCLC there is a trend toward sublobar, segmental resections of smaller tumours including an expanding use of video assisted thoracoscopy. Improvements in surgical and anaesthetic procedures have stimulated a renewed interest in the resection of locally advanced tumours. The understanding that local control alone may not give the best chance of long term survival has stimulated new trends in the use of neoadjuvant and adjuvant chemotherapy. There is a trend towards more detailed preoperative and intraoperative nodal staging in NSCLC, including video assisted techniques, and the identification of sentinel lymph node involvement to direct lymph node dissection. Increased understanding of the physiological benefits of surgery in emphysema have resulted in a re-evaluation of the selection of patients for lung cancer surgery. This together with a greater application of bronchoplastic and angioplastic techniques is leading to greater resection rates.

Palliative surgical debulking in malignant mesothelioma. Predictors of survival and symptom control

OBJECTIVE

Malignant mesothelioma (MM) typically presents at an advanced stage. In the UK surgical intervention has been mostly reserved for tissue diagnosis or chemical pleurodesis. However, the role of debulking surgery in symptom control has not been fully explored.

METHODS

In a prospective cohort study, 51 consecutive patients presenting with MM underwent palliative surgical debulking for symptomatic relief (all patients presented with dyspnoea, 39 also had pain and two had a co-existing pleural empyema). Patients with early disease who underwent extrapleural pneumonectomy were excluded. The treatment aims were pleural drainage, lung re-expansion, pleurodesis and pleural debulking for symptom control. If the lung re-expanded after drainage of the effusion a subtotal parietal pleurectomy was performed via Video Assisted Thoracic Surgery (VATS). If the lung remained entrapped, a parietal and visceral decortication using VATS or thoracotomy was performed. The changes in subjective dyspnoea and pain scores were recorded at 6 weeks and 3, 6 and 12 months after surgery. Prognostic factors were analyzed to determine their influence on survival and symptom control.

RESULTS

VATS pleurectomy was possible in 17 patients (34%), whilst decortication was required in the remainder (three by VATS and 31 by thoracotomy). Median postoperative stay was 7 days (range 2-17) with 30-day mortality of 7.8% (four of 51 patients). Morbidity included postoperative empyema in two patients (4%) and prolonged air-leak in five (9.8%). Overall significant symptomatic benefit was obtained up to 3 months after surgery but subsequently increasing mortality offset these benefits. Epithelial cell type and absence of weight loss prior to surgery were found to predict longer survival and successful symptom control.

CONCLUSIONS

Debulking surgery has a beneficial role in symptom control for unresectable MM. However, this surgery should be reserved for those patients who present with epithelial cell type and before significant loss of weight.

Delayed referral reduces the success of video-assisted thoracoscopic debridement for post-pneumonic empyema

The aim of this study was to evaluate the effect of preoperative delay on the efficacy of video-assisted thoracoscopic surgery (VATS) for post-pneumonic pleural empyema (PPE). This was a prospective study of 39 consecutive patients with PPE who were treated by VATS with curative intent over a 4-year period. Failure to obtain full lung re-expansion resulted in conversion to thoracotomy. Pre- and post-operative variables were correlated with surgical outcome. VATS debridement was successful in 16 (41%) patients while conversion to open decortication was needed in 23 patients (21 immediate, two delayed), There was no difference in the age/sex distribution of the two groups. In the failed VATS group the delay from hospital admission to operation was longer: 24 (2.1) vs. 16.6 (2.7) days (P = 0.03, 95% CI 0.53-14.3 days); operating time was longer: 128.2 (7.9) vs. 86.2 (10.4) min (P = 0.003, 95% CI 15.2-68.5 min) and post-operative stay was longer: 8.4 (0.8) vs. 5.2 (0.6) days (P = 0.03, 95% CI 1.1-5.3 days). VATS can be used successfully to treat PPE with a faster post-operative recovery when successful than open surgery. Delayed surgical intervention decreases the success of VATS thus earlier referral for surgical intervention in PPE (ideally within 21 days) is advocated to gain its full benefits.

Lobar volume reduction surgery: a method of increasing the lung cancer resection rate in patients with emphysema

BACKGROUND

Guidelines on patient selection for lung cancer resection identify a predicted postoperative forced expiratory volume in 1 second (ppoFEV(1)) of <40% as a predictor of high risk. Experience with lung volume reduction surgery suggests that ppoFEV(1) may be underestimated in those with concomitant emphysema.

METHODS

Anatomical lobectomy was performed in 29 patients with a resectable lung cancer within a poorly perfused, hyperinflated emphysematous lobe identified by radionuclide perfusion scintigraphy and computed tomographic scanning. Perioperative changes in spirometric parameters at 3 months were compared in 14 patients (group A) of mean age 69 years (range 48-78) with ppoFEV(1) <40% (mean (SD) 31.4 (7)%) and 15 patients (group B) with ppoFEV(1) >40% (mean (SD) 47 (5)%). The correlation between predicted and actual postoperative FEV(1) was also assessed.

RESULTS

In group B there was a significant perioperative reduction in FEV(1) (p=0.01) but in group A FEV(1) did not change significantly after lobectomy (p=0.87); mean difference in perioperative change between groups A and B 331 ml (95% CI 150 to 510). Despite the difference in ppoFEV(1) between the groups, there was no difference in actual FEV(1) at 3 months. In-hospital mortality was 14% in group A and zero in group B, but at a median follow up of 12 (range 6-40) months there was no difference in survival between the groups.

CONCLUSIONS

Selection for lung cancer resection in patients with emphysema using standard calculations of ppoFEV(1) may be misleading. The effect of lobar volume reduction allows for an extension of the selection criteria.

Post-pneumonectomy video-assisted thoracoscopic bullectomy using extra-corporeal membrane oxygenation

We describe a case of a patient who, 14 years after a pneumonectomy, required surgery for a life-threatening air-leak following accidental intubation of an emphysematous bulla in his remaining lung. To facilitate treatment by video-assisted thoracoscopic surgery, veno-venous extra-corporeal membrane oxygenation was employed.

Angiogenesis is an independent prognostic factor in malignant mesothelioma

Angiogenesis is essential for tumour growth beyond 1 to 2 mm in diameter. The clinical relevance of angiogenesis, as assessed by microvessel density (MVD), is unclear in malignant mesothelioma (MM). Immunohistochemistry was performed on 104 archival, paraffin-embedded, surgically resected MM samples with an anti-CD34 monoclonal antibody, using the Streptavidin-biotin complex immunoperoxidase technique. 93 cases were suitable for microvessel quantification. MVD was obtained from 3 intratumoural hotspots, using a Chalkley eyepiece graticule at x 250 power. MVD was correlated with survival by Kaplan-Meier and log-rank analysis. A stepwise, multivariate Cox model was used to compare MVD with known prognostic factors and the EORTC and CALGB prognostic scoring systems. Overall median survival from the date of diagnosis was 5.0 months. Increasing MVD was a poor prognostic factor in univariate analysis (P = 0.02). Independent indicators of poor prognosis in multivariate analysis were non-epithelial cell type (P = 0.002), performance status > 0 (P = 0.003) and increasing MVD (P = 0.01). In multivariate Cox analysis, MVD contributed independently to the EORTC (P = 0.006), but not to the CALGB (P = 0.1), prognostic groups. Angiogenesis, as assessed by MVD, is a poor prognostic factor in MM, independent of other clinicopathological variables and the EORTC prognostic scoring system. Further work is required to assess the prognostic importance of angiogenic regulatory factors in this disease.

A biological staging model for operable non-small cell lung cancer

BACKGROUND

Currently the best prognostic index for operable non-small cell lung cancer (NSCLC) is the TNM staging system. Molecular biology holds the promise of predicting outcome for the individual patient and identifying novel therapeutic targets. Angiogenesis, matrix metalloproteinases (MMP)-2 and -9, and the erb/HER type I tyrosine kinase receptors are all implicated in the pathogenesis of NSCLC.

METHODS

A retrospective analysis of 167 patients with resected stage I–IIIa NSCLC and >60 days postoperative survival with a minimum follow up of 2 years was undertaken. Immunohistochemical analysis was performed on paraffin embedded sections for the microvessel marker CD34, MMP-2 and MMP-9, EGFR, and c-erbB-2 to evaluate the relationships between and impact on survival of these molecular markers.

RESULTS

Tumour cell MMP-9 (HR 1.91 (1.23–2.97)), a high microvessel count (HR 1.97 (1.28–3.03)), and stage (stage II HR 1.44 (0.87–2.40), stage IIIa HR 2.21 (1.31–3.74)) were independent prognostic factors. Patients with a high microvessel count and tumour cell MMP-9 expression had a worse outcome than cases with only one (HR 1.68 (1.04–2.73)) or neither (HR 4.43 (2.29–8.57)) of these markers. EGFR expression correlated with tumour cell MMP-9 expression (p<0.001). Immunoreactivity for both of these factors within the same tumour was associated with a poor prognosis (HR 2.22 (1.45–3.41)).

CONCLUSION

Angiogenesis, EGFR, and MMP-9 expression provide prognostic information independent of TNM stage, allowing a more accurate outcome prediction for the individual patient. The development of novel anti-angiogenic agents, EGFR targeted therapies, and MMP inhibitors suggests that target specific adjuvant treatments may become a therapeutic option in patients with resected NSCLC.

A biological staging model for operable non-small cell lung cancer

BACKGROUND

Currently the best prognostic index for operable non-small cell lung cancer (NSCLC) is the TNM staging system. Molecular biology holds the promise of predicting outcome for the individual patient and identifying novel therapeutic targets. Angiogenesis, matrix metalloproteinases (MMP)-2 and -9, and the erb/HER type I tyrosine kinase receptors are all implicated in the pathogenesis of NSCLC.

METHODS

A retrospective analysis of 167 patients with resected stage I-IIIa NSCLC and >60 days postoperative survival with a minimum follow up of 2 years was undertaken. Immunohistochemical analysis was performed on paraffin embedded sections for the microvessel marker CD34, MMP-2 and MMP-9, EGFR, and c-erbB-2 to evaluate the relationships between and impact on survival of these molecular markers.

RESULTS

Tumour cell MMP-9 (HR 1.91 (1.23-2.97)), a high microvessel count (HR 1.97 (1.28-3.03)), and stage (stage II HR 1.44 (0.87-2.40), stage IIIa HR 2.21 (1.31-3.74)) were independent prognostic factors. Patients with a high microvessel count and tumour cell MMP-9 expression had a worse outcome than cases with only one (HR 1.68 (1.04-2.73)) or neither (HR 4.43 (2.29-8.57)) of these markers. EGFR expression correlated with tumour cell MMP-9 expression (p<0.001). Immunoreactivity for both of these factors within the same tumour was associated with a poor prognosis (HR 2.22 (1.45-3.41)).

CONCLUSION

Angiogenesis, EGFR, and MMP-9 expression provide prognostic information independent of TNM stage, allowing a more accurate outcome prediction for the individual patient. The development of novel anti-angiogenic agents, EGFR targeted therapies, and MMP inhibitors suggests that target specific adjuvant treatments may become a therapeutic option in patients with resected NSCLC.

Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema

BACKGROUND

We evaluated a technique of video-assisted thoracoscopic (VAT) decortication of the visceral cortex to reexpand entrapped lung in cases of chronic postpneumonic pleural empyema.

METHODS

A prospective cohort study of 48 consecutive patients with multiloculated postpneumonic pleural empyema in whom visceral pleural decortication was required was studied. The effect of VAT decortication on perioperative outcome and factors affecting its success were assessed.

RESULTS

Before the introduction of VAT decortication 12 patients were treated by thoracotomy (group T). In the subsequent 36 patients VAT decortication was attempted with success in 21 (group VS) but lung expansion was not observed in 15 patients (group VF) who required thoracotomy. There was no difference in the age or sex distribution of the 3 groups. Operating time was significantly longer in group T than group VS, mean difference 30.3 minutes (p = 0.001) and postoperative hospital stay was longer in group T than group VS, mean difference 2.9 days (p = 0.004). The success of VAT decortication was not related to either the delay between onset of symptoms or hospital admission and surgery; indeed the operating time decreased with increasing preoperative delay. However, success was related to increasing operative experience (p = 0.001).

CONCLUSIONS

VAT decortication is a feasible new technique to achieve lung reexpansion in chronic postpneumonic pleural empyema and has perioperative benefits over thoracotomy.

Metalloptysis: a late complication of lung volume reduction surgery

We describe three cases where patients expectorated titanium staples many months after lung volume reduction surgery (LVRS). The possible mechanisms and technical implications of this rare complication are discussed.

Prognostic factors for malignant mesothelioma in 142 patients: validation of CALGB and EORTC prognostic scoring systems

BACKGROUND

The incidence of malignant mesothelioma is increasing. There is the perception that survival is worse in the UK than in other countries. However, it is important to compare survival in different series based on accurate prognostic data. The European Organisation for Research and Treatment of Cancer (EORTC) and the Cancer and Leukaemia Group B (CALGB) have recently published prognostic scoring systems. We have assessed the prognostic variables, validated the EORTC and CALGB prognostic groups, and evaluated survival in a series of 142 patients.

METHODS

Case notes of 142 consecutive patients presenting in Leicester since 1988 were reviewed. Univariate analysis of prognostic variables was performed using a Cox proportional hazards regression model. Statistically significant variables were analysed further in a forward, stepwise multivariate model. EORTC and CALGB prognostic groups were derived, Kaplan-Meier survival curves plotted, and survival rates were calculated from life tables.

RESULTS

Significant poor prognostic factors in univariate analysis included male sex, older age, weight loss, chest pain, poor performance status, low haemoglobin, leukocytosis, thrombocytosis, and non-epithelial cell type (p<0.05). The prognostic significance of cell type, haemoglobin, white cell count, performance status, and sex were retained in the multivariate model. Overall median survival was 5.9 (range 0-34.3) months. One and two year survival rates were 21.3% (95% CI 13.9 to 28.7) and 3. 5% (0 to 8.5), respectively. Median, one, and two year survival data within prognostic groups in Leicester were equivalent to the EORTC and CALGB series. Survival curves were successfully stratified by the prognostic groups.

CONCLUSIONS

This study validates the EORTC and CALGB prognostic scoring systems which should be used both in the assessment of survival data of series in different countries and in the stratification of patients into randomised clinical studies.

Video-assisted thoracoscopic surgery for spontaneous pneumothorax--a 7-year learning experience

OBJECTIVES

To determine the effect of increasing experience of video-assisted thoracoscopic surgery (VATS) in the treatment of spontaneous pneumothorax (SP) on clinical efficacy and surgical practice.

PATIENTS AND METHODS

A prospective study of 180 consecutive operations in 173 patients who underwent VATS for SP by a single surgeon during a 7 year period.

RESULTS

118 patients, mean age 32.1 years (range 13-63 years), were treated for primary spontaneous pneumothorax (PSP) while 55 patients, mean age 65.9 years (range 28-92 years), were treated for secondary spontaneous pneumothorax (SSP). All patients had VAT parietal pleurectomy combined in 162 (90%) patients with stapled bullectomy. At a current median experience of 2.0 years (range 0.4-6.8 years), 12 (6.6%) patients required reoperation for treatment failures within 12 months of surgery--9 patients within 30 days of VATS and 3 for late recurrent pneumothorax. Two patients (both with SSP) died within 30 days of surgery. When compared with PSP, VATS in SSP is characterized by an elderly, male predominance, a longer postoperative stay, a higher mortality rate and a lower rate of late recurrence. With increasing experience of the technique, there has been a significant decrease in treatment failures. In the treatment of PSP, both operating time and postoperative stay have decreased significantly with experience whilst the use of staple cartridges per patient has increased significantly with experience in both PSP and SSP.

CONCLUSION

There is a demonstrable 'learning curve' effect on the clinical efficacy and surgical practice of video assisted thoracoscopic surgery for spontaneous pneumothorax.

A physiological comparison of flutter valve drainage bags and underwater seal systems for postoperative air leaks

BACKGROUND

A study was undertaken to compare the relative physiological effects of underwater seal (UWS) versus flutter valve (FV) pleural drainage systems in the treatment of postoperative air leaks.

METHOD

Fourteen patients with air leaks of 1-11 days duration, following lobectomy (n = 5), bullectomy (n = 4), decortication (n = 4), and pleural biopsy (n = 1) were analysed. Intrapleural pressure (IPP) measurements were made using an in-line external strain gauge connected directly to the intercostal tube. Patients were connected simultaneously to both UWS and FV drainage systems and pressures were measured sequentially, isolating each system in turn. Maximum (IPPmax) and minimum (IPPmin) intrapleural pressures were calculated from graphic traces. The degree of lung expansion was recorded by chest radiography.

RESULTS

At resting tidal volume IPPmax was significantly higher with the UWS system (mean difference 0.8 mm Hg, 95% CI 0 to 1.6, p = 0.046) and IPPmin was significantly lower with the FV system (1.8 mm Hg, 95% CI 0.3 to 3.3, p = 0.023). The lung was fully expanded in 50% of patients at the time of study. The mean difference in IPPmin between systems was significantly increased when the lung was fully expanded (mean 2.8 mm Hg, 95% CI 0.1 to 5.5, p = 0.042). The mean difference in IPPmax was not affected by the degree of lung expansion (0.79, 95% CI -0.83 to 2.4, p = 0.31).

CONCLUSION

The results of this study suggest that, when postoperative air leak exists without a persistent pleural space, the flutter valve may provide a physiologically more effective alternative to the underwater seal drainage system.

Academic outcome in long-term survivors of pediatric liver transplantation

Fifty long-term (3-9 year) survivors of pediatric liver transplantation were assessed using IQ, achievement, and school history measures. Forty-seven of these children had been evaluated before transplantation on intellectual measures, with mean scores for the group found to be in the low average range. At follow-up evaluation, the scores remained in the low average range on all intellectual measures; performance on academic tests was also within the low average range. Thirteen children (26%) were classified as having learning problems based on discrepancies between intellectual and academic function, but only five of them (38%) had received special education services. Nine of the children (18%) had IQ scores less than 70. Academic outcome did not relate to diagnosis, time between diagnosis and transplantation, age at time of transplantation, or average levels of cyclosporin A. Careful assessment and appropriate special education services are indicated to optimize the educational outcome of children who survive liver transplantation.

Psychiatric illness and family support in children and adolescents with diabetic ketoacidosis: a controlled study

OBJECTIVE

To compare compliance, psychiatric disorders, and family support in children with insulin-dependent diabetes mellitus (IDDM) hospitalized with diabetic ketoacidosis (DKA) and clinic controls.

METHOD

Twenty-five youths hospitalized with DKA and 25 matched outpatient subjects with IDDM with no history of DKA during the preceding year were assessed cross-sectionally, using the Diagnostic Interview Schedule for Children, measures of general and diabetes-specific family functioning, and measures of self-esteem and social competence. Levels of glycosylated hemoglobin and information about compliance with the treatment regimen were obtained.

RESULTS

A significantly higher number of psychiatric disorders was observed in the hospitalized children, with 88% meeting criteria for at least one disorder (versus 28% of controls). Self-esteem and social competence were lower in the hospitalized group, and their families scored lower on problem-solving and diabetes-specific "warmth-caring."

CONCLUSIONS

Children with recurrent DKA may be at greater risk of associated psychopathology than diabetic controls with no such history. DKA children's reports of noncompliance may be more sensitive than their parents' reports, and their families may lack warm, caring parent-child relationships.

Delayed referral reduces the success of video-assisted thoracoscopic surgery for spontaneous pneumothorax

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is now the generally preferred surgical treatment for spontaneous pneumothorax but is more difficult once pleural adhesions have developed. To test the hypothesis that VATS is under-used because of prolonged pleural intubation, we have audited the effect of preoperative management on subsequent surgical outcome.

METHOD

Data are expressed as median (range). A prospective audit of clinical outcome in 42 consecutive patients (30 male, 12 female, aged 39 [19-81] years) referred to a Regional Unit for non-elective pneumothorax surgery. VATS was attempted whenever possible.

RESULTS

VATS was successful in 32 patients (group V) but 10 (24%) patients (group T) required thoracotomy and decortication of an empyema thoracis. Only seven (17%) patients were operated upon within 7 days of presentation, and 10 patients (24%) waited for more than 21 days. The delay from presentation to operation was significantly longer in group T (22 days vs. 10 days, P < 0.05, Wilcoxon). There were significantly more preoperative pleural interventions in patients in group T than in group V (P < 0.05, Wilcoxon). Postoperative stay was longer in group T (7 days vs. 3 days, P < 0.05) and there was a significant overall correlation between preoperative delay and postoperative stay (r = 0.64).

CONCLUSION

Delayed referral for pneumothorax surgery and multiple pleural interventions predispose to pleural sepsis and preclude VATS detrimentally affecting clinical outcome. Changes in referral practice are advocated.

Video-assisted thoracoscopy in the evaluation of penetrating thoracic trauma

The management of patients who present with penetrating thoracic trauma but are haemodynamically stable may be subjective and imprecise. We report our initial experience with the use of video-assisted thoracoscopy in a series of five patients in whom accurate assessment was achieved and unnecessary thoracotomy avoided.