PubMed Posts

Introduction: Pleurectomy/decortication (P/D) in the treatment of malignant pleural mesothelioma includes a number of procedures with different clinical indications and therapeutic intents. To unify the nomenclature, IMIG and IASLC recently defined P/D-related procedures according to surgical technique, including ‘extended P/D’, ‘P/D’ and ‘partial pleurectomy’. The present systematic review aimed to assess the safety and efficacy of these techniques.

Methods: A systematic review of relevant studies was performed by electronic search of five online databases from 1985 to 2012 by two independent reviewers according to predefined selection criteria.

Results: Thirty-four studies involving 1916 patients who underwent pleurectomy were included for quantitative analysis. These included 12 studies on ‘extended P/D’, 8 studies on ‘P/D’ and 14 studies on ‘partial pleurectomy’. Perioperative mortality ranged from 0% to 11% and perioperative morbidity ranged from 13% to 43%. Median overall survival ranged from 7.1 to 31.7 months and disease-free survival ranged from 6 to 16 months. One study reported on quality-of-life outcomes using a standardized questionnaire suggesting superior outcomes for ‘extended P/D’ compared to extrapleural pneumonectomy.

Conclusions: Results of the present systematic review suggested similar perioperative mortality outcomes between different P/D techniques but a trend towards higher morbidity and length of hospitalization for patients who underwent ‘extended P/D’. However, overall and disease-free survival appeared to favour ‘extended P/D’ compared to less aggressive techniques. Future studies on P/D should adhere to recent definitions to enable accurate analysis of similar procedures. Direct comparisons of pleurectomy to extrapleural pneumonectomy remain challenging, and should be restricted to ‘extended P/D’ procedures only.

Objectives: Comparative long-term survival and oncological outcomes for patients with non-small-cell lung cancer (NSCLC) who undergo video-assisted thoracic surgery (VATS) or conventional open lobectomy remain uncertain. We conducted a multi-institutional propensity-matched study to stratify potential differences in these outcomes.

Methods: We established a multi-institutional registry for 4312 patients with NSCLC who underwent lobectomy between 2001 and 2008 from eight institutions in the People’s Republic of China. Age, gender, histological type and tumour staging were entered into a non-parsimonious multivariable logistic regression model to assess long-term survival outcomes. The predicted probability derived from the logistic equation was used as the propensity score for each individual. Based on similar propensity scores, we matched 1458 of the 1700 patients who underwent VATS lobectomy with 1458 of the 2612 patients who underwent open lobectomy and compared their long-term survival outcomes.

Results: The mean age of the 2916 matched patients was 59 (standard deviation = 11) years. After propensity-matching, VATS and open lobectomy patients were similar in regards to important prognostic variables. Three prognostic factors were independently associated with improved survival in the multivariate analysis: age < 60 (P < 0.001), female gender (P = 0.013) and pathological staging (P < 0.001). Patients who underwent VATS vs open lobectomy had similar long-term survival (P = 0.07).

Conclusions: The current propensity score analysis suggests that well-matched patients with NSCLC who underwent standardized VATS lobectomy had similar long-term survival outcomes when compared with those who underwent open lobectomy.

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Objective: Video-assisted thoracoscopic surgery (VATS) lobectomy has been gradually accepted as an alternative surgical approach to open thoracotomy for selected patients with non-small-cell lung cancer (NSCLC) over the past 20 years. The aim of this project was to standardize the perioperative management of VATS lobectomy patients through expert consensus and to provide insightful guidance to clinical practice.

Methods: A panel of 55 experts on VATS lobectomy was identified by the Scientific Secretariat and the International Scientific Committee of the ’20th Anniversary of VATS Lobectomy Conference-The Consensus Meeting’. The Delphi methodology consisting of two rounds of voting was implemented to facilitate the development of consensus. Results from the second-round voting formed the basis of the current Consensus Statement. Consensus was defined a priori as more than 50% agreement among the panel of experts. Clinical practice was deemed ‘recommended’ if 50-74% of the experts reached agreement and ‘highly recommended’ if 75% or more of the experts reached agreement.

Results: Fifty VATS lobectomy experts (91%) from 16 countries completed both rounds of standardized questionnaires. No statistically significant differences in the responses between the two rounds of questioning were identified. Consensus was reached on 21 controversial points, outlining the current accepted definition of VATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions.

Conclusion: The present Consensus Statement represents a collective agreement among 50 international experts to establish a standardized practice of VATS lobectomy for the thoracic surgical community after 20 years of clinical experience.

Background: Minimally invasive mitral valve surgery through a mini-thoracotomy approach was developed in the mid-1990s as an alternative to conventional sternotomy, but with reduced trauma and quicker recovery. However, technical demands and a paucity of comparative data have thus far limited the widespread adoption of minimally invasive mitral valve repair (MIMVR). Previous meta-analyses have grouped various surgical techniques and underlying valvular disease aetiologies together for comparison. The present study aimed to compare the clinical outcomes of MIMVR versus conventional mitral valve repair in patients with degenerative mitral valve disease.

Methods: A systematic review of the current literature was performed through nine electronic databases from January 1995 to July 2013 to identify all relevant studies with comparative data on MIMVR versus conventional mitral valve surgery. Measured endpoints included mortality, stroke, renal failure, wound infection, reoperation for bleeding, aortic dissection, myocardial infarction, atrial fibrillation, readmission within 30 days, cross clamp time, cardiopulmonary bypass time and durations of intensive care unit (ICU) stay and overall hospitalization. Echocardiographic outcomes were also assessed when possible.

Results: Seven relevant studies were identified according to the predefined study selection criteria, including one randomized controlled trial and six retrospective studies. Meta-analysis of clinical outcomes did not identify any statistically significant differences between MIMVR and conventional mitral valve repair. The duration of ICU stay was significantly shorter for patients who underwent MIMVR, but this did not translate to a shorter hospitalization period. Patients who underwent MIMVR required longer cross clamp time as well as cardiopulmonary bypass time. Both surgical techniques appeared to achieve satisfactory echocardiographic outcomes. Pain-related outcomes was assessed in one study and reported significantly less pain for patients who underwent MIMVR. However, this limited data was not suitable for meta-analysis.

Conclusions: The existing literature has limited data on comparative outcomes after MIMVR versus conventional mitral valve repair for patients with degenerative disease. From the available evidence, there are no significant differences between the two surgical techniques in regards to clinical outcomes. Patients who underwent MIMVR required longer cardiopulmonary bypass and cross clamp times, but the duration of stay in the ICU was significantly shorter than conventional mitral valve repair.

Background: Lobectomy for non-small cell lung cancer (NSCLC) can be performed either through open thoracotomy or video-assisted thoracoscopic surgery (VATS). To improve the understanding of current attitudes of the thoracic community toward VATS lobectomy, the Collaborative Research Group conducted the Cross-sectional Survey on Lobectomy Approach (X-SOLA) study. We surveyed a large cohort of lobectomy-performing thoracic surgeons to examine their adoption of VATS lobectomy and their opinions of this technique vs conventional open thoracotomy.

Methods: Participants included thoracic surgeons identified through an international index search from the Web of Science and the cardiothoracic surgery network. A confidential questionnaire was e-mailed in June 2012. Nonresponders were given two reminder e-mails at monthly intervals.

Results: The questionnaire, completed by 838 thoracic surgeons within a 3-month period, identified 416 surgeons who only performed lobectomy through open thoracotomy and 422 surgeons who performed VATS or robotic VATS. Of those who performed VATS, 95% agreed with the definition of “true” VATS lobectomy according to the Cancer and Leukemia Group B trial. Ninety-two percent of surgeons who did not perform VATS lobectomy responded that they were willing to learn this technique, but were hindered by limited resources, exposure, and mentoring. Both groups agreed there was a need for VATS lobectomy training in thoracic residency programs and in standardized workshops.

Conclusions: X-SOLA represents the largest cross-sectional report within the thoracic community to date, demonstrating the penetration of VATS lobectomy for NSCLC internationally. From our study, we were able to identify a number of obstacles to broaden the adoption of this minimally invasive technique.

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