Diminished Disease-Free Survival After Lobectomy: Screening Implications.

BACKGROUND: The aim of this study was to estimate the effect of lobectomy on life expectancy in healthy smokers and consider the implications for lung cancer screening. MATERIALS AND METHODS: In a retrospective cohort study that provided a minimum of 15 years of follow-up, we analyzed lung cancer survival, all-cause survival, and fatality (1-survival) of 261 persons with stage I non-small-cell lung cancer who underwent lobectomy at Portland Providence Medical Center between 1978 and 1994. We: (1) compared 5-year disease-free fatality (non-lung-cancer fatality) with lung cancer fatality; and (2) based on actuarial data that demonstrated life expectancy equivalence of the healthiest smokers (whom we assumed would be comparable with subjects judged eligible for lobectomy) in the US population, we compared their long-term, disease-free survival (our primary end point) with actuarial expectations by computing the Kaplan-Meier survival function of the differences between lifetimes since surgery in disease-free persons versus matched, expected remaining lifetimes in the US population. RESULTS: (1) Five-year disease-free fatality (16.1%) was 58% as high as 5-year lung cancer fatality (27.6%); (2) disease-free survival was reduced by 6.9-years (95% confidence interval, 5.5-8.3), 41% of actuarial life expectancy (17 years). The divergence from expected survival took place largely after 6 years of follow-up. CONCLUSION: Lobectomy materially diminishes long-term disease-free survival in the healthiest smokers--persons judged healthy enough to tolerate major surgery and to have sufficient pulmonary reserve to sustain loss of one-fifth of their lung tissue. In screened populations, diminished survival in overdiagnosed persons will offset, to an undetermined extent, the mortality benefit imparted by preemption of advanced lung cancer.

Does video-assisted thoracoscopic lobectomy for lung cancer provide improved functional outcomes compared with open lobectomy?

OBJECTIVE: We evaluated video-assisted thoracic surgery (VATS) and open (OPEN) lobectomy for lung cancer and impact upon 6-month postoperative (postop) functional health status and quality of life. METHODS: In this retrospective analysis of prospective, observational data, anatomic lobectomy with staging thoracic lymphadenectomy was performed with curative intent for lung cancer. OPEN consisted of either thoracotomy (TH) or median sternotomy (MS). Technique was selected on the basis of anatomic imperative (OPEN: larger or central; VATS smaller or peripheral tumours) and/or surgical skills (VATS lobectomy initiated in 2001). All patients completed the Short Form 36 Health Survey (SF36) and Ferrans and Powers quality-of-life index (QLI) preoperatively (preop) and 6 months postop. RESULTS: A total of 241 patients underwent lobectomy (OPEN, 192; VATS, 49). OPEN included MS 128 and TH 64. Comparison of MS and TH patient demographics, co-morbidities, pulmonary variables, intra-operative variables, stage and cell type, postop complications and 6-month clinical outcomes found no differences, allowing grouping together into OPEN. The VATS group had better pulmonary function testing (PFT), more adenocarcinoma and lower stage. The VATS and OPEN groups did not differ regarding operating time, postop complications and operative or 6-month mortality. The VATS group had less blood loss, transfusion, intra-operative fluid administration and shorter length of stay. Comparing within each group's preop to 6-month postop data, VATS patients were either the same or better in all SF36 categories (physical functioning, role functioning - physical, role functioning - emotional, social functioning, bodily pain, mental health, energy and general health). The OPEN group, however, was significantly worse in SF36 categories physical functioning, role functioning - physical and social functioning. The preop and 6 months postop VATS versus OPEN QLI scores were not different. At 6 months postop, hospital re-admission and use of pain medication was less in the VATS group. In addition, the VATS group had better preservation of preop performance status. CONCLUSIONS: VATS lobectomy for curative lung cancer resection appears to provide a superior functional health recovery compared with OPEN techniques.

Sternal preservation: a better way to treat most sternal wound complications after cardiac surgery.

BACKGROUND: Postcardiotomy sternal wound complications remain challenging. The prevailing approach for deep sternal wound infection of debridement and flap coverage without osseous closure makes subsequent reoperation difficult. METHODS: An analysis of all patients undergoing cardiac surgery at a single institution between 1986 and 2001 was conducted. Prospective data collection and chart review were used to compare different treatment strategies for sternal complications. RESULTS: Of 5337 patients, 122 had sternal wound complications (2.2%) comprising 15 (0.3%) uninfected dehiscences (El Oakley class 1), 45 (0.8%) superficial infections (El Oakley class 2A), and 62 (1.1%) deep sternal wound infections (El Oakley class 2B). Thirty-two patients with deep sternal infection were treated by debridement, rewiring, and delayed primary closure. There were initial treatment failures in 6 patients (18.8%) and ultimate failures in 2 patients (6.3%), both of whom died. One of these patients had previously received external beam radiation after a radical mastectomy for breast cancer. Median length of stay was 32 days and median time to wound healing was 85 days. Twenty-five patients were managed by muscle flap coverage without sternal reclosure. There were 6 initial treatment failures (24%) but no ultimate failures or deaths (p = NS). Median length of stay was 31 days and median infection time was 161 days. CONCLUSIONS: In patients with postcardiotomy deep sternal wound infection without previous chest radiation, debridement, rewiring, and delayed skin closure is effective. It offers a shorter healing time and probably makes late cardiac reoperation safer. We propose an algorithm for the management of poststernotomy complications.

What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery.

OBJECTIVE: To compare baseline preoperative and 6-month postoperative functional health status and quality of life in patients undergoing lung cancer resection. METHODS: Lung cancer surgery patients from three hospitals were administered the Short-Form 36 Health Survey (SF-36) and the Ferrans and Powers' quality-of-life index (QLI) before surgery and 6 months after surgery. Preoperative, intraoperative, hospital stay, and 6-month postoperative clinical data were collected. All p values