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Thoracic surgery and transplantation

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R. Stanbridge, S. L. Elkin, A. Suliman, A. Chuckwuemeka, S. Roberts, T. Athanasiou. St Marys Hospital, Imperial College Healthcare NHS Trust, London, UK

Objectives Does a minimally invasive approach (MI) for routine lung cancer resection offer similar 10-year survival to standard thoracotomy (ST)? We attempt to compare the two techniques, for which there are no long-term studies.

Methods All patients undergoing lung resection with curative intent for primary lung cancer between July 1998 and October 2008 primarily by a single surgical team were included. Surgical access was obtained through a mini 5–6 cm anterior thoracotomy with video assistance and direct visualisation. Follow-up was through a prospective lung cancer registry, PAS and NHS records. Univariate and Cox proportional hazards regression were used to identify independent predictors of late survival and the Kaplan–Meier product for actuarial survival.

Results 207 MI patients (81%) included 11 pneumonectomies and 3 sleeve resections. 50 ST patients (19%) included 5 pneumonectomies and 1 sleeve. All 257 had full lymph node resections. In-hospital mortality was 1.6%; conversion to an open procedure was 1.9%. Univariate analysis suggested that N2 disease (p = 0.02) and cancer stage (p = 0.03) were significant potential predictors of survival. Multivariate analysis showed stage III to be the significant independent predictor with hazard ratio 3.16 (1.36–7.36). There was no significant effect on survival for sex, histology, T3/4 status or incision type: 1.047 (0.62–1.75). Kaplan–Meier showed that survival differed significantly for stage I+II cancers, 73±4 months compared with stage III 51±7 months, with log rank χ2 of 5.1 and p = 0.024.

Conclusions 10-year survival for non-selected routine lung cancer resection relates to staging and not to the minimal access approach, which can be applied to 80% of resectable primary lung cancers.


1P. Agostini, 1H. Cieslik, 1S. Rathinam, 1E. Bishay, 1M. Kalkat, 1R. Steyn, 1P. Rajesh, 2B. Naidu. 1Heart of England NHS Foundation Trust, Birmingham, UK, 2University of Warwick, Coventry, UK

Postoperative pulmonary complications (PPCs) following lung resection have significant clinical and economic impact. Mini-tracheostomy (MT) is used to treat sputum retention and so reduce PPCs. The primary objective of this study was to determine any independent factors associated with the need for rescue mini-tracheostomy (RM) and prophylactic mini-tracheostomy (PM). The secondary objective was to observe the outcome of patients requiring MT.

Methods From May 2008 to July 2009, 271 consecutive patients underwent thoracotomy for planned lung resection. Data were collected prospectively regarding MT insertion, PPCs, length of stay (LOS) and high dependency unit (HDU) admission. Univariate analysis was used to test differences in outcome, and binary logistic regression to determine independent risk factors associated with RM and PM (p<0.05).

Results There were 150 males (55%). Mean age was 65 (±12) years and mean forced expiratory volume in 1 s (FEV1) was 77% (±19). Forty-four patients underwent MT (16%) of which 24 were inserted prophylactically (PM), based on the surgeon’s perioperative clinical assessment. Twenty patients with sputum retention had RM during the subsequent postoperative period. Age >75 years (odds ratio (OR) 2.9, CI 1.0 to 9.0) and chronic obstructive pulmonary disease (COPD; OR 4.1, CI 1.2 to 13.3) were independently associated with need for RM on multivariate analysis, and characterised 75% of the RM group. There was a significantly increased LOS, HDU stay and rate of PPCs in the RM group compared with patients not requiring MT and compared with the PM group (p<0.05). Age >75 years (OR 4.6 CI 1.7 to 12.3) and COPD (OR 3.7 CI 1.3 to 10.5) were also independently associated with PM. If all patients with COPD and/or those over the age of 75 (n = 95) received PM, 75% of RM (n = 15) could have been avoided in this patient population. Only minor complications of MT were noted in 2 patients (surgical emphysema, hoarseness of voice).

Conclusion Age >75 years and COPD were independently associated with the need for MT. RM is associated with significantly worse outcome, but PM in high risk patients has been shown to improve outcome. In our study, if all patients >75 years and/or with COPD received a PM, 6 would have to be performed to prevent 1 RM.


P. Kho, J. Karunanantham, M. Leung, E. Lim. The Royal Brompton Hospital, London, UK

Decortication is widely performed for empyema, but the effectiveness in achieving lung re-expansion has never been formally reported. The aim of this study is to quantify the degree of lung re-expansion in comparison with that achieved naturally after debridement alone.

Methods A retrospective review of patients who underwent either decortication or debridement for empyema between 2007 and 2009. The change of the cavity size with time was standardised and recorded before surgery, immediately after surgery and on follow-up. Differences were expressed as mean percentage change, and multivariable regression was used to compare the adjusted differences with time.

Results Of 25 patients who underwent surgical management of empyema, 16 (64%) underwent debridement alone and 9 (36%) underwent decortication. The mean age (SD) was 58 (19) years and 15 (60%) were men. There was immediate reduction in cavity depth in the debridement alone group by 36% and a further 18% reduction achieved in the decortication group. On radiological follow-up at a median (interquartile range (IQR)) of 45 (36–116) days, further reduction of 36% and 34% was achieved, leaving 27% and 12% of the original cavity size in the debridement and decortication groups, respectively. Procedure (debridement or decortication) was not associated with any difference in the eventual follow-up cavity size (p = 0.937).

Conclusions Resolution of an empyema collection and cavity occurs immediately after surgery, and continues in the postoperative period. Similar follow-up results were achieved by debridement alone without decortication in patients presenting with empyema despite the presence of an underlying trapped lung.


S. Kon, C. Orchard, A. Palmer, M. Carby. Royal Brompton & Harefield NHS Foundation Trust, UK

Introduction and Objectives Calcineurin inhibitor (CNI)-based immunosuppression regimens have contributed to the success of lung transplants by reducing early immunological injury and acute rejection rates. However, CNI-induced renal injury is a significant problem, with 16.5% of all non-renal transplant recipients having chronic renal failure at 36 months. Withdrawal of the CNI is a potential mechanism to prevent further damage. Sirolimus is a macrolide immunosuppressant with little impact on renal function. It inhibits T lymphocyte activation and proliferation, and antibody production. We report the medium term outcomes following institution of a “renal-sparing” protocol involving withdrawal of the CNI and replacement with sirolimus.

Methods Retrospective data were obtained on 29 lung transplant recipients with CNI nephrotoxicity who were converted to sirolimus between 1990 and 2008. Creatinine levels were followed up at regular intervals or until sirolimus was discontinued. Infective and rejection episodes per year were observed.

Results CNIs were withdrawn in 27 patients (93%), tapered in 1 patient and continued in 1 patient at a low dose due to an ABO mismatch transplant. Steroid cover with prednisolone was given in 23 patients until therapeutic sirolimus levels were obtained (5–10 ng/ml). All patients continued or were commenced on mycophenolate. Mean serum creatinine at conversion was 260±94 μmol/l compared with 77±20 μmol/l pretransplant. A switch to sirolimus showed a decrease in serum creatinine (fig 1) at 12 months (n = 24 p<0.05 Cr −31 μmol/l) and 24 months (n = 14 p<0.05 Cr −65 μmol/l). Our longest period of follow-up was at 48 months (n = 2 p<0.05 Cr −65 μmol/l) where the benefit of sirolimus was still maintained. The creatinine of nine patients remained unchanged and thus sirolimus was discontinued due to the need for renal transplantation/haemodialysis. Rates of infection and rejection were the same preconversion and postconversion to sirolimus (<1 episode/year). However, there were twice as many fungal infections postconversion to sirolimus. Treatment was well tolerated.

Conclusions Conversion to a sirolimus-based immunosuppression regimen can allow for stabilisation of renal function in the mid and long term, as well as some renal recovery in lung transplant patients with CNI nephrotoxicity.


S. Agarwal, J. Parmar, S. Tsui, J. Dunning, K. Dhital. Papworth Hospital NHS Trust, Cambridge, UK

Introduction Acute allograft rejection (AR) is the most important risk for obliterative bronchiolitis (OB) in lung transplant recipients (LTRs). Transbronchial lung biopsy (TBBx) is the gold standard for distinguishing AR from infections. Opinion is divided between surveillance bronchoscopy (SB) and clinically indicated bronchoscopy (CIB) as the procedure is not without risk.

Method We audited our current practice for SB performed in the year 2008. According to the unit guideline, SB and TBBx are performed at week 3, 6 and 12 after transplantation. The audit was designed to look at the adequacy of TBBx samples, microbiology results and complications.

Results A total of 28 transplants were performed in 2008 which included 25 (89%) bilateral lung transplants, 2 (7%) heart–lung transplant and 1 (3%) single lung transplant. 74 bronchoscopies and TBBx were performed besides CIB, depending on the patient’s clinical conditions. Results of only SB were reviewed. Reportable adequacy of TBBx samples was obtained in 65 (88%) patients. Adequacy was low in the first biopsy, 20/27 (74%), as compared with the second, 26/27(96%), and third, 19/20 (95%). There were 7 (10%) A1 rejections and 9 (13%) A2 rejections. Bacteriology was positive in 29/74 (39%) samples, mycology in 4/74 (7%) and virology positive in 1/74 (1%). Pseudomonas was the most common isolate, 16/74 (22%), and Aspergillus was isolated on 4/74 (5%) occasions. One of 74 samples was positive for Epstein–Barr virus and metapneumovirus. Two of 74 (3%) patients had pneumothorax. No pneumothorax required chest drain. There was no major bleeding requiring blood transfusion or intubations and there was no mortality as a result of SB.

Conclusion SB has a high yield of diagnosing asymptomatic AR and infections in LTRs. The risk of serious complications is low. Identification and treatment of asymptomatic rejection may prove beneficial in preventing OB and we believe the low risk of TBBx with high yield makes this a beneficial approach.

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