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International audience; INTRODUCTION: Molecular profile of resected stage I-II non-small cell lung cancer (NSCLC) would help refine prognosis and personalize induction or adjuvant strategies. We sought to report the molecular profile of resected stage I-II NSCLC and analyzed the impact of epidermal growth factor receptor (EGFR) mutations on outcomes in a Western population. PATIENTS AND METHODS: Surgical cases were identified from Biomarkers France study, a nationwide prospective study including NSCLC patients screened for EGFR, HER2, KRAS, BRAF, PIK3CA, ALK alterations from 2012 to 2013. Among surgical patients, clinical charts of the largest centers were reviewed in order to analyze the prognostic impact of EGFR mutations. RESULTS: In the BMF database (n = 17.636), surgical patients (n = 854) were characterized by a higher proportion of EGFR mutations than nonsurgical patients (12.9% vs. 10.2%, P = .025), while the other molecular alterations did not differ. The proportion of EGFR mutations was 27% in women undergoing surgery. In the study group (n = 293; EGFR wild type, n = 235; usual mutation, n = 50; rare mutation, n = 8), after a median follow-up of 67 months, 215 patients (74.4%) had not relapsed. No difference was found between EGFR-mutant and EGFR-wt tumors regarding recurrence site, disease-free survival, and overall survival. The 5-year disease-free survival and overall survival after surgical resection of stage I-II EGFR-mutated tumors were 65% and 75%, respectively. CONCLUSION: In resected stage I to II NSCLC, EGFR mutations were found in 12.9% of cases, associated with a 5-year overall survival of 75%, with no impact on recurrence site, disease-free survival, and overall survival.

Microsurgery, developed in the 1960s from experimental work in animals, has not undergone technological evolution until today. Robotics could lead to a major technological leap for two main reasons, the reduction of the size of the incisions thanks to the endoscopy and the improvement of the surgical act by the reduction of the movements.

Background The coronavirus disease 2019 (COVID-19) pandemic has decreased surgical activity, particularly in the field of oncology, because of the suspicion of a higher risk of COVID-19–related severe events. This study aimed to investigate the feasibility and safety of thoracic cancer surgery in the most severely affected European and Canadian regions during the COVID-19 pandemic. Methods The study investigators prospectively collected data on surgical procedures for malignant thoracic diseases from January 1 to April 30, 2020. The study included patients from 6 high-volume thoracic surgery departments: Nancy and Strasbourg (France), Freiburg (Germany), Milan and Turin (Italy), and Montreal (Canada). The centers involved in this research are all located in the most severely affected regions of those countries. An assessment of COVID-19–related symptoms, polymerase chain reaction (PCR)–confirmed COVID-19 infection, rates of hospital and intensive care unit admissions, and death was performed for each patient. Every deceased patient was tested for COVID-19 by PCR. Results In the study period, 731 patients who underwent 734 surgical procedures were included. In the whole cohort, 9 cases (1.2%) of COVID-19 were confirmed by PCR, including 5 in-hospital contaminants. Four patients (0.5%) needed readmission for oxygen requirements. In this subgroup, 2 patients (0.3%) needed intensive care unit and mechanical ventilatory support. The total number of deaths in the whole cohort was 22 (3%). A single death was related to COVID-19 (0.14%). Conclusions Maintaining surgical oncologic activity in the era of the COVID-19 pandemic seems safe and feasible, with very low postoperative morbidity or mortality. To continue to offer the best care to patients who do not have COVID-19, reports on other diseases are urgently needed.

We describe a case of platypnea-orthodeoxia syndrome (POS) due to atrial septal defect (ASD) occurring in the early postoperative course of a right pneumonectomy. Deformation of the atrial septum after right pneumonectomy deviates the blood from the inferior vena cava to ASD during the sitting position creating, a massive right-to-left shunt. Diagnosis can initially be missed by making contrast bubble test through the superior vena cava. The atrial septal defect was then closed using the surgical technique, allowing an instantaneous improvement of hematosis.

INTRODUCTION : La maladie des dépôts de chaînes légères d’immunoglobuline est une entité anatomoclinique entraînant, dans de rares cas, une destruction kystique du poumon. OBSERVATION : Nous rapportons le cas d’une patiente de 62 ans, suivie dans le cadre d’une gammapathie monoclonale de signification indéterminée, chez qui, suite à l’apparition d’une dyspnée croissante, des lésions pulmonaires kystiques diffuses sont découvertes au scanner thoracique. Une résection par thoracoscopie du lobe inférieur droit où prédominait l’atteinte kystique a permis le diagnostic histologique de maladie des dépôts de chaînes légères kappa non amyloïdes. La chirurgie a également eu un effet de réduction de volume pulmonaire s’accompagnant d’une amélioration clinique et fonctionnelle via l’amélioration de la ventilation des segments voisins. CONCLUSION : Cette observation de maladie des dépôts de chaînes légères avec atteinte kystique pulmonaire illustre les potentiels bénéfices cliniques et fonctionnels observés après chirurgie de réduction pulmonaire. [Effect of surgery of pulmonary cysts related to immunoglobulin light chain deposits] INTRODUCTION: Light chain deposition disease is a rare anatomo-clinical disorder, which rarely leads to cystic lung destruction. CASE REPORT: We report the case of a 62years old female patient with a history of a monoclonal gammopathy of unknown significance who developed progressive dyspnea. Thoracic CT-scan demonstrated a diffuse pulmonary cystic disorder with predominance in the right lower lobe. Thoracoscopic surgical resection of that lobe led to a diagnosis of non-amyloid kappa light chain deposits. Surgery also resulted in a lung volume reduction effect with clinical and functional benefits related to improved ventilation of adjacent segments. CONCLUSION: This report of pulmonary cystic disorder related to a light chain deposition disease highlights the potential clinical and functional benefits observed after lung volume reduction surgery.

The prognostic value of exon 19 and 21 EGFR mutations in stage IV non-small cell lung cancer (NSCLC) is well established. We aimed to evaluate the prognostic value of the mutations in surgically resected NSCLC. We retrospectively reviewed data from 1798 surgically resected NSCLC adenocarcinomas between 2007 and 2017 in three departments of thoracic surgery (Nancy/Strasbourg, France, and Torino, Italy) for whom mutational status was known. Overall survival (OS) was evaluated using log-rank and Cox proportional hazard models. EGFR exon 19 deletion was observed in 108 patients (55.1%) and exon 21 L858R mutations were observed in 88 patients (44.9%). In stage I, the median OS was not significantly different between exons 19 and 21 (p = 0.54), while, in stage II, the median OS reached 65 months [95% confidence interval (CI) 41.67–88.33] for exon 19 mutations and decreased to 48 months for exon 21 mutations (95% CI 44.21–51.79; p = 0.027). In multivariate analysis, exon 19 deletion remained a favorable prognostic factor [hazard ratio (HR) 0.314, 95% CI 0.098–0.997; p = 0.05]. In stage III, the median OS reached 66 months (95% CI 44.67–87.32) for exon 19 mutations and decreased to 32 months for exon 21 mutations (95% CI 29.86–34.14; p = 0.03). In multivariate analysis, exon 19 deletion remained a significantly favorable prognostic factor (HR 0.165, 95% CI 0.027–0.999; p = 0.05). The prognostic value of EGFR exon 19 and 21 mutations appears to be different according to disease stage in surgically resected NSCLC.

Resume Introduction En chirurgie thoracique, l’ extracorporeal life support (ECLS) represente un arsenal therapeutique indique en cas de defaillance de l’appareil respiratoire ou comme support mecanique pour un acte therapeutique. Les objectifs de cette revue generale sur l’ECLS en chirurgie thoracique sont de decrire le rationnel des techniques d’ECLS disponibles, de presenter les indications d’ECLS lors de defaillances de l’appareil respiratoire et aussi de demontrer l’interet de l’ECLS pour pratiquer l’ECLS en chirurgie thoracique selon une medecine fondee sur les preuves. Etat des connaissances L’ECLS doit se pratiquer dans des centres experts. Dans le syndrome de defaillance respiratoire aigue severe et refractaire, l’ECLS permet de mettre au repos les poumons en pratiquant une ventilation protectrice. En transplantation pulmonaire, l’ECLS peut etre pratiquee avec de bons resultats en pont a la transplantation pulmonaire, en temps que support cardiorespiratoire peroperatoire et en pont a la recuperation en cas de dysfonction primaire du greffon pulmonaire. L’ECLS en tant que support a un acte therapeutique tracheobronchique et/ou chez un insuffisant respiratoire severe est faisable sans majorer significativement le risque perioperatoire. Perspectives Les indications d’ECLS vont accroitre dans le temps sous l’impulsion des centres experts. Dans les annees a venir, les progres des techniques et de l’ingenierie ainsi que des connaissances approfondies permettront l’amelioration du pronostic des patients atteints de defaillance respiratoire sous assistance mecanique. Des etudes prospectives multicentriques et randomisees affineront les indications et les strategies de prise en charge globale de ces patients. Conclusion L’ECLS est un moyen therapeutique ameliorant le pronostic de patients atteints ou soumis aux risques de defaillance respiratoire.

Background Postpneumonectomy acute respiratory distress syndrome (ppARDS) is a life-threatening condition with a disastrous prognosis. This study assessed the efficacy of venovenous extracorporeal membrane oxygenation (VV-ECMO) in adult patients with unresponsive severe ppARDS. Methods We retrospectively reviewed data of all patients treated with VV-ECMO for ppARDS from January 2009 to December 2015. We calculated the Sequential Organ Failure Assessment score before ECMO insertion and monitored the subsequent mechanical ventilation settings. The primary end point was hospital survival. The secondary end point was the ability to achieve a protective ventilatory strategy allowing lung recovery on ECMO. Results VV-ECMO was indicated in 8 ppARDS patients for refractory hypoxemia (median partial pressure of arterial oxygen/fraction of inspired oxygen: 68 [range, 60 to 75] mm Hg). Median Sequential Organ Failure Assessment before ECMO was 15 (range, 12 to 17), predicting a mortality rate greater than 80%. Median duration of ECMO was 9.5 (range, 5 to 16) days. Tidal volumes and plateau pressures both decreased on ECMO (pre-ECMO tidal volume: 412 [range, 250 to 450 mL] vs ECMO tidal volume: 277 [range, 105 to 367 mL], p = 0.0156; pre-ECMO plateau pressure: 34 [range, 32 to 40] cm H 2 O vs ECMO plateau pressure: 24.5 [range, 23.3 to 27.3] cm H 2 O, p = 0.0195). ECMO could be weaned in 7 patients (87.5%). Hospital survival was 50%. Conclusions Hospital survival was better than predicted before ECMO insertion. In severe and refractory ppARDS, VV-ECMO allows lung recovery and therefore increased survival.

Background After lung transplantation (LT), early prediction of grade 3 pulmonary graft dysfunction (PGD) remains a research gap for clinicians. We hypothesized that it could be improved using extravascular lung water (EVLWi) and plasma biomarkers of acute lung injury. Methods After institutional review board approval and informed consent, consecutive LT recipients were included. Transpulmonary thermodilution-based EVLWi, plasma concentrations of epithelial (soluble receptor for advanced glycation endproducts [sRAGE]) and endothelial biomarkers (soluble intercellular adhesion molecule-1 and endocan [full-length and cleaved p14 fragment]) were obtained before and after LT (0 [H0], 6, 12, 24, 48 and 72 hours after pulmonary artery unclamping). Grade 3 PGD was defined according to the International Society for Lung and Heart Transplantation definition, combining arterial oxygen partial pressure (PaO2)/inspired fraction of oxygen (FiO2) ratio and chest X-rays. Association of clinical risk factors, EVLWi and biomarkers with grade 3 PGD was analyzed under the Bayesian paradigm, using logistic model and areas under the receiver operating characteristic curves (AUCs). Results In 47 LT recipients, 10 developed grade 3 PGD, which was obvious at H6 in 8 cases. Clinical risk factors, soluble intercellular adhesion molecule-1 and endocan (both forms) were not associated with grade 3 PGD. Significant predictors of grade 3 PGD included (1) EVLWi (optimal cutoff, 13.7 mL/kg; AUC, 0.74; 95% confidence interval [CI], 0.48-0.99), (2) PaO2/FiO2 ratio (optimal cutoff, 236; AUC, 0.68; 95% CI, 0.52-0.84), and (3) sRAGE (optimal cutoff, 11 760 pg/mL; AUC, 0.66; 95% CI, 0.41-0.91) measured at H0. Conclusions Immediate postreperfusion increases in EVLWi and sRAGE along with impaired PaO2/FiO2 ratios were early predictors of grade 3 PGD at or beyond 6 hours and may trigger early therapeutic interventions.

Background Atrial arrhythmias (AAs) are frequent after lung transplantation (LT) and late postoperatively. Several predictive factors of early postoperative AAs after LT have been identified but those of late AAs remain unknown. Whether AA after LT affects mortality is still being debated. This study assessed in a large cohort of LT patients the incidence of AAs early and late after surgery, their predictive factors and their effect on mortality.Methods and Results:We studied 271 consecutive LT patients over 9 years. Mean follow-up was 2.9±2.4 years. 33% patients developed postoperative AAs. Age (odds ratio (OR) 2.35; confidence interval (CI) [1.31-4.24]; P=0.004) and chronic obstructive pulmonary disease (OR 2.13; CI [1.12-4.03]; P=0.02) were independent predictive factors of early AAs. Late AAs occurred 2.2±2.7 years after transplant in 8.8% of the patients. Pretransplant systolic pulmonary arterial pressure (PTsPAP) was the only independent predictive factor of late AA (OR 1.028; CI [1.001-1.056]; P=0.04). Double LT was associated with long-term freedom from atrial fibrillation (AF) but not from atrial flutter (AFL). Early and late AAs after surgery had no effect on mortality. Double LT was associated with better survival. Conclusions Early AA following LT is common in contrast with the low occurrence of late, often organized, AA. Early and late AAs do not affect mortality. PTsPAP is an independent predictor of late AA. Double LT protects against late AF but not AFL.

IL-23/Th17 pathway has been identified to sustain inflammatory condition in several autoimmune diseases and therefore being targeted in various therapeutic and effective approaches. Patients affected with autoimmune myasthenia gravis exhibit a disease effector tissue, the thymus, that harbors ectopic germinal centers that sustain production of auto-antibodies, targeting proteins located in the neuromuscular junction, cause of the organ-specific chronic autoimmune disease. The present study aims to investigate the IL-23/Th17 cell pathway in the thymic inflammatory and pathogenic events. We found that thymuses of MG patients displayed overexpression of Interleukin-17, signature cytokine of activated Th17 cells. This activation was sustained by a higher secretion of Interleukin-23 by TEC, in addition to the increased expression of cytokines involved in Th17 cell development. The overexpression of Interleukin-23 was due to a dysregulation of interferon type I pathway. Besides, Interleukin-17 secreted, and Th17 cells were localized around thymic ectopic germinal centers. These cells expressed podoplanin, a protein involved in B-cell maturation and antibody secretion. Finally, production of Interleukin-23 was also promoted by Interleukin-17 secreted itself by Th17 cells, highlighting a chronic loop of inflammation sustained by thymic cell interaction. Activation of the IL-23/Th17 pathway in the thymus of autoimmune myasthenia gravis patients creates an unstoppable loop of inflammation that may participate in ectopic germinal center maintenance. To alleviate the physio-pathological events in myasthenia gravis patients, this pathway may be considered as a new therapeutic target.

Thoracic trauma is the second leading cause of death in case of trauma, after head trauma. Rib fractures are one of the most common injuries affecting trauma patients, occurring in approximately 10% of all cases, and they are associated with a mortality of 3–13%. Frequent complications of this condition are pneumonia, prolonged ventilator time, prolonged hospitalization, and chronic debilitating pain. It has been shown that a greater number of rib fractures are associated with an increased risk of complications, particularly in older patients. Optimal treatment of rib fractures has not been established; in particular, the role of surgery is a matter of debate.

We report an unusual case of a 53-year-old woman who presented with multiple lung cystic lesions presumed to be related to pulmonary hydatidosis, treated and followed for 3 years before surgical removal was decided. Unexpectedly, pathologic findings showed benign spindle cell proliferation. Immunohistochemical staining confirmed the smooth-muscle nature of the spindle cells, which were also positive for hormonal receptors and corresponded to multiple cystic pulmonary hamartomas.

Background: This study evaluates the number of video-assisted thoracic surgery-lobectomies (VATS-lobectomies) required for an experienced consultant thoracic surgeon to obtain competence and to perform standard quality surgery. Methods: We have analysed the initial VATS-experience (January 2012 to September 2014) of a confirmed senior consultant who has performed 145 consecutive anatomic resections by thoracoscopy. After excluding bilobectomies, segmentectomies, and lobectomies for infectious disease, we have focused into 119 consecutive lobectomies, classified into 4 chronologic groups of 30 each. We have considered: demographics; pathology; postoperative outcomes; conversion rate; morbidity. We compared the 4 groups in a Bayesian inference model (very strong probability of a difference if Pr>95% or Pr>80% or 5% Results: There was a very strong probability of difference of group 1 (first 30 lobectomies) compared to the 3 other groups: less incomplete fissures (Pr 1 =0.019, Pr 1 =0.037, Pr 1 =0.046), more node samplings (Pr 1>2 =0.977, Pr 1>3 =0.96, Pr 1>4 =0.997) and, conversely, less radical dissections (Pr 1 =0.022, Pr 1 =0.039, Pr 1 =0.003), less harvested nodes (Pr 1 ≤0.001, Pr 1 ≤0.001, Pr 1 ≤0.001), less pleural adhesions (Pr 1 =0.077, Pr 1 =0.044). Instead, there was a very strong probability of difference of group 4 compared to the first three groups (first 90 lobectomies): lower conversion rate (Pr 1>4 =0.992, Pr 3>4 =0.996, Pr 2>4 =0.995), lower duration of the operation (Pr 1>4 =0.946, Pr 2>4 =0.901, Pr 3>4 =0.932), less air leak (Pr 1>4 =0.936, Pr 2>4 =0.97) and shorter chest tube drainage (Pr 1>4 =0.94, Pr 2>4 =0.94, Pr 3>4 =0.937), as well as shorter hospital stay (Pr 2>4 =0.94, Pr 3>4 =0.937). Conclusions: The learning curve was bimodal. After the initial 30 lobectomies, oncologic quality of the procedure improved and stabilized. The surgeon became less selective and accepted to proceed with more complex cases (incomplete fissures, pleural adhesions). Efficiency was obtained after 90 lobectomies (shorter operative time and lower conversion rate).

OBJECTIVES Epidermal growth factor receptor (mEGFR) and v-Ki-ras2 Kirsten rat sarcoma viral oncogen homologue (mKRAS) mutations are the two main oncogenic drivers in resected non-small-cell lung cancer (NSCLC). We aimed to evaluate the correlation between histopathological prognostic factors and these mutations in resected NSCLC. METHODS We retrospectively reviewed data from 841 patients who underwent a surgical resection with a curative intent for NSCLC between 2007 and 2012. RESULTS KRAS mutations were observed in 255 patients (32%) and mEGFR in 103 patients (12%). A correlation was observed between mKRAS patients and lymph node involvement [Cramer's V: 0.451, P < 0.001, OR: 7.5 (95% CI: 5.3-10.7), P < 0.001]. Otherwise, a correlation was observed between mKRAS and the risk of harbouring 2 N2 stations [Cramer's V: 0.235, P = 0.02, OR: 3.04 (95% CI: 1.5-6.3), P = 0.004]. High lymph node ratio and angioinvasion were also significantly more frequent in mKRAS [Cramer's V: 0.373, P < 0.001, OR: 6.37 (95% CI: 3.9-10.5), P < 0.001; and Cramer's V: 0.269, P < 0.001, OR: 3.25 (95% CI: 2.4-4.4), P < 0.001, respectively]. Skip N2 and microscopic N2 were significantly more frequent in mEGFR [Cramer's V: 0.459, P < 0.001, OR: 18 (95% CI: 5.6-57.8), P < 0.001; and (Cramer's V: 0.45, P < 0.001 OR: 21.14 (95% CI: 9.2-48.3), P < 0.001, respectively]. CONCLUSIONS We observed a correlation between mKRAS and negative histopathological prognostic factors and between mEGFR and positive prognostic factors. One can wonder whether histopathological prognostic factors are only clinical reflections of molecular alterations.

Lobectomy for benign lung disease is renowned to be technically complex and to be subjected to an increased complication rate. The objective of this study was to evaluate whether the results obtained with video-assisted surgery (VATS) in benign disease are comparable to those obtained in oncologic surgery, where VATS has been validated. We have reviewed the files of 246 consecutive patients who underwent VATS lobectomy from January 2012 to August 2015. The cohort was divided into two groups according to pathology (benign or malignant). Outcome parameters on scrutiny were demographics, pathology, duration of air leak, drainage and hospital stay, conversion, and perioperative complication rate. Comparisons were made with the χ 2 test and Student’s t test; any p value ≤0.05 was considered as significant. Group 1 (36 patients) included patients who underwent lobectomy for benign disease and group 2 (210 patients) patients affected by lung cancer or pulmonary metastases. The two groups differed with reference to age (p

International audience; OBJECTIVES: Thymectomy may be part of the therapeutic strategy in patients with myasthenia gravis (MG) without thymoma. Median sternotomy is still considered as the gold standard, but during the last 15 years, several groups have demonstrated the non-inferiority of cervicotomy with upper sternotomy and minimally invasive techniques. To date, there is no consensus on surgical procedure choice. The aim of our study was to compare the morbidity and mortality of three techniques [cervicotomy with upper sternotomy versus sternotomy versus video-assisted thoracic surgery (VATS)/robotic-assisted thoracic surgery (RATS)] from the national database EPITHOR and to analyse French epidemiology. METHODS: From the national thoracic surgery database EPITHOR, we have extracted all the details regarding thymectomies performed for non-thymomatous MG. We have divided thymectomy into three groups: A-sternotomy; B-cervicotomy with upper sternotomy; C-VATS/RATS. We investigated the postoperative morbidity and mortality without analysis of the long-term evolution of the disease not available on EPITHOR. RESULTS: From 2005 to 2013, 278 patients were included: 131 (47%) in Group A, 31 (11%) in Group B and 116 (42%) in Group C. The sex ratio F/M was 2.3. The mean age was, respectively, 42 +/- 17, 42 +/- 16, 35 +/- 14 years old (P < 0.01). The number of patients without comorbidities was 63 (48%), 25 (81%) and 78 (65%), respectively (P < 0.01). The operative time was 94 +/- 37, 79 +/- 42 and 112 +/- 59 min, respectively (P < 0.01). The number of patients who presented at least one postoperative complication was 12 (14%), 0 and 3 (9%) (P = 0.03), respectively. The postoperative lengths of stay were 7.7 +/- 4.5, 5 +/- 1.7 and 4.5 +/- 2 days, respectively (P < 0.01). There was no death. CONCLUSIONS: In our study, we were unable to prove the superiority of minimally invasive techniques due to the important differences between the groups. However, this study shows us major changes in French surgical procedures during the last decade with an increase in minimally invasive procedures such as VATS and RATS.

The aim of this study was to report the feasibility of robotic intercostal nerve harvest in a pig model. A surgical robot, the da Vinci Model S system, was installed after the creation of 3 ports in the pig’s left chest. The posterior edges of the fourth, fifth, and sixth intercostal nerves were isolated at the level of the anterior axillary line. The anterior edges of the nerves were transected at the rib cartilage zone. Three intercostal nerve harvesting procedures, requiring an average of 33 minutes, were successfully performed in 3 pigs without major complications. The advantages of robotic microsurgery for intercostal nerve harvest include elimination of physiological tremor, free movement of joint-equipped robotic arms, and amplification of the surgeon’s hand motion by as much as 5 times. Robot-assisted neurolysis may be clinically useful for intercostal nerve harvest for brachial plexus reconstruction.

Objective To study patient survival and glycemic control before and after lung transplantation (LTx) according to the diabetes status in patients submitted to an organized management of diabetes mellitus (DM) at the Strasbourg University Hospital, France. Material and Methods Two hundred and sixty-seven LTx recipients were included retrospectively and analyzed according to diabetes status: pretransplant diabetes, new-onset diabetes mellitus after transplant (NODAT) or no diabetes. Organized DM management was coordinated by a diabetologist trained in DM management before and after transplantation and included pretransplant screening, a close monitoring of glycemia after transplant and optimized treatment before and after LTx. Results DM was well-controlled after transplantation: mean glycosylated hemoglobin and fasting blood glucose levels after LTx were 5.8 ± 0.2% and 5.4 ± 0.1 mmol/L respectively, in pretransplant DM patients and 5.7 ± 0.1% and 5.6 ± 0.2 mmol/L respectively, in NODAT patients. The overall median survival time was 8.3 ± 1.9 years. Pretransplant DM increased the risk of mortality (1.82-fold increase; 95% confidence interval, 1.08-3.06; P = .02) in LTx recipients. Conclusions Organized management of diabetes achieved very satisfactory glycemic control in both pretransplant DM and NODAT patients. However, no specific protocols have been created for managing DM following LTx. As DM continues to become an increasing comorbidity in LTx, there exist a significant need of studies in this area.

Emerging data highlight different clinical behaviors according to KRAS amino acid substitutions (AASs) in patients with non-small-cell lung cancer (NSCLC). We aimed to evaluate whether different KRAS AASs were associated with different responses to chemotherapy.We retrospectively reviewed data from 1190 patients with KRAS mutations who underwent first-line platinum-based chemotherapy for stage IV NSCLC. The response to different chemotherapy regimens was evaluated using the Response Evaluation Criteria In Solid Tumors criteria (v 1.1). Overall survival and time to progression (TTP) were secondary endpoints.Taxane was associated with the best response in the entire cohort (odds ratio, 2.52; 95% confidence interval [CI], 1.82-3.48; P .001), especially in G12V patients (odds ratio, 2.15; 95% CI, 1.05-4.41; P = .036). Taxane was associated with improved TTP in the entire cohort (hazard ratio [HR], 0.31; 95% CI, 0.26-0.38; P .001), especially in G13D patients (HR, 0.47; 95% CI, 0.22-1.01; P = .054). Pemetrexed was associated with the worst TTP in the entire cohort, particularly in G12V patients, who had the worst response rates (HR, 0.55; 95% CI, 0.30-0.99; P = .049). No impact on overall survival was observed according to different chemotherapy regimens and AASs.KRAS-specific AAS appears to induce different responses to chemotherapy regimens after first-line platinum-based chemotherapy in advanced NSCLC.

Background Adequate strategies using either transthoracic (TTE) or transesophageal (TEE) echocardiography in patients receiving cardiopulmonary resuscitation (CPR) is an ongoing area of research. Objectives As transthoracic point-of-care ultrasound (POCUS) during cardiac arrest resuscitation might result in an increased duration of interruptions in the delivery of chest compressions; the use of TEE has been proposed as an alternative. Methods No technical complications of either TTE nor TEE are so far being reported in the literature. Results We report the case of a left intramural atrial hematoma complicating TEE procedure during cardiac arrest. This highlights a unique and to our knowledge, first-in-man, described complicating TEE procedure during CPR. Conclusions Further research on the safety of transesophageal echo during CRP is mandatory and the question about any potential harm of particular interest.

We report a case of partial anomalous pulmonary venous return from the left upper lobe in a donor lung discovered during lung transplantation. The upper lobe vein could be implanted successfully into the donor atrial cuff to restore physiologic venous drainage. The abnormality was retrospectively identified on the donor's chest computed tomographic scan. Cardiac magnetic resonance imaging performed in the recipient 6 months after transplantation demonstrated patent left pulmonary venous drainage. This is the third reported case of partial anomalous pulmonary venous return in a donor lung, but the first description of direct ex vivo suture into the donor cuff.

Post-operative management of pIIIA-N2 non-small cell lung cancer (NSCLC) is still debated. Our objective was to identify subgroups of patients who could benefit from treatment based on invaded lymph node ratio (LNR). From January 2003 to December 2012, 297 pIIIA-N2 NSCLC patients treated with surgery followed by conformational radiation therapy (RT) were retrospectively analysed. Median follow-up time was 30 months. A correlation was observed between LNR and overall survival (OS) (R = −0.3, p

OBJECTIVES As the adoption of robotic procedures becomes more widespread, additional risk related to the learning curve can be expected. This article reports the results of a Delphi process to define procedures to optimize robotic training of thoracic surgeons and to promote safe performance of established robotic interventions as, for example, lung cancer and thymoma surgery. METHODS In June 2016, a working panel was spontaneously created by members of the European Society of Thoracic Surgeons (ESTS) and European Association for Cardio-Thoracic Surgery (EACTS) with a specialist interest in robotic thoracic surgery and/or surgical training. An e-consensus-finding exercise using the Delphi methodology was applied requiring 80% agreement to reach consensus on each question. Repeated iterations of anonymous voting continued over 3 rounds. RESULTS Agreement was reached on many points: a standardized robotic training curriculum for robotic thoracic surgery should be divided into clearly defined sections as a staged learning pathway; the basic robotic curriculum should include a baseline evaluation, an e-learning module, a simulation-based training (including virtual reality simulation, Dry lab and Wet lab) and a robotic theatre (bedside) observation. Advanced robotic training should include e-learning on index procedures (right upper lobe) with video demonstration, access to video library of robotic procedures, simulation training, modular console training to index procedure, transition to full-procedure training with a proctor and final evaluation of the submitted video to certified independent examiners. CONCLUSIONS Agreement was reached on a large number of questions to optimize and standardize training and education of thoracic surgeons in robotic activity. The production of the content of the learning material is ongoing.

Clamshell (bilateral anterolateral thoracotomy combined to transverse sternotomy) is an invasive surgical approach that is helpful in particular situations, especially bilateral lung transplantation. The closure technique remains challenging because clamshell incision can end with override, separation, or sternal pseudarthrosis complications. We describe the use of new absorbable sternal pins to stabilize the sternal closure and to help avoid additional sternal complications.

International audience; Myasthenia gravis (MG) with anti–acetylcholine receptor (AChR) Abs is an autoimmune disease characterized by severe defects in immune regulation and thymic inflammation. Because mesenchymal stem cells (MSCs) display immunomodulatory features, we investigated whether and how in vitro–preconditioned human MSCs (cMSCs) could treat MG disease. We developed a new humanized preclinical model by subcutaneously grafting thymic MG fragments into immunodeficient NSG mice (NSG-MG model). Ninety percent of the animals displayed human anti-AChR Abs in the serum, and 50% of the animals displayed MG-like symptoms that correlated with the loss of AChR at the muscle endplates. Interestingly, each mouse experiment recapitulated the MG features of each patient. We next demonstrated that cMSCs markedly improved MG, reducing the level of anti-AChR Abs in the serum and restoring AChR expression at the muscle endplate. Resting MSCs had a smaller effect. Finally, we showed that the underlying mechanisms involved (a) the inhibition of cell proliferation, (b) the inhibition of B cell–related and costimulatory molecules, and (c) the activation of the complement regulator DAF/CD55. In conclusion, this study shows that a preconditioning step promotes the therapeutic effects of MSCs via combined mechanisms, making cMSCs a promising strategy for treating MG and potentially other autoimmune diseases.

OBJECTIVES Data on thoracic lymph node involvement (LNI) in lung metastasis of colorectal cancer (CRC) are conflicting, with a 5-year overall survival (OS) ranging from 6 to 40%. We aimed to evaluate whether there are subgroups of patients according to the lymph node ratio (LNR). METHODS We retrospectively reviewed the data from 106 patients who underwent a thoracic procedure for CRC lung metastasis with pathologically proven thoracic LNI. RESULTS In the univariate analysis, the median OS was significantly poorer for a pN2 location of LNI (26 vs 16 months, P = 0.04), LNR ≥50% (30 vs 17 months, P = 0.005), high preoperative CEA (32 vs 16 months, P = 0.02), hepatic metastases (27 vs 11 months, P

Risk factors for lung cancer in lung transplant recipients are a history of smoking and immunosuppression, to which adds increasing use of lungs from donors with a smoking history. The three typical presentations are incidental diagnosis on the explanted lung, concerning less than 2%; lung cancer developing on the lung graft, accounting for less than 1%; and incidence of lung cancer on the native lung, estimated at 9%. Treatment along available guidelines may be hampered by decreased lung function owing to chronic rejection or adverse effects of immunosuppression. Prognosis is comparable to a general population in resected stage I cancer and is less favorable in advanced stages.

Management of stage IIIA-N2 non-small cell lung cancer is still matter of ongoing controversy. The debate is flawed by the heterogeneity of this group of patients, lack of strong evidence from controlled trials, diverging treatment strategies, and hesitating estimation of prognosis. Surgery is credited a survival advantage in a trimodality setting. For many teams, N2 is by principle managed with induction chemotherapy, followed by surgery if the patient is down-staged. However, surgery remains a suitable option even in case of persistent N2. On the other hand, outcomes are comparable, regardless whether chemotherapy has been given as induction or adjuvant treatment. Hence, upfront surgery without invasive staging, followed by adjuvant therapies, appears reasonable in resectable single station N2 disease, simplifying patient care and reducing cost. We expect that molecular biomarkers will improve estimation of prognosis and patient selection in the future.

Background Minimally invasive surgery, stereotactic radiotherapy, and radiofrequency ablation are commonly proposed in the case of pulmonary colorectal-metastasis as alternatives to conventional open surgery. Preoperative imaging assessment by computed tomography (CT) scan and fluorodeoxyglucose positron emission tomography (FDG-PET) are critical to guide oncologic radical treatment. Our aim was to investigate the accuracy of CT and FDG-PET for the evaluation of the number of pulmonary colorectal metastases and thoracic lymph nodal involvement (LNI). Methods Patients who underwent lung surgical resection for pulmonary colorectal metastases from 2004 to 2014 were analyzed. Concordance between histology, CT scan, and FDG-PET findings were assessed. Results Data of 521 patients were analyzed. Of those, FDG-PET was performed in 435 (83.5%). A moderate agreement between both CT scan (kappa index: 0.42) and FDG-PET (kappa index: 0.42) findings and the histologically proven number of metastases was observed. The number of histologically proven metastases was correctly discriminated in 61.7% of cases with CT scan and in 61.8% of cases with FDG-PET. Multiple metastases were discovered in 20.9% of clinical single metastasis cases with CT scan, and in 24.4% of those cases with FDG-PET. One hundred fifty patients (29.1%) presented with pathologic LNI. A poor agreement was observed between LNI and CT scan findings (kappa index: 0.02), and a weak agreement was observed concerning LNI and FDG-PET findings (kappa index: 0.39). Conclusions Computed tomography and FDG-PET have limitations if the objective is to detect all malignant nodules and to discriminate the LNI in cases of pulmonary metastases of colorectal cancer.

To investigate whether prophylactic postoperative NIV prevents respiratory complications following lung resection surgery in COPD patients. In seven thoracic surgery departments, 360 COPD patients undergoing lung resection surgery were randomly assigned to two groups: conventional postoperative treatment without (n = 179) or with (n = 181) prophylactic NIV, applied intermittently during 6 h per day for 48 h following surgery. The primary endpoint was the rate of acute respiratory events (ARE) at 30 days postoperatively (ITT analysis). Secondary endpoints were acute respiratory failure (ARF), intubation rate, mortality rate, infectious and non-infectious complications, and duration of ICU and hospital stay. ARE rates did not differ between the prophylactic NIV and control groups (57/181, 31.5 vs. 55/179, 30.7 %, p = 0.93). ARF rate was 18.8 % in the prophylactic NIV group and 24.5 % in controls (p = 0.20). Re-intubation rates were similar in the prophylactic NIV and control group [10/181 (5.5 %) and 13/179 (7.2 %), respectively, p = 0.53]. Mortality rates were 5 and 2.2 % in the control and prophylactic NIV groups, respectively (p = 0.16). Infectious and non-infectious complication rates, and duration of ICU and hospital stays were similar between groups. Prophylactic postoperative NIV did not reduce the rate of ARE in COPD patients undergoing lung resection surgery and did not influence other postoperative complications rates, mortality rates, and duration of ICU and hospital stay.

Purpose Using the metabolomics by NMR high-resolution magic angle spinning spectroscopy, we assessed the lung metabolome of various animal species in order to identify the animal model that could be substituted to human lung in studies on fresh lung biopsies. Methods The experiments were conducted on intact lung biopsy samples of pig, rat, mouse, and human using a Bruker Advance III 500 spectrometer. Thirty-five to 39 metabolites were identified and 23 metabolites were quantified. Principal component analysis, partial least-squares discriminant analysis, and analysis of variance tests were performed in order to compare the metabolic profiles of each animal lung biopsies to those of the human lung. Results The metabolic composition between human and pig lung was similar. However, human lung was distinguishable from mouse and rat regarding: Trimethylamine N-oxide and betaine which were present in rodents but not in human lung, carnitine, and glycerophosphocholine which were present in mouse but not in human lung. Conversely, succinic acid was undetected in rat lung. Furthermore, fatty acids concentration was significantly higher in rodent lungs compared to human lung. Conclusion Using the metabolomics by NMR high-resolution magic angle spinning spectroscopy on lung biopsy, samples allowed to highlight that pig lung seems to be close to human lung as regarding its metabolite composition with more similarities than dissimilarities. Magn Reson Med 71:35–43, 2014. © 2013 Wiley Periodicals, Inc.

Introduction: Diabetes mellitus (DM) is a risk factor for mortality and morbidity after solid organ transplantation (kidney, liver). The objective of our study was to determine the effect of DM on survival and unscheduled hospitalizations after lung transplantation. Patients and methods: We included retrospectively 256 patients who received a single or double lung transplantation at Strasbourg University Hospital between 2004 and 2014. The indications for lung transplantation were: COPD (43,4%), cystic fibrosis (21,9%), and pulmonary fibrosis (19,2%). 80% were bilateral transplantations. We grouped the patients into 3 relevant categories of DM: pre- and post-transplant DM, new onset (>3 months) diabetes after transplantation (NODAT) and the control group of non-diabetic patients. Results: 78 patients had pre&post DM and 48 patients developed NODAT. Cystic fibrosis patients had the highest prevalence (50%) of pre&post DM and NODAT. We found a significant difference for unscheduled hospital stays between the 3 groups: the duration of hospital stays [mean±SD] was 86±121 days/year for pre&post DM patients, 50±67 days/year for NODAT, and 78±120 days/year for non-diabetic patients (p=0,032). We observed a worse survival after transplantation in pre&post DM compared to patients without pre-transplant DM (3-months median conditional survival: 6.3 ± 1.6 vs 8.8 ± 0.7 years, p = 0.016). There was no difference in survival for NODAT patients compared to non-diabetic patients (3 months conditional median survival: 10.5 ± 2 years versus 8.4 ± 1.6, NS). Conclusion: DM might have an impact on survival after lung transplantation. An organized and cooperative management of pre&post DM and NODAT seems warranted.

OBJECTIVES The role of perioperative chemotherapy (POC) and targeted therapies in lung metastasectomy for colorectal cancer (CRC) is still subject to debate. We aimed to evaluate whether POC and targeted therapies were associated with different outcomes according to the mutational status. METHODS We reviewed data from 223 patients who underwent pulmonary metastasectomy for CRC from 1998 to 2015 and for whom the V-Ki-ras2 Kirsten sarcoma viral oncogene homologue (KRAS) and V-raf Murine sarcoma viral oncogene homologue B1 (BRAF) mutational statuses were known. RESULTS A total of 167 patients (74%) underwent POC: 62 (37%) received neoadjuvant therapy, 59 (35%) were in the adjuvant setting and 46 (28%) were in both the neoadjuvant and adjuvant settings. POC did not significantly influence either the loco-regional recurrence free survival (LRRFS) (P = 0.21) or the overall survival (OS) (P = 0.29). Furthermore, in cases of adjuvant chemotherapy, outcomes were not significantly different in cases of neoadjuvant chemotherapy or both neoadjuvant and adjuvant treatment (P = 0.26 for OS, P = 0.14 for LRRFS). For patients with KRAS mutation, perioperative bevacizumab was associated with a significant improvement in both LRRFS [70 months (41.58–98.42) vs 24 months (1.15–46.86), P = 0.001] and OS [101 vs 55 months (49.77–60.23), P = 0.004]. However, this benefit was only significant in cases of KRAS exon 2 codon 12 mutations [median OS: 101 months (83.97–118.02) vs 60 months (53–66.99), P

In thoracic surgery, extracorporeal life support (ECLS) techniques are performed to (I) provide a short to mid term extracorporeal mechanical support; (II) realize the gas exchanges; and (III)-depending the configuration of the circuit-substitute the failed heart function. The objective of this review is to describe the rational of the different ECLS techniques used in thoracic surgery and lung transplantation (LTx) with a specific attention to the vascular access. Venovenous extracorporeal membrane oxygenation (VV ECMO) is the most common ECLS technique used in thoracic surgery and represents the best strategy to support the lung function. VV ECMO needs peripheral vascular access. The selection between his double-site or single-site configuration should be decided according the level of O2 requirements, the nosological context, and the interest to perform an ECLS ambulatory strategy. Venoarterial (VA) ECMO uses peripheral and/or central cannulation sites. Central VA ECMO is mainly used in LTx instead a conventional cardiopulmonary bypass (CPB) to decrease the risk of hemorrhagic issues and the rate of primary graft dysfunction (PGD). Peripheral VA ECMO is traditionally realized in a femoro-femoral configuration. Femoro-femoral VA ECMO allows a cardiocirculatory support but does not provide an appropriate oxygenation of the brain and the heart. The isolated hypercapnic failure is currently supported by extracorporeal CO2 removal (ECCO2R) devices inserted in jugular or subclavian veins. The interest of the Novalung (Novalung GmbH, Hechingen, Germany) persists due to his central configuration indicated to bridge to LTx patients suffering from pulmonary hypertension. The increasing panel of ECLS technologies available in thoracic surgery is the results of a century of clinical practices, engineering progress, and improvements of physiological knowledges. The selection of the ECLS technique-and therefore the vascular access to implant the device-for a given nosological context trends to be defined according an evidence-based medicine.

Background After lung transplantation, bronchial complications are one of the major concerns for surgeons and physicians. In the era of evolving immunosuppressive regimens and surgical approaches, we have reassessed risk factors for bronchial complications after lung transplantation. Methods We undertook a retrospective study of all consecutive lung transplantations performed at a single center from 2004 to 2014. We monitored the incidence of symptomatic bronchial complications. Demographic data of donors and recipients were also studied. Our objective was to evaluate the impact of 3 subsequent immunosuppressive regimens (including the use of induction therapy), and of a technical modification of bronchial anastomosis on the incidence of airway complications. Results We performed 270 consecutive lung transplantations during the study period. On multivariate analysis, bronchial complications were not directly associated with the different immunosuppressive regimens. In subgroup analysis, when comparing different immunosuppressive regimens, primary graft dysfunction within 72 hours (odds ratio [OR] = 2.55; p = 0.08), lung infection within the first month (OR = 2.96; p = 0.039), diabetes before transplantation (OR = 2.66; p = 0.11) and chronic obstructive pulmonary disease (OR = 2.20; p = 0.04) appeared as major risk factors (c-index = 0.77 on multivariate analysis). The use of a modified bronchial suture technique was associated with fewer bronchial complications (OR = 0.47; p = 0.059) (c-index = 0.71 on multivariate analysis). Conclusions The mode of immunosuppression had no influence on airway complications. We were able to reproduce the beneficial effect of a modified suture technique.

OBJECTIVES The literature concerning relations between thoracic surgery and digestive motility is poor. The aim of our study was two-fold: (i) to show a link between thoracic surgery and gastric distension and (ii) between post-operative pneumoniae and gastric distension. METHODS A retrospective analysis was conducted in 262 patients who had undergone a thoracotomy for lung resection between January and December 2007. Transverse diameter of the stomach was measured on chest X-rays performed on Day 0 and on Day 1. Gastric distension was defined as a ratio (R) D1/D0 higher than 1.3 (min: 0.5; max: 4.1). Three groups were defined: Group 1 (absence of distension) R < 1.3; Group 2 (moderate distension) 1.3 ≤ R < 2.3; Group 3 (major distension) R ≥ 2.3. International criteria of the Center of Disease Control were used to define pneumonia. Appropriate statistical tests were carried out. RESULTS There were 73 women (27.9%) and 189 men (72.1%), ages ranged from 20 to 83 years (average: 59.9 years). As for gastric distension, 194 patients (74.04%) constituted Group 1, 53 (20.23%) Group 2 and 15 (5.73%) Group 3. Pneumonectomy significantly increased the incidence of gastric distension on Day 1 (P = 0.04). The side, mediastinal lymphadenectomy and personal medical past history of upper gastro-intestinal tract surgery had no statistically significant influence on the incidence of gastric distension. Univariate analysis showed that patients with gastric distension on D1 had significantly more infectious pneumonia on Day 5 (P < 0.0001): 16 (8.25%) patients in Group 1, vs 14 (26.41%) in Group 2 and 7 (46.67%) in Group 3. Furthermore, on Day 5, 33.33% (n = 8) of pneumectomies had pneumonia, against 12.18% (n = 29) of patients who had undergone another type of surgery (P = 0.01). On multivariate analysis, gastric distension was an independent predictive factor of infectious pneumonia on Day 5 (Group 3: odds ratio = 16.127 [4.267; 60 959], P < 0.0001). CONCLUSIONS We established, in our cohort of patients, a link between pneumonectomy and gastric distension on Day 1 and infectious pneumonia on Day 5. A prospective multicentre study would be desirable to verify these data.

Resume Introduction Les malformations arterioveineuses notamment pulmonaires (MAVP), representent les principales complications viscerales de la maladie de Rendu-Osler (MRO). En cas d’apparition d’une pleuresie chez un patient connu avec des MAVP, la principale hypothese a evoquer est l’hemothorax mais d’autres diagnostics sont possibles notamment une pleuresie purulente. Observation Nous rapportons le cas d’une femme de 35 ans aux antecedents de MAVP dans le cadre d’une MRO. Elle est admise en urgence dans un contexte de dyspnee et de douleurs thoraciques gauches d’apparition subaigue. Les premiers examens realises aux urgences orientent vers un hemothorax. Une arteriographie pulmonaire ne retrouve pas de saignement actif mais la presence d’une probable malformation arterioveineuse au niveau du lobe inferieur gauche. Une tentative d’embolisation est realisee quasi-concomitamment a un drainage thoracique qui permet finalement d’evacuer une collection purulente. L’evolution est par la suite favorable apres s’etre toutefois compliquee d’un syndrome de detresse respiratoire aigue puis d’une embolie pulmonaire. Conclusion Une pleuresie purulente est un evenement infectieux rarement associe a la MRO dans un contexte de MAVP non traitees, ou en cas de pleuresie la principale etiologie a evoquer reste l’hemothorax.

Aim A dosimetric study comparing intensity modulated radiotherapy (IMRT) by TomoTherapy to conformational 3D radiotherapy (3D-RT) in patients with superior sulcus non-small cell lung cancer (NSCLC). Background IMRT became the main technique in modern radiotherapy. However it was not currently used for lung cancers. Because of the need to increase the dose to control lung cancers but because of the critical organs surrounding the tumors, the gains obtainable with IMRT is not still demonstrated. Material and methods A dosimetric comparison of the planned target and organs at risk parameters between IMRT and 3D-RT in eight patients who received preoperative or curative intent irradiation. Results In the patients who received at least 66 Gy, the mean V95% was significantly better with IMRT than 3D-RT ( p = 0.043). IMRT delivered a lower D2% compared to 3D-RT ( p = 0.043). The IH was significantly better with IMRT ( p = 0.043). The lung V 5 Gy and V 13 Gy were significantly higher in IMRT than 3D-RT ( p = 0.043), while the maximal dose ( D max ) to the spinal cord was significantly lower in IMRT ( p = 0.043). The brachial plexus D max was significantly lower in IMRT than 3D-RT ( p = 0.048). For patients treated with 46 Gy, no significant differences were found. Conclusion Our study showed that IMRT is relevant for SS-NSCLC. In patients treated with a curative dose, it led to a reduction of the exposure of critical organs, allowing a better dose distribution in the tumor. For the patients treated with a preoperative schedule, our results provide a basis for future controlled trials to improve the histological complete response by increasing the radiation dose.

Standards are needed to control the quality of the lungs from nonheart-beating donors as potential grafts. This was here assessed using the metabolomics 1H high-resolution magic angle spinning NMR spectroscopy. Selective perfusion of the porcine bilung block was set up 30 min after cardiac arrest with cold Perfadex®. Lung alterations were analyzed at 3, 6, and 8 h of cold ischemia as compared to baseline and to nonperfused lung. Metabolomics analysis of lung biopsies allowed identification of 35 metabolites. Levels of the majority of the metabolites increased over time at 4°C without perfusion, indicating cellular degradation, whereas levels of glutathione decreased. When lung was perfused at 4°C, levels of the majority of the metabolites remained stable, including levels of glutathione. Levels of uracil by contrast showed a reverse profile, as its signal increased over time in the absence of perfusion while being totally absent in perfused samples. Our results showed glutathione and uracil as potential biomarkers for the quality of the lung. The metabolomics 1H high-resolution magic angle spinning NMR spectroscopy can be efficiently applied for the assessment of the quality of the lung as an original technique characterized by a rapid assessment of intact biopsy samples without extraction and can be implemented in hospital environment.

Introduction Atrial arrhythmias (AA) frequently occur after thoracic surgery, and are usually transient and benign. Strokes are a rare but serious neurological complication after lung transplantation. Although their incidence is now well known, their predictive factors remain uncertain. Objective The objective of this study was to evaluate the occurrence of postoperative AA in a cohort of lung transplanted patients and their relationship with the onset of stroke. Patients, materials and methods In total, 271 consecutive lung transplanted patients between 2005 and 2014 were retrospectively studied and followed during a mean of 3.2 ± 2.4 years. The data collected included clinical features, preoperative assessment, surgical reports and clinical follow-up. All arrhythmias recorded since the transplantation were analyzed. All strokes were collected. Results Thirty-three percent of patients presented AA in the immediate postoperative period. Fifteen patients (5.5%) presented stroke after transplantation, in 13 cases of ischemic origin. For 80%, stroke occurred within the first 6 months postoperatively. Mean CHA2DS2-VASc score was 1.1. Per- or postoperative low cardiac output was found as the only independent predictive factor of stroke onset [OR 4.6; CI (1.18–17.86); P = 0.027]. Postoperative AA and CHA2DS2-VASc score were not significantly associated with stroke. Postoperative AA did not affect in-house and long-term mortality. Conclusion AA are frequent after lung transplantation and don’t affect mortality. Neither AA nor CHA2DS2-VASc score are related to the occurrence of stroke. In contrast, a perioperative low cardiac output is an independent predictive factor of stroke after lung transplantation.

Background Pneumonectomy remains a high-risk procedure. Comprehensive patient selection should be based on analysis of proven risk factors. Methods The records of 323 pneumonectomy patients were retrospectively reviewed. Multiple demographic data were collected. End points were operative mortality at 30 and at 90 days, major procedurally related complications, and cardiovascular events. Univariate and multivariate statistical analyses were performed. Results Smoking habits, chronic obstructive pulmonary disease (COPD) status, induction chemotherapy status, diabetes, and obesity had no statistical influence on short-term outcomes. After right pneumonectomy, 30-day mortality (p = 0.045) and the incidence of bronchopleural fistulas (p = 0.009) were increased. Multivariate analysis for postoperative bronchopleural fistulas discovered that right pneumonectomies are the sole risk factor (p = 0.015). Univariate analysis for postoperative atrial fibrillation showed that male gender, age 70 and older, hypertension, and dyslipidemia are risk factors. Multivariate analysis found no definite risk factor. Patients with coronary artery disease had more postoperative cardiovascular events (p = 0.003). Among patients free of coronary artery disease, COPD led to an increased 90-day mortality rate (p = 0.028). Conclusions Patients with right pneumonectomies are at increased risk. Postoperative cardiovascular events are more frequent in coronary artery disease patients. COPD is a risk factor in patients free of coronary disease.

Background Operative management of patients with persistent N2 disease after induction therapy is still debated. Methods One hundred fifty-three consecutive patients underwent pneumonectomy from January 1999 until July 2005; 28 patients (18.3%) had persistent N2 disease after induction therapy (group 1), 32 patients (20.9%) had pathologic stage N0 or N1 after induction therapy (group 2), and 93 patients (60.8%) with pathologic N2 disease underwent immediate surgery (group 3). Short-term end points were operative mortality at 30 and 90 days and major complications. Long-term end points were 5-year survival and disease-free survival rates. Results Demographics of the three groups were similar (age, sex, side of operation, type of chemotherapy, smoking status, and comorbidity such as coronary artery disease, diabetes, and chronic obstructive pulmonary disease). Thirty-day postoperative mortality was 10.7% in group 1, 3.1% in group 2 (p = 0.257), and 4.3% in group 3 (p = 0.201); 90-day postoperative mortality was 10.7% in group 1, 12.5% in group 2 (p = 0.577), and 9.7% in group 3 (p = 0.558). Incidence of major postoperative complications was similar. Five-year survival rate was 32.2% (median, 28 months; 95% confidence interval, 7 to 43) in group 1, 34.8% (median, 27 months; 95% confidence interval, 7 to 47) in group 2 (p = 0.685), and 12.4% (median, 15 months; 95% confidence interval, 11 to 19) in group 3 (p = 0.127). No statistical difference was found in terms of 5-year event-free survival, or regarding the side of pneumonectomy. Conclusions Our results suggest that pneumonectomy is justified in patients with persistent N2 disease after induction chemotherapy.