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Eur J Cardiothorac Surg 2008;33:837-843. doi:10.1016/j.ejcts.2008.02.006
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Factors affecting early and long-term outcomes after completion pneumonectomy

Olivier Chataigner, Elie Fadel*, Bedrettin Yildizeli, Abdallah Achir, Sacha Mussot, Dominique Fabre, Olaf Mercier, Philippe G. Dartevelle

Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Paris-Sud University, 133, Avenue de la Resistance, 92350 Le Plessis Robinson, France

Received 4 September 2007; received in revised form 29 January 2008; accepted 1 February 2008.

* Corresponding author. Tel.: +33 1 40 94 29 42; fax: +33 1 40 94 55 83. (Email: fadel{at}ccml.com).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Objective: To identify factors that affect operative mortality and morbidity and long-term survival after completion pneumonectomy. Methods: We retrospectively reviewed the charts of consecutive patients who underwent completion pneumonectomy at our cardiothoracic surgery department from January 1996 to December 2005. Results: We identified 69 patients, who accounted for 17.8% of all pneumonectomies during the study period; 22 had benign disease and 47 malignant disease (second primary lung cancer, n = 19; local recurrence, n = 17; or metastasis, n = 11). There were 50 males and 19 females with a mean age of 60 years (range, 29–80 years). Postoperative mortality was 12% and postoperative morbidity 41%. Factors associated with postoperative mortality included obesity (p = 0.005), coronary artery disease (p = 0.03), removal of the right lung (p = 0.02), advanced age (p = 0.02), and renal failure (p < 0.0001). Preoperative renal failure was the only significant risk factor for mortality by multivariate analysis (p = 0.036). Bronchopleural fistula developed in seven patients (10%), with risk factors being removal of the right lung (p = 0.04) and mechanical stump closure (p = 0.03). Overall survival was 65% after 3 years and 46% after 5 years. Long-term survival was not affected by the reason for completion pneumonectomy. Conclusion: Although long-term survival was acceptable, postoperative mortality and morbidity rates remained high, confirming the reputation of completion pneumonectomy as a challenging procedure. Significant comorbidities and removal of the right lung were the main risk factors for postoperative mortality. Improved patient selection and better management of preoperative renal failure may improve the postoperative outcomes of this procedure, which offers a chance for prolonged survival.

Key Words: Completion pneumonectomy • Lung cancer • Benign lung disease • Complications


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Completion pneumonectomy (CP) is removal of the remaining lung after a first lung resection procedure done to treat a benign or malignant disease. CP results in higher mortality and morbidity rates compared to standard pneumonectomy [1], with operative mortality rates of up to 21% in early studies [2]. Indications for CP are expanding as a result of the rising incidence of lung cancer, increased survival rates after pulmonary resection for lung cancer or infection, increased indications of sleeve lobectomies, and improvements in imaging techniques. Thus, a 100% increase in CP procedures was noted at the Mayo Clinic between 1985 and 1998 [2]. Preoperative workup tests, anesthesia techniques, and postoperative management have improved in recent years, opening up the possibility that morbidity and mortality rates associated with CP may have decreased.

The purpose of this study was to review our experience with CP over the last decade (1996–2005) in order to determine postoperative mortality and morbidity rates, long-term survival, and risk factors for poor outcomes.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 Appendix A
 References
 
Between January 1996 and December 2005, 69 patients underwent CP at the Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie-Lannelongue Hospital, France. They accounted for 17.8% of all pneumonectomies performed during the same period. This CP rate (6.9/year) was nearly four times higher than the rate during the previous 15 years (29/15, 1.9 per year, 4.8% of all pneumonectomies, p = 0.005). Data were obtained from the hospital database, hospital charts, referring physicians, and/or patients or their families.

Study variables included: the primary reason for CP, age, sex, side, smoking history, preoperative comorbidities (renal failure defined as creatinine clearance <60 ml/min, obesity as body mass index >27, hypertension if systolic pressure >140 mmHg or diastolic pressure >90 mmHg or if a medical treatment is established, and coronary artery disease if a preoperative coronary revascularization is performed or if a myocardial ischemia is diagnosed and medically treated), pulmonary function, neoadjuvant treatment, interval between the first resection and CP, TNM stage in lung cancer patients where available, operative findings, surgical procedure, duration of postoperative ventilation, operative mortality, postoperative morbidity, and long-term mortality. Follow-up data were recorded until June 2007 or until death. Postoperative death was defined as death within 30 days after CP or before hospital discharge. The study was approved by our institutional review board. Informed consent was not required for this retrospective study.

There were 50 males and 19 females with a mean age of 60 years (range, 29–80 years). The reason for the first lung resection was benign disease in 11 patients and malignant disease in 58 patients. Malignancies consisted of primary non-small cell lung cancer (NSCLC) in 46 patients and lung metastasis in 12 patients. The 46 patients with NSCLC had squamous cell carcinoma (n = 23), adenocarcinoma (n = 22), or carcinoid tumor (n = 1). According to the TNM classification [3], most patients with lung cancer had focal disease (stage I in 27 patients, stage II in 15, stage IIIA in 2, stage IIIB in 1, and stage IV in 1). The first surgical procedure was a lobectomy (n = 40), sleeve lobectomy (n = 5), lobectomy extended to the chest wall (n = 4), right upper lobectomy extended to the carina (n = 1), bilobectomy (n = 13), or segmentectomy (n = 6). The median interval between the first resection and CP for malignant disease was 49.5 months and ranged from 5 to 198 months.

The reason for CP was benign disease in 22 (32%) patients, NSCLC in 36 (54%), and lung metastasis in 11 (14%) (Table 1 ). Benign diseases included postoperative bronchopleural fistula (BPF) (n = 9), destructive lung disease with resistant pneumonia (n = 6), bronchiectasis (n = 3), aspergillosis (n = 3), and bronchial anastomotic stricture after sleeve lobectomy (n = 1). Recurrent lung cancer and second primary lung cancer were differentiated using the criteria proposed by Martini et al. [4]. A second primary NSCLC occurred in 19 patients and a local recurrence of previously resected NSCLC in 17. Histological findings in the 36 patients who underwent CP for NSCLC were adenocarcinoma (n = 16), squamous cell carcinoma (n = 16), and bronchoalveolar cell carcinoma (n = 4). The nodal stage was N0 in 23 (64%) patients, N1 in 8 (22%), and N2 in 5 (14%). Postoperative NSCLC stages were stage IA in 10 patients, IB in seven, IIA in two, IIB in five, IIIA in five, and stage IIIB in seven patients. The site of the primary tumor in the 11 patients who underwent CP for lung metastasis was colon adenocarcinoma (n = 4), soft tissue sarcoma (n = 4), pharyngeal squamous cell carcinoma (n = 1), thymoma (n = 1), and primary mediastinal nonseminomatous germ cell tumor (n = 1).


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  		Table 1 Indications for completion pneumonectomy in the 69 study patients
 
Preoperatively, 48 (70%) patients were chronic cigarette smokers with smoking histories of more than 20 pack-years. Other comorbidities were noted in 47 (68%) patients and included chronic obstructive pulmonary disease in 27 (39%), hypertension in 14 (20%), coronary artery disease in 8 (12%), renal failure in four (6%), dyslipidemia in four (6%), diabetes mellitus in two (3%), and morbid obesity in one (1.4%). Median percent predicted forced expiratory volume in 1 s (FEV1) was 54.5% (range, 30–96%). Preoperative chemotherapy was given alone to nine (13%) patients and with radiation therapy to six (9%) patients. Adjuvant therapy, used in 19 patients (28%), consisted in chemotherapy (n = 10, 14%), radiation therapy (n = 5, 7%), or both (n = 4, 6%).

Tumor spread and functional status were evaluated preoperatively. Physical examination, chest roentgenography, spirometry, arterial blood gases, quantitative ventilation measurements, and perfusion scans were performed routinely to evaluate functional status. Patients at high risk for heart disease were screened by echocardiography, thallium stress testing and, in some cases, selective coronary arteriography. Tumor spread to the airway was evaluated by fiberoptic bronchoscopy with routine biopsy collection unless a hypervascular lesion was noted. In patients with benign lung disease, fiberoptic bronchoscopy played a key role in selection to CP by demonstrating BPF or assessing the extent of parenchymal destruction. Mediastinal nodal status was investigated by computed tomography (CT) and, in our more recent experience, by positron emission tomography (PET). In patients with NSCLC, mediastinoscopy was done when CT showed mediastinal nodes larger than >1 cm in diameter or when PET showed mediastinal fixation. Investigations for extrathoracic metastases were performed routinely. A pulmonary angiogram was performed when the tumor adhered to the main pulmonary artery. In high-risk patients, right heart catheterization was performed before and after balloon occlusion of the relevant pulmonary artery in order to detect pulmonary hypertension, an established contraindication to CP.

CP was performed after one-lung ventilation was established through a double-lumen endotracheal tube. A posterolateral thoracotomy was made in the fifth intercostal space. On the right, the arch of the azygos vein was divided in some cases, allowing excellent exposure of the main bronchus. No irreversible procedures were performed until resectability was confirmed. First, pleural adhesions were removed and, when tumor invasion of the chest wall was suspected, en bloc chest wall resection was performed, producing a larger window to the mediastinum. The hilar, carinal, paratracheal, esophageal, and inferior pulmonary ligament lymph nodes were routinely dissected in patients with NSCLC or metastases. Specimens of the resection margins were taken for frozen-section examination to ensure complete resection. A flap was used routinely to cover the bronchial stump and to separate it from the pulmonary artery, thus preventing bronchovascular fistula. A tube was inserted to ensure drainage for 1–2 days. At the end of the procedure, the bronchial suture was checked bronchoscopically, and secretions were removed from the airways. Most patients were extubated in the operating room. Pain relief was achieved using epidural analgesia or patient-controlled analgesia. When postoperative mechanical ventilation was necessary, a standard endotracheal tube was substituted for the double-lumen tube. If needed, temporary tracheostomy was performed at the end of operation to reduce the physiologic respiratory dead space and to facilitate direct aspiration when the predicted residual ventilatory functional reserve was borderline or patient cooperation was poor.

Patient data are reported as medians and ranges for quantitative variables and as absolute and relative frequencies for qualitative variables. The effects of risk factors on endpoints were evaluated using Student's t-tests and Fisher's exact tests in the univariate analysis and multiple logistic regression in the multivariate analysis. The Kaplan–Meier method was used to calculate expected survival rates after CP; operative mortality was included in this analysis. Statistical significance was calculated using the log rank test. A p value not greater than 0.05 was considered significant. All 69 patients were included in the survival analysis. Follow-up was complete for all patients. Data processing and analysis were done using the Statview software package version 5 (Abacus Concept, Berkeley, CA).


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 Appendix A
 References
 
Complete resection (R0) was achieved in all patients with malignant disease. The right lung was removed in 44 (64%) patients and the left lung in 25 (36%). Intrapericardial dissection was performed in 47 patients (68%). The bronchial stump was kept short, and bronchial closure was with interrupted sutures in 46 (67%) patients and staples (Ethicon® TA 30, WA 2.5 cm) in 23 (33%). The pedicled flap used to cover the bronchial suture line was from the serratus anterior muscle (n = 8), adjacent pleura (n = 34), or mediastinum (n = 24). CP for lung malignancies was extended to adjacent structures in 10 patients (14%) including the chest wall in five (7%), carina in three (4%), superior vena cava with polytetrafluoroethylene graft replacement in one (1%), and esophageal muscle in one (1%). A blood transfusion was required intra- and postoperatively in 13 patients (19%) (median, 3 units; range, 1–9 units).

There were no intraoperative deaths. Overall, eight (11.6%) patients died in the postoperative period, from multisystem failure due to contralateral pneumonia (n = 3), pulmonary embolism (n = 3), or BPF with acute respiratory distress syndrome (ARDS) (n = 2). Postoperative mortality was 14% (5/36) in patients with primary lung cancer, 9% (1/11) in those with lung metastasis, and 9% (2/22) in those with benign disease (p > 0.05). Postoperative mortality in all patients with malignant disease was 12.8% (6/47). No deaths occurred among the nine patients who underwent CP for BPF. Factors associated with postoperative death in the univariate analysis included CP on the right side (p = 0.04), advanced age (p = 0.02), and renal failure (p = 0.004). Preoperative renal failure was the factor significantly associated with death in the multivariate analysis (p = 0.036) (Table 2 ).


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  		Table 2 Factors associated with operative mortality
 
Postoperative complications occurred in 28 patients (41%). Empyema developed in seven patients (10%), of whom one was managed with chest tube insertion and pleural lavage, one with open debridement, and five with a Clagett procedure. BPF developed in five patients, who underwent a Clagett procedure. Of six patients with hemothorax, three required surgery. Chylothorax occurred in one patient, who required surgical ligation of the thoracic duct. The remaining nine patients experienced medical complications including pneumonia in four patients, arrhythmia in three, pulmonary embolus in one, and renal failure in one. Thus, 15 (22%) patients required additional surgery. By univariate analysis, only preoperative percent predicted FEV1 < 50% was associated with postoperative complications (p = 0.03). By multivariate analysis, no significant factor was found.

Overall, BPF developed after CP in seven (10%) patients, all of whom had a prolonged (>24 h) postoperative mechanical ventilation and were among the 44 patients who had removal of the right lung (p < 0.04 vs removal of the left lung). BPF was more common, but not statistically significant, when the bronchial stump was closed by staples as opposed to interrupted suture (17.3% vs 6.5%, p = ns). Two patients with BPF died on postoperative days 11 and 17, respectively, from ARDS. The remaining five patients were treated successfully by a Clagett procedure followed by BPF closure with a pedicled omentum flap.

Follow-up was complete for all patients. Mean follow-up was 3.6 years (range, 1–10 years). Overall 3-, 5- and 10-year survival rates from the time of CP were 65%, 46%, and 36%, respectively (Fig. 1 ). For patients with NSCLC, lung metastases, and benign disease, 5-year survival rates were 41%, 41%, and 52%, respectively (p = ns). Among the 22 patients who underwent CP for benign disease, 5-year actuarial survival rates were 49% when CP was performed for a complication of NSCLC surgery (n = 12) and 56% when it was performed after surgery for benign disease (n = 10) (p = ns) (Fig. 2 ). Among the 36 patients who underwent CP for NSCLC, 5-year survival rates were similar in the subgroup with second primary cancers (n = 19) and in the subgroup with recurrences (n = 17) (38% vs 41%; p = ns). However, survival rates were affected by lung cancer stage, as shown in Fig. 3 . The 5-year survival rate was 69% in stage I, 36% in stage II and 17% in stage III disease. Patients with stage I and II disease had better survival rates than patients with stage III disease (56% vs17%; p = 0.02).


Figure 1
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  		Fig. 1. Overall survival curve for completion pneumonectomy calculated using the Kaplan–Meier method.

 

Figure 2
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  		Fig. 2. Survival curve for completion pneumonectomy according to reason for the procedure calculated using the Kaplan–Meier method.

 

Figure 3
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  		Fig. 3. Survival curve for completion pneumonectomy for lung cancer according to stage calculated using the Kaplan–Meier method.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
Appendix A
 References
 
CP is removal of the remaining lung after partial lung resection. A reasonable possibility is that a process akin to preconditioning ensures better tolerance by the heart and lung of this second procedure, compared to one-stage pneumonectomy. However, mortality and morbidity rates are higher after CP than after standard pneumonectomy [2]. Intraoperative mortality during CP has ranged from 0% to 5.3% (Table 3 ), with the main cause of death being cataclysmic bleeding after injury to the heart or large vessels [5,6], usually due to major pleural and sometimes pericardial adhesions related to previous surgery or infection. Intraoperative blood loss is considerably higher after CP than after standard pneumonectomy. Although none of our patients died during surgery, we agree with others [5,7,8] that CP is a highly demanding procedure that should be performed only by skilled thoracic surgeons. More specifically, extrapleural plane dissection, which is generally performed in redo thoracic surgery, can be very difficult, particularly in the apical area and when previous surgery was through the extrapleural plane. Thus, CP for parenchymal destruction by infection or radiation therapy carries a very high risk of intraoperative bleeding. If the pericardium was not opened during the first procedure, intrapericardial control of the pulmonary artery and veins is recommended to avoid vessel injuries [7].


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  		Table 3 Operative mortality after completion pneumonectomy in the literature
 
The small number of patients studied in our series, as well as in the other published series of CP, is a significant weakness to statistical results and may represent a major bias. However, the overall postoperative mortality rate of 11.6% in our study is consistent with recently reported rates of 2.6–20.9% [2,5,6,8–20] (Table 3). Thus, postoperative mortality is usually higher after CP than after standard pneumonectomy [1,9]. In a study of pneumonectomy for malignant disease performed at the Mayo Clinic between 1985 and 1998, CP was an independent risk factor for postoperative mortality [1]. Although CP was performed for BPF in eight of our patients (36% of all patients who had CP for benign disease), the postoperative mortality rate in the benign-disease group was 9%. This rate compares favorably with other studies (Table 3). Thus, in several studies, CP for benign disease, most notably BPF, was associated with higher postoperative mortality rates than was CP for lung malignancies [2]. Postoperative mortality rates after CP for benign disease were as high as 30.8% [10] and 27.6% [11] in two retrospective studies, probably as a result of major intraoperative difficulties. In contrast, postoperative mortality in patients who had CP for malignant disease in our study was 14.6%, in keeping with recent results (Table 3). Risk factors for postoperative mortality in our study were obesity, coronary artery disease, advanced age, renal failure, and CP on the right side but only in the univariate analysis. Overall results from univariate analysis presented seem just as valid as results from multivariate, as previously reported [2]. Thus, major preoperative comorbidities and complexity of the procedure contribute to increase postoperative mortality after CP. In our study, 68% of patients had at least one major comorbidity before surgery, a fact that probably contributed to the relatively high mortality rate. In all likelihood, had these comorbidities not been present at the first surgical procedure, one-stage pneumonectomy would have been performed. Improved patient selection to CP would probably result in lower mortality rates.

Postoperative complications occurred in 41% of our patients. Empyema and cardiopulmonary complications were the most common. Similarly, earlier studies reported postoperative complications in 18–62% of patients (Table 4 ). The BPF rate was higher after CP than after standard pneumonectomy [5,6,11]. In our study, BPF developed in 10% of patients, with two risk factors, CP on the right side and bronchial stump stapling. However, all of them occurred in patients with prolonged postoperative mechanical ventilation suggesting that the stapled bronchial stump is more vulnerable in such conditions. Conversely, among patients who underwent CP for BPF complicating the first procedure, none experienced new BPF development. This finding may be related to our policy in BPF patients of routine bronchial stump closure by interrupted suture followed by coverage with a pedicled muscle flap.


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  		Table 4 Completion pneumonectomy: data on complication and bronchopleural fistula rates from earlier studies (1988–2004) and our study
 
The overall 5-year survival rate was 46% in our study. Although long-term survival tended to be better in patients with benign disease, the difference with patients who had malignancies was not statistically significant, in contradiction to previous reports [11–13]. Neither did survival differ significantly between patients with second primaries and those with recurrences. Long-term survival rates in our study are consistent with several other reports [6,10,14,15]. However, as shown in Table 5 , survival varies widely, probably because case series are small. In patients with lung cancer, although long-term survival rates still depend on cancer stage, CP can be curative. Therefore, close follow-up is in order after surgery for NSCLC. If a local recurrence or second primary is diagnosed, CP should be considered, provided the patient has no comorbidities that contraindicate the procedure. Indeed, patient selection for CP is of utmost importance and should be carefully performed. Because most of time the management of the local recurrence is performed by the same thoracic surgeon who did the first lung resection, this recurrence is sometimes seen as a failure making the indication for CP more favorable. Also, patients in whom pneumonectomy was contraindicated during the first procedure should not be considered for CP before a careful workup.


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  		Table 5 Five-year survival after completion pneumonectomy in earlier studies (1988–2007) and our study
 
In summary, CP remains a challenging procedure associated with high operative mortality and morbidity rates. In our study, the main factors associated with postoperative mortality were significant comorbidities and CP on the right side. However, CP is associated with good long-term survival rates, even in patients with lung malignancies. CP should therefore be considered in selected patients after a careful preoperative workup to rule out major comorbidities. CP should be performed by skilled thoracic surgeons, in order to improve the postoperative outcome.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A
References
 
Conference discussion

Dr J. Alvarez (Perth, Australia): This is, in my view, a very useful and pragmatic paper. Dr Chataigner points out that the incidence of this beast is increasing and accounted for 20% of all your pneumonectomies over a decade period. So retrospectively you have a sizable number of patients. And frankly, that half of the patients were non-small cell lung cancer. Your operative mortality is 12%, and you shouldn’t be terribly surprized given the quality of the surgery that is required and also because two-thirds of the patients were on the right.

And your incidence of bronchopleural fistula is about 10%. And you pointed out that the right lung and the use of the stapler were, on univariate analysis anyway, potential significant factors, you have demonstrated impressive long-term results, survival at 5 years was 46%. And this is bearing in mind that the median presentation time was just short of 4 years, at 49 months.

I wouldn’t be too harsh in terms of your operative mortality. I’m a cardiothoracic surgeon. I’m tremendously aware of the warmth that exists between cardiac and thoracic surgeons in the USA and Europe, this is not so much the case in Australia. Repeat cardiac surgeries have had a five-fold mortality compared with first-time cardiac surgery. This is big time stuff.

Your former EACTS president, Dr Fuentes, a few years ago pointed out that pneumonectomy, by and large, has a mortality of about 10%, so I think your results are very acceptable, you shouldn’t be too harsh. I’m not trying to say we shouldn’t improve our results, but those are facts of life.

Furthermore, 77% of your patients were still chronic smokers. Mediastinoscopy was only performed if the CT was positive (i.e. mediastinal nodes more than 10 mm) or the PET scan was positive. You use a flap in all your cases to cover the bronchial stump and, of course, you advocate de rigueur to open up the pericardium. Your conclusions are basically that this operation should be done by those who can perform this operation safely and you’ve got to pick the right patients.

I’ve briefly got four questions that may add hopefully help you to pick the right patients. First of all, just the management of your pneumonectomy space – I’ll perhaps just ask them, they’re four quick questions.

The management of pneumonectomy space, is very important, a leading cause of death with pneumonectomy is idiopathic postpneumonectomy pulmonary edema. You don’t report any such fatality. I imagine it's because of the previous surgery. What do you advocate for management of the pneumonectomy space – tube, no tube, clamp release?

Dr Chataigner: Can you repeat slowly because my English is not so good.

Dr Alvarez: The pneumonectomy space, do you put a tube? Do you not put a tube?

Dr Chataigner: Yes, we always put a tube.

Dr Alvarez: Now, smoking, 70% were smokers. Do you actually perform pneumonectomies of the patients who are actively smoking, or do you advocate them to abstain for a period of time?

Dr Chataigner: Yes, all the patients stopped smoking preoperatively.

Dr Alvarez: Do you have an idea for how long?

Dr Chataigner: Six hours!!

Dr Alvarez: There could be a point made if you’re actively smoking not to do a pneumonectomy.

My question in terms of bronchopulmonary fistulas, could you be absolutely certain that it is the mechanical closure of the right bronchus that is the actual reason for the BPF?

Could it be that in this redo surgery you need to do a bit more dissection to get the staple across?

Dr Chataigner: All our bronchopleural fistulas were on the right side. And I think it's because of the anatomic configuration: the mediastinum can cover the bronchial stump on the left side but it's difficult on the right side. Maybe on the right side should we put a serratus muscle or another pedicle flap.

Dr Alvarez: My follow-up question, in that given all of the BPFs, and your numbers are small, I congratulate you, but mortality is high not surprizingly – even that all your BPFs occurred on the right-hand side, would you consider another method to deal with the remaining bronchial stump? – because whether you use a pleural or mediastinal flap, given it's a redo operation, these tissues are not exactly the most mobile, you only use the serratus anterior, I presume in the eight cases where the indication for the pneumonectomy was actually the presence of a bronchopleural fistula, so would you advocate a different technique on the right-hand side, say the use of an intercostal muscle flap or using serratus anterior in all cases at the time of surgery?

Dr Chataigner: First, for the closure of the bronchus, we can use manual closure, and to cover the bronchial stump probably we should use on the right side the omentum or, more frequently, the entire serratus muscle to prevent bronchopleural fistula.

Dr Alvarez: And finally, although your long-term results are very, very good, about 14% of patients, or one in six, had N2 disease. So that one in six of your patients were really stage III.

Now, given that the operative mortality in that group is about 15%, a complication rate that is substantial, but the 5-year survival was 17%, with most of the deaths occurring at 18–20 months, would you really advocate a completion pneumonectomy on the righthand side in patients with stage III disease? Would you advocate perhaps being more liberal with the use of mediastinoscopy despite the CT and the PET scan or the use of IVUS?

Dr Chataigner: For the mediastinoscopy, we always made mediastinoscopy when we saw lymph nodes on the CT scan or on the PET scan. For the operation for patients with stage III disease, the alternative was chemotherapy or radiation therapy, but I think the survival rate after chemotherapy or radiation therapy is less than after surgery. Even if 17% is a low percentage of survival, I think it's better with surgery than with the other treatment. So I think we should perform completion pneumonectomy even in stage III disease.

Dr L. LangLazdunski (London, United Kingdom): I’m not really clear about the bronchial stump. Do you cover routinely and prophylactically the bronchial stump? What is the material used? Is it pleural flap or intercostal muscle, or the omentum?

Dr Chataigner: We usually use pedicle flap to cover the bronchial stump, adjacent parietal pleura, and in some cases the serratus entire muscle; on the 69 completion pneumonectomies, we used 66 pedicle flaps to cover the bronchial stump, whatever the side.

Dr J. Nakajima (Tokyo, Japan): You said that completion pneumonectomy of the right lung is more risky than that of the left lung. I think that there is another problem, that is, the completion pneumonectomy by upper lobectomy and completion pneumonectomy by lower lobectomy, which do you think more risky?

Dr Chataigner: We analyzed these factors and then we don’t find any significant difference concerning morbidity or longterm survival. But probably when we perform completion pneumonectomy with lower lobectomy, there is more complication, but we don’t find any significant difference in this study.


   Footnotes
 
{star} Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A
 References
 

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