Open versus laparoscopically-assisted oesophagectomy for cancer: a multicentre randomised controlled phase III trial - the MIRO trial

<p>Abstract</p> <p>Background</p> <p>Open transthoracic oesophagectomy is the standard treatment for infracarinal resectable oesophageal carcinomas, although it is associated with high mortality and morbidity rates of 2 to 10% and 30 to 50%, respectively, for both the abdominal and thoracic approaches. The worldwide popularity of laparoscopic techniques is based on promising results, including lower postoperative morbidity rates, which are related to the reduced postoperative trauma. We hypothesise that the laparoscopic abdominal approach (laparoscopic gastric mobilisation) in oesophageal cancer surgery will decrease the major postoperative complication rate due to the reduced surgical trauma.</p> <p>Methods/Design</p> <p>The MIRO trial is an open, controlled, prospective, randomised multicentre phase III trial. Patients in study arm A will receive laparoscopic-assisted oesophagectomy, i.e., a transthoracic oesophagectomy with two-field lymphadenectomy and laparoscopic gastric mobilisation. Patients in study arm B will receive the same procedure, but with the conventional open abdominal approach. The primary objective of the study is to evaluate the major postoperative 30-day morbidity. Secondary objectives are to assess the overall 30-day morbidity, 30-day mortality, 30-day pulmonary morbidity, disease-free survival, overall survival as well as quality of life and to perform medico-economic analysis. A total of 200 patients will be enrolled, and two safety analyses will be performed using 25 and 50 patients included in arm A.</p> <p>Discussion</p> <p>Postoperative morbidity remains high after oesophageal cancer surgery, especially due to major pulmonary complications, which are responsible for 50% of the postoperative deaths. This study represents the first randomised controlled phase III trial to evaluate the benefits of the minimally invasive approach with respect to the postoperative course and oncological outcomes in oesophageal cancer surgery.</p> <p>Trial Registration</p> <p><a href="http://www.clinicaltrials.gov/ct2/show/NCT00937456">NCT00937456</a> (ClinicalTrials.gov)</p

Single-lung and double-lung transplantation: technique and tips

International audienceThe first successful single-lung and double-lung transplantations were performed in the eighties. Since then both surgical and anesthesiological management have improved. The aim of this paper is to describe the surgical technique of lung transplantation: from the anesthesiological preparation, to the explantation and implantation of the lung grafts, and the preparation of the donor lungs. We will also describe the main surgical complications after lung transplantation and their management. Each step of the surgical procedure will be illustrated with photos and videos

Resultados del tratamiento quirúrgico de las hernias hiatales tipo III y IV por vía transtorácica izquierda

Objetivo. El objetivo de este trabajo es reportar los resultados a corto y largo plazo del tratamiento quirúrgico de las hernias hiatales tipo III y IV por vía transtorácica izquierda. Métodos. Se revisaron retrospectivamente las historias de los pacientes que presentaron una hernia hiatal tipo III o IV y fueron tratados por vía transtorácica izquierda. Se evaluaron las indicaciones, la elección de la técnica, la morbimortalidad y el resultado funcional de la reparación. Resultados. Sesenta y cinco pacientes fueron incluidos en el estudio. La evaluación preoperatoria demostró un predominio de la hernia tipo III (86%) en relacion con la tipo IV (14%). Las técnicas de reparación utilizada en la mayoría de los casos fueron la de Nissen (29%) o la de Belsey-Mark IV (15%) en los casos de esófago de longitud normal y la gastroplastia de alargamiento tipo Collis-Nissen en los casos de esófago corto (20%). Se constató una baja morbilidad y no hubo ningún deceso postoperatorio. El seguimiento promedio de los pacientes fue 42 meses. La evaluación a largo plazo mostró una notable mejoría de los síntomas. La reparación fue considerada como morfológicamente normal en el 76% de los pacientes. La esofagitis por reflujo, presente en el 62% de los pacientes antes de la cirugía, persistió en solo un paciente (6%) (P 15 mm Hg) en 13 pacientes. La pH-metría fue normal en 24 pacientes (92%). La medicación antiácida fue reducida significativamente de 40% en el preoperatorio a 21% en el postoperatorio (P < 0,001). Conclusión. La presencia de obesidad, esófago corto, hernia masiva, patologías esofágicas asociadas o antecedentes de cirugías previas constituyen las indicaciones para la elección de la vía transtorácica. Los resultados a largo plazo son aceptables con un buen control de los síntomas, una buena recuperación del daño de la mucosa y una reparación anatómica duradera

Long-term outcome of open versus hybrid minimally invasive Ivor Lewis oesophagectomy: a propensity score matched study

International audienceOBJECTIVES: It has been suggested that laparoscopic Ivor Lewis (IL) oesophagectomy reduces postoperative morbidity and mortality rates. However, data related to the long-term outcomes of this hybrid minimally invasive procedure are scarce. METHODS: All of the patients who had an IL oesophagectomy for cancer were extracted from a prospective database. Patients were matched one to one according to the surgical approach (laparoscopy versus laparotomy) and on the basis of a propensity score including eight variables: age, gender, American Society of Anaesthesiologists score, forced expiratory volume in 1 s, surgery (first-line treatment, after neoadjuvant treatment and salvage surgery), histology, location and pathological stage. The first end point was the assessment of the 5-year survival and disease-free survival rates. The secondary end points were R0 resection rate, number of resected lymph nodes (LNs) and patterns of recurrence. RESULTS: Over a 12-year period, 272 IL oesophagectomies were performed. A total of 140 patients were matched in two homogeneous groups: laparotomy (n = 70) and laparoscopy (n = 70). The 5-year overall survival and disease-free survival rates were 65% and 48% in laparotomy group and 73% and 51% in the laparoscopy group (P = 0.891; P = 0.912). R0 resection rates were, respectively, 93% vs 97% (P = 0.441). The number and distribution of resected LNs were similar between the groups except at the level of the celiac axis (P < 0.001). Depending on the surgical approach, the patterns of recurrence were similar in both groups. CONCLUSIONS: Laparoscopic IL oesophagectomy does not compromise the long-term oncological outcome compared to open IL oesophagectomy. The quality of the operations is similar for both techniques except for the number of resected LNs at the level of the celiac trunk. Further randomized controlled trials are necessary to confirm these results

Molecular Detection of Microorganisms in Distal Airways of Patients Undergoing Lung Cancer Surgery

International audienceBackgroundWhereas proximal airways of patients undergoing lung cancer surgery are known to present specific microbiota incriminated in the occurrence of postoperative respiratory complications, little attention has been paid to distal airways and lung parenchyma considered to be free from bacteria. We have hypothesized that molecular culture-independent techniques applied to distal airways should allow identification of uncultured bacteria, virus, or emerging pathogens and predict the occurrence of postoperative respiratory complications.MethodsMicrobiological assessments were obtained from the distal airways of resected lung specimens from a prospective cohort of patients undergoing major lung resections for cancer. Microorganisms were detected using real-time polymerase chain reaction (PCR) assays targeting the bacterial 16s ribosomal RNA gene and Herpesviridae, cytomegalovirus (CMV), and herpesvirus simplex. All postoperative microbiological assessments were compared with the PCR results.ResultsIn all, 240 samples from 87 patients were investigated. Colonizing agents were exclusively Herpesviridae (CMV, n = 13, and herpesvirus simplex, n = 1). All 16s ribosomal RNA PCR remained negative. Thirteen patients (15%) had a positive CMV PCR (positive-PCR group), whereas the remaining 74 patients constituted the negative-PCR group. Postoperative pneumonia occurred in 24% of the negative-PCR group and in 69% of the positive-PCR group (p = 0.003). Upon stepwise logistic regression, performance status, percent of predicted diffusion lung capacity for carbon monoxide, and positive PCR were the risk factors of postoperative respiratory complications. The CMV PCR had a positive predictive value of 0.70 in prediction of respiratory complications.ConclusionsWhen tested by molecular techniques, lung parenchyma and distal airways are free of bacteria, but CMV was found in a high proportion of the samples. Molecular CMV detection in distal airways should be seen as a reliable marker to identify patients at risk for postoperative respiratory complications

Pulmonary Endogenous Fluorescence Allows the Distinction of Primary Lung Cancer from the Perilesional Lung Parenchyma.

Pre-therapeutic pathological diagnosis is a crucial step of the management of pulmonary nodules suspected of being non small cell lung cancer (NSCLC), especially in the frame of currently implemented lung cancer screening programs in high-risk patients. Based on a human ex vivo model, we hypothesized that an embedded device measuring endogenous fluorescence would be able to distinguish pulmonary malignant lesions from the perilesional lung tissue.Consecutive patients who underwent surgical resection of pulmonary lesions were included in this prospective and observational study over an 8-month period. Measurements were performed back table on surgical specimens in the operative room, both on suspicious lesions and the perilesional healthy parenchyma. Endogenous fluorescence signal was characterized according to three criteria: maximal intensity (Imax), wavelength, and shape of the signal (missing, stable, instable, photobleaching).Ninety-six patients with 111 suspicious lesions were included. Final pathological diagnoses were: primary lung cancers (n = 60), lung metastases of extra-thoracic malignancies (n = 27) and non-tumoral lesions (n = 24). Mean Imax was significantly higher in NSCLC targeted lesions when compared to the perilesional lung parenchyma (p<0,0001) or non-tumoral lesions (p<0,0001). Similarly, photobleaching was more frequently found in NSCLC than in perilesional lung (p<0,0001), or in non-tumoral lesions (p<0,001). Respective associated wavelengths were not statistically different between perilesional lung and either primary lung cancers or non-tumoral lesions. Considering lung metastases, both mean Imax and wavelength of the targeted lesions were not different from those of the perilesional lung tissue. In contrast, photobleaching was significantly more frequently observed in the targeted lesions than in the perilesional lung (p≤0,01).Our results demonstrate that endogenous fluorescence applied to the diagnosis of lung nodules allows distinguishing NSCLC from the surrounding healthy parenchyma and from non-tumoral lesions. Inconclusive results were found for lung metastases due to the heterogeneity of this population

Shape of Fluorescent signals in the perilesional lung and the associated targeted lesions.

<p>^a. Comparison of the percentage of each shape between perilesional lung parenchyma and targeted lesions. Statistical analysis using the Pearson χ². statistical significance defined as * p<0,01, ** p<0,001, ***p<0,0001.</p><p>^b. Comparison of the percentage of each shape between NSLC and non-tumoral lesions and lung metastases. Statistical analysis using the Pearson χ². Statistical significance defined as ^§p = 0,02, ^§§p<0,01, ^§§§p<0,001.</p><p>NSCLC: Non Small Cell Lung Cancer. PB: Photobleaching.</p