1. Ann Thorac Surg. 2015 Aug 21. pii: S0003-4975(15)01034-6. doi: 10.1016/j.athoracsur.2015.06.026. [Epub ahead of print] A Predictive Score for Bronchopleural Fistula Established Using the French Database Epithor. Pforr A(1), Pagès PB(2), Baste JM(3), Thomas P(4), Falcoz PE(5), Lepimpec Barthes F(6), Dahan M(7), Bernard A(1); Epithor Project (French Society of Thoracic and Cardiovascular Surgery). Author information: (1)Centre Hospitalier Universitaire (CHU) Dijon, Bocage Hospital, Dijon, France. (2)Centre Hospitalier Universitaire (CHU) Dijon, Bocage Hospital, Dijon, France. Electronic address: pierrebenoit.pages@chu-dijon.fr. (3)CHU Rouen, Charles Nicolle Hospital, Rouen, France. (4)CHU Marseille, North Hospital, Marseille, France. (5)CHU Strasbourg, Civil Hospital, Strasbourg, France. (6)Georges Pompidou European Hospital, Paris, France. (7)CHU Toulouse, Larrey Hospital, Toulouse, France. BACKGROUND: Bronchopleural fistula (BPF) remains a rare but fatal complication of thoracic surgery. The aim of this study was to develop and validate a predictive model of BPF after pulmonary resection and to identify patients at high risk for BPF. METHODS: From January 2005 to December 2012, 34,000 patients underwent major pulmonary resection (lobectomy, bilobectomy, or pneumonectomy) and were entered into the French National database Epithor. The primary outcome was the occurrence of postoperative BPF at 30 days. The logistic regression model was built using a backward stepwise variable selection. RESULTS: Bronchopleural fistula occurred in 318 patients (0.94%); its prevalence was 0.5% for lobectomy (n = 139), 2.2% for bilobectomy (n = 39), and 3% for pneumonectomy (n = 140). The mortality rate was 25.9% for lobectomy (n = 36), 16.7% for bilobectomy (n = 6), and 20% for pneumonectomy (n = 28). In the final model, nine variables were selected: sex, body mass index, dyspnea score, number of comorbidities per patient, bilobectomy, pneumonectomy, emergency surgery, sleeve resection, and the side of the resection. In the development data set, the C-index was 0.8 (95% confidence interval: 0.78 to 0.82). This model was well calibrated because the Hosmer-Lemeshow test was not significant (χ(2) = 10.5, p = 0.23). We then calculated the logistic regression coefficient to build the predictive score for BPF. CONCLUSIONS: This strong model could be easily used by surgeons to identify patient at high risk for BPF. This score needs to be confirmed prospectively in an independent cohort. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved. PMID: 26303974 [PubMed - as supplied by publisher] 2. Eur Respir J. 2015 Oct;46(4):1131-9. doi: 10.1183/13993003.00354-2015. Epub 2015 Aug 6. Time trends in surgery for lung cancer in France from 2005 to 2012: a nationwide study. Morgant MC(1), Pagès PB(2), Orsini B(3), Falcoz PE(4), Thomas PA(3), Barthes Fle P(5), Dahan M(5), Bernard A(1); Epithor project (French Society of Thoracic and Cardiovascular Surgery). Author information: (1)CHU Dijon, Bocage Central Hospital, Dijon, France. (2)CHU Dijon, Bocage Central Hospital, Dijon, France pierrebenoit.pages@chu-dijon.fr. (3)CHU Marseille, North Hospital, Marseille, France. (4)CHU Strasbourg, Civil Hospital, Strasbourg, France. (5)CHU Toulouse, Larrey Hospital, Toulouse, France. The aim of this study was to assess the evolution of survival in patients treated surgically for non-small cell lung cancer (NSCLC) between 2005 and 2012.From January 2005 to December 2012, 34 006 patients underwent pulmonary resection for NSCLC and were included in the French national database Epithor. Patients' characteristics, procedures and survival were analysed. Survival according to the management was evaluated for each 2-year period separately: 2005-2006, 2007-2008, 2009-2010 and 2011-2012.The proportions of early-stage cancers and adenocarcinomas increased significantly over the periods. 3-year overall survival (OS) increased significantly from 80.5% for the first period to 81.4% for the last period. For the periods 2005-2006 and 2007-2008, 3-year OS was lower after segmentectomy than after lobectomy (77 and 73% versus 82 and 83%, respectively). For the periods 2009-2010 and 2011-2012, 3-year OS in the two sub-groups was similar. OS after bi-lobectomy or pneumonectomy was lower than after lobectomy for all periods analysed. Systematic nodal dissection increased OS for all periods. Chemotherapy but not radiotherapy improved OS in the first 12 postoperative months for all periods.Changes in histological type and stage linked to advances in surgical and medical practices since 2005 led to an increase in OS in patients with surgical-stage NSCLC. Copyright ©ERS 2015. PMID: 26250496 [PubMed - in process] 3. Eur J Cardiothorac Surg. 2015 Jun 12. pii: ezv195. [Epub ahead of print] Surgical management of spontaneous pneumothorax: are there any prognostic factors influencing postoperative complications? Delpy JP(1), Pagès PB(2), Mordant P(3), Falcoz PE(4), Thomas P(5), Le Pimpec-Barthes F(6), Dahan M(7), Bernard A; EPITHOR project (French Society of Thoracic and Cardiovascular Surgery). Author information: (1)CHU Dijon, Bocage Hospital, Dijon, France. (2)CHU Dijon, Bocage Hospital, Dijon, France pierrebenoit.pages@chu-dijon.fr pb.pages@live.fr. (3)Bichat-Claude Bernard Hospital, Paris, France. (4)CHU Strasbourg, Civil Hospital, Strasbourg, France. (5)CHU Marseille, North Hospital, Marseille Cedex, France. (6)Georges Pompidou European Hospital, Paris, France. (7)CHU Toulouse, Larrey Hospital, Toulouse, France. OBJECTIVES: There are no guidelines regarding the surgical approach for spontaneous pneumothorax. It has been reported, however, that the risk of recurrence following video-assisted thoracic surgery is higher than that following open thoracotomy (OT). The objective of this study was to determine whether this higher risk of recurrence following video-assisted thoracic surgery could be attributable to differences in intraoperative parenchymal resection and the pleurodesis technique. METHODS: Data for 7647 patients operated on for primary or secondary spontaneous pneumothorax between 1 January 2005 and 31 December 2012 were extracted from Epithor®, the French national database. The type of pleurodesis and parenchymal resection was collected. Outcomes were (i) bleeding, defined as postoperative pleural bleeding; (ii) pulmonary and pleural complications, defined as atelectasis, pneumonia, empyema, prolonged ventilation, acute respiratory distress syndrome and prolonged air leaks; (iii) in-hospital length of stay and (iv) recurrence, defined as chest drainage or surgery for a second pneumothorax. RESULTS: Of note, 6643 patients underwent videothoracoscopy and 1004 patients underwent OT. When compared with the thoracotomy group, the videothoracoscopy group was associated with more parenchymal resections (62.4 vs 80%, P = 0.01), fewer mechanical pleurodesis procedures (93 vs 77.5%, P < 10(-3)), fewer postoperative respiratory complications (12 vs 8.2%, P = 0.01), fewer cases of postoperative pleural bleeding (2.3 vs 1.4%, P = 0.04) and shorter hospital lengths of stay (16 vs 9 days, P = 0.01). The recurrence rate was 1.8% (n = 18) in the thoracotomy group versus 3.8% (n = 254) in the videothoracoscopy group (P = 0.01). The median time between surgery and recurrence was 3 months (range: 1-76 months). CONCLUSIONS: In the surgical management of spontaneous pneumothorax, videothoracoscopy is associated with a higher rate of recurrence than OT. This difference might be attributable to differences in the pleurodesis technique rather than differences in the parenchymal resection. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. PMID: 26071433 [PubMed - as supplied by publisher] 4. Eur J Cardiothorac Surg. 2015 Oct;48(4):608-11. doi: 10.1093/ejcts/ezu505. Epub 2015 Jan 5. Index of prolonged air leak score validation in case of video-assisted thoracoscopic surgery anatomical lung resection: results of a nationwide study based on the French national thoracic database, EPITHOR†. Orsini B(1), Baste JM(2), Gossot D(3), Berthet JP(4), Assouad J(5), Dahan M(6), Bernard A(7), Thomas PA(8). Author information: (1)Department of Thoracic Surgery and Diseases of Esophagus, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille University, North Hospital, Marseille, France bastienorsini1@gmail.com. (2)Department of Thoracic Surgery, CHU Rouen, Rouen, France. (3)Department of Thoracic Surgery, Institut Mutualiste Montsouris, Paris, France. (4)Department of Thoracic and Vascular Surgery, CHU Montpellier, Montpellier, France. (5)Department of Thoracic Surgery, Assistance Publique Hôpitaux de Paris, Tenon Hospital, Paris, France. (6)Department of Thoracic Surgery, CHU Toulouse, Larrey Hospital, Toulouse, France. (7)Department of Thoracic Surgery, CHU Dijon, Bocage Hospital, Dijon, France. (8)Department of Thoracic Surgery and Diseases of Esophagus, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille University, North Hospital, Marseille, France. OBJECTIVES: The incidence rate of prolonged air leak (PAL) after lobectomy, defined as any air leak prolonged beyond 7 days, can be estimated to be in between 6 and 15%. In 2011, the Epithor group elaborated an accurate predictive score for PAL after open lung resections, so-called IPAL (index of prolonged air leak), from a nation-based surgical cohort constituted between 2004 and 2008. Since 2008, video-assisted thoracic surgery (VATS) has become popular in France among the thoracic surgical community, reaching almost 14% of lobectomies performed with this method in 2012. This minimally invasive approach was reported as a means to reduce the duration of chest tube drainage. The aim of our study was thus to validate the IPAL scoring system in patients having received VATS anatomical lung resections. METHODS: We collected all anatomical VATS lung resections (lobectomy and segmentectomy) registered in the French national general thoracic surgery database (EPITHOR) between 2009 and 2012. The area under the receiver operating characteristic (ROC) curve estimated the discriminating value of the IPAL score. The slope value described the relation between the predicted and observed incidences of PALs. The Hosmer-Lemeshow test was also used to estimate the quality of adequacy between predicted and observed values. RESULTS: A total of 1233 patients were included: 1037 (84%) lobectomies and 196 (16%) segmentectomies. In 1099 cases (89.1%), the resection was performed for a malignant disease. Ninety-six patients (7.7%) presented with a PAL. The IPAL score provided a satisfactory predictive value with an area under the ROC curve of 0.72 (0.67-0.77). The value of the slope, 1.25 (0.9-1.58), and the Hosmer-Lemeshow test (χ(2) = 11, P = 0.35) showed that predicted and observed values were adequate. CONCLUSION: The IPAL score is valid for the estimation of the predictive risk of PAL after VATS lung resections. It may thus a priori be used to characterize any surgical population submitted to potential preventive measures. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. PMID: 25564213 [PubMed - in process] 5. Ann Thorac Surg. 2015 Jan;99(1):258-63. doi: 10.1016/j.athoracsur.2014.08.035. Epub 2014 Nov 20. Videothoracoscopy versus thoracotomy for the treatment of spontaneous pneumothorax: a propensity score analysis. Pagès PB(1), Delpy JP(2), Falcoz PE(3), Thomas PA(4), Filaire M(5), Le Pimpec Barthes F(6), Dahan M(7), Bernard A(2); Epithor Project (French Society of Thoracic and Cardiovascular Surgery). Author information: (1)Centre Hospitalier Universitaire Dijon, Bocage Hospital, Dijon, France. Electronic address: pierrebenoit.pages@chu-dijon.fr. (2)Centre Hospitalier Universitaire Dijon, Bocage Hospital, Dijon, France. (3)Centre Hospitalier Universitaire Strasbourg, Civil Hospital, Strasbourg, France. (4)Centre Hospitalier Universitaire Marseille, North Hospital, Marseille, France. (5)Centre Hospitalier Universitaire Clermont-Ferrand, Centre Jean Perrin Hospital, Clermont-Ferrand, France. (6)Georges Pompidou European Hospital, Paris, France. (7)Centre Hospitalier Universitaire Toulouse, Larrey Hospital, Toulouse, France. Comment in Ann Thorac Surg. 2015 Jan;99(1):263-4. BACKGROUND: Few randomized controlled trials have been published on outcomes after treatment of spontaneous pneumothorax. The objective of this study was to assess recurrence, pulmonary complications, prolonged air leak, and hospital duration of stay in patients undergoing videothoracoscopic surgery (VATS) or thoracotomy for spontaneous pneumothorax. METHODS: From January 2005 to December 2012, 7,396 patients underwent operations for spontaneous pneumothorax and were entered into the French national database. The propensity score, which is the conditional probability of assignment to a particular treatment given a vector of observed covariates, was used for the analysis. Three statistical analyses were performed: matching, subclassification, and the inverse probability of treatment weighting. The primary end point was recurrence, defined as a pneumothorax requiring a chest tube or new operation. The secondary end point was pulmonary complications, prolonged air leak, and hospital duration of stay. RESULTS: VATS was performed in 6,419 patients and thoracotomy in 997 patients. Pleurodesis was performed by abrasion or pleurectomy in 5,873 patients (79%) and by using a chemical agent in 1,523 patients (21%). The median time to recurrence was 3 months (range, 1 to 76 months). The recurrence rate was higher in the VATS group regardless of the statistical analysis that was used: 2.1 for unmatched samples, 2.5 for matched samples, 2.3 for subclassification, and 1.7 for the inverse probability of treatment weighting. VATS significantly reduced the hospital duration of stay by 1 day but did not significantly reduce pulmonary complications or prolonged air leak. CONCLUSIONS: VATS reduced the hospital duration of stay, but the risk of recurrence was higher. This information should be delivered to patients before pneumothorax operations. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved. PMID: 25440269 [PubMed - indexed for MEDLINE] 6. J Thorac Cardiovasc Surg. 2015 Jan;149(1):73-82. doi: 10.1016/j.jtcvs.2014.09.063. Epub 2014 Sep 28. Pneumonectomy for lung cancer: contemporary national early morbidity and mortality outcomes. Thomas PA(1), Berbis J(2), Baste JM(3), Le Pimpec-Barthes F(4), Tronc F(5), Falcoz PE(6), Dahan M(7), Loundou A(8); EPITHOR group. Collaborators: Alauzen M, Andro JF, Aubert M, Avaro JP, Azorin J, Bagan P, Bellenot F, Blin V, Boitet P, Bordigoni L, Borrelly J, Brichon PY, Cardot G, Carrie JM, Clement F, Corbi P, Debaert M, Debrueres B, Dubrez J, Ducrocq X, Dujon A, Dumont P, Fernoux P, Filaire M, Frassinetti E, Frey G, Gossot D, Grosdidier G, Guibert B, Hagry O, Jaillard S, Jarry JM, Kaczmarek D, Laborde Y, Lenot B, Levy F, Lombart L, Marcade E, Marcade JP, Marzelle J, Massard G, Mazeres F, Mensier E, Metois D, Michaud J, Paris E, Mondine P, Monteau M, Moreau JM, Mouroux J, Mugniot A, Mulsant P, Naffaa N, Neveu P, Pavy G, Peillon C, Pons F, Porte H, Regnard JF, Riquet M, Looyeh BS, Thomas P, Tiffet O, Tremblay B, Valla J, Velly JF, Wack B, Wagner JD, Woelffe D. Author information: (1)Department of Thoracic Surgery, North Hospital - APHM, Aix-Marseille University, Marseille, France. Electronic address: pathomas@ap-hm.fr. (2)Department of Public Health, North Hospital, EA 3279 Research Unit, Aix-Marseille University, Marseille, France. (3)Department of General and Thoracic Surgery, Rouen, France. (4)Department of Thoracic Surgery, HEGP, Paris, France. (5)Department of Thoracic Surgery, Louis Pradel Hospital, Lyon, France. (6)Department of Thoracic Surgery, NHC, Strasbourg, France. (7)Department of Thoracic Surgery, Larrey Hospital, Toulouse, France. (8)Methodological Assistance to Clinical Research, Faculty of Medicine, Department of Public Health, Marseille, France. Comment in J Thorac Cardiovasc Surg. 2015 Jan;149(1):83-4. J Thorac Cardiovasc Surg. 2015 Jan;149(1):82-3. OBJECTIVE: The study objective was to determine contemporary early outcomes associated with pneumonectomy for lung cancer and to identify their predictors using a nationally representative general thoracic surgery database (EPITHOR). METHODS: After discarding inconsistent files, a group of 4498 patients who underwent elective pneumonectomy for primary lung cancer between 2003 and 2013 was selected. Logistic regression analysis was performed on variables for mortality and major adverse events. Then, a propensity score analysis was adjusted for imbalances in baseline characteristics between patients with or without neoadjuvant treatment. RESULTS: Operative mortality was 7.8%. Surgical, cardiovascular, pulmonary, and infectious complications rates were 14.9%, 14.1%, 11.5%, and 2.7%, respectively. None of these complications were predicted by the performance of a neoadjuvant therapy. Operative mortality analysis, adjusted for the propensity scores, identified age greater than 65 years (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.5-2.9; P < .001), underweight body mass index category (OR, 2.2; 95% CI, 1.2-4.0; P = .009), American Society of Anesthesiologists score of 3 or greater (OR, 2.310; 95% CI, 1.615-3.304; P < .001), right laterality of the procedure (OR, 1.8; 95% CI, 1.1-2.4; P = .011), performance of an extended pneumonectomy (OR, 1.5; 95% CI, 1.1-2.1; P = .018), and absence of systematic lymphadenectomy (OR, 2.9; 95% CI, 1.1-7.8; P = .027) as risk predictors. Induction therapy (OR, 0.63; 95% CI, 0.5-0.9; P = .005) and overweight body mass index category (OR, 0.60; 95% CI, 0.4-0.9; P = .033) were protective factors. CONCLUSIONS: Several risk factors for major adverse early outcomes after pneumonectomy for cancer were identified. Overweight patients and those who received induction therapy had paradoxically lower adjusted risks of mortality. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved. PMID: 25439468 [PubMed - indexed for MEDLINE] 7. Eur J Cardiothorac Surg. 2015 Sep;48(3):435-40. doi: 10.1093/ejcts/ezu439. Epub 2014 Nov 20. Pneumonectomy for benign disease: indications and postoperative outcomes, a nationwide study†. Rivera C(1), Arame A(2), Pricopi C(2), Riquet M(2), Mangiameli G(2), Abdennadher M(2), Dahan M(3), Le Pimpec Barthes F(2). Author information: (1)General Thoracic Surgery, Georges Pompidou European Hospital, Paris Descartes University, Paris, France EPITHOR Group, French Society of Thoracic and Cardiovascular Surgery, Paris, France caroline.rivera@egp.aphp.fr krorivera@yahoo.fr. (2)General Thoracic Surgery, Georges Pompidou European Hospital, Paris Descartes University, Paris, France. (3)EPITHOR Group, French Society of Thoracic and Cardiovascular Surgery, Paris, France. OBJECTIVES: Pneumonectomy for benign disease is rare but is thought to have a higher more postoperative morbidity and mortality than when performed for lung cancer. We questioned this by assessing and analysing indications and postoperative outcomes of patients who underwent this type of resection. METHODS: We used Epithor, the French national thoracic database including 91 public and private institutions with more than 220 000 procedures. We prospectively collected data of 5975 patients who underwent pneumonectomy between January 2003 and June 2013. The 321 patients (5.4%) who underwent pneumonectomy (n = 201) or completion pneumonectomy (n = 120) for benign disease were compared with those treated for malignant disease. RESULTS: The patients' mean age was 55.2 years (53.5; 56.8) for benign indications vs 61.6 years (61.4; 61.9) for malignant disease; the sex ratio was 1.8 (207 males) and 4 (4543 males), respectively; 53% of patients (n = 169) had an American Society of Anesthesiologist (ASA) score of ≥3 vs 29% (n = 1598) for malignant disease. For benign disease, most frequent indications were infection or abscess (n = 114, 37.1%), post-tuberculosis destroyed lung (n = 47, 15.3%), aspergillosis or aspergilloma (n = 33, 10.7%), bronchiectasis (n = 41, 13.3%), haemorrhage (n = 26, 8.5%) and benign tumour (n = 20, 6.5%). Complications occurred in 53% (n = 170) of patients and the postoperative in-hospital mortality rate was 22.1% (n = 71). These results were significantly worse than those for malignant indications: 38.9% (n = 2198) of morbidity (P < 0.0001) and 5.1% (n = 288) of in-hospital mortality (P < 0.0001). For benign disease, there was no difference in fistula formation regarding side (P = 0.07) or type of resection (P = 0.6). Morbidity was higher for completion pneumonectomy: 62.5 vs 47.3% (P = 0.008). Mortality was significantly higher in case of resection for infection or abscess (P = 0.01) and for haemorrhage (P = 0.002). Emergency procedures were associated with worse postoperative outcomes (P < 0.0001). CONCLUSIONS: Pneumonectomy for benign disease achieves cure with very high levels of morbidity and mortality. This type of surgical treatment should be considered as a salvage procedure. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. PMID: 25414429 [PubMed - in process] 8. J Thorac Cardiovasc Surg. 2014 Sep;148(3):841-8; discussion 848. doi: 10.1016/j.jtcvs.2014.01.030. Epub 2014 Jan 25. The impact of hospital and surgeon volume on the 30-day mortality of lung cancer surgery: A nation-based reappraisal. Falcoz PE(1), Puyraveau M(2), Rivera C(3), Bernard A(4), Massard G(5), Mauny F(2), Dahan M(6), Thomas PA(7); Epithor Group. Author information: (1)Department of Thoracic Surgery, Strasbourg University Hospital, Strasbourg, France. Electronic address: pierre-emmanuel.falcoz@wanadoo.fr. (2)Clinical Methodology Center, Besançon University Hospital, Besançon, France. (3)Department of Thoracic Surgery, Bayonne Hospital, Bayonne, France. (4)Department of Thoracic Surgery, Dijon University Hospital, Dijon, France. (5)Department of Thoracic Surgery, Strasbourg University Hospital, Strasbourg, France. (6)Department of Thoracic Surgery, Toulouse University Hospital, Toulouse, France. (7)Department of Thoracic Surgery, Marseille University Hospital, Marseille, France. Comment in J Thorac Cardiovasc Surg. 2014 Sep;148(3):848-9. OBJECTIVE: Our objective was to analyze the time trend variation of 30-day mortality after lung cancer surgery, and to quantify the impact of surgeon and hospital volumes over a 5-year period in France. METHODS: We used Epithor, the French national thoracic database and benchmark tool, which catalogues more than 180,000 procedures of 89 private and public hospitals in France. From January 2005 to December 2010, 19,556 patients who underwent major lung resection (lobectomy, bilobectomy, pneumonectomy) were included in our study. Multilevel logistic models were designed to investigate the relationship between 30-day mortality and surgeon (model 1) or hospital (model 2) volumes. The 3 levels considered were the patient, the surgeon, and the hospital. RESULTS: From 2005 to 2007, the 30-day mortality of patients who underwent major lung resection averaged 10%, and then decreased until it reached 3.8% in 2010 (P < .0001). A significant decrease in 30-day mortality was observed over time (P = .0046). During the study period, the mean annual number of procedures per surgeon was 46.1 (standard deviation [SD] = 23.6) and per hospital was 97.9 (SD = 50.8). Model 1 showed that surgeon volume had a significant impact on 30-day mortality (P = .03), whereas model 2 failed to show that hospital volume influenced 30-day mortality (P = .75). CONCLUSIONS: Since 2007, when France's first National Cancer Plan became effective, 30-day mortality of primary lung cancer surgery has decreased and currently measures 3.8%. Low mortality was correlated with higher surgeon volume but was not influenced by hospital volume, which cannot be considered a proxy measure for determining the safety of lung cancer surgery. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved. PMID: 24534677 [PubMed - indexed for MEDLINE] 9. Eur J Cardiothorac Surg. 2014 Apr;45(4):652-9; discussion 659. doi: 10.1093/ejcts/ezt452. Epub 2013 Sep 23. National perioperative outcomes of pulmonary lobectomy for cancer: the influence of nutritional status. Thomas PA(1), Berbis J, Falcoz PE, Le Pimpec-Barthes F, Bernard A, Jougon J, Porte H, Alifano M, Dahan M; EPITHOR Group. Collaborators: Alauzen M, Andro JF, Aubert M, Avaro JP, Azorin J, Bagan P, Bellenot F, Blin V, Boitet P, Bordigoni L, Borrelly J, Brichon PY, Cardot G, Carrie JM, Clement F, Corbi P, Debaert M, Debrueres B, Dubrez J, Ducrocq X, Dujon A, Dumont P, Fernoux P, Filaire M, Frassinetti E, Frey G, Gossot D, Grosdidier G, Guibert B, Hagry O, Jaillard S, Jarry JM, Kaczmarek D, Laborde Y, Lenot B, Levy F, Lombart L, Marcade E, Marcade JP, Marzelle J, Massard G, Mazeres F, Mensier E, Metois D, Michaud J, Paris E, Mondine P, Monteau M, Moreau JM, Mouroux J, Mugniot A, Mulsant P, Naffaa N, Neveu P, Pavy G, Peillon C, Pons F, Porte H, Regnard JF, Riquet M, Looyeh BS, Thomas P, Tiffet O, Tremblay B, Valla J, Velly JF, Wack B, Wagner JD, Woelffe D. Author information: (1)Department of Thoracic Surgery, North Hospital - APHM, Aix-Marseille University, Marseille, France. OBJECTIVES: Nutritional assessment is not included yet as a major recommendation in lung cancer guidelines. The purpose of this study was thus to assess the influence on surgical outcome of the nutritional status of patients with primary lung cancer undergoing lobectomy. METHODS: We queried Epithor, the national clinical database of the French Society of Thoracic and Cardiovascular Surgery, and identified a retrospective cohort of 19 635 patients having undergone lobectomy for a primary lung cancer in the years 2005-11. Their nutritional status was categorized according to the WHO definition: underweight (BMI < 18.5): 857 patients (4.4%), normal (18.5 ≤ BMI < 25): 9391 patients (47.8%), overweight (25 ≤ BMI < 30): 6721 patients (34.2%), obese (BMI ≥ 30): 2666 patients (13.6%). Operative mortality, pulmonary, cardiovascular, infectious and surgical complications rates were collected and analysed for these various BMI groups. RESULTS: In the normal-weight category, operative mortality, pulmonary, surgical, cardiovascular and infectious complications rates were 2.7, 14.6, 13.8, 5.5 and 4.1%, respectively. When compared with that of normal BMI patients, adjusted operative mortality was significantly lower in overweight (2.3%; odd ratio (OR): 0.72 [95% confidence interval (CI): 0.59-0.89]; P = 0.002) and obese patients (1.9%, OR: 0.54 [95% CI: 0.40-0.74]; P < 0.001), and significantly higher in underweight patients (4.1%, OR: 1.89 [95% CI: 1.30-2.75]; P = 0.001). Underweight patients experienced significantly more pulmonary (21.1%; P < 0.001), surgical (23.2%; P < 0.001) and infectious (5.1%; P = 0.05) complications (P < 0.0001). Among surgical complications, prolonged air leaks (17.6%; P < 0.001) and bronchial stump dehiscence (1.5%; P = 0.001) were significantly more frequent in underweight patients than in normal BMI patients. Obesity was not associated with increased incidence of postoperative complications, except for arrhythmia (5.6%; P < 0.05), deep venous thrombosis and pulmonary embolism (1.5%; P = 0.005). Moreover, a statistical protective effect of obesity was observed regarding surgical complications (7.1%; P < 0.001). CONCLUSIONS: Despite having an increased risk of some postoperative cardiovascular complications, obese patients should undergo surgical standard of care therapy for appropriately stage-specific lung cancer. In underweight patients, in addition to preoperative rehabilitation including a nutritional program, attention should be given to aggressive prophylactic respiratory therapy in the perioperative period, and specific intraoperative actions to prevent prolonged air leaks and bronchial stump dehiscence. PMID: 24062351 [PubMed - indexed for MEDLINE] 10. Lung Cancer. 2012 May;76(2):216-21. doi: 10.1016/j.lungcan.2011.10.010. Epub 2011 Nov 9. Are postoperative consequences of neoadjuvant chemotherapy for non-small cell lung cancer more severe in elderly patients? Rivera C(1), Jougon J, Dahan M, Falcoz PE, Bernard A, Brouchet L. Author information: (1)Epithor database Scientific Comity, French Society of Thoracic and Cardiovascular Surgery, 56 boulevard Vincent Auriol, 75013 Paris, France. krorivera@yahoo.fr OBJECTIVES: The purpose of this study was to assess the postoperative morbidity of patients ≥75 years with non-small cell lung cancer (NSCLC) who underwent neoadjuvant chemotherapy, comparing them to younger patients. METHODS: We performed a case-control study over a 5-year period using Epithor, the French Society of Thoracic and Cardiovascular Surgery database, including to date more than 160,000 procedures from 103 institutions. We collected prospectively the data concerning 1510 patients with NSCLC who underwent preoperative chemotherapy, from January 2005 to December 2009. In order to compare patients with similar characteristics, we matched the 81 patients ≥75 to 81 controls (<75) for gender, American Society of Anesthesia (ASA) score, Performance Status (PS), Forced Expiratory Volume (FEV1) and histological subtype of the tumor. The patients of the control group were randomized within the 1429 patients <75 included. Lung cancer surgical treatment, post-operative morbidity and mortality rates, and length of stay (LOS) were compared between the two age groups. RESULTS: There was no significant difference in type of resection between the two groups (p=0.07): pneumonectomy 15% (n=12) for patients ≥75 vs 28% (n=23) for younger patients, lobectomy 65% (n=53) vs 54% (n=44), bilobectomy 14% (n=11) vs 6% (n=5) and sub-lobar resection 4% (n=3) for the two groups. There was no significant difference in type of mediastinal lymphadenectomy (p=0.48) between the two age groups. Elderly patients presented a more important number of postoperative complications (p=0.04) and these ones were more severe (p=0.03). There was no significant difference in postoperative mortality with 30-day mortality: 4.9%, n=4, versus 2.5%, n=2, (p=0.83); 60-day mortality: 6.2%, n=5, versus 2.5%, n=2, (p=0.61); and 90-day mortality was the same. Hospital LOS was longer for the elderly (14.9 days, CI95%[12.5;17.4] vs 11.9 days, CI95%[10.7;13.3], p<0.001). CONCLUSION: Postoperative morbidity after neoadjuvant chemotherapy is more important in elderly patients. These data should be taken into account when considering the interest of preoperative treatment in elderly patients with resectable NSCLC. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved. PMID: 22078278 [PubMed - indexed for MEDLINE] 11. Ann Thorac Surg. 2011 Sep;92(3):1062-8; discussion 1068. doi: 10.1016/j.athoracsur.2011.04.033. Characterization and prediction of prolonged air leak after pulmonary resection: a nationwide study setting up the index of prolonged air leak. Rivera C(1), Bernard A, Falcoz PE, Thomas P, Schmidt A, Bénard S, Vicaut E, Dahan M. Author information: (1)CHU Bordeaux, Haut Leveque Hospital, Pessac, France. krorivera@yahoo.fr BACKGROUND: The objective of this study was to better characterize prolonged air leak (PAL), defined as an air leak longer than 7 days, and to develop and validate a predictive model of this complication after pulmonary resection. METHODS: All lung resections entered in Epithor, the French national thoracic database (French Society of Thoracic and Cardiovascular Surgery), were analyzed. Data collected between 2004 and 2008 (n=24,113) were used to build the model using backward stepwise variable selection, and the 2009 data (n=6,813) were used for external validation. The primary outcome was PAL. Results of the predictive model were used to propose a score: the index of PAL (IPAL). RESULTS: Prevalence of PAL after pulmonary resection was 6.9% (n=1,655) in the development data set. In the final model, 9 variables were selected: gender, body mass index, dyspnea score, presence of pleural adhesions, lobectomy or segmentectomy, bilobectomy, bulla resection, pulmonary volume reduction, and location on upper lobe. In the development data set, the C-index was 0.71 (95% confidence interval [CI], 0.70 to 0.72). At external validation, the C-index was 0.69 (95% CI, 0.66 to 0.72) and the calibration slope (ie, the agreement between observed outcomes and predictions) was 0.874 (<1). A score chart based on these analyses has been proposed. The formula to calculate the IPAL is the following: gender (F=0; M=4)-(body mass index-24)+2×dyspnea score+pleural adhesion (no=0; yes=4)+pulmonary resection (wedge=0; lobectomy or segmentectomy=7; bilobectomy=11; bulla resection=2; volume reduction=14)+location (lower or middle lobe=0; upper=4). CONCLUSIONS: Surgeons can easily use the well-validated model to determine intraoperative preventive measures of PAL. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved. PMID: 21871301 [PubMed - indexed for MEDLINE] 12. Chest. 2011 Oct;140(4):874-80. doi: 10.1378/chest.10-2841. Epub 2011 Mar 24. Surgical management and outcomes of elderly patients with early stage non-small cell lung cancer: a nested case-control study. Rivera C(1), Falcoz PE, Bernard A, Thomas PA, Dahan M. Author information: (1)Department of Thoracic Surgery, Haut Lévêque Hospital, University of Bordeaux, Bordeaux, France. krorivera@yahoo.fr Comment in Chest. 2011 Oct;140(4):839-40. BACKGROUND: The number of oncogeriatric patients with non-small cell lung cancer (NSCLC) is expected to increase in the next decades. METHODS: We used the French Society of Thoracic and Cardiovascular Surgery database Epithor that includes information on > 140,000 procedures from 98 institutions. We prospectively collected data from January 2004 to December 2008 on 1,969 patients aged ≥ 70 years with NSCLC stage I or II and matched them with 1,969 control subjects aged < 70 years for sex, American Society of Anesthesia score, performance status, and FEV(1). Surgical treatment and postoperative outcomes were compared between the two age groups. RESULTS: The absence of radical lymphadenectomy was more frequent in the older patients (14%, n = 269) than in the younger patients (9%, n = 170) (P < .0001). There was no significant difference in type of resection between older and younger patients, respectively (pneumonectomy, 8% [n = 164] vs 11% [n = 216]; lobectomy, 79% [n = 1,559] vs 77% [n = 1,521]; bilobectomy, 4% [n = 88] vs 5% [n = 97]; sublobar resection, 7% [n = 143] vs 6% [n = 118]; P = .08). Differences in number (P = .07) and severity (P = .69) of complications were not significant. Postoperative mortality was higher in elderly patients at every end point (30-day mortality, 3.6% [n = 70] vs 2.2% [n = 43] [P = .01]; 60-day mortality, 4.1% [n = 80] vs 2.4% [n = 47] [P = .003]; 90-day mortality, 4.7% [n = 93] vs 2.5% [n = 50] [P = .0002]). CONCLUSIONS: Elderly patients with NSCLC should not be denied pulmonary resection on the basis of chronologic age alone. Among patients aged ≥ 70 years, 90-day mortality compared acceptably with mortality among younger matched patients. Additionally, the data show that for older patients, a 90-day mortality better represents their real mortality risk than 30- or 60-day figures. Our contemporary, multiinstitutional data importantly reveal that elderly patients, compared with their younger counterparts, do not have increased morbidity, incidence, or severity after pulmonary resection. PMID: 21436251 [PubMed - indexed for MEDLINE] 13. Eur J Cardiothorac Surg. 2011 Jun;39(6):981-6. doi: 10.1016/j.ejcts.2010.09.022. Epub 2010 Oct 27. Surgical treatment of lung cancer in the octogenarians: results of a nationwide audit. Rivera C(1), Dahan M, Bernard A, Falcoz PE, Thomas P. Author information: (1)Department of Thoracic Surgery, Haut Leveque Hospital, University of Bordeaux, France. krorivera@yahoo.fr Comment in Eur J Cardiothorac Surg. 2011 Jun;39(6):987-8. OBJECTIVE: The elderly is a fast-growing segment of the population and the number of oncogeriatric patients with lung cancer is expected to increase. The purpose of this study was to overview surgical habits for lung cancer in octogenarians. METHODS: We used EPITHOR(®), the French national thoracic database, created in 2002 and including more than 135000 procedures from 93 institutions. We collected prospectively data concerning 622 patients 80 years or older, and 16461 patients younger than 80 years with lung cancer from 1 January 2004 to 31 December 2008. We compared patients' characteristics, lung-cancer presentation, and surgical treatment between these two groups. RESULTS: Patients' characteristics analysis: the distribution by gender, body mass index, and forced expiratory volume was comparable for the two groups. American Society of Anesthesiologists (ASA) score (ASA 1 and 2: 59%, n=363 vs 71%, n=11543, p<0.0001) and performance status (PS) were worse for older patients (PS 0 and 1: 86%, n=470 vs 89%, n=12685, p<0.0001). Mean age (82.0, confidence interval (CI) 95% (81.9; 82.2)) and sex ratio (2.51, n=445 males) were stable for octogenarians across 5 years. Lung-cancer presentation analysis: in the elderly, stages I and II were of 71% (n=361) versus 66% (n=8735) in the younger group (p=0.001). Surgical treatment analysis: resections in octogenarians were pneumonectomy 10% (n=62) versus 15% (n=2409) for patients under 80 years, lobectomy 67% (n=415) versus 65% (n=10734), bilobectomy 4% (n=25) versus 5% (n=809), sub-lobar resection 11% (n=70) versus 8% (n=1355) (p=0.034). They underwent video-assisted thoracic surgery in 7% (n=43) versus 6% (n=917) (p=0.034). No lymph node dissection was more frequent in patients 80 years or older (8%, n=45) than in younger patients (5%, n=738) (p=0.0004). CONCLUSION: Taken as a whole, octogenarians underwent more sub-lobar resections and less mediastinal lymph node dissections than younger patients. Effective management of lung cancer in older patients should be tailed to individual needs. Surgical treatment should not be denied on chronological age alone anymore. Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved. PMID: 21030267 [PubMed - indexed for MEDLINE] 14. J Thorac Cardiovasc Surg. 2011 Feb;141(2):449-58. doi: 10.1016/j.jtcvs.2010.06.044. Epub 2010 Aug 9. Risk model of in-hospital mortality after pulmonary resection for cancer: a national database of the French Society of Thoracic and Cardiovascular Surgery (Epithor). Bernard A(1), Rivera C, Pages PB, Falcoz PE, Vicaut E, Dahan M. Author information: (1)Department of Thoracic Surgery, CHU Dijon, France. alain.bernard@chu-dijon.fr OBJECTIVES: The estimation of risk-adjusted in-hospital mortality is essential to allow each thoracic surgery team to be compared with national benchmarks. The objective of this study is to develop and validate a risk model of mortality after pulmonary resection. METHODS: A total of 18,049 lung resections for non-small cell lung cancer were entered into the French national database Epithor. The primary outcome was in-hospital mortality. Two independent analyses were performed with comorbidity variables. The first analysis included variables as independent predictive binary comorbidities (model 1). The second analysis included the number of comorbidities per patient (model 2). RESULTS: In model 1 predictors for mortality were age, sex, American Society of Anesthesiologists score, performance status, forced expiratory volume (as a percentage), body mass index (in kilograms per meter squared), side, type of lung resection,extended resection, stage, chronic bronchitis, cardiac arrhythmia, coronary artery disease, congestive heart failure, alcoholism, history of malignant disease, and prior thoracic surgery. In model 2 predictors were age, sex, American Society of Anesthesiologists score, performance status, forced expiratory volume, body mass index, side, type of lung resection, extended resection, stage, and number of comorbidities per patient. Models 1 and 2 were well calibrated, with a slope correction factor of 0.96 and of 0.972, respectively. The area under the receiver operating characteristic curve was 0.784 (95% confidence interval, 0.76-0.8) in model 1 and 0.78 (95% confidence interval, 0.76-0.797) in model 2. CONCLUSIONS: Our preference is for the well-calibrated model 2 because it is easier to use in practice to estimate the adjusted postoperative mortality of lung resections for cancer. Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved. PMID: 20692003 [PubMed - indexed for MEDLINE] 15. J Thorac Cardiovasc Surg. 2008 Jul;136(1):242-3. doi: 10.1016/j.jtcvs.2007.11.062. Focus on the thoracoscore. Falcoz PE, Dahan M; French Society of Thoracic and Cardiovascular Surgery; Epithor Group. Comment on J Thorac Cardiovasc Surg. 2007 Oct;134(4):883-7. PMID: 18603109 [PubMed - indexed for MEDLINE] 16. Rev Mal Respir. 2007 Sep;24(7):877-82. [Surgical management and outcomes of lung cancer in women - results from the Epithor database]. [Article in French] Brouchet L(1), Mazieres J, Bauvin E, Bigay-Game L, Renaud C, Berjaud J, Dahan M. Author information: (1)Service de Chirurgie Thoracique, Clinique des Voies Respiratoires, Hôpital Rangueil-Larrey, CHU de Toulouse, France. brouchet.l@chu-toulouse.fr INTRODUCTION: Rates of lung cancer in women have been increasing continually for several years. The basic surgical management of this condition is the same in both sexes but a number of differences are apparent. METHODS: We analysed data entered onto the Epithor database between June 2002 and June 2006 concerning 8535 surgical resections performed in primary lung cancer. RESULTS: 22.5 percent of patients were women. They were significantly younger (59.6 years vs 62.7 years) and had a lower BMI (24.7 kg x m(-2) vs 25.5 kg x m(-2)). They were in a better physical condition in terms of American Society of Anaesthesiology score and performance status, with better preserved lung function and fewer co-morbidities (1.8 vs 2.1) compared to men. The percentage of adenocarcinomas was higher in women and a higher proportion had early stage disease. 30 day mortality was three times as high in men who also experienced much greater post-operative morbidity. Multivariate analysis revealed an odds ratio of 0.49 (95% CI 0.3-0.8) for mortality and 0.54 (95% CI 0.4-0.6) for morbidity in women compared to men. CONCLUSION: Women with lung cancer have less risk of post-operative morbidity and mortality than men. These data suggest that they might be able to benefit from more aggressive perioperative therapy. PMID: 17925670 [PubMed - indexed for MEDLINE] 17. J Thorac Oncol. 2007 Jul;2(7):626-31. Impact of induction treatment on postoperative complications in the treatment of non-small cell lung cancer. Brouchet L(1), Bauvin E, Marcheix B, Bigay-Game L, Renaud C, Berjaud J, Falcoze PE, Venissac N, Raz D, Jablons D, Mazières J, Dahan M. Author information: (1)Department of Thoracic Surgery, Rangueil-Larrey University Hospital, Toulouse, France. brouchet.l@chu-toulouse.fr INTRODUCTION: A main drawback of neoadjuvant chemotherapy is that it may increase operative morbidity and mortality. The aim of this study was to determine the impact of chemotherapy on these complications. METHODS: Patient data were collected from the Epithor database. From June 2002 to June 2004, 3888 successive observations of surgery for lung cancer have been reported from 51 thoracic surgery departments throughout France. Logistic regression analysis was performed to identify preoperative clinical characteristics of patients with significant postoperative complications. RESULTS: Of 3888 patients, 555 (14.3%) received induction chemotherapy. The groups were similar with respect to sex and the number of comorbidities. The in-hospital mortality rate was 3.01%. The multivariate analysis allows us to identify age (older than 65 years), sex (male), preoperative clinical score (moderate and severe), surgical procedure (right pneumonectomy and bilobectomy) as significantly associated with in-hospital mortality. No statistical difference was observed according to the delivery or preoperative chemotherapy. In total, 1219 patients (31.4%) had at least one postoperative complication. Using a multivariate analysis, we observed a significant correlation between morbidity and age (older than 65 years), sex (male), presence of comorbidities (two or more), clinical score (moderate), and type of operation (bilobectomy). Preoperative administration of chemotherapy did not significantly influenced postoperative morbidity. CONCLUSIONS: Preoperative chemotherapy is not associated with an increase in either the mortality rate or major surgical complications. Future randomized trials are warranted to confirm the survival benefit of this strategy. PMID: 17607118 [PubMed - indexed for MEDLINE]