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Department of Cardio-Thoracic Surgery, UMC Utrecht, Heidelberglaan 100, Utrecht, 3584 CX The Netherlands
(Email: npvdkaaij{at}gmail.com).
The study by Mansour and colleagues [1] is conducted to determine preoperative risk factors for early mortality and morbidity after pneumonectomy. Endpoints of this study are operative mortality, major procedure-related complications, and cardiovascular events. The authors have analyzed risk factors in an impressive number (323) of pneumonectomy patients. The major findings are that pneumonectomy of the right lung is a risk factor for bronchopleural fistulas and resulted in increased 30-day mortality, the cardiovascular event is more frequent in coronary artery disease patients, and chronic obstructive pulmonary disease is a risk for patients without coronary disease. The study is interesting and aims to give insight in the difficult matter of adequate patient selection for pneumonectomy. Still, there are several elements to comment on.
First, important complications related to pneumonectomy, such as postoperative bleeding that requires reoperation, pneumonia of the contralateral lung, and cardiac arrhythmias other than atrial fibrillation (AF) have not been investigated. In addition, significant preoperative details of patients are lacking, such as American Society of Anesthesiologists (ASA) classification, type of pneumonectomy performed (ie, normal, extended, or completion pneumonectomy), epidural analgesia, underlying disease, and TNM classification. Furthermore, the study lacks association between morbidity and mortality, because it does identify risk factors for operative mortality and postoperative complications, whereas the end result of these complications on mortality is unclear. Finally, in an attempt to find similarities between this study and other studies, the authors focused on four particular studies [2–5], but they did not include other important studies [6–9]. If all these studies were compared, few parallel risk factors would be identified. Still, there seems to be enough evidence that right-sided pneumonectomy results in worse outcome than left-sided pneumonectomy. One of the contributing factors may be a shorter main bronchus of the right lung, which is a risk factor for bronchopleural fistula. Other factors include 1) a larger lung volume and blood supply of the right lung, which results in a larger reduction in pulmonary function, after right-sided pneumonectomy, a more pronounced increase in pulmonary artery pressure and development of postpneumonectomy pulmonary edema, and 2) a higher rate of cardiac arrythmia after right-sided pneumonectomy [2]. Furthermore, there is now growing evidence that induction chemotherapy followed by pneumonectomy has little or no effect on mortality [3, 10], although this was not supported by all the studies.
Thus, what can be learned from this study? Should we alter the selection of our patients or change the preoperative and postoperative management? Regarding the high complication rate after pneumonectomy, what survival benefit must be achieved for lung cancer surgery justifying (right-sided) pneumonectomy? What treatment benefit can be expected? As with most studies, this study raises more questions than it answers.
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