Completion pneumonectomy (CP) refers to the complete

ORIGINAL ARTICLE Completion Pneumonectomy in Ptients with Cncer Postopertive Survivl nd Mortlity Fctors Myeul Tbutin, MD, MSc,* Sébstien Courud, MD, MSc, Benoit Guibert, MD, Pierre Mulsnt, MD, Pierre-Jen Souquet, MD, nd Frnçois Tronc, MD, PhD* Objective: To describe postopertive complictions nd long-term outcomes of completion pneumonectomy nd highlight prognostic fctors. Method: We retrospectively reviewed the records of 46 ptients (38 men, 8 women) who underwent completion pneumonectomy for lung cncer between 1995 nd 2009 in one of two thorcic surgery deprtments. Most were current or former smokers (n = 41; 89%) nd did not undergo chemotherpy (n = 38; 83%) or rdiotherpy (83%) before surgery. Results: Complictions fter surgery were respirtory filure (n = 11; 24.4%), bronchopleurl fistul (n = 6; 13%, with no side preference), nd empyem (n = 6; 13%). Blood trnsfusion ws necessry for 43% of the cses (n = 20). The dy 90 deth rte ws 15.2% (n = 7). Postopertive stging showed mostly limited disese. Ten ptients (21.7%) underwent opertion for second primry cncer, 25 for locl recurrence (54.3%), five for microscopiclly incomplete resection, nd six for other resons.medin overll survivl fter completion surgery ws 30 months (medin follow-up: 46.5 months). Among the 15 living ptients (33%), 11 re free of disese (24%). In Cox regression model, fctors negtively influencing overll survivl were: ge older thn 65 yers (odds rtio [OR] = 2.47; p = 0.012), current smoker sttus (OR = 2.285; p = 0.033), postopertive pulmonry (OR = 5.144; p = 0.004), crdic (OR = 3.404; p = 0.033), or prietl wound complictions (OR = 5.439; p = 0.016). Conclusion: Despite its incresed postopertive complictions nd mortlity compred with stndrd pneumonectomy, completion pneumonectomy offers encourging long-term results. Five min fctors seem predictive of shorter overll survivl. Key Words: Completion pneumonectomy, Lung cncer, Bronchopleurl fistul, Postopertive hemorrhge, Thorcic surgery. (J Thorc Oncol. 2012;7: 1556 1562) *Thorcic Surgery Deprtment, Hospices Civils de Lyon, Hôpitl Louis Prdel, 28 venue du doyen Lépine, Bron, Frnce; Lyon Sud Chrles Mérieux Medicl Fculty, Clude Bernrd Lyon I University, Oullins, Frnce; Respirtory Medicine nd Thorcic Oncology Deprtment, nd Thorcic Surgery Deprtment, Centre Hospitlier Lyon Sud, Hospices Civils de Lyon, CH Lyon Sud, Pierre Bénite Cedex, Frnce. Drs. Tbutin nd Courud hve contributed eqully to this study. Disclosure: The uthors declre no conflict of interest. Address for correspondence: Myeul Tbutin, MD, MSc, Chirurgie Thorcique, Hôpitl Louis Prdel, 28 venue du Doyen Lépine, 69500 Bron, Frnce. E-mil: myeul.tbutin@chu-lyon.fr Copyright 2012 by the Interntionl Assocition for the Study of Lung Cncer ISSN: 1556-0864/12/0710-1556 Completion pneumonectomy (CP) refers to the complete removl of remining lung fter n initil ipsilterl prtil resection. 1 Compred with stndrd pneumonectomy, CP runs greter risk of postopertive morbidity nd mortlity, lrgely becuse of the technicl difficulties induced by the need to free ll the remining lung tissue nd itertively dissect the lung hilum. 2 Most of the studies published to dte hve confirmed these chrcteristics, 3 7 nd thus recommend tht this intervention be performed only by experienced surgeons 8,9 on crefully selected ptients. 10,11 Some dt suggest tht postopertive mortlity my be greter in ptients operted for benign lesions compred with those operted for neoplsi, 2,8,12,13 lthough it should be noted tht this fcet remins controversil. 14 16 There re currently little dt on fctors influencing long-term survivl nd postopertive mortlity. Thus our objective in this retrospective multicenter study ws to ssess survivl in ptients who underwent CP for neoplstic events only (primry or metsttic to the lung) nd report fctors ssocited with survivl or postopertive mortlity. PATIENTS AND METHODS Methods All CP ptient cses from Jnury 1, 1995, to December 31, 2009, in two thorcic surgery deprtments in Lyon (Frnce) were reviewed. Only those cses flling within the neoplstic context were retined for nd included in this retrospective study, tht is one or both of the surgicl interventions ws/ were for neoplsi. Cses in which both surgicl interventions were for nonmlignnt cuses were excluded, s were those with incomplete files. All dt used in the study were retrieved from the rchived ptient medicl files. When lcking in the medicl files, survivl dt (dtes of deth) were collected from ptients primry cre physicins or birthplce city hll records. In ddition to hbitul demogrphic dt nd dt on the neoplstic disese nd pertinent ptient history, we lso gthered informtion specific to the surgery nd postopertive complictions. Medin follow-up ws 46.5 months (0 178) since CP, nd 102, 7 months since first surgery (12 320). Sttisticl Anlyses Sttisticl nlyses were performed with SPSS v17.0 (IBM Corp., Armonk, NY). Proportion comprisons were 1556 Journl of Thorcic Oncology Volume 7, Number 10, October 2012

Journl of Thorcic Oncology Volume 7, Number 10, October 2012 Completion Pneumonectomy in Ptients with Cncer done with Person s χ 2 test or Fisher s F test s needed. The Kpln Meier method ws used for survivl nlyses. Survivl comprisons were clculted using the log-rnk test. For multivrite nlyses, Cox regression ws used for fctors linked to survivl nd binry logistic regression for postopertive mortlity. A p vlue of 0.05 or less ws considered sttisticlly significnt. Popultion Forty-six of the 51 initilly reviewed cse files met the study inclusion criteri (2 exclusions for nonmlignncy nd 3 for incomplete files). Chrcteristics of included ptients re provided in Tble 1. Forced expirtory volume (FEV1) ws evluted for ll ptients. If preopertive FEV1 ws inferior to 80% nd/or diffusion cpcity inferior to 80%, pulmonry ventiltion/ perfusion scn ws performed to evlute prticiption of the removed lung. A predictive postopertive FEV1 less thn 35% ws considered s contrindiction for surgery. Exercise testing before opertion ws not relized in this series. Opertive Technique The first tsk of the surgeon ws to crefully red the surgicl report on the ptient s previous procedure. All opertions were done by reopening the previously used thorcotomy incision. Section of the posterior prt of the fifth rib, to provide esier ccess to the pleurl spce, ws done if necessry. Excessive bleeding from the chest wll ws prevented by mobiliztion of the lung through the intrpleurl spce whenever possible. This prt of the procedure ws prticulrly difficult nd hemorrgic when the first opertion hd been done extrpleurlly. Once the lung ws freed, the pulmonry blood vessels were ligted extrpericrdilly if possible (Tble 2). The pericrdium ws opened when extrpericrdil dissection ws not possible. If the pericrdil cvity ws completely obliterted, we tried to isolte nd divide the bronchus first nd then ligte the pulmonry blood vessels. The bronchus ws trnscted s close s the trchel bifurction s possible. The stump ws lmost never covered with flp when surgery ws performed on the left side, becuse it ws buried deeply under the ort. On the right side, it ws often covered with vible tissue (n = 17) such s pleur from the rch of the zygos, pericrdium, or intercostl muscle. In mny cses, fibrin glue ws generously pplied on the bronchil stump. RESULTS Events resulting in CP nd technicl spects re provided in Tble 2. Histologiclly, denocrcinom ws the most common entity (45.2%; n = 21). Antomicl pthology findings were identicl between the initil surgery nd CP in more thn three qurters of the cses (76.9%; n = 30). Expressed by the tumor, lymph node, nd metstsis clssifiction (7th edition, 2009), 17 the neoplsms were generlly smll (T1: 30.8%, n = 12; T2: 48.7%, n = 19), without medistinl lymph node involvement (N0: 79.5%; n = 31) nd without metstsis (M0: 97.5%; n = 39). Consequently, there were more frequently erly stges (stge I: 55%, n = 22; II: 22.5%, n = 9; IIIA: 20%, n = 8) thn lte ones (stge IIIB: 0; IV: 2.5% [1 ptient presenting pleurl crcinosis]). Long-term survivl ccording to the stge is presented in Figure 1. Most ptients (68.9%; n = 31) did not receive djuvnt tretments fter CP. Tble 3 presents the principle postopertive outcomes. Cuses of mortlity in the first 90 dys were: bronchopleurl fistul (42, 8%: n = 3), respirtory filure (28, 6%; n = 2), nd uncler (28, 6%; n = 2: 1 deth t home in context of cute respirtory filure nd 1 in intensive cre ttributed to multiple cerebrl septic emboli). Bronchopleurl fistul (BPF) cused the deth of three of the six ffected ptients. The three others were successfully treted, two by endoscopic ppliction of tissue dhesive nd one by thorcostomy nd ltissimus dorsi myoplsty. In this series, the men hospitl sty ws 19.6 dys (rnge, 7 169), of which men 5.2 dys were spent with chest drin in plce. At the end of the follow-up period (September 1, 2010) 15 ptients (32.6%) were still live. Five-yer cturil survivl ws 47%. The cuses of deth for the 31 other ptients were: lung cncer (30.4%; n = 14), CP (15.2%, n = 7; corresponding to the dy-90 [D90] mortlity rte), nd other or unknown (21.8%; n = 10). The medin of post-cp progression-free survivl (PFS) ws 16 months (95% confidence intervl [CI] = 9.614 22.386). Twenty-one ptients (50%) presented recurrence t the end of the follow-up period. In univrite nlyses, no demogrphic or preopertive criteri (including cncer stge nd comorbidity) ws found to be ssocited with postopertive mortlity before D90 (Tble 4). Fctors ssocited with risk of deth t D90 were inferior lobe (left or right) CP (43.6% versus 100%; p = 0.01), postopertive, respirtory complictions nd/or more thn two complictions (12.8% versus 100%; p < 0.0001; 28.2% versus 83.3%; p = 0.017, respectively), nd fistul formtion (7.7% versus 50%; p = 0.024). Fctors influencing overll survivl were lso nlyzed. Agin in univrite nlyses, fctors significntly ssocited with improved survivl were: ge less thn 65 yers (65 versus 21 months; p = 0.013), never or former smoker sttus (44 versus 8 months; p = 0.011), lymphdenectomy during CP (44 versus 6 months; p = 0.015), bsence of respirtory complictions (44 versus 0 months; p < 0.0001), nd bsence of thorcotomy wound complictions (44 versus 4 months; p = 0.023). Femle sex (p = 0.052), bsence of crdic complictions (p = 0.053) nd bsence of reintubtion (p = 0.069) provided nonsignificnt tendency towrd better survivl. The type of CP (inferior lobe versus other) ws not found to be ssocited with overll survivl. Multivrite nlyses were done with demogrphic nd postopertive criteri, significnce showing trend for incresed mortlity in univrite nlysis (Tble 4). Fctors ssocited with postopertive mortlity were: pulmonry compliction (p < 0.00001), BPF (p = 0.024), more thn two postopertive complictions (p = 0.017), nd CP on the lower lobe (p = 0.01). Age younger thn 65 yers remined fctor of good prognosis (hzrd rtio [HR] = 2.665 [1.139 6.238], p = 0.024) s did never or former smoker sttus (HR = 2.270 [1.058 4.870], p = 0.035). For postopertive criteri, the bsence of respirtory, crdic nd wound Copyright 2012 by the Interntionl Assocition for the Study of Lung Cncer 1557

Tbutin et l. Journl of Thorcic Oncology Volume 7, Number 10, October 2012 TABLE 1. Min Chrcteristics of the Popultion Chrcteristic n % Demogrphic criteri Sex Mle 38 82.6 Femle 8 17.4 Men ge (yrs) (± SD) 59.2 (± 9) Smoking sttus Nonsmoker 5 10.9 Former smoker 24 52.2 Current smoker 17 37 Men FEV1 (± SD) in % (n = 41) 71.1% (± 13.46%) Men predicted postopertive lung volume 63.7% (± 16.79%) (±SD) in % on pulmonry ventiltion/ perfusion scn (n = 21) First surgery chrcteristics Cuse for first surgery Primry lung cncer 43 93.4 Lung metstses 2 4.4 Aspergillom 1 2.2 Pthology (n = 45) Adenocrcinom 17 37.8 Squmous cell crcinom 25 55.6 Lrge cell crcinom 1 2.2 Typicl crcinoid 1 2.2 Fibrosrcom 1 2.2 Lymph node dissection (n = 43) 42 97.7 Men durtion between first surgery nd CP (± SD; mx min) Preopertive comorbidities before CP Number of comorbidities 54.6 mos (±64.9; 0 310) None 10 21.7 2 31 67.5 > 2 5 10.8 Type of comorbidity COPD b 26 70.3 Coronry rtery disese 8 17.4 Hert filure 1 2.2 Dibetes 8 17.4 Renl filure c 5 13.2 Corticosteroid or IS use 1 2.2 Peripherl rteril disese 2 4.3 Preopertive ntineoplstic tretment Chemotherpy < 3 mos 8 17.4 Medistinl rdiotherpy (ny time) 8 17.4 ASA score 2 37 80.4 3 9 19.6 Defined s quit smoking 12 months go or longer. b Defined s FEV1/VC < 70%. c Defined s cretinine clernce < 60 ml/mn. FEV1, forced expired volume in 1 second; COPD, chronic obstructive pulmonry disese; CP, completion pneumonectomy; IS, immunosuppressive tretment; ASA, Americn Society of Anesthesiology. TABLE 2. Min Chrcteristics of the Completion Surgery Chrcteristic N % Cuse of the CP Mlignnt disese 42 91.2 Secondry primry NSCLC 10 (1 crcinoid) 21.7 Recurrent NSCLC b 25 54.3 R1 fter 1st surgery 5 (1 in situ) 10.9 Metstses 2 4.3 Benign disese 3 6.6 Persistnt telectsis fter initil 1 2.2 surgery Aspergillom 1 2.2 Hemngiom 1 2.2 NC c 1 2.2 Loction of the CP Right/left lung completion 28/18 61/39 Upper/lower/both lobe(s) 21/24/1 46/52/2 Employed surgicl techniques Intrpericrdil dissection 19 41 Chest wll resection 1 2 Vsculr resection 0 0 Bronchil stump covered with 17 37 flp ll Pleur 14 82 Pericrdi 2 12 Muscle 1 6 Lymphdenectomy 38 83 Hospitl cre Medin hospitl length of sty 11 (7 169) (dys; min mx) Medin durtion of thorcic dringe(dys; min mx) 5 (2 15) Defined s the ppernce of cncer histologiclly different from tht of the initil surgery, or histologiclly identicl 5 yrs or more fter the initil surgery. b Defined s the ppernce of cncer histologiclly identicl to tht of the initil surgery within 5 yrs fter the surgery. c First surgery for spergillom. NSCLC, non smll-cell lung cncer; R1, presence of microscopic residue fter the initil surgery; CP, completion pneumonectomy; NC, not counted. complictions were ll good prognosis fctors with respective HR of 5.144 (1.662 15.919; p = 0.004), 3.404 (1.101 10.527; p = 0.033), nd 5.439 (1.373 21.539; p = 0.016). No dditionl fctors ssocited with improved overll survivl were found when postopertive deths (< D90) were excluded. Similrly, smoking sttus ws the only fctor significntly ssocited with overll survivl from the dte of the initil surgery. None of these fctors were ssocited with PFS. Disese-descriptive fctors (T > 1, N > 0, nd stge > 1) were ssocited with neither overll survivl nor PFS, probbly becuse of the size of the test popultion. For periopertive fctors, only lymphdenectomy during CP ws significntly ssocited in nondjusted nlysis, but its ssocition disppered fter djustment for stge nd lymph node sttus. For postopertive complictions, fter exclusion of postopertive deths, only wound complictions remined significntly ssocited with survivl (HR: 5.793 [1.219 27.538]; p = 0.027). 1558 Copyright 2012 by the Interntionl Assocition for the Study of Lung Cncer

Journl of Thorcic Oncology Volume 7, Number 10, October 2012 Completion Pneumonectomy in Ptients with Cncer FIGURE 1. Overll survivl fter completion pneumonectomy regrding stge of the tumor. OS, overll survivl. Finlly, there ws no influence of ntineoplstic neodjuvnt tretments on postopertive course, specificlly for BPF, or pulmonry complictions. DISCUSSION In our series, we found elevted rtes of postopertive mortlity (15.2%) nd morbidity (55.6%) comprble with those of other published CP series (Tble 5). Similrly, our CP mortlity nd morbidity rtes were higher thn those of stndrd pneumonectomy. This is gin comprble with the mjority of literture dt, 18,19 lthough some uthors hve found similr rtes for the two interventions. 12,14 For comprison, Thibout et l. 20 studied ptients who underwent pneumonectomy fter chemotherpy; their popultion ws tken from the sme thorcic surgery deprtments s ours (nd involved the sme surgeons). They found much lower rtes of D90 mortlity nd BPF thn we did: 9.2% versus 15.2% nd 7% versus 13%, respectively. The percentge of ptients trnsfused with more thn two red blood pcks ws lso much lower in the study by Thibout et l. 20 thn in ours (8% versus 35%), confirming the hemorrhgic nture of CP. 5,21 The development of BPF or respirtory filure emerged in our study s risk fctor for postopertive mortlity. This ws not unexpected, s similr results hve been reported in the literture for stndrd pneumonectomy. 22,23 However, contrry to other studies, 8,12,24 our study did not find tht right-sidedness in CP ws mortlity risk fctor, but this my be explined by the smll size of our study popultion. Furthermore, we did not find BPF to occur more frequently in the right lung thn in the left. Surprisingly, our results indicted tht inferior lobe CP ws significntly ssocited with incresed postopertive mortlity. This spect tends not to pper in the literture, with the exception of the study by Mssrd et l. 4 who described incresed, but sttisticlly insignificnt, periopertive bleeding in inferior lobe CP. We hypothesize tht this my be explined by the incresed difficulty encountered when dissecting the root bronchus in the ftermth of superior lobectomy. Whtever the cse my be, this finding should be confirmed in lrger series. Overll, our findings concerning long-term survivl were encourging. We did not perform subgroup nlysis compring ptients with lung metstses (n = 2) with the others, but the results of two retrospective studies focused uniquely on this popultion my suggest tht CP is not tretment of choice for lung metstses, given the poor long-term survivl nd significnt surgicl risks. 10,24 The study of prognosis fctors is lrgely lcking in the literture: on one hnd, the smll number of ptients in most series mkes their sttisticl nlysis difficult, nd on the other, the studies on lrge cohorts hve been predominntly focused on fctors involved in BPF formtion 12,13 or postopertive mortlity. 5,8 In multivrite nlyses to determine risk fctors for postopertive mortlity, Chtigner et l. 8 pointed to chronic renl filure, wheres Miller et l. 5 indicted preopertive corticosteroid use nd low preopertive hemoglobin. To our knowledge, no studies hve reported on fctors influencing long-term survivl. In our cohort, ge older thn 65 yers, current smoker sttus t CP, nd postopertive respirtory, crdic, or prietl wound complictions negtively influence long-term survivl. Copyright 2012 by the Interntionl Assocition for the Study of Lung Cncer 1559

Tbutin et l. Journl of Thorcic Oncology Volume 7, Number 10, October 2012 TABLE 3. Postopertive Outcomes Event n % Mortlity Mortlity before D30 6 13 Cuse of deth before D30 v BPF 2 33.3 Respirtory filure 2 33.3 Unspecified 2 33.3 Mortlity before D90 7 15.2 Complictions / morbidity Men of blood cell pcks trnsfused in 1.97 (0 14) periopertive period (min mx) Types of complictions b Hemorrhge c 11 24.4 Reopertion c 3 6.7 Crdic compliction (ischemic/ 4 (2 / 2) 8.8 rhythmic) c Respirtory filure c 11 24.4 Reintubtion d 5 11.4 Prietl wound compliction c 3 6.7 Chylothorx c 0 0 Recurrent nerve prlysis c 2 4.4 Empyem c 6 13 Thromboembolic disese c 0 0 BPF c 6 13 Number of complictions/ptient c None 20 44.4 2 13 28.9 > 2 12 26.1 Survivl Medin OS* fter CP (mos) (CI = 95%) d 30 (5.299 54.701) Medin OS fter initil surgery (mos) 79 (55.931 102.069) (CI = 95%) Medin OS fter CP (mos), excluding 73 (0 155.643) postopertive deths (CI = 95%) d Medin PFS* (mos) fter CP (IC95%) e 16 (9.614 22.386) Progression Recurrence 21 50 Locl 6 14.3 Distnt 15 35.7 No recurrence 21 50 n = 20 ptients trnsfused. b Complictions cn be cumultive. c n = 1 missing vlues. d 2 missing vlues (4 = 15 censored dt). e n = 9 censored dt.* OS, overll survivl; PFS, progression-free survivl; CI, confidence intervl; CP, completion pneumonectomy; BPF, bronchopleurl fistul. An originl spect is the significnt prognostic influence tht we found for prietl wound complictions. An ltered generl or nutritionl stte present t CP nd ffecting the ptient s overll survivl expectncy is possible explntion for this. 25 The precise evlution of postopertive morbidity (55.6%) is difficult retrospectively. Complictions re dominted by respirtory nd hemorrhgic disorders (the ltter identified s significnt periopertive bleeding indicted in the opertive report or s significnt bleeding observed postopertively in the pneumonectomy cvity, necessitting or not new surgicl intervention) nd the development of BPF. More thn 43% of the ptients in our study received periopertive trnsfusions, lthough we found no ssocition between the number of trnsfusion pcks nd postopertive mortlity or long-term survivl. This ltter spect is in contrdiction with Thoms et l. 26 who, in lrger cohort of pneumonectomy ptients, found significnt link between the quntity of dministered blood pcks nd postopertive mortlity. Nevertheless, these observtions nd those of other surgicl series finding reduced long-term survivl in trnsfused ptients 27 29 illustrte how the hemorrhgic nture of CP continues to be mjor issue in ptients operted for cncer. Tking into ccount the erly stge of lung cncer in the mjority of our ptients, less invsive therpeutic options such s chemordition nd stereotctic rdiotherpy could be discussed. Those techniques hve lower morbidity nd mortlity, 30 nd long-term survivl seems interesting. 31,32 However, long-term survivl compred with redo surgery in cse of locl recurrence hs not yet been evluted prospectively. Moreover, in their retrospective study on postrecurrence survivl in completely resected stge I non smll-cell lung cncer with locl recurrence, Hung et l. 32 conclude tht surgicl resection should be considered in selected cndidtes with resectble locl recurrent disese, becuse reoperted ptients survived longer thn ptients treted with chemotherpy nd/or rdiotherpy. A prospective study on the subject could be useful. CONCLUSION Our present retrospective study confirms tht CP, compred with stndrd pneumonectomy, is burdened with higher postopertive morbidity nd mortlity. We found tht bleeding remins mjor issue in this intervention s does the incresed risk of BPF formtion. Risk fctors for postopertive mortlity detected were BPF formtion, respirtory filure, more thn two complictions (mong those nlyzed in the study) nd, more originlly, CP in n inferior lobe. Prognosis fctors ffecting overll survivl were ge older thn 65 yers, current smoker sttus t CP, nd postopertive respirtory, crdic or prietl wound complictions. Long-term survivl remins encourging nd justifies the interest in this surgery. CP is rre surgicl intervention; this explins the frequently smll popultions in the vrious retrospective studies nd thus their lck of sttisticl power to demonstrte congruent prognostic fctors. Improving current knowledge of these fctors is nevertheless vitl to permit more precise selection of ptients ble to benefit from surgery. A met-nlysis to ddress these weknesses would thus be welcome ddition to the literture. 1560 Copyright 2012 by the Interntionl Assocition for the Study of Lung Cncer

Journl of Thorcic Oncology Volume 7, Number 10, October 2012 Completion Pneumonectomy in Ptients with Cncer TABLE 4. Fctors Influencing Postopertive Mortlity nd Long-Term Survivl Deth D90 Overll Survivl Fctor Considered n Ded/n in Ct. (%) p Medin (in mos) (95%CI) P Hzrd rtio (95% CI) by Cox Model p Demogrphic criteri Age (yrs) < 65 5/34 (14.7%) 0.058 65.6 (18.1 112.2) 0.012 1 0.024 65 2/12 (16.7%) 21.2 (5.9 54.9) 2.7 (1.0 6.2) Tobcco smoking sttus Never or former smoker 3/29 (10.3%) 0.0216 44.9 (10.8 79.0) 0.013 1 0.035 Current smoker 4/17 (23.5%) 8.279 (3.6 13.0) 2.3 (1.1 4.9) Surgery complictions Bronchopleurl fistul No 3/39 (7.7%) 0.024 44.9 (11.2 78.6) 0.347 Yes 3/6 (50%) 1.3 (0.0 26.4) Pulmonry compliction No 0/34 (0%) < 0.00001 65.15 (34.3 96.0) < 0.00001 1 0.004 Yes 6/11 (54.5%) 1.3 (0.0 7.8) 5.1 (1.7 15.9) Crdic compliction No 4/41 (9.8%) 0.080 44.9 (10.1 79.8) 0.047 1 0.033 Yes 2/4 (50%) 0.6 (0.0 18.2) 3.4 (1.1 10.5) Prietl wound compliction No 5/42 (11.9%) 0.356 44.9 (5.9 84.0) 0.023 1 0.016 Yes 1/3 (33.3%) 4.9 (0.0 10.7) 5.4 (1.4 21.6) Number of complictions < 2 1/29 (3.4%) 0.017 44.9 (5.8 84.1) 0.231 2 5/16 (31.3%) 11.4 (0.0 28.0) Surgery criteri CP on the lower lobe 7/24 (29.2%) 0.01 21.2 (1.8 40.6) 0.390 CP elsewhere 0/22 (0%) 44.9 (10.6 79.2) n = 1 missing vlue. CI, confidence intervl; CP, completion pneumonectomy TABLE 5. Comprison between our Study nd Others Concerning Postopertive Mortlity (D90 Deth in our Study), Bronchopleurl Fistul Occurrence, nd Intr nd Postopertive Trnsfusions Series Yr N n with Mlignnt Disese Postopertive Mortlity Rte for Cncer Ptients (%) Bronchopleurl Fistul (%) Periopertive Blood Trnsfusions (%) Mc Govern et l. 2 1988 113 84 9.4 11.7 Grégoire et l. 14 1993 60 41 11.6 13.3 Mssrd et l. 4 1995 37 32 17.3 2.7 54 l-kttn et l. 11 1995 38 26 0 0 Verhgen et l. 7 1996 37 33 15.6 5.4 Muysoms et l. 6 1998 138 80 13.2 4.3 Regnrd et l. 13 1999 80 62 6.4 3.8 66 Tronc et l. 1 1999 77 57 10.5 10.4 Fujimoto et l. 15 2001 66 49 2.3 7.6 Terzi et l. 9 2002 59 59 3.4 52.4 Miller et l. 5 2002 115 58 17.6 7 Guggino et l. 12 2004 55 42 13.2 12.7 30 Jungrithmyr et l. 3 2004 86 41 10 10.4 Chtigner et l. 8 2007 69 47 12.8 10 19 Current study 2011 46 46 15 13 43 Copyright 2012 by the Interntionl Assocition for the Study of Lung Cncer 1561

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