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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Major lung resections&#44; particularly lobectomy&#44; have advanced greatly&#44; and are now regularly performed in thoracic surgery departments&#46; These procedures have undergone particular scrutiny in inter-departmental benchmarking processes&#44; and auditing can provide a good indication of the quality of the unit&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> There are&#44; however&#44; certain interventions that can be controversial in special circumstances&#44; some of which are addressed in the articles reviewed below&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#44;3</span></a></p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Lung Resection Surgery in Octogenarians</span><p id="par0010" class="elsevierStylePara elsevierViewall">Recent decades have seen a significant increase in the life expectancy of the population&#46; In subjects over the age of 70&#44; the incidence of lung cancer &#40;LC&#41; and consequent mortality is very high&#44; and one of the most hotly debated issues in the surgical approach to these patients is whether age is a limiting factor for surgery&#46; Specifically&#44; the controversy centers on patients aged 80 or older&#46; At this age&#44; early stage LC diagnoses are common&#44; and as such&#44; many patients are candidates for surgery with curative intent&#46; Although some authors working in the field have concluded that octogenarian patients undergoing lung resection have similar morbidity and mortality rates to the rest of the population&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#44;4&#44;5</span></a> elderly patients are obviously more frail&#46; Some studies report higher mortality figures in patients of advanced age after major lung surgery&#44; although the subject remains a matter for debate&#46; The results of a study by Rodriguez et al&#46; are consistent with others that found no differences in surgical risk associated with age&#58; older and younger groups had similar postoperative cardiorespiratory complications and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4&#8211;6</span></a> However&#44; significant differences were found in the logistical regression model for predicted postoperative FEV1&#37; &#40;ppoFEV1&#37;&#41;&#44; confirming that&#44; as in the general population&#44; resection of the least possible amount of lung parenchyma should be attempted to avoid postoperative complications and loss of quality of life&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Another very important question to bear in mind is the patients&#8217; attitude toward surgery&#46; Very few articles address this issue in depth&#44; but in daily practice&#44; we see that elderly patients do not approach their disease in the same way as younger ones&#44; and they often question the real value of invasive surgery when their life expectancy is already limited&#46; A joint discussion between the surgeon and patient is therefore essential&#44; and must include a clear explanation of complications that can arise and expected postoperative quality of life&#46; Screening of candidates for major lung resection must be particularly meticulous in the case of octogenarian patients&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> When surgery is proposed&#44; video-assisted thoracoscopic resections may be an improvement in terms of postoperative complications and survival in the elderly&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">7&#44;8</span></a> The alternative approach of sublobar resection or video-assisted thoracoscopic segmentectomy must also be considered where possible&#44; as this procedure has shown some excellent results in stage I LC less than 2<span class="elsevierStyleHsp" style=""></span>cm in diameter&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">9&#44;10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Pneumonectomy and Possible Alternatives</span><p id="par0020" class="elsevierStylePara elsevierViewall">The incidence of complications and postoperative mortality after pneumonectomy is high&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">11&#44;12</span></a> up to 3 times the risk of lobectomy&#46; Postoperative problems mainly involve bronchopleural fistulas and cardiorespiratory complications&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> After the immediate postoperative stage&#44; the intervention induces physiological changes that can significantly affect the pneumonectomized subject&#39;s quality of life and mortality&#44; as reported in many studies&#44; and in particular by Deslauriers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> It is interesting to compare pneumonectomy with lobectomy in stage IB LC&#46; The skill and expertise of the surgeon may play a part in the surgical approach to these tumors&#46; The future clinical course of a patient may depend on avoiding pneumonectomy&#44; and opting for parenchyma-sparing techniques&#44; such as angioplasty and bronchoplasty&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">14&#44;15</span></a> An additional advance in this type of surgery has been the use of cryopreserved grafts&#46; These procedures may be technically complex&#44; but morbidity and mortality rates have not been higher in the series published to date&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> Indeed&#44; as noted in the aforementioned article&#44; the number of pneumonectomies carried out in a surgical unit decreases as surgeons acquire expertise&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Nevertheless&#44; there are occasions&#44; such as infiltration of the hilar structures or interlobar extension&#44; when pneumonectomy is unavoidable and lobectomy must be ruled out as a treatment option&#46; In these cases&#44; prognosis is poorer&#44; due to both the intervention itself and tumor invasion across the fissure&#44; which&#44; in the opinion of some authors&#44; suggests that the malignancy is more aggressive&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">17&#44;18</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Pneumonectomy in Elderly Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">The second study we would like to discuss is related with the first&#44; in that it addresses an issue also widely debated in the specialized literature&#58; pneumonectomy in elderly patients&#46; Older age&#44; lower FEV1 and whole lung resection were factors for poorer survival and quality of life in the study reported by Rodr&#237;guez et al&#46; This topic is of interest because several groups have explicitly advised against pneumonectomy in octogenarians&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> or have classified this procedure as very high risk&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> In these cases&#44; then&#44; the use of minimally invasive surgical techniques and alternatives to pneumonectomy also becomes more important&#44; as discussed above&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="par0035" class="elsevierStylePara elsevierViewall">These studies have their limitations&#44; including the lack of DLCO assessments in the early part of the series&#44; the limited number of cases&#44; and scant information on the indication for pneumonectomy&#46; A multicenter approach could be of interest for addressing these questions&#44; and could help to clarify some unresolved issues in LC surgery&#46;</p></span></span>"
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Editorial
Morbidity, Mortality and Survival After Surgery for Lung Cancer
Morbilidad, mortalidad y supervivencia en las resecciones pulmonares en el carcinoma broncogénico
Jorge Freixinet Gilart
Corresponding author
, Pedro Miguel Rodríguez Suárez
Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Isla de Gran Canaria, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Major lung resections&#44; particularly lobectomy&#44; have advanced greatly&#44; and are now regularly performed in thoracic surgery departments&#46; These procedures have undergone particular scrutiny in inter-departmental benchmarking processes&#44; and auditing can provide a good indication of the quality of the unit&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> There are&#44; however&#44; certain interventions that can be controversial in special circumstances&#44; some of which are addressed in the articles reviewed below&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#44;3</span></a></p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Lung Resection Surgery in Octogenarians</span><p id="par0010" class="elsevierStylePara elsevierViewall">Recent decades have seen a significant increase in the life expectancy of the population&#46; In subjects over the age of 70&#44; the incidence of lung cancer &#40;LC&#41; and consequent mortality is very high&#44; and one of the most hotly debated issues in the surgical approach to these patients is whether age is a limiting factor for surgery&#46; Specifically&#44; the controversy centers on patients aged 80 or older&#46; At this age&#44; early stage LC diagnoses are common&#44; and as such&#44; many patients are candidates for surgery with curative intent&#46; Although some authors working in the field have concluded that octogenarian patients undergoing lung resection have similar morbidity and mortality rates to the rest of the population&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#44;4&#44;5</span></a> elderly patients are obviously more frail&#46; Some studies report higher mortality figures in patients of advanced age after major lung surgery&#44; although the subject remains a matter for debate&#46; The results of a study by Rodriguez et al&#46; are consistent with others that found no differences in surgical risk associated with age&#58; older and younger groups had similar postoperative cardiorespiratory complications and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4&#8211;6</span></a> However&#44; significant differences were found in the logistical regression model for predicted postoperative FEV1&#37; &#40;ppoFEV1&#37;&#41;&#44; confirming that&#44; as in the general population&#44; resection of the least possible amount of lung parenchyma should be attempted to avoid postoperative complications and loss of quality of life&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Another very important question to bear in mind is the patients&#8217; attitude toward surgery&#46; Very few articles address this issue in depth&#44; but in daily practice&#44; we see that elderly patients do not approach their disease in the same way as younger ones&#44; and they often question the real value of invasive surgery when their life expectancy is already limited&#46; A joint discussion between the surgeon and patient is therefore essential&#44; and must include a clear explanation of complications that can arise and expected postoperative quality of life&#46; Screening of candidates for major lung resection must be particularly meticulous in the case of octogenarian patients&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> When surgery is proposed&#44; video-assisted thoracoscopic resections may be an improvement in terms of postoperative complications and survival in the elderly&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">7&#44;8</span></a> The alternative approach of sublobar resection or video-assisted thoracoscopic segmentectomy must also be considered where possible&#44; as this procedure has shown some excellent results in stage I LC less than 2<span class="elsevierStyleHsp" style=""></span>cm in diameter&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">9&#44;10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Pneumonectomy and Possible Alternatives</span><p id="par0020" class="elsevierStylePara elsevierViewall">The incidence of complications and postoperative mortality after pneumonectomy is high&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">11&#44;12</span></a> up to 3 times the risk of lobectomy&#46; Postoperative problems mainly involve bronchopleural fistulas and cardiorespiratory complications&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> After the immediate postoperative stage&#44; the intervention induces physiological changes that can significantly affect the pneumonectomized subject&#39;s quality of life and mortality&#44; as reported in many studies&#44; and in particular by Deslauriers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> It is interesting to compare pneumonectomy with lobectomy in stage IB LC&#46; The skill and expertise of the surgeon may play a part in the surgical approach to these tumors&#46; The future clinical course of a patient may depend on avoiding pneumonectomy&#44; and opting for parenchyma-sparing techniques&#44; such as angioplasty and bronchoplasty&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">14&#44;15</span></a> An additional advance in this type of surgery has been the use of cryopreserved grafts&#46; These procedures may be technically complex&#44; but morbidity and mortality rates have not been higher in the series published to date&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> Indeed&#44; as noted in the aforementioned article&#44; the number of pneumonectomies carried out in a surgical unit decreases as surgeons acquire expertise&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Nevertheless&#44; there are occasions&#44; such as infiltration of the hilar structures or interlobar extension&#44; when pneumonectomy is unavoidable and lobectomy must be ruled out as a treatment option&#46; In these cases&#44; prognosis is poorer&#44; due to both the intervention itself and tumor invasion across the fissure&#44; which&#44; in the opinion of some authors&#44; suggests that the malignancy is more aggressive&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">17&#44;18</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Pneumonectomy in Elderly Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">The second study we would like to discuss is related with the first&#44; in that it addresses an issue also widely debated in the specialized literature&#58; pneumonectomy in elderly patients&#46; Older age&#44; lower FEV1 and whole lung resection were factors for poorer survival and quality of life in the study reported by Rodr&#237;guez et al&#46; This topic is of interest because several groups have explicitly advised against pneumonectomy in octogenarians&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> or have classified this procedure as very high risk&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> In these cases&#44; then&#44; the use of minimally invasive surgical techniques and alternatives to pneumonectomy also becomes more important&#44; as discussed above&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="par0035" class="elsevierStylePara elsevierViewall">These studies have their limitations&#44; including the lack of DLCO assessments in the early part of the series&#44; the limited number of cases&#44; and scant information on the indication for pneumonectomy&#46; A multicenter approach could be of interest for addressing these questions&#44; and could help to clarify some unresolved issues in LC surgery&#46;</p></span></span>"
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ISSN: 15792129
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