title: The sequence of vessel interruption during lobectomy for non-small cell lung cancer: is it indeed important?
abstract: OBJECTIVE
  During pulmonary resections for non-small cell lung cancer, the pulmonary vein is traditionally interrupted first to prevent seeding of malignant cells and consequently decrease metastatic implantation. This hypothesis was never confirmed scientifically. The aim of the present study was to determine whether the sequence of vessel interruption during lobectomy (lobar vein or lobar artery first) affects disease recurrence.
  
  
  METHODS
  A historical prospective study was performed of 279 consecutive patients with complete follow-up, who survived lobectomy for non-small cell lung cancer during 1992 to 1998, in a single center. Pre-, intra-, and postoperative variables were collected from the medical records; recurrence and vital status were obtained from follow-up files, central population registry, and personal confirmation, updated to December 2000. Comparison of recurrence rates by sequence of ligation and other independent variables was assessed by univariate and multivariate logistic regression analyses.
  
  
  RESULTS
  A total of 133 patients (48%) had vein interruption before the artery (V-first) and 146 (52%) had artery interruption first (A-first). The distribution of demographic, clinical, and other characteristics was similar between the 2 groups, except for the operated side and performing surgeons. The morbidity, blood requirement, and length of stay were equal for both groups. The total recurrence rate (A-first, 53%; V-first, 51%) was similar. Multivariate analysis (controlling for the effect of the performing surgeon) revealed elevated risk for recurrence among patients with high disease stage (odds ratio = 2.54), male gender (odds ratio = 1.59), intraoperative lung manipulation (odds ratio = 2.72), and blood transfusion (odds ratio = 1.49). Sequence of vessel interruption was not found as a risk factor for recurrence (odds ratio = 1.29; 95% 0.73 to 2.29, P =.4).
  
  
  CONCLUSIONS
  Our results did not show that sequence of vessel interruption during lobectomy plays a role in tumor recurrence. A prospective study with randomization in selection of method as well as surgeons for each patient is needed to confirm these results.
authors.affiliation: Department of Thoracic Surgery and Cancer Epidemiology Unit, Gertner Institute, Sheba Medical Center, Tel Hashomer, Israel.
authors.forename: Yael
authors.initials: Y
authors.lastname: Refaely
authors.forename: Siegal
authors.initials: S
authors.lastname: Sadetzki
authors.forename: Angela
authors.initials: A
authors.lastname: Chetrit
authors.forename: David A
authors.initials: DA
authors.lastname: Simansky
authors.forename: Michael
authors.initials: M
authors.lastname: Paley
authors.forename: Baruch
authors.initials: B
authors.lastname: Modan
authors.forename: Alon
authors.initials: A
authors.lastname: Yellin
mesh_terms: D002289:Carcinoma, Non-Small-Cell Lung / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008175:Lung Neoplasms / Q000601:surgery*; D008297:Male; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control; D011013:Pneumonectomy / Q000379:methods*; D011446:Prospective Studies; D011651:Pulmonary Artery / Q000601:surgery*; D011667:Pulmonary Veins / Q000601:surgery*; D012044:Regression Analysis