title: The effects of an intentional transition from extrapleural pneumonectomy to extended pleurectomy/decortication.
abstract: OBJECTIVE
  For many years, extrapleural pneumonectomy (EPP) was the operation of choice for the radical management of pleural mesothelioma in the UK. However, doubts surrounding the efficacy of EPP, and the change in demographics of the affected population, have prompted a transition in our practice towards extended pleurectomy/decortication (EPD). The aim of this study was to determine the effects an intentional transition from EPP to EPD has had on patient outcome.
  
  
  METHODS
  Data from 362 patients undergoing radical surgery (229 EPD, 133 EPP) during 1999-2014 were included. Demographics and outcome were compared between the two groups; EPP versus EPD.
  
  
  RESULTS
  The median age of patients undergoing EPD was significantly higher than those undergoing EPP [57 years (range 14-70 years) vs 65 years (range 42-81 years), P < 0.001]. There was a significantly higher proportion of patients with performance status ≥1 in the EPD group (46.3 vs 35.4%, P = 0.047). There was no difference in the median length of hospital stay between the two groups [14 days (range 1-133 days) vs 13 days (range 0-93 days), P = 0.409]. There was also no difference between the groups in terms of in-hospital mortality (EPP 5.3% and EPD 6.6%, P = 0.389), 30-day mortality [EPP 8 (6.0%) and EPD 8 (3.5%), P = 0.294] or 90-day mortality [EPP 18 (13.5%) and EPD 21 (9.2%), P = 0.220]. There was a significantly higher early reoperation rate in the EPP group (15.0 vs 6.2%, P = 0.008) but a significantly higher late reoperation rate in the EPD group (0.8 vs 5.3%, P = 0.037). There was no significant difference in overall survival or disease-free interval between the two groups (P = 0.899 and P = 0.399, respectively). However, overall survival was significantly greater in patients over the age of 65 undergoing EPD (12.5 vs 4.7 months, P = 0.001).
  
  
  CONCLUSIONS
  The transition from EPP to EPD in our standard practice has enabled us to operate on more elderly, frail patients with no significant increase in use of hospital resources, and without detriment to overall survival.
authors.affiliation: University of Leicester Hospitals Trust, Leicester, UK a.sharkey@hotmail.co.uk ajs114@le.ac.uk.
authors.forename: Annabel J
authors.initials: AJ
authors.lastname: Sharkey
authors.affiliation: IRCCS Arcispedale, Reggio Emilia, Italy.
authors.forename: Sara
authors.initials: S
authors.lastname: Tenconi
authors.affiliation: University of Leicester Hospitals Trust, Leicester, UK.
authors.forename: Apostolos
authors.initials: A
authors.lastname: Nakas
authors.affiliation: University of Leicester Hospitals Trust, Leicester, UK.
authors.forename: David A
authors.initials: DA
authors.lastname: Waller
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017024:Chemotherapy, Adjuvant; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008654:Mesothelioma / Q000601:surgery* / Q000628:therapy; D008875:Middle Aged; D010997:Pleural Neoplasms / Q000601:surgery* / Q000628:therapy; D011013:Pneumonectomy / Q000379:methods* / Q000639:trends; D011364:Professional Practice / Q000639:trends; D018714:Radiotherapy, Adjuvant; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
keywords: Extended pleurectomy/decortication; Extrapleural pneumonectomy; Mesothelioma; Pleural mesothelioma; Survival; Thoracic surgery