Operative Mortality and Respiratory Complications After Lung Resection for Cancer: Impact of Chronic Obstructive Pulmonary Disease and Time Trends

Guidelines for preoperative pulmonary function assessment in patients with lung cancer who will undergo surgery (The Japanese Association for Chest Surgery)

This article translates the guidelines for preoperative pulmonary function assessment in patients with lung cancer who will undergo surgery, established by the Japanese Association of Chest Surgery on May 17, 2021, from Japanese to English. The last version of these guidelines was created on April 5, 2011. Over the past decade, changes in clinical practice have occurred that do not align with the current guidelines, prompting a revision in conjunction with the introduction of new evidence this time. This guideline was developed with reference to the internationally adopted GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. Extraction of evidence, systematic review, and quality assessment are entrusted to each guideline review committee and the Pulmonary Function Assessment Working Group. Committee members are also responsible for determining the selection of evidence and the extraction period, with a particular emphasis on adopting items considered to be of special importance. The recommended assessment and management is categorized into a general overview, pulmonary function assessment, cardiopulmonary exercise test, pulmonary function assessment for lung cancer with interstitial pneumonia, preoperative smoking cessation, and pulmonary rehabilitation. These are described by the strength of recommendation, the strength of evidence, and the consensus rate.

Multimodal prehabilitation before lung resection surgery: a multicentre randomised controlled trial

BACKGROUND

Respiratory muscle training may improve ventilatory efficiency (VE/VCO2 slope), a strong predictor of postoperative pulmonary complications. We hypothesised that multimodal prehabilitation, incorporating high-intensity respiratory muscle training, before lung resection would reduce postoperative complications and length of hospital stay.

METHODS

We conducted a prospective multicentre, randomised controlled trial (NCT04826575) to examine the effect of prehabilitation in individuals undergoing lung resection. Participants were defined as high-risk for postoperative pulmonary complications if they achieved VE/VCO2 slope ≥33, as determined by cardiopulmonary exercise testing. Participants were then randomised to either usual care or multimodal prehabilitation, which consisted of a 14-day programme of high-intensity respiratory muscle training, smoking cessation, nutritional support, and psychological support. The primary outcome were postoperative pulmonary and cardiovascular complications (pneumonia, atelectasis, respiratory failure necessitating mechanical ventilation, adult respiratory distress syndrome, prolonged air leak).

RESULTS

A total of 122 patients (46% female; age range: 64-75 yr) completed the study. Postoperative pulmonary complications occurred in 20/58 (34%) of patients randomised to multimodal prehabilitation, compared with 35/64 (55%) patients receiving usual care (odds ratio 2.29 [95% confidence interval 1.10-4.77]; P=0.029). Hospital length of stay was shorter after multimodal rehabilitation (9 days [7-11]), compared with patients randomised to receive usual care (7 days [6-9]; P=0.038). After prehabilitation, mean (sd) VE/VCO2 slope decreased from 39 (8) to 36 (9); P=0.01. Prehabilitation also improved patient-reported quality of life measures.

CONCLUSIONS

In high-risk patients undergoing elective lung resection surgery, multimodal prehabilitation, including high-intensity respiratory muscle training to target VE/VCO2, reduced postoperative pulmonary complications and hospital length of stay.

Significance of measuring the severity of emphysema, in combination with spirometry, on the risk evaluation of patients undergoing major lung resection for cancer†

OBJECTIVES

Predicted postoperative forced expiratory volume in 1 s (ppoFEV1) and predicted postoperative diffusing capacity of the lungs for carbon monoxide (ppoDLco) are the two most significant parameters for predicting the risk of cardiopulmonary complications after major lung resection for lung cancer. Although the severity of pulmonary emphysema on computed tomography may be an important risk factor for postoperative complications, the clinical significance of measuring the severity of pulmonary emphysema, in combination with ppoFEV1 and ppoDLco, has never been evaluated.

METHODS

We measured the severity of pulmonary emphysema, representing the percentage of low-attenuation area (< -950 Hounsfield units), in the whole lung field, in addition to ppoFEV1 and ppoDLco, in 451 patients who underwent major lung resection for primary lung cancer. We also measured the volume of the upper and lower lobes of emphysematous and non-emphysematous lungs.

RESULTS

Postoperative cardiopulmonary complications developed in 60 patients (13.3%). According to a receiver operating characteristic curve analysis for the diagnostic potential of postoperative complications, the area under the curve was highest for the severity of emphysema, followed by ppoDLco and ppoFEV1. According to a stepwise multivariable logistic regression analysis, the severity of emphysema and ppoDLco was identified as independent risk factors for postoperative complications. Neither the heterogeneous distribution of emphysema nor that of non-emphysema was associated with the occurrence of complications in patients with upper lobe disease or in patients with lower lobe disease.

CONCLUSIONS

The severity of emphysema on computed tomography is a relevant risk factor for cardiopulmonary complications after major lung resection.

CLINICAL REGISTRATION NUMBER

The study was approved by our institutional review board of No. 240077.

Association between recovery from desaturation after stair climbing and postoperative complications in lung resection

OBJECTIVE

The stair-climbing test (SCT) is used as a surrogate for cardiopulmonary exercise testing, which measures maximal oxygen uptake, and considered a useful method for assessing exercise capacity in thoracic surgery. This study aims to investigate whether the recovery time of percutaneous oxygen saturation (SpO2) after stair climbing is a predictor of postoperative complications after lobectomy.

METHODS

We retrospectively identified 54 patients who performed SCT and underwent lobectomy between January 2015 and February 2023 at Shizuoka Cancer Center. The SpO2 recovery time was defined as the time required to recover from the minimum to resting value after stair climbing. The association between SpO2 recovery time and early postoperative pulmonary complications within 30 days after surgery was analyzed.

RESULTS

Eleven patients (20.4%) had postoperative pulmonary complications (≥ Clavien-Dindo Classification Grade 2). The cutoff value of SpO2 recovery time obtained from the receiver operating characteristic curve analysis was 90 s [sensitivity, 81.8%; specificity, 72.1%; AUC, 0.77 (95% confidence interval, 0.64-0.90)]. The occurrence of postoperative pulmonary complications was 42.9% in the delayed recovery time (DRT; SpO2 recovery time ≥ 90 s) group and 6.1% in the non-DRT (SpO2 recovery time < 90 s) group (p = 0.002). DRT was a predictor of postoperative pulmonary complications (odds ratio, 11.60; 95% CI 2.19-61.80).

CONCLUSIONS

DRT of SpO2 after stair climbing is a predictor of postoperative pulmonary complications following lobectomy in borderline patients who require exercise capacity assessment. SpO2 monitoring after stair climbing may be useful as one of the preoperative assessments in patients undergoing lobectomy.

Causes of ventilatory inefficiency in lung resection candidates

Introduction

Ventilatory efficiency (V'E/V'CO2 ) has been shown to predict postoperative pulmonary complications (PPCs) in lung resection candidates. V'E/V'CO2 is determined by arterial partial pressure of carbon dioxide (P aCO2 ) and by dead space to tidal volume ratio (V D/V T). We hypothesised P aCO2 and V D/V T contribute equally to the increase in V'E/V'CO2 in lung resection patients.

Methods

Consecutive lung resection candidates from two prior prospective studies were included in this post hoc analysis. All subjects underwent preoperative spirometry, cardiopulmonary exercise testing and arterial blood gas analysis at rest and peak exercise. PPCs were prospectively assessed during the first 30 postoperative days, or hospital stay. A t-test, Mann-Whitney U-test and two-tailed Fisher's exact test were used to compare patients with and without PPCs. p-values <0.05 were considered statistically significant.

Results

Of 398 patients, PPC developed in 64 (16%). Patients with PPCs more frequently underwent lobectomy by open thoracotomy, had longer hospital and ICU length of stay and higher 30- and 90-day mortality. Moreover, patients with PPCs exhibited a higher V'E/V'CO2 ratio both at rest and peak exercise. Both ratios were independently associated with PPCs. At rest, the contribution of P aCO2 and V D/V T to the increase in V'E/V'CO2 ratio in patients with PPCs was 45% and 55%, respectively. At peak exercise, the contribution of P aCO2 and V D/V T to the increase in V'E/V'CO2 ratio was 16% and 84%, respectively.

Conclusions

V D/V T (V'/Q' mismatch and/or rapid shallow breathing pattern) is the dominant contributor to the increase in V'E/V'CO2 in lung resection candidates who develop PPCs.

The Saudi Thoracic Society Evidence-based guidelines for the diagnosis and management of chronic obstructive pulmonary disease

The Saudi Thoracic Society (STS) developed an updated evidence-based guideline for diagnosing and managing chronic obstructive pulmonary disease (COPD) in Saudi Arabia. This guideline aims to provide a comprehensive and unbiased review of current evidence for assessing, diagnosing, and treating COPD. While epidemiological data on COPD in Saudi Arabia are limited, the STS panel believes that the prevalence is increasing due to rising rates of tobacco smoking. The key objectives of the guidelines are to facilitate accurate diagnosis of COPD, identify the risk for COPD exacerbations, and provide recommendations for relieving and reducing COPD symptoms in stable patients and during exacerbations. A unique aspect of this guideline is its simplified, practical approach to classifying patients into three classes based on symptom severity using the COPD Assessment Test and the risk of exacerbations and hospitalizations. The guideline provides the reader with an executive summary of recommended COPD treatments based on the best available evidence and also addresses other major aspects of COPD management and comorbidities. This guideline is primarily intended for use by internists and general practitioners in Saudi Arabia.

A New Functional Threshold for Minimally Invasive Lobectomy

OBJECTIVE

To assess the performance of a lower predicted postoperative (ppo) forced expiratory volume in 1 second (FEV 1 ) or diffusion capacity of the lung for carbon monoxide (DLCO) (ppoFEV 1 /ppoDLCO) threshold to predict cardiopulmonary complications after minimally invasive surgery (MIS) lobectomy.

BACKGROUND

Although MIS is associated with better postoperative outcomes than open surgery, MIS uses risk-assessment algorithms developed for open surgery. Moreover, several different definitions of cardiopulmonary complications are used for assessment.

METHODS

All patients who underwent MIS lobectomy for clinical stage I to II lung cancer from 2018 to 2022 at our institution were considered. The performance of a ppoFEV 1 /ppoDLCO threshold of <45% was compared against that of the current guideline threshold of <60%. Three different definitions of cardiopulmonary complications were compared: Society of Thoracic Surgeons (STS), European Society of Thoracic Surgeons (ESTS), and Berry and colleagues' study.

RESULTS

In 946 patients, the ppoFEV 1 /ppoDLCO threshold of <45% was associated with a higher proportion correctly classified [79% (95% CI, 76%-81%) vs 65% (95% CI, 62%-68%); P <0.001]. The complication with the biggest difference in incidence between ppoFEV 1 /ppoDLCO of 45% to 60% and >60% was prolonged air leak [33 (13%) vs 34 (6%); P <0.001]. The predicted probability curves for cardiopulmonary complications were higher for the STS definition than for the ESTS or Berry definitions across ppoFEV 1 and ppoDLCO values.

CONCLUSIONS

The ppoFEV 1 /ppoDLCO threshold of <45% more accurately classified patients for cardiopulmonary complications after MIS lobectomy, emphasizing the need for updated risk-assessment guidelines for MIS lobectomy to optimize additional cardiopulmonary function evaluation.

Timing effects of short-term smoking cessation on lung cancer postoperative complications: a systematic review and meta-analysis

BACKGROUND

Preoperative smoking cessation may reduce postoperative complications in patients with lung cancer. However, the optimal duration of short-term preoperative smoking cessation remains unclear.

METHODS

Three databases, PubMed, Embase, and the Cochrane Library, were searched for studies published up to April 5, 2024. The Newcastle-Ottawa scale was used to assess the risk of bias. The included studies compared the incidence of postoperative complications between patients with different preoperative smoking cessation times and those with persistent preoperative smoking. A meta-analysis of postoperative complications and events such as pneumonia was performed in patients with lung cancer.

RESULTS

Fourteen studies met the inclusion criteria and included a total of 50,741 patients who had undergone pulmonary resection. The meta-analysis showed that preoperative smoking cessation of > 2 weeks and < 1 month did not reduce the incidence of postoperative complications (odds ratio [OR] 1.05; 95% confidence interval [CI] 0.76-1.44; P = 0.78) and pneumonia (OR 0.98; 95% CI 0.60-1.61; P = 0.95). Moreover, preoperative smoking cessation for > 1 month was effective in reducing the incidence of postoperative complications (OR 0.72; 95% CI 0.63-0.83; P < 0.01) as well as pneumonia (OR 0.80; 95% CI 0.49-1.33; P = 0.40).

CONCLUSIONS

This meta-analysis suggests that preoperative smoking cessation for > 1 month is effective in reducing complications and pneumonia after pulmonary resection in patients with lung cancer, especially as video-assisted thoracoscopic surgery (VATS) and robotic-assisted surgery become more common.

The prognostic significance of modified frailty index-5 in patients undergoing pneumonectomy for lung cancer

OBJECTIVES

In some centrally located lung cancers, complete excision of the mass cannot be achieved with parenchymal-sparing procedures and pneumonectomy may be required. The mortality and morbidity rates of pneumonectomy were reported to be considerably high. Here, we investigated the effectivity of modified frailty index-5 (MFI-5) in patients undergoing pneumonectomy for non-small cell lung cancer.

METHODS

Data of patients who underwent pneumonectomy for non-small cell lung cancer between January 2018 and December 2023 were reviewed retrospectively. The MFI-5 score was determined by preoperative diabetes mellitus, hypertension, chronic obstructive pulmonary diseases, congestive heart failure and functional status. The effectiveness of the MFI-5 score for the presence of postoperative major complications and 30-day mortality was investigated by multivariate logistic regression analysis. A P-value <0.05 was considered statistically significant.

RESULTS

A total of 107 patients who met the inclusion criteria were included in the study. Eight (7.5%) of patients were female, and the mean age was 61.4 ± 8.7. The MFI-5 score was 0 in 48 patients (44.9%), 1 in 27 patients (25.2%) and 2 in 20 patients (18.7%). Postoperative 30-day mortality was detected in 4 patients (3.7%), and the major complications occurred in 42 patients (39.3%). In multivariate analysis, an MFI-5 score of 2 or higher (P = 0.008, OR: 4.9) was statistically significant for complications, whereas age, gender, side of the operation, <2 MFI-5 score, tumor diameter, type of surgery and lymph node metastasis status were not statistically significant (P > 0.05).

CONCLUSIONS

The MFI-5 score is a significant indicator for predicting major postoperative events in patients who underwent pneumonectomy for non-small cell lung cancer.

CLINICAL REGISTRATION NUMBER

2024-323, approved by Gazi University Local Ethics Committee.

Different DLCO Parameters as Predictors of Postoperative Pulmonary Complications in Mild Chronic Obstructive Pulmonary Disease Patients with Lung Cancer

Background

Numerous studies have investigated methods of predicting postoperative pulmonary complications (PPCs) in lung cancer surgery, with chronic obstructive pulmonary disease (COPD) and low forced expiratory volume in 1 second (FEV1) being recognized as risk factors. However, predicting complications in COPD patients with preserved FEV1 poses challenges. This study considered various diffusing capacity of the lung for carbon monoxide (DLCO) parameters as predictors of pulmonary complication risks in mild COPD patients undergoing lung resection.

Methods

From January 2011 to December 2019, 2,798 patients undergoing segmentectomy or lobectomy for non-small cell lung cancer (NSCLC) were evaluated. Focusing on 709 mild COPD patients, excluding no COPD and moderate/severe cases, 3 models incorporating DLCO, predicted postoperative DLCO (ppoDLCO), and DLCO divided by the alveolar volume (DLCO/VA) were created for logistic regression. The Akaike information criterion and Bayes information criterion were analyzed to assess model fit, with lower values considered more consistent with actual data.

Results

Significantly higher proportions of men, current smokers, and patients who underwent an open approach were observed in the PPC group. In multivariable regression, male sex, an open approach, DLCO <80%, ppoDLCO <60%, and DLCO/VA <80% significantly influenced PPC occurrence. The model using DLCO/VA had the best fit.

Conclusion

Different DLCO parameters can predict PPCs in mild COPD patients after lung resection for NSCLC. The assessment of these factors using a multivariable logistic regression model suggested DLCO/VA as the most valuable predictor.

Criteria for continuous neuraxial analgesia associated with reduced mortality in patients undergoing thoracotomy

INTRODUCTION

Both thoracic epidural analgesia and thoracic paravertebral analgesia are effective techniques to control pain and minimize the stress response following thoracic surgery. We hypothesized that continuous neuraxial techniques may be associated with a decrease in the incidence of postoperative mortality after thoracotomy. Additionally, we aimed to identify subgroup populations that may benefit more from neuraxial anesthesia.

METHOD

1620 patients who underwent open thoracotomy were included in this retrospective study from the German Thoracic Registry database at four university hospitals. All-cause inpatient mortality was determined for patients who had and did not have neuraxial anesthesia. Logistic regression was used to adjust for and explore various covariates.

RESULTS

Continuous neuraxial analgesia was associated with a lower overall mortality in the postoperative period (2.9%, 23/796 vs 5.3%, 44/824, p=0.02) only after the univariate analysis but not the multivariable analysis (OR 0.49, 95 % CI 0.237 to 1.12, p=0.15). In patients with epidural or paravertebral catheters, mortality was significantly lower in the following subgroups: age >75 (5/113 vs 18/77, OR 0.1, 95% CI 0.02 to 0.67, p=0.02), American Society of Anesthesiologists Performance Score >III (11//97 vs 33/155, OR 0.32, 95% CI 0.11 to 0.89, p=0.03), chronic kidney disease (5/83 vs 16/77, OR 0.16, 95% CI 0.03 to 0.82, p=0.03), and postoperative sepsis (9/21 vs 17/25, OR 0.13, 95% CI 0.07 to 0.44, p<0.01).

CONCLUSIONS

Neuraxial analgesic techniques are associated with reductions in postoperative mortality after open thoracic surgery in selected patients.

Association between chronic obstructive pulmonary disease and in-hospital mortality after percutaneous coronary intervention: a retrospective cohort study in Germany

Chronic obstructive pulmonary disease (COPD) is one of the leading chronic diseases worldwide. However, the impact of COPD on outcome after percutaneous coronary intervention (PCI) remains unclear. In this retrospective cohort study, we analyzed the data of hospitalized patients undergoing PCI in Germany between 2015 and 2019. We compared in-hospital mortality, hospital length of stay and peri-interventional ventilation time (VT) in patients with and without COPD, including different COPD severity grades, COPD with exacerbation (COPDe) and infection (COPDi). We analyzed the data of 3,464,369 cases undergoing PCI. A total of 291,707 patients (8.4%) suffered from COPD. Patients suffering from COPD died more often (2.4% vs. 2.0%; p < 0.001), stayed longer hospitalized (5 days (2-10) vs. 3 days (1-6); p < 0.001), were more frequent (7.2% vs. 3.2%) and longer ventilated (26 h (7-88) vs. 23 h (5-92); p < 0.001). Surprisingly, COPD was associated with a 0.78-fold odds of in-hospital mortality and with reduced VT (- 1.94 h, 95% CI, - 4.34 to 0.43). Mild to severe COPD was associated with a lower risk of in-hospital mortality and reduced VT, whereas very severe COPD, COPDe and COPDi showed a higher risk of in-hospital mortality. We found a paradoxical association between mild to severe COPD and in-hospital mortality, whereas very severe COPD, COPDe and COPDi were associated with higher in-hospital mortality. Further investigations should illuminate, whether comorbidities affect these associations.

Optimizing lung cancer radiation therapy: A systematic review of multifactorial risk assessment for radiation-induced lung toxicity

BACKGROUND

Radiation therapy (RT) is essential in treating advanced lung cancer, but may lead to radiation pneumonitis (RP). This systematic review investigates the use of pulmonary function tests (PFT) and other parameters to predict and mitigate RP, thereby improving RT planning.

METHODS

A systematic review sifted through PubMed and on BioMed Central, targeting articles from September 2005 to December 2022 containing the keywords: Lung Cancer, Radiotherapy, and pulmonary function test.

RESULTS

From 1153 articles, 80 were included. RP was assessed using CTCAEv.4 in 30 % of these. Six studies evaluated post-RT quality of life in lung cancer patients, reporting no decline. Patients with RP and chronic obstructive pulmonary disease (COPD) generally exhibited poorer overall survival. Notably, forced expiratory volume in one second (FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) declined 24 months post-RT, while forced vital capacity (FVC) stayed stable. In the majority of studies, age over 60, tumors located in the lower part of the lung, and low FEV1 before RT were associated with a higher risk of RP. Dosimetric factors (V5, V20, MLD) and metabolic imaging emerged as significant predictors of RP risk. A clinical checklist blending patient and tumor characteristics, PFT results, and dosimetric criteria was proposed for assessing RP risk before RT.

CONCLUSION

The review reveals the multifactorial nature of RP development following RT in lung cancer. This approach should guide individualized management and calls for a prospective study to validate these findings and enhance RP prevention strategies.

Qualitative assessment of expectations on the content, form and way of delivery of a prehabilitation programme in patients with lung resection surgery - A Swiss tertiary centre experience

Objective

To assess the interest in a prehabilitation programme of patients awaiting lung resection and to identify expectations from such a programme.

Introduction

At present, in Switzerland, there are no multimodal clinical prehabilitation programmes for lung resection patients awaiting surgery.

Methods

Semi-structured face-to-face interviews were conducted with patients who have had or were awaiting lung resection at a Swiss tertiary centre. Thematic analysis was performed to identify common prespecified themes.

Results

Twenty-two patients (45.5% female, age 70.6 ± 16.6 years) were interviewed. Seventy-seven percent were interested in a prehabilitation programme. Sixty-two percent, 67% and 90% were interested in endurance, strength and respiratory training, respectively. Six patients (27%) were active smokers, of whom two (one-third) were interested in a smoking cessation programme. Seventy-six percent were interested in nutrition counselling and 90% in receiving education on risk factor management. Forty percent preferred centre-based training/counselling sessions, 20% preferred home-based training/counselling and 30% found both forms acceptable. Patients were willing to perform prehabilitation activities on 2.6 days/week for a total of 162 min/week. Participating in peer groups was desired by only 25%.

Conclusions

Patients with lung resection were highly interested in participating in prehabilitation, albeit only for a mean time cost of 2.7 h per week. Offering a prehabilitation programme with a combination of in-hospital group sessions and home-based training seems feasible.

Decurarization After Thoracic Anesthesia using sugammadex compared to neostigmine (DATA trial): a multicenter randomized double-blinded controlled trial

BACKGROUND

Thoracic surgery is a high-risk surgery especially for the risk of postoperative pulmonary complications. Postoperative residual paralysis has been shown to be a risk factor for pulmonary complications. Nevertheless, there are few data in the literature concerning the use of neuromuscular blocking agent antagonists in patients undergoing lung surgery.

METHODS

Seventy patients were randomized in three Italian centers to receive sugammadex or neostigmine at the end of thoracic surgery according to the depth of the residual neuromuscular block. The primary outcome was the time from reversal administration to a train-of-four ratio (TOFR) of 0.9. Secondary outcomes were the time to TOFR of 1.0, to extubation, to postanesthesia unit (PACU) discharge, postoperative complications until 30 days after surgery, and length of hospital stay.

RESULTS

Median time to recovery to a TOFR of 0.9 was significantly shorter in the sugammadex group compared to the neostigmine one (88 vs. 278 s - P < 0.001). The percentage of patients who recovered to a TOFR of 0.9 within 5 min from reversal administration was 94.4% and 58.8% in the sugammadex and neostigmine groups, respectively (P < 0.001). The time to extubation, but not the PACU stay time, was significantly shorter in the sugammadex group. No differences were found between the study groups as regards postoperative complications and length of hospital stay. The superiority of sugammadex in shortening the recovery time was confirmed for both deep/moderate and shallow/minimal neuromuscular block.

CONCLUSIONS

Among patients undergoing thoracic surgery, sugammadex ensures a faster recovery from the neuromuscular block and earlier extubation compared to neostigmine.

Thoracic paravertebral block for perioperative lung preservation during VATS pulmonary surgery: study protocol of a randomized clinical trial

BACKGROUND

Postoperative pulmonary complications (PPCs) extend the length of stay of patients and increase the perioperative mortality rate after video-assisted thoracoscopic (VATS) pulmonary surgery. Thoracic paravertebral block (TPVB) provides effective analgesia after VATS surgery; however, little is known about the effect of TPVB on the incidence of PPCs. The aim of this study is to determine whether TPVB combined with GA causes fewer PPCs and provides better perioperative lung protection in patients undergoing VATS pulmonary surgery than simple general anaesthesia.

METHODS

A total of 302 patients undergoing VATS pulmonary surgery will be randomly divided into two groups: the paravertebral block group (PV group) and the control group (C group). Patients in the PV group will receive TPVB: 15 ml of 0.5% ropivacaine will be administered to the T4 and T7 thoracic paravertebral spaces before general anaesthesia induction. Patients in the C group will not undergo the intervention. Both groups of patients will be subjected to a protective ventilation strategy during the operation. Perioperative protective mechanical ventilation and standard fluid management will be applied in both groups. Patient-controlled intravenous analgesia is used for postoperative analgesia. The primary endpoint is a composite outcome of PPCs within 7 days after surgery. Secondary endpoints include blood gas analysis, postoperative lung ultrasound score, NRS score, QoR-15 score, hospitalization-related indicators and long-term prognosis indicators.

DISCUSSION

This study will better evaluate the impact of TPVB on the incidence of PPCs and the long-term prognosis in patients undergoing VATS lobectomy/segmentectomy. The results may provide clinical evidence for optimizing perioperative lung protection strategies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05922449 . Registered on June 25, 2023.

Value of preoperative evaluation of FEV1 in patients with destroyed lung undergoing pneumonectomy - a 20-year real-world study

BACKGROUND

Clinical guidelines recommend a preoperative forced expiratory volume in one second (FEV1) of > 2 L as an indication for left or right pneumonectomy. This study compares the safety and long-term prognosis of pneumonectomy for destroyed lung (DL) patients with FEV1 ≤ 2 L or > 2 L.

METHODS

A total of 123 DL patients who underwent pneumonectomy between November 2002 and February 2023 at the Department of Thoracic Surgery, Beijing Chest Hospital were included. Patients were sorted into two groups: the FEV1 > 2 L group (n = 30) or the FEV1 ≤ 2 L group (n = 96). Clinical characteristics and rates of mortality, complications within 30 days after surgery, long-term mortality, occurrence of residual lung infection/tuberculosis (TB), bronchopleural fistula/empyema, readmission by last follow-up visit, and modified Medical Research Council (mMRC) dyspnea scores were compared between groups.

RESULTS

A total of 96.7% (119/123) of patients were successfully discharged, with 75.6% (93/123) in the FEV1 ≤ 2 L group. As compared to the FEV1 > 2 L group, the FEV1 ≤ 2 L group exhibited significantly lower proportions of males, patients with smoking histories, patients with lung cavities as revealed by chest imaging findings, and patients with lower forced vital capacity as a percentage of predicted values (FVC%pred) (P values of 0.001, 0.027, and 0.023, 0.003, respectively). No significant intergroup differences were observed in rates of mortality within 30 days after surgery, incidence of postoperative complications, long-term mortality, occurrence of residual lung infection/TB, bronchopleural fistula/empyema, mMRC ≥ 1 at the last follow-up visit, and postoperative readmission (P > 0.05).

CONCLUSIONS

As most DL patients planning to undergo left/right pneumonectomy have a preoperative FEV1 ≤ 2 L, the procedure is generally safe with favourable short- and long-term prognoses for these patients. Consequently, the results of this study suggest that DL patient preoperative FEV1 > 2 L should not be utilised as an exclusion criterion for pneumonectomy.

Lung cancer mortality and associated predictors: systematic review using 32 scientific research findings

Background

Cancer is a chronic disease brought on by mutations to the genes that control our cells' functions and become the most common cause of mortality and comorbidities. Thus, this study aimed to assess the comprehensive and common mortality-related risk factors of lung cancer using more than thirty scientific research papers.

Methods

Possible risk factors contributing to lung cancer mortality were assessed across 201 studies sourced from electronic databases, including Google Scholar, Cochrane Library, Web of Science (WOS), EMBASE, Medline/PubMed, the Lung Cancer Open Research Dataset Challenge, and Scopus. Out of these, 32 studies meeting the eligibility criteria for meta-analysis were included. Due to the heterogeneous nature of the studies, a random-effects model was applied to estimate the pooled effects of covariates.

Results

The overall prevalence of mortality rate was 10% with a 95% confidence interval of 6 and 16%. Twenty studies (62.50%) studies included in this study considered the ages of lung cancer patients as the risk factors for mortality. Whereas, eighteen (56.25%) and thirteen (40.63%) studies incorporated the gender and smoking status of patients respectively. The comorbidities of lung cancer mortality such as cardiovascular disease, hypertension, diabetes, and pneumonia were also involved in 7 (21.90%), 6 (18.75%), 5 (15.63%), and 2 (6.25%) studies, respectively. Patients of older age are more likely to die as compared to patients of younger age. Similarly, lung patients who had smoking practice were more likely to die as compared to patients who hadn't practiced smoking.

Conclusion

The mortality rate of lung cancer patients is considerably high. Older age, gender, stage, and comorbidities such as cardiovascular, hypertension, and diabetes have a significant positive effect on lung cancer mortality. The study results will contribute to future research, management, and prevention strategies for lung cancer.

One-Lung Ventilation and Postoperative Pulmonary Complications After Major Lung Resection Surgery. A Multicenter Randomized Controlled Trial

OBJECTIVES

The effect of one-lung ventilation (OLV) strategy based on low tidal volume (TV), application of positive end-expiratory pressure (PEEP), and alveolar recruitment maneuvers (ARM) to reduce postoperative acute respiratory distress syndrome (ARDS) and pulmonary complications (PPCs) compared with higher TV without PEEP and ARM strategy in adult patients undergoing lobectomy or pneumonectomy has not been well established.

DESIGN

Multicenter, randomized, single-blind, controlled trial.

SETTING

Sixteen Italian hospitals.

PARTICIPANTS

A total of 880 patients undergoing elective major lung resection.

INTERVENTIONS

Patients were randomized to receive lower tidal volume (LTV group: 4 mL/kg predicted body weight, PEEP of 5 cmH2O, and ARMs) or higher tidal volume (HTL group: 6 mL/kg predicted body weight, no PEEP, and no ARMs). After OLV, until extubation, both groups were ventilated using a tidal volume of 8 mL/kg and a PEEP value of 5 cmH2O. The primary outcome was the incidence of in-hospital ARDS. Secondary outcomes were the in-hospital rate of PPCs, major cardiovascular events, unplanned intensive care unit (ICU) admission, in-hospital mortality, ICU length of stay, and in-hospital length of stay.

MEASUREMENTS AND MAIN RESULTS

ARDS occurred in 3 of 438 patients (0.7%, 95% CI 0.1-2.0) and in 1 of 442 patients (0.2%, 95% CI 0-1.4) in the LTV and HTV group, respectively (Risk ratio: 3.03 95% CI 0.32-29, p = 0.372). Pulmonary complications occurred in 125 of 438 patients (28.5%, 95% CI 24.5-32.9) and in 136 of 442 patients (30.8%, 95% CI 26.6-35.2) in the LTV and HTV group, respectively (risk ratio: 0.93, 95% CI 0.76-1.14, p = 0.507). The incidence of major complications, in-hospital mortality, and unplanned ICU admission, ICU and in-hospital length of stay were comparable in both groups.

CONCLUSIONS

In conclusion, among adult patients undergoing elective lung resection, an OLV with lower tidal volume, PEEP 5 cmH2O, and ARMs and a higher tidal volume strategy resulted in low ARDS incidence and comparable postoperative complications, in-hospital length of stay, and mortality.

High-Flow Oxygen Therapy in the Perioperative Setting and Procedural Sedation: A Review of Current Evidence

High-flow oxygen therapy (HFOT) is a respiratory support system, through which high flows of humidified and heated gas are delivered to hypoxemic patients. Several mechanisms explain how HFOT improves arterial blood gases and enhances patients' comfort. Some mechanisms are well understood, but others are still unclear and under investigation. HFOT is an interesting oxygen-delivery modality in perioperative medicine that has many clinical applications in the intensive care unit (ICU) and the operating room (OR). The purpose of this article was to review the literature for a comprehensive understanding of HFOT in the perioperative period, as well as its uses in procedural sedation. This review will focus on the HFOT definition, its physiological benefits, and their mechanisms, its clinical uses in anesthesia, and when it is contraindicated.

[Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]

The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.

Intensity of one-lung ventilation and postoperative respiratory failure: A hospital registry study

BACKGROUND

Studies linked a high intensity of mechanical ventilation, measured as high mechanical power (MP) to postoperative respiratory failure (PRF) in the setting of two-lung ventilation. We investigated whether a higher MP during one-lung ventilation (OLV) is associated with PRF.

METHODS

In this registry-based study, adult patients who underwent general anesthesia with OLV for thoracic surgeries between 2006 and 2020 at a New England tertiary healthcare network were included. The association between MP during OLV and PRF (emergency non-invasive ventilation or reintubation within seven days) was assessed in a cohort weighted through a generalized propensity score conditional on a priori defined preoperative and intraoperative factors. Dominance of components of MP and intensity of OLV versus two-lung ventilation in predicting PRF was investigated.

RESULTS

Out of 878 included patients, 106 (12.1%) developed PRF. The median (IQR) MP during OLV was 9.8 J/min (7.5-11.8) and 8.3 J/min (6.6-10.2) in patients with and without PRF respectively. A higher MP during OLV was associated with PRF (ORadj 1.22 per 1 J/min increase; 95%CI 1.13-1.31; p < 0.001) and characterized by a U-shaped dose-response curve, with the lowest probability of PRF (7.5%) at 6.4 J/min. Dominance analysis of PRF predictors showed a stronger contribution of driving pressure over respiratory rate and tidal volume, the dynamic over the static component of MP, and MP during OLV over two-lung ventilation (contribution to Pseudo-R2: 0.017, 0.021, and 0.036, respectively).

CONCLUSION

A higher intensity of OLV, mainly driven by driving pressure, is dose-dependently associated with PRF and might constitute a target for mechanical ventilation.

Hyperoxemia post thoracic surgery - Does it matter?

Introduction

Post-operative oxygen therapy is used to prevent hypoxemia and surgical site infection. However, with improvements of anesthesia techniques, post-operative hypoxemia incidence is declining and the benefits of oxygen on surgical site infection have been questioned. Moreover, hyperoxemia might have adverse effects on the pulmonary and cardiovascular systems. We hypothesized hyperoxemia post thoracic surgery is associated with post-operative pulmonary and cardiovascular complications.

Methods

Consecutive lung resection patients were included in this post-hoc analysis. Post-operative pulmonary and cardiovascular complications were prospectively assessed during the first 30 post-operative days, or hospital stay. Arterial blood gases were analyzed at 1, 6 and 12 h after surgery. Hyperoxemia was defined as arterial partial pressure of oxygen (PaO₂)>100 mmHg. Patients with hyperoxemia duration in at least two adjacent time points were considered as hyperoxemic. Student t-test, Mann-Whitney U test and two-tailed Fisher exact test were used for group comparison. P values < 0.05 were considered statistically significant.

Results

Three hundred sixty-three consecutive patients were included in this post-hoc analysis. Two hundred five patients (57%), were considered hyperoxemic and included in the hyperoxemia group. Patients in the hyperoxemia group had significantly higher PaO₂ at 1, 6 and 12 h after surgery (p < 0.05). Otherwise, there was no significant difference in age, sex, comorbidities, pulmonary function tests parameters, lung surgery procedure, incidence of post-operative pulmonary and cardiovascular complications, intensive care unit and hospital length of stay and 30-day mortality.

Conclusion

Hyperoxemia after lung resection surgery is common and not associated with post-operative complications or 30-day mortality.

A comparative study of four thoracic mortality scores

BACKGROUND

The percentage of patients in resectable stages at initial diagnosis of non-small cell lung cancer (NSCLC) raises due to better screening programs. Therefore, risk prediction models are becoming more critical. Here, we validated and compared four established scoring models, the Thoracoscore, Epithor, Eurloung 2, and the simplified Eurolung 2 (2b), in their ability to predict 30-day mortality.

METHODS

All consecutive patients undergoing anatomical pulmonary resection were included. The performance of the four scoring systems was assessed with Hosmer-Lemeshow goodness-of-fit test (calibration) and receiver operating characteristic (ROC) curves (discrimination). We compared the area under the curve (AUC) of the ROC curves by DeLong's method.

RESULTS

A total of 624 patients underwent surgery for NSCLC at our institution between 2012 and 2018 30-day mortality was 2.2% (14 patients). The AUC for Eurolung 2 and the simplified Eurolung 2 (0.82) were greater than those of the other scoring systems, Epithor (0.71) and Thoracoscore (0.65). In addition, the DeLong analysis showed a significant superiority of Eurolung 2 and Eurolung 2b over the Thoracoscore (p = 0.04); there were no significant differences compared to Epithor.

CONCLUSION

Eurolung 2 and the simplified Eurolung 2 were the favorable scoring systems for predicting 30-day mortality compared to Thoracoscore and Epithor. Therefore, we recommend using Eurolung 2 or the simplified Eurolung 2 for preoperative risk stratification.

Atrial resection for T4 non-small cell lung cancer with left atrium involvement: a systematic review and meta-analysis of survival

PURPOSE

Extended resection for non-small cell lung cancer (NSCLC) with T4 left atrium involvement is controversial. We performed a systematic review and meta-analysis to evaluate the short- and long-term outcomes of this treatment strategy.

METHODS

We searched the PubMed database for studies on atrial resection in NSCLC patients. The primary investigated outcome was the effectiveness of the surgery represented by survival data and the secondary outcomes were postoperative morbidity, mortality, and recurrence.

RESULTS

Our search identified 18 eligible studies including a total of 483 patients. Eleven studies reported median overall survival and 17 studies reported overall survival rates. The estimated pooled 1, 3, 5-year overall survival rates were 69.1% (95% CI 61.7-76.0%), 21.5% (95% CI 12.3-32.3%), and 19.9% (95% CI 13.9-26.6%), respectively. The median overall survival was 24 months (95% CI 17.7-27 months). Most studies reported significant associations between better survival and N0/1 status, complete resection status, and neoadjuvant therapy.

CONCLUSION

Extended lung resection, including the left atrium, for NSCLC is feasible with acceptable morbidity and mortality when complete resection is achieved. Lymph node N0/1 status coupled with the use of neoadjuvant therapies is associated with better outcomes.

Association between driving pressure and postoperative pulmonary complications in patients undergoing lung resection surgery: A randomised clinical trial

BACKGROUND

It is uncertain whether an association exists for decreases in driving pressure and the occurrence of postoperative pulmonary complications (PPCs) in patients undergoing selective lung resection surgery. Thus, we designed this study to determine whether the positive end-expiratory pressure (PEEP) titration to the lowest driving pressure compared with conventional low PEEP level during one-lung ventilation (OLV) in patients undergoing selective lung resection surgery decreases PPCs.

METHODS

This single-centre, randomised trial approved by the Ethical Committee of the Sun Yat-Sen University Cancer Center involved patients who signed written consent. Patients were randomised to the PEEP titration to the lowest driving pressure group (n = 104), or to the conventional low level of PEEP group (n = 103), consisting a PEEP level of 4 cm H₂O during OLV. All patients received volume-controlled ventilation with a tidal volume of 6 mL/kg of predicted body weight. The primary outcome was defined as positive if 4 or more of eight Melbourne Group Scale (MGS) variables developed within the first 3 days after surgery. The incidence of major PPCs occurring during postoperative 7 days was also recorded.

RESULTS

Among 222 patients who were randomised, 207 (93%) completed the trial (109 men [53%]; mean age, 56.9 years). The primary outcome occurred in 4 of 104 patients (4%) in the PEEP titration to the lowest driving pressure group compared with 13 of 103 patients (13%) in the conventional low level of PEEP group (risk ratio, 0.32 [95% CI, 0.10-0.90]; P = 0.021).

CONCLUSIONS

Among patients undergoing selective lung surgery, intraoperative OLV with PEEP titration to the lowest driving pressure compared with conventional low PEEP level (4 cm H₂O) significantly reduced PPCs within the first 3 postoperative days, however, did not significantly reduce PPCs within the first 7 postoperative days.

Impact of pharmacological interventions on intrapulmonary shunt during one-lung ventilation in adult thoracic surgery: a systematic review and component network meta-analysis

BACKGROUND

Intrapulmonary shunt is a major determinant of oxygenation in thoracic surgery under one-lung ventilation. We reviewed the effects of available treatments on shunt, Pao₂/FiO₂ and haemodynamics through systematic review and network meta-analysis.

METHODS

Online databases were searched for RCTs comparing pharmacological interventions and intrapulmonary shunt in thoracic surgery under one-lung ventilation up to March 30, 2022. Random-effects (component) network meta-analysis compared 24 treatments and 19 treatment components. The Confidence in Network Meta-Analysis (CINeMA) framework assessed evidence certainty. The primary outcome was intrapulmonary shunt fraction during one-lung ventilation.

RESULTS

A total of 55 RCTs were eligible for systematic review (2788 participants). The addition of N₂O (mean difference [MD]=-15%; 95% confidence interval [CI], -25 to -5; P=0.003) or almitrine (MD=-13%; 95% CI, -20 to -6; P<0.001) to propofol anaesthesia were efficient at decreasing shunt. Combined epidural anaesthesia (MD=3%; 95% CI, 1-5; P=0.005), sevoflurane (MD=5%; 95% CI, 2-8; P<0.001), isoflurane (MD=6%; 95% CI, 4-9; P<0.001), and desflurane (MD=9%; 95% CI, 4-14; P=0.001) increased shunt vs propofol. Almitrine (MD=147 mm Hg; 95% CI, 58-236; P=0.001), dopexamine (MD=88 mm Hg; 95% CI, 4-171; P=0.039), and iloprost (MD=81 mm Hg; 95% CI, 4-158; P=0.038) improved Pao₂/FiO₂. Certainty of evidence ranged from very low to moderate.

CONCLUSIONS

Adding N₂O or almitrine to propofol anaesthesia reduced intrapulmonary shunt during one-lung ventilation. Halogenated anaesthetics increased shunt in comparison with propofol. The effects of N₂O, iloprost, and dexmedetomidine should be investigated in future research. N₂O results constitute a research hypothesis currently not backed by any direct evidence. The clinical availability of almitrine is limited.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42022310313.

Identifying biomarkers of ventilator induced lung injury during one-lung ventilation surgery: a scoping review

Background

Ventilator-induced lung injury (VILI) can occur as a result of mechanical ventilation to two lungs. Thoracic surgery often requires one-lung ventilation (OLV). The potential for VILI is likely higher in OLV. The impact of OLV on development of post-operative pulmonary complications is not well understood. We aimed to perform a scoping review to determine reliable biomarkers of VILI after OLV.

Methods

A scoping review was performed using Cochrane Collaboration methodology. We searched Medline, EMBASE and SCOPUS. Gray literature was searched. Studies of adult human or animal models without pre-existing lung damage exposed to OLV, with biomarker responses analyzed were included.

Results

After screening 5,613 eligible papers, 89 papers were chosen for full text review, with 29 meeting inclusion. Approximately half (52%, n=15) of studies were conducted in humans in an intra-operative setting. Bronchoalveolar lavage (BAL) & serum analyses with enzyme-linked immunosorbent assay (ELISA)-based assays were most commonly used. The majority of analytes were investigated by a single study. Of the analytes that were investigated by two or more studies (n=31), only 16 were concordant in their findings. Across all sample types and studies 84% (n=66) of the 79 inflammatory markers and 75% (n=6) of the 8 anti-inflammatory markers tested were found to increase. Half (48%) of all studies showed an increase in TNF-α or IL-6.

Conclusions

A scoping review of the state of the evidence demonstrated that candidate biomarkers with the most evidence and greatest reliability are general markers of inflammation, such as IL-6 and TNF-α assessed using ELISA assays. Studies were limited in the number of biomarkers measured concurrently, sample size, and studies using human participants. In conclusion these identified markers can potentially serve as outcome measures for studies on OLV.

Postoperative Patient-Reported Outcomes after Uniportal Video-Assisted Thoracoscopic Surgery Using the Perioperative Symptom Assessment for Lung Surgery Scale

This study aimed to use a new special inventory for lung surgery patients to evaluate postoperative symptoms and functional status and to identify factors that may affect these after uniportal video-assisted thoracoscopic surgery (VATS). In this single-center longitudinal cohort observational study, we used a new scale, the perioperative symptom assessment for lung surgery (PSA-Lung), to evaluate the recovery from symptoms and the functional status of patients undergoing uniportal VATS. We divided patients into two groups, according to patients' symptom scores, and compared the clinical characteristics between the two groups under each item. Then, we conducted a qualitative interview regarding coughing in postoperative week 4. Exactly 104 patients were enrolled in this study. The two highest-scoring patient-reported outcome (PRO) items were "shortness of breath" and "coughing" in the fourth week after surgery. Thirty-one patients reported that "coughing" severely influenced their lives in postoperative week 4. Using the PSA-Lung inventory, we found that "shortness of breath" was the worst symptom in postoperative week 4. Although "coughing" was not the most important symptom in the early postoperative period, it affected some patients' lives in postoperative week 4. Therefore, further research is required to determine the optimal cut-off point for coughing.

Ventilation during Lung Resection and Critical Care: Comparative Clinical Outcomes

Recent evidence suggests that outcomes do not meaningfully differ between thoracic surgery patients who are ventilated with a low or higher tidal volume and the effects of low versus higher positive end-expiratory pressure are unclear.

Identification and Validation of Prognostic Markers for Lung Squamous Cell Carcinoma Associated with Chronic Obstructive Pulmonary Disease

Background

Globally, the incidence and associated mortality of chronic obstructive pulmonary disease (COPD) and lung carcinoma are showing a worsening trend. There is increasing evidence that COPD is an independent risk factor for the occurrence and progression of lung carcinoma. This study aimed to identify and validate the gene signatures associated with COPD, which may serve as potential new biomarkers for the prediction of prognosis in patients with lung carcinoma.

Methods

A total of 111 COPD patient samples and 40 control samples were obtained from the GSE76925 cohort, and a total of 4933 genes were included in the study. The weighted gene coexpression network analysis (WGCNA) was performed to identify the modular genes that were significantly associated with COPD. The KEGG pathway and GO functional enrichment analyses were also performed. The RNAseq and clinicopathological data of 490 lung squamous cell carcinoma patients were obtained from the TCGA database. Further, univariate Cox regression and Lasso analyses were performed to screen for marker genes and construct a survival analysis model. Finally, the Human Protein Atlas (HPA) database was used to assess the gene expression in normal and tumor tissues of the lungs.

Results

A 6-gene signature (DVL1, MRPL4, NRTN, NSUN3, RPH3A, and SNX32) was identified based on the Cox proportional risk analysis to construct the prognostic RiskScore survival model associated with COPD. Kaplan–Meier survival analysis indicated that the model could significantly differentiate between the prognoses of patients with lung carcinoma, wherein higher RiskScore samples were associated with a worse prognosis. Additionally, the model had a good predictive performance and reliability, as indicated by a high AUC, and these were validated in both internal and external sets. The 6-gene signature had a good predictive ability across clinical signs and could be considered an independent factor of prognostic risk. Finally, the protein expressions of the six genes were analyzed based on the HPA database. The expressions of DVL1, MRPL4, and NSUN3 were relatively higher, while that of RPH3A was relatively lower in the tumor tissues. The expression of SNX32 was high in both the tumor and paracarcinoma tissues. Results of the analyses using TCGA and GSE31446 databases were consistent with the expressions reported in the HPA database.

Conclusion

Novel COPD-associated gene markers for lung carcinoma were identified and validated in this study. The genes may be considered potential biomarkers to evaluate the prognostic risk of patients with lung carcinoma. Furthermore, some of these genes may have implications as new therapeutic targets and can be used to guide clinical applications.

Anesthetic Management during Robotic-Assisted Minimal Invasive Thymectomy Using the Da Vinci System: A Single Center Experience

Background: Robotic-assisted surgery is gaining more adaption in different surgical specialties. The number of patients undergoing robotic-assisted thymectomy is continuously increasing. Such procedures are accompanied by new challenges for anesthesiologists. We are presenting our primary anesthesiologic experience in such patients. Methods: This is a retrospective single center study, evaluating 28 patients who presented with thymoma or myasthenia gravis (MG) and undergone minimal invasive robotic-assisted thoracic thymectomy between 01/2020−01/2022. We present our fast-track anesthesia management as a component of the enhanced recovery program and its primary results. Results: Mean patient’s age was 46.8 ± 18.1 years, and the mean height was 173.1 ± 9.3 cm. Two-thirds of patients were female (n = 18, 64.3%). The preoperative mean forced expiratory volume in the first second (FEV1) was 3.8 ± 0.7 L, forced vital capacity (FVC) was 4.7 ± 1.1 L, and the FEV1/FVC ratio was 80.4 ± 5.3%. After the creation of capnomediastinum, central venous pressure and airway pressure have been significantly increased from the baseline values (16.5 ± 4.9 mmHg versus 13.4 ± 5.1 mmHg, p < 0.001 and 23.4 ± 4.4 cmH2O versus 19.3 ± 3.9 cmH2O, p < 0.001, respectively). Most patients (n = 21, 75%) developed transient arrhythmias episodes with hypotension. All patients were extubated at the end of surgery and discharged awake to the recovery room. The first 16 (57.1%) patients were admitted to the intensive care unit and the last 12 patients were only observed in intermediate care. Postoperatively, one patient developed atelectasis and was treated with non-invasive ventilation therapy. Pneumonia or reintubation was not observed. Finally, no significant difference was observed between MG and thymoma patients regarding analgesics consumption or incidence of complications. Conclusions: Robotic-assisted surgery is a rapidly growing technology with increased adoption in different specialties. Fast-track anesthesia is an important factor in an enhanced recovery program and the anesthetist should be familiar with challenges in this kind of operation to achieve optimal results. So far, our anesthetic management of patients undergoing robotic-assisted thymectomy reports safe and feasible procedures.

Assessment of a computed tomography-based radiomics approach for assessing lung function in lung cancer patients

PURPOSE

We aimed to assess radiomics approaches for estimating three pulmonary function test (PFT) results (forced expiratory volume in one second [FEV1], forced vital capacity [FVC], and the ratio of FEV1 to FVC [FEV₁/FVC]) using data extracted from chest computed tomography (CT) images.

METHODS

This retrospective study included 85 lung cancer patients (mean age, 75 years ±8; 69 men) who underwent stereotactic body radiotherapy between 2012 and 2020. Their pretreatment chest breath-hold CT and PFT data before radiotherapy were obtained. A total of 107 radiomics features (Shape: 14, Intensity: 18, Texture: 75) were extracted using two methods: extraction of the lung tissue (<-250 HU) (APPROACH 1), and extraction of small blood vessels and lung tissue (APPROACH 2). The PFT results were estimated using the least absolute shrinkage and selection operator regression. Pearson's correlation coefficients (r) were determined for all PFT results, and the area under the curve (AUC) was calculated for FEV₁/FVC (<70 %). Finally, we compared our approaches with the conventional formula (Conventional).

RESULTS

For the estimated FEV₁/FVC, the Pearson's r were 0.21 (P =.06), 0.69 (P <.01), and 0.73 (P <.01) for Conventional, APPROACH 1, and APPROACH 2, respectively; the AUCs for FEV₁/FVC (<70 %) were 0.67 (95 % confidence interval [CI]: 0.55, 0.79), 0.82 (CI: 0.72, 0.91; P =.047) and 0.86 (CI: 0.78, 0.94; P =.01), respectively.

CONCLUSIONS

The radiomics approach performed better than the conventional equation and may be useful for assessing lung function based on CT images.

Effect of Socio-Economic Status on Perioperative Outcomes After Robotic-Assisted Pulmonary Lobectomy

Background: Lower socioeconomic status (SES) has been correlated with poor survival rates and surgical outcomes following lung cancer resection. This study sought to determine whether this disparity exists perioperatively in lung cancer patients following robotic-assisted video-thoracoscopic pulmonary lobectomy. 

Methods: We retrospectively reviewed 447 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon for known or suspected lung cancer. Ten patients were excluded due to incomplete data. We used median income by residential ZIP code as a surrogate for SES status and grouped patients based on whether ZIP-based median income was less than (Group 1) or greater than (Group 2) 300% of the federal poverty income level. The effects of SES status groups on incidence of postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality were evaluated by the logistic regression model and Inverse Gaussian regression model, respectively.

Results: Without adjustment, Group 1 tended to have a higher rate of postoperative complications, with 54% of patients experiencing complications compared to 34% of patients in Group 2 (p=0.007). Median chest tube duration and hospital LOS were also significantly longer in Group 1 than in Group 2 (p=0.034). In multivariable logistical regression analysis, while controlling for covariates and considering effect modifications, lower SES was significantly and positively associated with postoperative complications (odds ratio (OR)=1.98, p=0.039). Preoperative chronic obstructive pulmonary disease (COPD) was also a positive and significant predictor of postoperative complications (OR=1.89, p=0.017), chest tube duration (p=0.020), and LOS (p=0.010).

Conclusions: Lower median income is associated with a greater number of postoperative complications following pulmonary resection for lung cancer when controlling for covariates.

Predictors of respiratory failure after thoracic surgery: a retrospective cohort study with comparison between lobar and sub-lobar resection

Objective

Only approximately 15% of patients with lung cancer are suitable for surgery and clinical postoperative outcomes vary. The aim of this study was to investigate variables associated with post-surgery respiratory failure in this patient cohort.

Methods

Patients who underwent surgery for lung cancer were retrospectively studied for respiratory function. All patients had undergone lung resection by a mini-thoracotomy approach. The study population was divided into two subgroups for comparison: lobectomy group, who underwent lobar resection; and sub-lobar resection group.

Results

A total of 85 patients were included, with a prevalence of lung cancer stage IA and adenocarcinoma histotype. Lobectomy (versus sub-lobar resection), the presence of chronic obstructive pulmonary disease (COPD), and a COPD assessment test (CAT) score >10, were all associated with an increased risk of respiratory failure. The partial pressure of arterial oxygen decreased more in the lobectomy group than in the sub-lobar resection group following surgery, with a significant postoperative between-group difference in values. Postoperative CAT scores were also better in the sub-lobar resection group.

Conclusions

Post-surgical variations in functional parameters were greater in the group treated by lobectomy. COPD, high CAT score and surgery type were associated with postoperative development of respiratory failure.

General Anesthesia for Patients With Chronic Obstructive Pulmonary Disease and Postoperative Respiratory Failure: A Retrospective Analysis of 120 Patients

Background: Chronic obstructive pulmonary disease (COPD) has been considered a risk factor for postoperative respiratory failure after general anesthesia. However, the association between COPD severity and postoperative respiratory failure among COPD patients is unknown. Our aim was to compare the prevalence of postoperative respiratory failure in COPD patients according to disease severity after general anesthesia.

Methods: We retrospectively reviewed COPD patients undergoing spinal surgery with general anesthesia at our clinical center between January 2016 and January 2021. These subjects were divided into four groups (group I = mild COPD, group II = moderate COPD, group III = severe COPD, and group IV = very severe COPD) according to their preoperative lung function. The primary endpoint was a respiratory failure 1 week after surgery. The diagnosis of respiratory failure was made with the presence of one or more of the following criteria: prolonged ventilator dependence, unplanned postoperative intubation, and partial pressure of arterial oxygen (PaO₂) ≤ 50 mmHg while the patient was breathing ambient air in the hospital. The extubation time, perioperative PaO₂ and partial pressure of arterial carbon dioxide (PaCO₂), postoperative lung infection, and length of hospitalization were also compared.

Results: A total of 120 patients who underwent spinal surgery with general anesthesia were included in this retrospective study. Postoperative respiratory failure occurred in 0 (0.0%) patient in group I, 1 (1.5%) patient in group II, 1 (2.5%) patient in group III, and 1 (14.5%) patient in group IV 1 week after surgery (p = 0.219). The duration of anesthesia was 243.3 ± 104.3 min in group I, 235.5 ± 78.8 min in group II, 196.0 ± 66.3 min in group III, and 173.1 ± 63.7 min in group IV (p < 0.001). Preoperative PaO₂, PaCO₂, intraoperative oxygenation index [a ratio of PaO₂ to fraction of inspired oxygen (FiO₂)], and postoperative PaO₂ were significantly different among the four groups (p < 0.001, 0.001, 0.046, <0.001, respectively). No significant differences among the four groups were seen in extubation time, pulmonary infection, or hospital stay (p = 0.174, 0.843, 0.253, respectively). The univariate analysis revealed that higher preoperative PaO₂ was associated with a lower rate of postoperative respiratory failure (OR 0.83; 95% CI, 0.72 to 0.95; p = 0.007).

Conclusion: The severity of COPD as assessed with GOLD classification was not associated with the development of postoperative respiratory failure. However, lower preoperative PaO₂ was associated with greater odds of postoperative respiratory failure in COPD patients.

Impact of smoking status and chronic obstructive pulmonary disease on pulmonary complications post lung cancer surgery

Introduction

Smoking and chronic obstructive pulmonary disease (COPD) are associated with an increased risk of post-operative pulmonary complications (PPCs) following lung cancer resection. It remains unclear whether smoking cessation reduces this risk.

Methods

Retrospective review of a large, prospectively collected database of over 1000 consecutive resections for lung cancer in a quaternary lung cancer centre over a 23-year period.

Results

One thousand and thirteen patients underwent curative-intent lobectomy or pneumonectomy between 1995 and 2018. Three hundred and sixty-two patients (36%) were ex-smokers, 314 (31%) were current smokers and 111 (11%) were never smokers. A pre-operative diagnosis of COPD was present in 57% of current smokers, 57% of ex-smokers and 20% of never smokers. Just over 25% of patients experienced a PPC. PPCs were more frequent in current smokers compared to never smokers (27% vs 17%, p = 0.036), however, no difference was seen between current and ex-smokers (p = 0.412) or between never and ex-smokers (p = 0.113). Those with a diagnosis of COPD, independent of smoking status, had a higher frequency of both PPCs (65% vs 35%, p<0.01) and overall complications (60% vs 40%, p<0.01) as well as a longer length of hospital stay (10 vs 9 days, p<0.01).

Conclusion

Smoking and COPD are both associated with a higher rate of PPCs post lung cancer resection. COPD, independent of smoking status, is also associated with an increased overall post-operative complication rate and length of hospital stay. An emphasis on COPD treatment optimisation, rather than smoking cessation in isolation, may help improve post-operative outcomes.

Effect of Pulmonary Rehabilitation on Postoperative Clinical Status in Patients with Lung Cancer and Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Pulmonary rehabilitation (PR) has a curative effect in patients undergoing pneumonectomy for lung cancer. Nevertheless, the contribution of PR to the clinical status of patients with chronic obstructive pulmonary disease (COPD) undergoing lung resection has not been adequately elucidated. The aim of this systematic review of randomized and nonrandomized controlled trials was to appraise the impact of PR compared to conventional treatment based on postoperative clinical status in patients with lung cancer and COPD. Literature in English from PubMed, Cochrane Library, Science Citation Index, and Embase databases and in Chinese from the Chinese National Knowledge Infrastructure and the WANFANG Database was retrieved from inception to November 2021, employing the keywords "Pulmonary Neoplasms," "Chronic Obstructive Pulmonary Diseases," "Physical Therapy Modalities," and "pulmonary rehabilitation." Only studies that reported PR results were included. This review was registered in the International Prospective Register of Systematic Reviews (number: CRD42021224343). A total of nine controlled trials with 651 patients were included. Postoperative pulmonary complications (PPCs) were the primary outcome measure. PR decreased the risk of complications after surgery compared to regular treatment (odds ratio (OR) 0.21, 95% confidence interval (CI) 0.12-0.37, P < 0.01). PR reduced the risk of pneumonia after surgery compared to regular treatment (OR 0.36, 95% CI 0.15-0.86, P=0.02). There was a significant difference in the postoperative length of stay (mean difference -2.13 days, 95% CI -2.65 to -1.61 days, P < 0.05). PR was an effective intervention that decreased PPCs in patients suffering from lung cancer and COPD. However, due to the limitations of the available data, the results should be interpreted with caution.

Olmesartan Attenuates Single-Lung Ventilation Induced Lung Injury via Regulating Pulmonary Microbiota

Single-lung ventilation (SLV) associated acute lung injury is similar to ischemia reperfusion (IR) injury which is usually occurred during lung surgery. Olmesartan (Olm), a novel angiotensin receptor blocker (ARB), has been reported to ameliorate organ IR injury. Several recent studies have shown that lung microbiota may be involved in pulmonary diseases, but the effect of pulmonary microbiota in SLV-induced lung injury has not been reported. This study aims to determine the mechanism of how Olm attenuates SLV induced lung injury. Our data showed that 7 days Olm treatment before modeling markedly alleviated SLV-induced lung injury by suppressing inflammation and reactive oxygen species. Bronchoalveolar lavage fluid samples from the injured side were collected for 16S rRNA gene-based sequencing analysis and 53 different bacteria at the genus and species levels were identified. Furthermore, the injured lung samples were collected for metabolomics analysis using liquid chromatography-mass spectrometry analyses to explore differential metabolites. The Kyoto Encyclopedia of Genes and Genomes (KEGG) was applied to analyze the correlation between differential metabolites and lung microbiota. A total of 38 pathways were identified according to differential metabolites and 275 relevant pathways were enriched via analyzing the microbial community, 24 pathways were both identified by analyzing either metabolites or microbiota, including pyrimidine metabolism, purine metabolism, aminoacyl-tRNA biosynthesis and ATP-binding cassette transporter. Besides classical blockage of the renin-angiotensin II system, Olm could also alleviate SLV-induced lung injury by rewiring the interaction between pulmonary microbiota and metabolites.

Evaluating the impact of personalized rehabilitation nursing intervention on postoperative recovery of respiratory function among thoracic surgery patients: A protocol for systematic review and meta-analysis

BACKGROUND

Owing to clinical developments and economic strain, perioperative care has undergone considerable changes. Therefore, it is important to review and critique the efficacy of existing practices in a context that is placing increasing emphasis on better efficacy and cost-containment. Considering that the objective involves devising approaches to minimize postoperative complications and reduce medical care, efforts should concentrate on postsurgical pulmonary complications that are common. The present analysis aims to examine how customized rehabilitation nursing intercession impacts the postsurgical restoration of respiratory functions in thoracic surgery patients.

METHODS

Prespecified search strategies will be employed to perform a methodological search of 6 databases namely EMBASE, Cochrane Library, PubMed, Web of Science, WanFang Database, and China National Knowledge Infrastructure. The analysis will comprise original publications that evaluated how personalized rehabilitation nursing intervention impacts postsurgical restoration of respiratory function in those who have undergone thoracic surgery. All considered publications are before December 25, 2021. Different authors will conduct an independent study selection process to evaluate the quality of the publications and extract required data. Based on the standardized mean difference and its 95% confidence interval, we estimate the summary effects for each meta-analyses. Based on heterogeneity in considered articles, the related data will be pooled through either a random- or fixed-effect meta-analysis. Lastly, the overall quality of evidence using appropriate methods will be performed.

RESULTS

The results of this analysis will systematically evaluate how customized rehabilitation nursing interference impact postsurgical healing of respiratory functions in patients who have undergone thoracic surgery by collecting the existing evidence.

ETHICS AND DISSEMINATION

Not required.

OPEN SCIENCE FRAMEWORK REGISTRATION NUMBER

10.17605/OSF.IO/NBVYW.

Functional analysis of the airways after pulmonary lobectomy through computational fluid dynamics

Pulmonary lobectomy, which consists of the partial or complete resection of a lung lobe, is the gold standard intervention for lung cancer removal. The removal of functional tissue during the surgery and the re-adaptation of the remaining thoracic structures decrease the patient's post-operative pulmonary function. Residual functionality is evaluated through pulmonary function tests, which account for the number of resected segments without considering local structural alterations and provide an average at-the-mouth estimation. Computational Fluid Dynamics (CFD) has been demonstrated to provide patient-specific, quantitative, and local information about airways airflow dynamics. A CFD investigation was performed on image-based airway trees reconstructed before and after the surgery for twelve patients who underwent lobectomy at different lobes. The geometrical alterations and the variations in fluid dynamics parameters and in lobar ventilation between the pre and post-operative conditions were evaluated. The post-operative function was estimated and compared with current clinical algorithms and with actual clinical data. The post-operative configuration revealed a high intersubject variability: regardless of the lobectomy site, an increment of global velocity, wall pressure, and wall shear stress was observed. Local flow disturbances also emerged at, and downstream of, the resection site. The analysis of lobar ventilation showed severe variations in the volume flow rate distribution, highlighting the compensatory effects in the contralateral lung with an increment of inflow. The estimation of post-operative function through CFD was comparable with the current clinical algorithm and the actual spirometric measurements. The results confirmed that CFD could provide additional information to support the current clinical approaches both in the operability assessment and in the prescription of personalized respiratory rehabilitation.

Effect of pressure controlled volume guaranteed ventilation during pulmonary resection in children

The purpose of the study was to evaluate the effect of pressure controlled volume guaranteed ventilation in children requiring one lung ventilation during pulmonary resection. Patients were randomly assigned to the lung protective ventilation combined with pressure controlled volume guaranteed group (PCV-VG group) or the lung protective ventilation combined with volume controlled ventilation group (VCV group). Both groups received tidal-volume ventilation of 8 ml kg⁻¹ body weight during two lung ventilation and 6 ml kg⁻¹ during OLV, with sustained 5 cmH₂O positive end-expiratory pressure. Data collections were mainly performed at 10 min after induction of anaesthesia during TLV (T1), 5 min after OLV initiation (T2) and 5 min after complete CO2 insufflations (T3). In total, 63 patients were randomly assigned to the VCV (n = 31) and PCV-VG (n = 32) groups. The PCV-VG group exhibited lower PIP than the VCV group at T1 (16.8 ± 2.3 vs. 18.7 ± 2.7 cmH₂O, P = 0.001), T2 (20.2 ± 2.7 vs. 22.4 ± 3.3 cmH₂O, P = 0.001), and T3 (23.8 ± 3.2 vs. 26.36 ± 3.7 cmH₂O, P = 0.01). Static compliance was higher in the PCV-VG group at T1, T2, and T3 (P = 0.01). After anaesthesia induction, lung aeration deteriorated, but with no immediate postoperative difference in both groups. Postoperative lung aeration improved and returned to normal from 2.5 h postextubation in both groups. PH was lower and PaCO₂ was higher in VCV group than PCV-VG group during one lung ventilation. No differences were observed in PaO₂-FiO₂-ratio at T2 and T3, the incidence of postoperative pulmonary complications, intraoperative desaturation and the length of hospital stay. In paediatric patients, who underwent pulmonary resection requiring one lung ventilation, PCV-VG was superior to VCV in its ability to provide lower PIP, higher static compliance and lower PaCO₂ at one lung ventilation during pneumothorax. However, its beneficial effects on different pathological situations in pediatric patients need more investigation.

[Correlation Analysis of the Lung Volume Reduction and the Lung Function Loss after the Thoracoscopic Lobectomy]

BACKGROUND

To investigate the correlation between the reduction of lung volume and the degree of lung function damage after lobectomy.

METHODS

A total of 131 patients (72 males and 59 females) who underwent thoracoscopic lobectomy in the First Affiliated Hospital of Suzhou University from January 2019 to July 2020 (including thoracoscopic resection of left upper lobe, left lower lobe, right upper lobe, right middle lobe and right lower lobe). In order to compare the difference between postoperative pulmonary function and preoperative pulmonary function, the pulmonary function measurements were recorded at 7 days before operation, and 3 months, 6 months and 1 year after operation. Forced expiratory volume in 1 second (FEV1) was used as the main evaluation parameter of pulmonary function. The original lung volume and the remaining lung volume at each stage were calculated by Mimics Research 19.0 software. The correlation between lung volume and lung function was analyzed.

RESULTS

FEV1 in postoperative patients was lower than that before operation, and the degree of decline was positively correlated with the resection volume of lung lobes (the maximum value was shown in the left lower lobe group). Significantly, there was no significant difference in the degree of pulmonary function reduction between 3 months, 6 months and 1 year after operation.

CONCLUSIONS

The decrease of lung tissue volume after lobectomy is the main reason for the decrease of lung function, especially in the left lower lobe. And 3 months after lobectomy can be selected as the evaluation node of residual lung function.

Preoperative Physical Inactivity Affects the Postoperative Course of Surgical Patients with Lung Cancer

OBJECTIVE

Preoperative performance status is an important factor in thoracic surgery, but little is known about the effect of preoperative physical activity (PA) on the postoperative course. This study investigated the associations between preoperative PA and postoperative complications and clinical outcomes of lung cancer surgery.

METHODS

This prospective observational study included patients who underwent surgery for lung cancer at a single institution. PA was measured before hospitalization for 5 consecutive days and then after surgery until hospital discharge. The daily step count and time spent performing moderate intensity activity (> 3 metabolic equivalents) were measured with an accelerometer. We examined the correlations between PA and preoperative pulmonary function and physical fitness, and examined the relationship between postoperative complication and PA. Finally, a multivariate analysis was performed with pre-hospital PA as the dependent variable.

RESULTS

Forty-two patients were analyzed. Univariate analysis found no correlation between pre-hospital PA and preoperative pulmonary function, but found significant positive correlations between pre-hospital PA and time spent performing moderate intensity activity, in-hospital PA, preoperative 6-minute walk distance, and maximum gait speed (r > 0.5, p < 0.01). The nine patients who developed postoperative complications had significantly lower pre-hospital and postoperative step count than the patients with no complication (p = 0.04). Multiple regression analysis showed that pre-hospital PA was significantly associated with time spent performing moderate intensity activity, maximum gait speed, and postoperative complication.

CONCLUSIONS

Evaluation of pre-hospital PA is useful in predicting the postoperative course after lung cancer surgery.

[The role of the intensive care unit after thoracic surgery]

Lung (bronchial) cancer is the leading cause of cancer-related death in Western countries today. Thoracic surgery represents a major therapeutic strategy and the various advances made in recent years have made it possible to develop less and less invasive techniques. That said, the postoperative period may be lengthy, post-surgical approaches need to be more precisely codified, and it matters that the different interventions involved be supported by sound scientific evidence. To date, however, there exists no evidence that preventive postoperative admission to intensive care is beneficial for patients having undergone lung resection surgery without immediate complications. A stratification of the risk of complications taking into consideration the patient's general state of health (e.g., nutritional status, degree of autonomy, etc.), comorbidities and type of surgery could be a useful predictive tool regarding the need for postoperative intensive care. However, serious post-operative complications remain relatively frequent and post-operative management of these intensive care patients is liable to become complex and long-lasting. In the aftermath of the validation of "enhanced recovery after surgery" (ERAS) in thoracic surgery, new protocols are needed to optimize management of patients having undergone pulmonary resection. This article focuses on the main postoperative complications and more broadly on intensive care patient management following thoracic surgery.

Effect of ulinastatin on the inflammatory response after video-assisted thoracic lobectomy in patients with lung cancer: a randomized controlled study

Background:

The first-line treatment for lung cancer is surgical resection, and one-lung ventilation (OLV) is the most basic anesthetic management method in lung surgery. During OLV, inflammatory cytokines are released in response to the lung tissue damage and promote local and contralateral lung damage through the systemic circulation. We designed a randomized, prospective study to evaluate the effect of the urinary trypsin inhibitor (UTI) ulinastatin on the inflammatory response after video-assisted thoracic lobectomy in patients with lung cancer.

Methods:

Adult patients aged 19 to 70 years, who were scheduled for video-assisted thoracic lobectomy surgery to treat lung cancer between May 2020 and August 2020, were enrolled in this randomized, prospective study. UTI (300,000 units) mixed with 100 mL of normal saline in the ulinastatin group and 100 mL of normal saline in the control group was administered over 1 h after inducing anesthesia.

Results:

The baseline (T0) interferon-γ (IFN-γ)/interleukin-4 (IL-4) ratio was not different between the groups (6941.3 ± 2778.7 vs. 6954.3 ± 2752.4 pg/mL, respectively; P > 0.05). The IFN-γ/IL-4 ratio was significantly higher in ulinastatin group at 30 min after entering the recovery room than control group (20,148.2 ± 5054.3 vs. 6674.0 ± 2963.6, respectively; adjusted P < 0.017).

Conclusion:

Administering UTI attenuated the anti-inflammatory response, in terms of INF-γ expression and the IFN-γ/IL-4 ratio, after video-assisted thoracic surgery in lung cancer patients.

Trial registration:

Clinical Research Information Service of Korea National Institute of Health (CRIS), KCT0005533.