The current status of postoperative complications and risk factors after a pulmonary resection for primary lung cancer. A multivariate analysis

Perioperative outcomes of uniportal versus three-port video-assisted thoracoscopic surgery in lung cancer patients aged ≥ 75 years old: a cohort study

BACKGROUND

Increasing attention has been raised on the surgical option for lung cancer patients aged ≥75 years, however, few studies have focused on whether uniportal video-assisted thoracoscopic surgery (VATS) is safe and feasible for these patients. This study aimed to evaluate short-term results of uniportal versus three-port VATS for the treatment of lung cancer patients aged ≥75 years.

METHODS

We retrospectively evaluated 582 lung cancer patients (≥75 years) who underwent uniportal or three-port VATS from August 2007 to August 2021 based on the Western China Lung Cancer Database. The baseline and perioperative outcomes between uniportal and three-port VATS were compared in the whole cohort (WC) and the patients undergoing lobectomy (lobectomy cohort, LC) respectively. Propensity score matching (PSM) was used to minimize confounding bias between the uniportal and three-port cohorts in WC and LC.

RESULTS

Intraoperative blood loss was significantly less in the uniportal than three-port LC (50 mL vs. 83 mL, P = 0.007) before PSM and relatively less in the uniportal than three-port LC (50 mL vs. 83 mL, P = 0.05) after PSM. Significantly more lymph nodes harvested (13 vs. 9, P = 0.007) were found in the uniportal than three-port LC after PSM. In addition, in WC and LC, there were no significant differences between uniportal and three-port cohorts in terms of operation time, the rate of conversion to thoracotomy during surgery, nodal treatments (dissection or sampling or not), the overall number of lymph node stations dissected, postoperative complications, volume and duration of postoperative thoracic drainage, hospital stay after operation and hospitalization expenses before and after PSM (P > 0.05).

CONCLUSIONS

There were no significant differences in short-term outcomes between uniportal and three-port VATS for lung cancer patients (≥75 years), except relatively less intraoperative blood loss (P < 0.05 before PSM and P = 0.05 after PSM) and significantly more lymph nodes harvested (P < 0.05 after PSM) were found in uniportal LC. It is reasonable to indicate that uniportal VATS is a safe, feasible and effective operation procedure for lung cancer patients aged ≥75 years.

A prospective observational study of postoperative adjuvant chemotherapy for non-small cell lung cancer in elderly patients (≥ 75 years)

BACKGROUND

To examine the effects of postoperative adjuvant chemotherapy for elderly (≥ 75 years of age) patients with completely resected non-small cell lung cancer (NSCLC), we conducted a multi-institutional and prospective observational study.

METHODS

Patients were recruited between January 2014 and December 2017, and assigned to two cohort groups based on the patients' choice either to receive postoperative adjuvant chemotherapy (Cohort B) or not (Cohort A). All the patients were observed for 2 years after enrollment. The primary endpoint was the postoperative change of Karnofsky Performance Status (KPS) at 2 years. The secondary endpoints were postoperative recurrence-free survival (RFS) and overall survival (OS) at 2 years, and the completion rate of the adjuvant chemotherapy.

RESULTS

Two hundred and seventy-two patients were enrolled (Cohort A, n = 225; Cohort B, n = 47). At any time point after surgery, no marked difference of KPS was observed between Cohort B and Cohort A. The RFS at 2 years was 70.8% (95% confidence interval [CI], 64.3-76.4) in Cohort A and 76.0% (95% CI 60.8-85.9) in Cohort B. The OS at 2 years was 85.9% (95% CI 80.4-89.9) in Cohort A and 89.1% (95% CI 75.8-95.3) in Cohort B. The completion rate of planned chemotherapy was 49.9% (95% CI 34.1-63.9%).

CONCLUSIONS

The elderly patients were not likely to choose to receive postoperative adjuvant chemotherapy; however, no significant adverse effect on postoperative KPS was identified.

TRIAL REGISTRATION

Clinical Trial Registration ID: UMIN000020736.

Is there an ideal position and size of chest drain following anatomical lung resection?

BACKGROUND

Chest drains are placed after surgery to enable lung re-expansion. However, there remains little guidance on optimal placement. This study aims to identify the ideal size and position for chest drain insertion with regards to post-operative outcomes.

METHODS

383 patients undergoing lobectomy in 1-year had their chest drain size and x-ray position noted (1 (apical), 2 (mid-zone) or 3 (basal)). Primary outcome was residual air space on immediate post-operative x-ray. Secondary outcomes were length of drain in situ (<72 versus ≥72 h), persisting pleural effusion, surgical emphysema, post-operative pneumonia (POP), and length of hospital stay (<5 versus ≥5 days). Fisher's exact analysis for the primary outcome and binary logistic regression analysis for all outcomes were used. Results presented as odds ratios (OR±95%CI).

RESULTS

Univariate analysis for residual air space showed increased risk in area 2 (OR = 1.61, p = 0.041) and 3 (OR = 2.59, p = 0.0043) compared with area 1. Multivariate analysis for residual air space showed increased risk in area 2 (OR = 2.39, p < 0.001) and 3 (OR = 2.86, p < 0.001) compared with area 1. Drain size had no impact on residual air space in univariate or multivariate analysis. Multivariate analysis showed area 2 drains remained in situ for >72 h (OR = 1.49, p = 0.017), had persisting effusions (OR = 2.03, p = 0.004) and POP (OR = 2.10, p = 0.023) compared with area 1. This risk is magnified further for drains in area 3. Drains ≥28F had reduced risk of surgical emphysema (OR = 0.23, p = 0.027) in multivariate analysis.

CONCLUSION

A ≥28F, apical chest drain reduces the risk of post-operative complications, allowing early removal and discharge.

Impact of Sarcopenia on Early Postoperative Complications in Early-Stage Non-Small-Cell Lung Cancer

Background

Risk assessment for pulmonary resection in patients with early-stage non–small-cell lung cancer (NSCLC) is important for minimizing postoperative morbidity. Depletion of skeletal muscle mass is closely associated with impaired nutritional status and limited physical ability. We evaluated the relationship between skeletal muscle depletion and early postoperative complications in patients with early-stage NSCLC.

Methods

Patients who underwent curative lung resection between 2016 and 2018 and who were diagnosed with pathological stage I/II NSCLC were included, and their records were retrospectively analyzed. The psoas volume index (PVI, cm³/m³) was calculated based on computed tomography images from routine preoperative positron emission tomography-computed tomography. Early postoperative complications, defined as those occurring within 90 days of surgery, were compared between the lowest sex-specific quartile for PVI and the remaining quartiles.

Results

A strong correlation was found between the volume and the cross-sectional area of the psoas muscle (R²=0.816). The overall rate of complications was 57.6% among patients with a low PVI and 32.8% among those with a normal-to-high PVI. The most common complication was prolonged air leak (low PVI, 16.9%; normal-to-high PVI, 9.6%), followed by pneumonia (low PVI, 13.6%; normal-to-high PVI, 7.9%) and recurrent pleural effusion (low PVI, 11.9%; normal-to-high PVI, 6.8%). The predictors of overall complications were low PVI (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.07–4.09; p=0.03), low hemoglobin level (OR, 0.686; 95% CI, 0.54–0.87; p=0.002), and smoking history (OR, 3.93; 95% CI, 2.03–7.58; p<0.001).

Conclusion

Low PVI was associated with a higher rate of early postoperative complications in patients with early-stage NSCLC.

Postoperative Cardiac Ischemic Complications in Lung Cancer Patients

Background. Perioperative myocardial ischemia often complicates extracardiac surgery. The problems of its prediction, diagnostics, treatment and prevention are not solved. Frequency, structure and clinical features of cardiac ischemic complications of surgical treatment of lung cancer are not well understood.The aim of the study was to investigate the frequency of postoperative myocardial infarction and myocardial ischemia in the surgical treatment of patients with non-small cell lung cancer.Methods. The frequency (%) of myocardial infarction (MI) with and without ST segment elevation of electrocardiogram, acute myocardial ischemia in a complete sample of cancer patients (n = 2051) who underwent treatment for non-small cell lung cancer for the last 10 years was calculated. By comparing the relative indicators and calculating the Odds Ratio (OR), we studied the relationship between the cardiac ischemic events with age, type of surgery, prevalence and localization of the tumour. The clinical manifestations and pathomorphology of postoperative myocardial infarction were analysed.Results. Cardiac ischemic complications of thoracotomy for lung cancer occurred in 2.73 % (95% CI 1.98–3.48) cases. Myocardial infarction with ST segment elevation was recorded in 1.07 % (95% CI 0.58–1.57) patients, MI without ST segment elevation – in 0.54 % (95% CI 0.17–0.9), myocardial ischemia – in 1.12 % (95% CI 0.62–1.63). An increase in the frequency of ischemic events after pneumonectomy was observed compared with lobectomy (OR 6.5, 95% CI 3.5–12.2) and after right-sided pneumonectomy compared with left-sided one (OR 3.2, 95% CI 1.6–6.3), and also the age over 70. Hospital mortality from MI was 39.3 %. According to autopsies of patients who died of МI, coronary atherothrombosis was detected in 2 of 22 cases.Conclusion. In the surgical treatment of non-small cell lung cancer, cardiac ischemic events develop in 2.73 % of patients. The greatest risk is associated with right-sided pneumonectomy.

Lung Cancer Stage is an Independent Risk Factor for Surgical Mortality

Aims and Background

To study surgical mortality and evaluate major risk factors, with specific focus on the role of pathological stage in patients undergoing lung cancer resection.

Methods and Study Design

Age, gender, comorbidity, resection volume, experience of the hospital and surgical team have been reported as variables related to postoperative morbidity and mortality in lung cancer. The role of pathological tumor stage on postoperative mortality has never been fully evaluated. The study included 1418 consecutive lung cancer resections performed from 1998 to 2002 in two institutions. The effect of age, gender, comorbidity, resection volume, pathological stage and induction therapies on postoperative mortality was assessed by univariable and multivariable logistic regression analysis.

Results

Postoperative mortality was 1.8% overall, 3.7% (9/243) for pneumonectomy, 1.7% (17/1016) for lobectomy, and null (0/159) for sublobar resections (P = 0.020). At multivariable analysis, cardiovascular comorbidity (P = 0.008), resection volume (P = 0.036) and pathological stage (P = 0.027) emerged as significant predictors of surgical mortality.

Conclusions

Early stage lung cancer resection has a favorable effect on surgical mortality, not only by preventing the need for pneumonectomy, but also by reducing mortality after lobectomy.

Incidence and risk factors of postoperative pneumonia following cancer surgery in adult patients with selected solid cancer: results of "Cancer POP" study

The aim of this study was to investigate the incidence and risk factors of postoperative pneumonia (POP) within 1 year after cancer surgery in patients with the five most common cancers (gastric, colorectal, lung, breast cancer, and hepatocellular carcinoma [HCC]) in South Korea. This was a multicenter and retrospective cohort study performed at five nationwide cancer centers. The number of cancer patients in each center was allocated by the proportion of cancer surgery. Adult patients were randomly selected according to the allocated number, among those who underwent cancer surgery from January to December 2014 within 6 months after diagnosis of cancer. One‐year cumulative incidence of POP was estimated using Kaplan–Meier analysis. An univariable Cox's proportional hazard regression analysis was performed to identify risk factors for POP development. As a multivariable analysis, confounders were adjusted using multiple Cox's PH regression model. Among the total 2000 patients, the numbers of patients with gastric cancer, colorectal cancer, lung cancer, breast cancer, and HCC were 497 (25%), 525 (26%), 277 (14%), 552 (28%), and 149 (7%), respectively. Overall, the 1‐year cumulative incidence of POP was 2.0% (95% CI, 1.4–2.6). The 1‐year cumulative incidences in each cancer were as follows: lung 8.0%, gastric 1.8%, colorectal 1.0%, HCC 0.7%, and breast 0.4%. In multivariable analysis, older age, higher Charlson comorbidity index (CCI) score, ulcer disease, history of pneumonia, and smoking were related with POP development. In conclusions, the 1‐year cumulative incidence of POP in the five most common cancers was 2%. Older age, higher CCI scores, smoker, ulcer disease, and previous pneumonia history increased the risk of POP development in cancer patients.

A Prospective Observational Study of Pulmonary Resection for Non-small Cell Lung Cancer in Patients Older Than 75 Years

The operative morbidity rate in elderly patients with lung cancer is high in comparison to nonelderly patients, probably because of the increase in comorbidities that occurs with aging. However, previous reports were retrospective and were performed at single institutions; thus, the preoperative comorbidities and operative morbidity could not be fully assessed. We conducted a multi-institutional prospective observational study of elderly patients (>75 years of age) with a completely resected non-small cell lung cancer. From March 2014 to April 2015, 264 patients from 22 hospitals affiliated with the National Hospital Organization in Japan were prospectively registered in the present study. The primary end point was operative morbidity (National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0). The secondary end points were operative mortality and the risk factors for operative morbidity. Preoperative comorbidities were assessed according to the Adult Comorbidity Evaluation-27 index. The mean age at the time of surgery was 79.3 years (range 75-90 years). Forty-one percent of the patients were >80 years of age. Twenty-six percent underwent sublobar resection. The incidence of morbidities of any grade was 43.2% (90% confidence interval: 38.2%-48.2%). Respiratory system-related morbidity (19.3%), followed by cardiovascular system-related morbidity (10.2%), was the most common morbidity. The in-hospital mortality rate was 1.1% (3 of 264 patients). A multivariate analysis of the risk factors for operative morbidity showed that both Adult Comorbidity Evaluation-27 grade and the blood loss volume were significant factors. The results of the present prospective multi-institutional study should be used as a reference in the surgical treatment of elderly patients with lung cancer.

The impact of overdiagnosis on the selection of efficient lung cancer screening strategies

The U.S. Preventive Services Task Force (USPSTF) recently updated their national lung screening guidelines and recommended low-dose computed tomography (LDCT) for lung cancer (LC) screening through age 80. However, the risk of overdiagnosis among older populations is a concern. Using four comparative models from the Cancer Intervention and Surveillance Modeling Network, we evaluate the overdiagnosis of the screening program recommended by USPSTF in the U.S. 1950 birth cohort. We estimate the number of LC deaths averted by screening (D) per overdiagnosed case (O), yielding the ratio D/O, to quantify the trade-off between the harms and benefits of LDCT. We analyze 576 hypothetical screening strategies that vary by age, smoking, and screening frequency and evaluate efficient screening strategies that maximize the D/O ratio and other metrics including D and life-years gained (LYG) per overdiagnosed case. The estimated D/O ratio for the USPSTF screening program is 2.85 (model range: 1.5-4.5) in the 1950 birth cohort, implying LDCT can prevent ∼3 LC deaths per overdiagnosed case. This D/O ratio increases by 22% when the program stops screening at an earlier age 75 instead of 80. Efficiency frontier analysis shows that while the most efficient screening strategies that maximize the mortality reduction (D) irrespective of overdiagnosis screen through age 80, screening strategies that stop at age 75 versus 80 produce greater efficiency in increasing life-years gained per overdiagnosed case. Given the risk of overdiagnosis with LC screening, the stopping age of screening merits further consideration when balancing benefits and harms.

Identifying patients at higher risk of pneumonia after lung resection

BACKGROUND

Pneumonia is considered as one of the most common and serious complications after lung resection. The purpose of this study was to identify the risk factors associated with postoperative pneumonia (POP) after lung resection and to develop a scoring system to stratify patients with increased risk of POP.

METHODS

A retrospective review of a prospective database of patients between September 2014 and June 2016 was carried out. Logistic regression analysis was used to examine the risk factors for POP. Bootstrap resampling analysis was used for internal validation. Regression coefficients were used to develop weighted risk scores for POP.

RESULTS

Results revealed that age ≥64 years, smoking (current or previous), high pathological stage, and extent of excision of more than one lobe as risk factors. Logistic regression analysis showed that the predictors of POP were as follows: age ≥64 years, smoking, extent of excision of more than one lobe. A weighted score based on these factors was developed which was follows: smoking (three points), age ≥64 years (four points), and extent of excision of more than one lobe (five points). POP score >5 points offered the best combination of sensitivity (64.7%) and specificity (83.3%), and an area under receiver operating characteristic (ROC) curve (AUC) of 0.830 [95% confidence interval (CI): 0.746-0.914].

CONCLUSIONS

Patients with older age, smoking and extent of excision of more than one lobe have a higher risk for pneumonia after lung cancer surgery. Also, the scoring system helps to guide decision making of POP risk reduction.

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis

BACKGROUND

Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients.

METHODS

Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three- and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses.

RESULTS

The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68-5.95] (first meta-analysis) and 5.26% (95% CI: 3.47-7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P<0.001) thirty-day postoperative mortality, respectively (first meta-analysis). The pooled percentages for postoperative complications were 34.32% (95% CI: 24.59-44.75) (first meta-analysis) and 45.59% (95% CI: 35.62-55.74) (second meta-analysis). Higher percentages of squamous histology (P=0.001), lobectomy (P=0.002) and p-T1 or p-T2 (P=0.034) were associated with higher proportions of postoperative complications (second meta-analysis). The pooled three- and five- year survival probabilities were 68.25% (95% CI: 45.93-86.86) and 52.03% (95% CI: 34.71-69.11), respectively. Higher mean age (P=0.046) and percentage lobectomy (P=0.009) significantly reduced the five-year survival probability.

CONCLUSIONS

Lobectomy and age were both accompanied by reduced five-year survival rate. Also, combined aorto-coronary bypass grafting (CABG) with lobectomy for squamous pT1 or pT2 LC displayed a higher risk of postoperative complications. Moreover, medical decision between combined or staged surgery is suggested to be individualized based on adequacy of coronary arterial perfusion, age, patient's preoperative performance status (taking into account possible co-morbidities per patient), tumor's staging and extent of lung resection.

A retrospective comparative analysis of elderly and younger patients undergoing pulmonary resection for stage I non-small cell lung cancer

Background

Age has been a critical predictor for immediate postoperative and long-term results after the pulmonary resection for lung cancer. In this study, we evaluated and compared surgical outcome of stage I non-small cell lung cancer and associated predictive factors between elderly and younger groups.

Methods

Short- and long-term outcomes of elderly group (≥70 years) who were surgically treated and pathologically diagnosed as stage I non-small cell lung cancer from 2004 to 2010 were compared to the results of younger group (<70 years).

Results

Total of 1340 patients were included in this study, and the patients were divided into the elderly group (n = 285) and the younger group (n = 1055). The proportions of squamous cell carcinoma (36.8 vs. 20.0 %, p < 0.001) and stage IB cancer (58.3 vs. 40.6 %, p < 0.001) were significantly higher in the elderly group than the younger group. The 30-day and 90-day mortalities were significantly higher in the elderly group (1.8 vs. 0%; p = 0.014, 3.9 vs. 0.5 %; p < 0.001, respectively). The elderly patients also had significantly worse long-term outcomes than the younger group (5-year overall survival rate, 69.0 vs. 91.1 %; p < 0.001, 5-year disease-free survival rate, 53.3 vs. 80.2 %; p < 0.001). Decreased diffusion capacity less than 70 % was an important predictive factor for short- and long-term outcomes in both the younger and the elderly group.

Conclusions

Elderly patients with low diffusion capacity are at risk for significantly worse outcome, indicating that patient selection should include assessment of pulmonary function, including diffusion capacity.

Impact of Pulmonary Function Measurements on Long-Term Survival After Lobectomy for Stage I Non-Small Cell Lung Cancer

BACKGROUND

Pulmonary function tests predict respiratory complications after lobectomy. We evaluated the impact of pulmonary function measurements on long-term survival after lobectomy for stage I non-small cell lung cancer.

METHODS

The relationship between percent predicted forced expiratory volume in 1 second (FEV1) and percent predicted diffusing capacity of the lung for carbon monoxide (Dlco) and overall survival for patients who underwent lobectomy without induction therapy for stage I (T1-2N0M0) non-small cell lung cancer from 1996 to 2012 was evaluated using the Kaplan-Meier approach and a multivariable Cox proportional hazard model.

RESULTS

During the study period, 972 patients (mean Dlco 76 ± 21, mean FEV1 73 ± 21) met inclusion criteria. Perioperative mortality was 2.6% (n = 25). The 5-year survival of the entire cohort was 60.1%, with a median follow-up of 43 months. The 5-year survival for patients with percent predicted FEV1 stratified by more than 80%, 61% to 80%, 41% to 60%, and 40% or less was 70.1%, 59.3%, 52.5%, and 53.4%, respectively. The 5-year survival for patients with percent predicted Dlco stratified by more than 80%, 61% to 80%, 41% to 60%, and 40% or less was 70.2%, 63.4%, 44.2%, and 33.1%, respectively. In multivariable survival analysis, both larger tumor size (hazard ratio 1.15, p = 0.01) and lower Dlco (hazard ratio 0.986, p < 0.0001) were significant predictors of worse survival. The association of FEV1 and survival was not statistically significant (p = 0.18).

CONCLUSIONS

Survival after lobectomy for patients with stage I non-small cell lung cancer is impacted by lower Dlco, which can be used in the risk and benefit assessment when choosing therapy.

Clinical outcomes and changes in lung function after segmentectomy versus lobectomy for lung cancer cases

OBJECTIVE

We compared the clinical outcomes and changes in pulmonary function test (PFT) results after segmentectomy or lobectomy for non-small cell lung cancer.

METHODS

The retrospective study included 212 patients who had undergone segmentectomy (group S) and 2336 patients who had undergone lobectomy (group L) from 1997 to 2012. The follow-up and medical record data were collected. We used all the longitudinal PFT data within 24 months postoperatively and performed linear mixed modeling. We analyzed the 5-year overall and disease-free survival in stage IA patients. We used propensity score case matching to minimize the bias due to imbalanced group comparisons.

RESULTS

During the perioperative period, 1 death (0.4%) in group S and 7 (0.3%) in group L occurred. The hospital stay for the 2 groups was similar (median, 5.0 vs 5.0 days; range, 2-99 vs 2-58). The mean overall and disease-free survival period of those with T1a after segmentectomy or lobectomy seemed to be similar (4.2 vs 4.5 years, P=.06; and 4.1 vs 4.4 years, P=.07, respectively). Compared with segmentectomy, lobectomy yielded marginally significantly better overall (4.4 vs 3.9 years, P=.05) and disease-free (4.1 vs 3.6 years; P=.05) survival in those with T1b. We did not find a significantly different effect on the PFTs after segmentectomy or lobectomy.

CONCLUSIONS

Both surgical types were safe. We would advocate lobectomy for patients with stage IA disease, especially those with T1b. A retrospective study with a large sample size and more detailed information should be conducted for PFT evaluation, with additional stratification by lobe and laterality.

Resection rate and outcome of pulmonary resections for non-small-cell lung cancer: a nationwide study from Iceland

BACKGROUND

The proportion of patients with non-small-cell lung cancer (NSCLC) who undergo surgery with curative intent is one measure of effectiveness in treating lung cancer. To the best of our knowledge, surgical resection rate (SRR) for a whole nation has never been reported before. We studied the SRR and surgical outcome of NSCLC patients in Iceland during a recent 15-year period.

METHODS

This was a retrospective study of all pulmonary resections performed with curative intent for NSCLC in Iceland from 1994 to 2008. Information was retrieved from medical records and from the Icelandic Cancer Registry. Patient demographics, postoperative tumor, node, metastasis stage, overall survival, and complication rates were compared over three 5-year periods.

RESULTS

Of 1530 confirmed cases of NSCLC, 404 were resected, giving an SRR of 26.4%, which did not change significantly during the study period. Minor and major complication rates were 37.4% and 8.7%, respectively. Operative mortality rates were 0.7% for lobectomy, 3.3% for pneumonectomy, and 0% for lesser resection. Five-year survival after all procedures was 40.7% and improved from the first to the last 5-year period (34.8% versus 43.8%, p = 0.04). Five-year survival for stages I and II together was 46.8%, with no significant change in stage distribution between periods. Five-year survival after pneumonectomy was 22.0%, which was significantly lower than for lobectomy (44.6%) and lesser resection (40.7%) (p < 0.005). Unoperated patients had a 5-year survival of 4.8%, as compared to 12.4% for all the NSCLC patients together.

CONCLUSION

Compared with most other published studies, the SRR of NSCLC in Iceland is high. Short-term outcome is good, with a low rate of major complications and an operative mortality of only 1.0%. Five-year survival improved significantly over the study period.

Pre- and post-operative cardiac evaluation of dogs undergoing lobectomy and pneumonectomy

This study aimed to assess the influence of lobectomy and pneumonectomy on cardiac rhythm and on the dimensions and function of the right-side of the heart. Twelve dogs undergoing lobectomy and eight dogs undergoing pneumonectomy were evaluated preoperatively and one month postoperatively with electrocardiography and Doppler echocardiography at rest. Pulmonary artery systolic pressure (PASP) was estimated by the tricuspid regurgitation jet (TRJ) via the pulse wave Doppler velocity method. Systemic inflammatory response syndrome criteria (SIRS) were also evaluated based on the clinical and hematological findings in response to lobectomy and pneumonectomy. Following lobectomy and pneumonectomy, we predominantly detected atrial fibrillation and varying degrees of atrioventricular block (AVB). Dogs that died within seven days of the lobectomy (n = 2) or pneumonectomy (n = 1) had complete AVB. Preoperative right atrial, right ventricular, and pulmonary artery dimensions increased gradually during the 30 days (p<0.05) following pneumonectomy, but did not undergo significant changes during that same period after lobectomy. Mean PASP was 56.0 ± 4.5 mmHg in dogs having significant TRJ after pneumonectomy. Pneumonectomy, but not lobectomy, could lead to increases (p<0.01) in the SIRS score within the first day post-surgery. In brief, it is important to conduct pre- and postoperative cardiac evaluation of dogs undergoing lung resections because cardiac problems are a common postoperative complication after such surgeries. In particular, complete AVB should be considered a life-threatening complication after pneumonectomy and lobectomy. In addition, pneumonectomy appears to increase the likelihood of pulmonary hypertension development in dogs.

[Prevention and treatment of atelectasis after thoracotomy for lung cancer]

背景与目的

肺不张是开胸术后的常见并发症，严重时会危及患者生命。本文旨在分析和探讨肺癌患者行开胸术后发生肺不张的原因和围手术期的预防和处理措施，以便降低肺不张的发生率，并提高其治愈率，以进一步降低围手术期死亡率。

方法

回顾性统计和分析我科因肺癌行开胸手术的374例患者中发生肺不张的资料和处理措施。

结果

374例肺癌患者行开胸手术后发生肺不张的有14例，经积极有效地治疗后肺不张的肺叶均复张。

结论

肺癌开胸术后肺不张发生率不高，有效的术前准备、良好的围术期处理和术后治疗可以降低开胸术后肺不张的发生率，提高治愈率。

Pulmonary function tests do not predict pulmonary complications after thoracoscopic lobectomy

BACKGROUND

Pulmonary function tests predict respiratory complications and mortality after lung resection through thoracotomy. We sought to determine the impact of pulmonary function tests upon complications after thoracoscopic lobectomy.

METHODS

A model for morbidity, including published preoperative risk factors and surgical approach, was developed by multivariable logistic regression. All patients who underwent lobectomy for primary lung cancer between December 1999 and October 2007 with preoperative forced expiratory volume in 1 second (FEV1) or diffusion capacity to carbon monoxide (Dlco) 60% or less predicted were reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics. Pulmonary complications were defined as atelectasis requiring bronchoscopy, pneumonia, reintubation, and tracheostomy.

RESULTS

During the study period, 340 patients (median age 67) with Dlco or FEV1 60% or less (mean % predicted FEV1, 55+/-1; mean % predicted Dlco, 61+/-1) underwent lobectomy (173 thoracoscopy, 167 thoracotomy). Operative mortality was 5% (17 patients) and overall morbidity was 48% (164 patients). At least one pulmonary complication occurred in 57 patients (17%). Significant predictors of pulmonary complications by multivariable analysis for all patients included Dlco (odds ratio 1.03, p=0.003), FEV1 (odds ratio 1.04, p=0.003), and thoracotomy as surgical approach (odds ratio 3.46, p=0.0007). When patients were analyzed according to operative approach, Dlco and FEV1 remained significant predictors of pulmonary morbidity for patients undergoing thoracotomy but not thoracoscopy.

CONCLUSIONS

In patients with impaired pulmonary function, preoperative pulmonary function tests are predictors of pulmonary complications when lobectomy for lung cancer is performed through thoracotomy but not through thoracoscopy.

Noninvasive ventilation for acute respiratory failure after lung resection: an observational study

BACKGROUND

A single prospective randomized study found that, in selected patients with acute respiratory failure (ARF) following lung resection, noninvasive ventilation (NIV) decreases the need for endotracheal mechanical ventilation and improves clinical outcome.

METHOD

We prospectively evaluated early NIV use for ARF after lung resection during a 4-year period in the setting of a medical and a surgical ICU of a university hospital. We documented demographics, initial clinical characteristics and clinical outcomes. NIV failure was defined as the need for tracheal intubation.

RESULTS

Among 690 patients at risk of severe complications following lung resection, 113 (16.3%) experienced ARF, which was initially supported by NIV in 89 (78.7%), including 59 with hypoxemic ARF (66.3%) and 30 with hypercapnic ARF (33.7%). The overall success rate of NIV was 85.3% (76/89). In-ICU mortality was 6.7% (6/89). The mortality rate following NIV failure was 46.1%. Predictive factors of NIV failure in univariate analysis were age (P = 0.046), previous cardiac comorbidities (P = 0.0075), postoperative pneumonia (P = 0.0016), admission in the surgical ICU (P = 0.034), no initial response to NIV (P < 0.0001) and occurrence of noninfectious complications (P = 0.037). Only two independent factors were significantly associated with NIV failure in multivariate analysis: cardiac comorbidities (odds ratio, 11.5; 95% confidence interval, 1.9-68.3; P = 0.007) and no initial response to NIV (odds ratio, 117.6; 95% confidence interval, 10.6-1305.8; P = 0.0001).

CONCLUSION

This prospective survey confirms the feasibility and efficacy of NIV in ARF following lung resection.

Obesity Does Not Increase Complications After Anatomic Resection for Non-Small Cell Lung Cancer

BACKGROUND

The effect of obesity on complications after resection for lung cancer is unknown. We hypothesized that obesity is associated with increased complications after anatomic resections for non-small cell lung cancer.

METHODS

A review of our prospective general thoracic database identified 499 consecutive anatomic resections for non-small cell lung cancer from November 2002 to May 2006. Body mass index (BMI) was used to group patients as nonobese (BMI > 18.5 to < 30) and obese (BMI > or = 30). Patient characteristics and oncologic and operative variables were compared between groups. Multivariable logistic regression models were fit with BMI included at every level. Outcomes examined included in-hospital morbidity, mortality, length of stay, and readmission.

RESULTS

Seventy-five percent (372 of 499) were nonobese, and 25% (127 of 499) were obese. Preoperative variables were similar, except for a greater incidence of diabetes mellitus (p < 0.0001) in the obese group. Overall mortality was 1.4% (7 of 499) and was not different between groups (p = 0.85). Thirty-day readmission rates (p = 0.76) and length of stay (p = 0.30) were similar. Obese patients had a higher incidence of acute renal failure (p = 0.001). A complication occurred in 33% (124 of 372) of nonobese and 31% (39 of 127) of obese patients (p = 0.59). Respiratory complications occurred in 22% (81 of 372) of nonobese and 14% (18 of 127) of obese patients (p = 0.06). Significant predictors of any complication include performance status, diffusing capacity, and tumor stage. Significant predictors of respiratory complications include performance status, diffusing capacity, chronic renal insufficiency, prior thoracic surgery, and chest wall resection.

CONCLUSIONS

In contrast to our hypothesis, obesity does not increase the incidence of perioperative complications, mortality, or length of stay after anatomic resection for non-small cell lung cancer.

Influence of preoperative exercise capacity on length of stay after thoracic cancer surgery

BACKGROUND

Stress testing is frequently used to assess cardiac risk before thoracic surgery. However, the relationship between treadmill exercise capacity and length of stay (LOS) has not been investigated. We hypothesized that exercise capacity, a strong predictor of long-term prognosis, can also predict LOS after thoracic cancer surgery.

METHODS

Accordingly, 191 consecutive patients who had exercise stress testing before major thoracic cancer surgery were retrospectively grouped by poor (<4 metabolic equivalents [METs], n = 31), fair (4 to 7 METs, n = 107), good (7 to 10 METs, n = 30), and excellent (>10 METs, n = 23) exercise capacity. The relationship between exercise capacity and LOS was then determined.

RESULTS

Average LOS was inversely related to exercise capacity, with a nearly twofold increase in LOS between the excellent and poor exercise groups (4.8 versus 9.2 days). This relationship remained significant even after controlling for operation type, history of dyspnea, sex, and smoking history in analysis of covariance. Prolonged hospital stay (10 days or more) was strongly predicted by exercise capacity. Failure to exceed 4 METs was associated with a high risk of prolonged stay (9 of 31, 39%), whereas none of the 23 patients who exceeded 10 METs had a prolonged stay.

CONCLUSIONS

Treadmill exercise capacity has independent predictive value for LOS and risk of prolonged stay after thoracic cancer surgery. These findings have important implications for risk assessment and cost, suggesting that preoperative programs designed to improve exercise capacity may favorably influence LOS and associated costs.

Nutritional status affects long term survival after lobectomy for lung cancer

STUDY OBJECTIVES

Nutritional status has been reported as a predictor of complications following surgery for lung cancer. However, the impact of impaired nutrition in the long term has not been extensively studied. We have analysed our own experience after lobectomy for non-small cell lung cancer (NSCLC).

PATIENTS

Six hundred and forty-two consecutive patients undergoing lobectomy for primary lung cancer in a single centre between October 1991 and April 2004 were included in the study.

STUDY DESIGN

Impaired nutritional status was defined as any of low pre-operative albumin level (less than 30g/L), recent history of weight loss or low body mass index (BMI)--less than 18.5kg/m(2). There were 400 males and 242 females, median age 66 (range 32-89 years). Outcomes studied were hospital mortality and complications, and long term survival.

RESULTS

A high proportion of patients (185 of 642, 28%) were classed as having poor nutritional status. There were 12 hospital deaths (1.9%). Nutritional depletion had no significant impact on hospital mortality (1.3% versus 2.7%), cardiac (14.4% versus 16.8%), or respiratory (17.5% versus 18.9%) complications. The overall median survival was 48+/-6 months (standard error). On Cox multivariate analysis, impaired nutritional status, tumour stage and need for en bloc chest wall excision were all independent predictors of survival.

CONCLUSIONS

Nutritional status does not appear to significantly influence immediate outcomes following lobectomy for lung cancer. However, it is a predictor of survival in the long term independently of tumour extension and staging.

[Risk factors in bronchogenic carcinoma surgery]

OBJECTIVE

To analyze the factors that determine the risk of morbidity and mortality associated with lung resection in patients with bronchogenic carcinoma.

PATIENTS AND METHODS

Prospective multicenter study conducted between October 1, 1993 and September 30, 1997 in the 19 hospitals that make up the Bronchogenic Carcinoma Cooperative Group. During the study period, 2994 patients with bronchogenic carcinoma underwent surgery. The morbidity and mortality data at 30 days from all centers were recorded in a single registry.

RESULTS

Major resection was performed in 2491 patients, whereas 212 underwent minor resection. The resection had to be extended in 296 and exploratory thoracotomy was carried out in 291. Postoperative complications were reported in 1057 patients (35.2%). Complications directly related to surgery were the most common (22.9%), followed by respiratory (19.5%) and cardiovascular (10.7%) complications. Of the patients with complications, 654 patients (21.8%) had only 1, whereas 403 (13.4%) had more than 1. After classification of complications, 21% were found to be minor and 14.2% were major. Mortality at 30 days was 6.8% (204 patients), and strongly linked to the presentation of major complications--40.8% of those with such complications died.

CONCLUSIONS

Surgical treatment of bronchogenic carcinoma in Spain is associated with high morbidity and mortality. The morbidity reported in the present study lies in the middle of the ranges found in the literature, whereas mortality lies at the high end of the range. The presence of major complications and/or multiple complications should be considered as strong risk factors.

Genetics of postoperative complications following thoracic surgery

The field of complex trait-gene interaction research has expanded exponentially in recent years, and new insights into the ways patients respond to surgical stimuli have arisen from this body of work. From a physiological systems perspective, thoracic surgical procedures (thoracotomy in particular) represent a massive input stimulus, and it is, therefore, not surprising that approximately 30% of these patients experience an adverse postoperative event. The best risk prediction models have typically explained about 60% to 70% of the risk, leaving a large residual component unaccounted for. It is quite possible that there is a genetic (heritable) component to this residual risk. This article explores some of the concepts underlying gene-disease interactions, the preliminary work that has been done to date in this area, and finally discusses some of the more important methodological issues involved in complex trait association study design.

Detected troponin elevation is associated with high early mortality after lung resection for cancer

Background

Myocardial infarction can be difficult to diagnose after lung surgery. As recent diagnostic criteria emphasize serum cardiac markers (in particular serum troponin) we set out to evaluate its clinical utility and to establish the long term prognostic impact of detected abnormal postoperative troponin levels after lung resection.

Methods

We studied a historic cohort of patients with primary lung cancer who underwent intended surgical resection. Patients were grouped according to known postoperative troponin status and survival calculated by Kaplan Meier method and compared using log rank. Parametric survival analysis was used to ascertain independent predictors of mortality.

Results

From 2001 to 2004, a total of 207 patients underwent lung resection for primary lung cancer of which 14 (7%) were identified with elevated serum troponin levels within 30 days of surgery, with 9 (64%) having classical features of myocardial infarction.

The median time to follow up (interquartile range) was 22 (1 to 52) months, and the one and five year survival probabilities (95% CI) for patients without and with postoperative troponin elevation were 92% (85 to 96) versus 60% (31 to 80) and 61% (51 to 71) versus 18% (3 to 43) respectively (p < 0.001).

T stage and postoperative troponin elevation remained independent predictors of mortality in the final multivariable model. The acceleration factor for death of elevated serum troponin after adjusting for tumour stage was 9.19 (95% CI 3.75 to 22.54).

Conclusion

Patients with detected serum troponin elevation are at high risk of early mortality with or without symptoms of myocardial infarction after lung resection.

Prospective Study of Infection Risk Factors in 988 Lung Resections

PURPOSE

To evaluate the incidence of surgical site infections (SSI), as related to risk factors, in patients undergoing lung resections (LR).

METHODS

We evaluated 988 consecutive patients prospectively who underwent LR between 1996 and 2005 at the Center for Thoracic Surgery of the University of Insubria, Varese, Italy. Patients were divided into four groups: Pneumonectomy (n=104), lobectomy/bi-lobectomy (n=438), wedge resection by thoracotomy (n=155), and wedge resection by video-thoracoscopy (VATS) (n=291). The recorded risk factors for SSI were hemoglobin concentration, serum albumin concentration, lymphocyte count, percentage of predicted forced expiratory volume in 1 sec (FEV1), duration of surgery, blood transfusion, age>70 years, and comorbidity. The postoperative SSIs (superficial and deep incisional SSI, pneumonia, empyema) were recorded in they occurred within 30 days, and the final outcome was recorded.

RESULTS

Postoperative infections were found in 141 patients (14.3%) and included 166 thoracic infections, among them 32 incisional SSIs (3.2%), 103 cases of pneumonia (10.4%); and 24 empyemas (2.4%). The overall incidence of SSI was significantly lower in patients having wedge resections by VATS (5.5%) than in the other three groups (17.9%) (p<0.001). The overall mortality rate was 1.2% (12/988), of which six deaths (0.6%) were caused by complications of infection. The infection rate correlated with duration of surgery>180 min, age>70 years, serum albumin<3.5 g/dL, and the presence of any comorbidity. Moreover, 18% of patients with FEV1>70% had postoperative pneumonia, a significant increase (p<0.01) compared with patients with FEV1>or=70%.

CONCLUSIONS

In this prospective study, the SSI rate after LR was 14.3%, and the 30-day operative mortality rate was 1.2%, with most of the deaths caused by pneumonia. After VATS LR procedures, the incidence of SSI was lower at 5.5%. Finally, SSI correlated with the duration of surgery, serum albumin, concurrent comorbidity, age, and FEV1.

Postoperative Pneumonia after Major Lung Resection

BACKGROUND

Postoperative pneumonia (POP) is a life-threatening complication of lung resection. The incidence, causative bacteria, predisposing factors, and outcome are poorly understood.

DESIGN

Prospective observational study.

METHODS

A prospective study of all patients undergoing major lung resections for noninfectious disease was performed over a 6-mo period. Culture of intraoperative bronchial aspirates was systematically performed. All patients with suspicion of pneumonia underwent bronchoscopic sampling and culture before antibiotherapy.

RESULTS

One hundred and sixty-eight patients were included in the study. Bronchial colonization was identified in 31 of 136 patients (22.8%) on analysis of intraoperative samples. The incidence of POP was 25% (42 of 168). Microbiologically documented and nondocumented pneumonias were recorded in 24 and 18 cases, respectively. Haemophilus species, Streptococcus species, and, to a much lesser extent, Pseudomonas and Serratia species were the most frequently identified pathogens. Among colonized and noncolonized patients, POP occurred in 15 of 31 and 20 of 105 cases, respectively (p = 0.0010; relative risk, 2.54). Death occurred in 8 of 42 patients who developed POP and in 3 of 126 of patients who did not (p = 0.0012). Patients with POP required noninvasive ventilation or reintubation more frequently than patients who did not develop POP (p < 0.0000001 and p = 0.00075, respectively). POP was associated with longer intensive care unit and hospital stay (p < 0.0000001 and p = 0.0000005, respectively). Multivariate analysis showed that chronic obstructive pulmonary disease, extent of resection, presence of intraoperative bronchial colonization, and male sex were independent risk factors for POP.

CONCLUSIONS

Pneumonia acquired in-hospital represents a relatively frequent complication of lung resections, associated with an important percentage of postoperative morbidity and mortality.

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

BACKGROUND

Smoking is a common risk factor for chronic obstructive pulmonary disease (COPD), cardiovascular disease, and lung cancer. In this observational study, we examined the impact of COPD severity and time-related changes in early outcome after lung cancer resection.

METHODS

Over a 15-year period, we analyzed an institutional registry including all consecutive patients undergoing surgery for lung cancer. Using the receiver-operating characteristic (ROC) curve, we analyzed the relationship between forced expiratory volume in 1 second (FEV1) and postoperative mortality and respiratory morbidity. Multiple regression analysis has also been applied to identify other risk factors.

RESULTS

A preoperative FEV1 less than 60% was a strong predictor for respiratory complications (odds ratio [OR] = 2.7, confidence interval [CI]: 1.3 to 6.6) and 30-day mortality (OR = 1.9, CI: 1.2 to 3.9), whereas thoracic epidural analgesia was associated with lower mortality (OR = 0.4; CI: 0.2 to 0.8) and respiratory complications (OR = 0.6; CI: 0.3 to 0.9). Mortality was also related to age greater than 70 years, the presence of at least three cardiovascular risk factors, and pneumonectomy. From the period 1990 to 1994, to 2000 to 2004, we observed significant reductions in perioperative mortality (3.7% versus 2.4%) and in the incidence of respiratory complications (18.7% versus 15.2%), that was associated with a higher rate of lesser resection (from 11% to 17%, p < 0.05) and increasing use of thoracic epidural analgesia (from 65% to 88%, p < 0.05).

CONCLUSIONS

Preoperative FEV1 less than 60% is a main predictor of perioperative mortality and respiratory morbidity. Over the last 5-year period, diagnosis of earlier pathologic cancer stages resulting in lesser pulmonary resection as well as provision of continuous thoracic epidural analgesia have contributed to improved surgical outcome.

Prognostic factors in non-small cell lung cancer surgery

AIMS

Complete surgical resection of primary tumours remains the treatment with the greatest likelihood for survival in early-stage non-small cell lung cancer (NSCLC). Although TNM stage is the most important prognostic parameter in NSCLC, additional parameters are required to explain the large variability in postoperative outcome. The present review aims at providing an overview of the currently known prognostic markers for postoperative outcome.

METHODS

We performed an electronic literature search on the MEDLINE database to identify relevant studies describing the risk factors in NSCLC surgery. The references reported in all the identified studies were used for completion of the literature search.

RESULTS

Poor pulmonary function, cardiovascular disease, male gender, advanced age, TNM stage, non-squamous cell histology, pneumonectomy, low hospital volume and little experience of the surgeon were identified as risk factors for postoperative outcome. However, with the exception of TNM stage and extent of resection, the literature demonstrates conflicting results on the prognostic power of most factors. The role of molecular biological factors, neoadjuvant treatment and adjuvant treatment is not well investigated yet.

CONCLUSIONS

The advantage of knowing about the existence of comorbidity and prognostic risk factors may provide the clinician with the ability to identify poor prognostic patients and establish the most appropriate treatment strategy. The assessment of prognostic factors remains an area of active investigation and a promising field of research in optimising therapy of NSCLC patients.

Bronchial colonization and postoperative respiratory infections in patients undergoing lung cancer surgery

STUDY OBJECTIVES

To evaluate the risk factors associated with postoperative respiratory infection in patients undergoing lung cancer surgery, with special emphasis on the perioperative pattern of airway colonization.

DESIGN

Prospective cohort study.

SETTING

Department of Pneumology and Thoracic Surgery of a tertiary hospital.

PATIENTS

Seventy-eight consecutive patients undergoing lung cancer surgery were evaluated. Patients were followed up until hospital discharge or death.

INTERVENTIONS

Fiberoptic bronchoscopies with bilateral protected specimen brush or bronchial aspirates were performed during anesthesia prior to the initiation of the surgical procedure.

RESULTS

Sixty-five patients (83%) had perioperative bronchial colonization by either potentially pathogenic microorganisms (PPMs) [28 patients, 36%] or non-potentially pathogenic microorganisms (56 patients, 72%). The 24 patients (31%) with a postoperative respiratory infection (pneumonia, purulent tracheobronchitis, or pleural empyema) had significantly higher perioperative bronchial colonization by PPMs (15 patients [63%] vs 13 patients [24%], p = 0.003) and a higher bacterial index (mean +/- SD, 3.6 +/- 3.3 vs 0.9 +/- 1.4; p = 0.003), compared to patients without infection. The agreement between pathogens found in perioperative evaluation and during postoperative infection was total in 5 patients (21%), partial in 5 patients (21%), and no concordance in 14 patients (58%). In the multivariate analysis, the presence of perioperative airway colonization by a PPM (odds ratio [OR], 6.9; p = 0.001) and a higher postoperative pain score (OR, 4.1; p = 0.014) were independent predictors of postoperative respiratory infection.

CONCLUSION

Adequate control of postoperative pain, as well as the conditions that potentially cause airway colonization by PPMs, could be beneficial in preventing postoperative respiratory infections after lung cancer surgery.

Surgical management of lung cancer in Western Australia in 1996 and its outcomes

BACKGROUND

All cases of lung cancer diagnosed in Western Australia in 1996 in which surgery was the primary treatment, were reviewed. Reported herein are the characteristics of the patients, the treatment outcomes and a comparison of the management undertaken with that recommended by international guidelines.

METHODS

All patients with a new diagnosis of lung cancer in Western Australia in the calendar year of 1996 were identified using two different population-based registration systems: the Western Australian (WA) Cancer Registry and the WA Hospital Morbidity Data System. A structured questionnaire on the diagnosis and management was completed for each case. Date of death was determined through the WA Cancer Registry.

RESULTS

Six hundred and sixty-eight patients with lung cancer were identified; 132 (20%) were treated with surgery. Lobectomy was the most frequently performed procedure (71%), followed by pneumonectomy (19%). Major complications affected 23% of patients. Postoperative mortality was 6% (3% lobectomy, 12% pneumonectomy). At 5 years the absolute survival was as follows for stage I, II, IIIA, IIIB, respectively: 51%, 45%, 12%, 5%.

CONCLUSIONS

Investigations and choice of surgery in WA in 1996 reflect current international guidelines. The survival of patients with resectable lung cancer remains unsatisfactory.

Non-small cell lung cancer: evaluation of pleural abnormalities on CT scans with 18F FDG PET

PURPOSE

To evaluate the accuracy of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) in differentiation of pleural malignancy and cancer-unrelated pleural disease in patients with non-small cell lung cancer (NSCLC) and pleural abnormalities at computed tomography (CT).

MATERIALS AND METHODS

In 92 patients, pleural abnormalities were detected at contrast material-enhanced thoracic CT, which was performed for newly diagnosed NSCLC (n = 41) or restaging (n = 51). CT findings were negative for pleural malignancy when pleural effusion with attenuation of 10 HU or less and/or rib fractures with no evidence of pathologic fracture were present; findings were indeterminate when pleural effusion with attenuation greater than 10 HU and/or solid pleural abnormalities without osseous destruction of the chest wall were present; and findings were positive if any osseous destruction of the chest wall adjacent to a pleural mass was present. All patients underwent FDG PET. Findings were negative for pleural malignancy if pleural activity was absent, equal to, or less than mediastinal background activity; findings were positive if pleural activity was higher than mediastinal background activity. Reading of CT and FDG PET scans was first performed separately and then was combined. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPP), and accuracy were calculated for CT and FDG PET separately and for CT and FDG PET combined, with cytologic and/or histologic analysis as standard of reference.

RESULTS

In detection of pleural malignancies, CT findings were indeterminate in 65 (71%) patients and true-negative in 27 (29%). Respective sensitivity, specificity, PPV, NPV, and accuracy of FDG PET in detection of pleural malignancies were 100%, 71%, 63%, 100%, and 80%; and those of CT and FDG PET combined, 100%, 76%, 67%, 100%, and 84%.

CONCLUSION

Findings suggest that a negative FDG PET scan for indeterminate pleural abnormalities at CT indicates a benign character, while positive findings on an FDG PET scan are sensitive for malignancy.

Infections in 346 consecutive video-assisted thoracoscopic procedures

BACKGROUND

Postoperative infections, as related to risk factors, in patients undergoing video-assisted thoracoscopic surgery (VATS) procedures have been studied infrequently.

MATERIALS AND METHODS

We evaluated 346 consecutive patients who underwent VATS procedures between October 1996 and June 2002 at our center. Patients preoperatively were free of chest infections and were divided into two groups: Group A (n = 139) who underwent lung wedge resection; group B (n = 207), who underwent pleural biopsy (n = 183) or biopsy of a mediastinal mass (n = 24). We recorded prospectively the following preoperative infection risk parameters: Hemoglobin concentration, hematocrit, serum albumin concentration, lymphocyte count, length of preoperative stay, duration of surgery, blood transfusion, age, comorbidity, and chronic obstructive pulmonary disease specifically (COPD, measured as FEV(1) <70% of expected). Short-term antibiotic prophylaxis was given to 94% of patients in group A and to 90% of patients in group B. As outcome measures we recorded the occurrence of postoperative infections within 30 days (surgical site infection, pneumonia, empyema) and the final patient outcome.

RESULTS

Patients who developed postoperative infections (all the above types included) were 17/346 (4.9%), the difference between group A (5.0%) and group B (4.8%) being not significant. The overall surgical site infection rate was 1.7%. Groups A and B showed a similar incidence of surgical site infection (2.8% vs. 1.0%; p = NS), of pneumonia (2.8% vs. 3.4%; p = NS), and of empyema (0.7% vs. 2.0%; p = NS). Among assessed infection risk parameters, a FEV(1) <70% of expected was the only parameter associated with a significantly increased incidence of surgical site infection (p < 0.05).

CONCLUSIONS

This prospective study confirms that the wound infection rate is low (1.7%) after minimally invasive VATS procedures. The cumulative incidence of postoperative infections (including wound infection, pneumonia, empyema) was similar after lung wedge resection and after pleural or mediastinal mass biopsy procedures. Among the infection risk parameters, COPD was the only parameter associated with a significantly increased incidence of postoperative infection. Our results suggest that patients with COPD who undergo VATS for lung wedge resections and for pleural/mediastinal biopsy should receive antibiotic prophylaxis to prevent surgical site infection.

Risk factors for the development of postoperative complications after bronchial sleeve resection for malignancy: a univariate and multivariate analysis

BACKGROUND

This study was designed to identify risk factors responsible for postoperative complications after bronchoplastic procedures.

METHODS

Excluding sleeve pneumonectomies between January 1994 and December 2001, 108 patients underwent bronchoplastic procedures for bronchial malignancy. Prospectively documented data were age, gender, side, type of bronchial reconstruction, extended resection, histology, TNM stage, diseased lobe, and bronchial tumour occlusion. Cardiovascular (CV) risk factors included heart disease, arterial hypertension, cerebro-occlusive disease, peripheral artery disease of the lower extremities, diabetes mellitus, and abdominal aortic aneurysm. Patients were grouped according to the presence/absence of any CV risk factor and the absolute number of CV risk factors present (zero to four). Non-CV risk factors included neoadjuvant chemotherapy, alcoholism, lung disease, sleep apnea, history of recent pneumococcal sepsis, and repeat thoracotomy. Groups were assembled according to the presence or absence of any non-CV risk factor, neoadjuvant chemotherapy, and alcoholism. Respiratory risk factors included lung function and blood gas analysis. Groups were assembled according to the absolute number of respiratory risk factors in each person (zero to three) and the combination of respiratory and CV risk factors. Complications were defined as septic (pneumonia, empyema, brochopleural fistula, colitis) and aseptic. For univariate statistical analysis, t test, cross-tabulation, and chi2 test were used. All factors with a significance of p < 0.1 were entered into a binary backwards-stepwise logistic regression model.

RESULTS

The combination of respiratory and CV risk factors (p = 0.012, OR = 0.165) was predictive for overall complications. Coronary artery disease (p = 0.02, OR = 0.062) and the combination of two respiratory risk factors (p = 0.008, OR = 0.062) were predictive for septic complications. Peripheral artery disease (p = 0.024, OR = 0.28), moderate (p = 0.01, OR = 0.13) and severe chronic obstructive pulmonary disease (p = 0.018, OR = 0.11), and extended resections (p = 0.003, OR = 0.017.) were predictive for aseptic complications.

CONCLUSIONS

Comorbidity significantly influences the postoperative complication rate and is therefore crucial for evaluation of patients for bronchoplastic procedures. Different risk factors are responsible for the occurrence of septic and aseptic complications after bronchoplastic procedures.

Lung cancer in elderly patients

Lung cancer is one of the most common causes of death in elderly patients in the United States. Treatment advances have improved survival in selected patients. The available treatments carry the risk of morbidity and mortality but the benefit in most patients far outweighs the risks, given the dismal prognosis of untreated disease. Elderly patients with lung cancer need careful attention during pretreatment assessment. Advanced age alone, however, should not contraindicate aggressive treatment. In the high-risk groups it is important to involve a team of physicians including surgeons, radiation oncologists, medical oncologists, and pulmonologists, who are familiar with current treatment options and their risks.

Hydro-jet-assisted pneumonectomy: a new technique in a porcine model

BACKGROUND AND OBJECTIVES

Hydro-jet technology has long been used to cut various materials, such as metal and wood, in the industrial field. In the medical field, this technology has been applied successfully in selective cutting of the parenchyma of the liver. However, to our knowledge, no data are available on the use of the hydro-jet technique for pneumonectomy. The purpose of this study was to evaluate a new dissection technique in which a high-pressure water stream (hydro-jet) and a new dissection probe for pulmonary resection are used.

METHODS

Thirty pigs underwent right pneumonectomy. Pigs were randomized to either the conventional or hydro-jet-assisted dissection technique. The feasibility of this technique and the features of surgical dissection were evaluated and compared between the two groups.

RESULTS

Pneumonectomy was successful in all animals. The mean operative times were 55 and 65 minutes and the mean volumes of blood loss were 37 and 65 mL for the hydro-jet and conventional dissection techniques, respectively. Complications included vascular injury in 6% and 20% of cases with the hydro-jet and conventional techniques, respectively. The use of hydro-jet for pneumonectomy had clear technical advantages over the conventional dissection. Hydro-jet resulted in a selective dissection of fibrous and connective tissue, preserving blood vessels for later ligation. Therefore, the dissection was performed in a relatively bloodless field. The ease of dissection with the bent-tip dissector represents another advantage. The continuous water flow allows a clear view for the operator.

CONCLUSIONS

This study shows that hydro-jet dissection represents an excellent alternative to the conventional technique for pulmonary resection. The improved anatomic dissection combined with an almost bloodless operating field secondary to continuous water flow may decrease dissection-related complications.

Predictors of early morbidity after major lung resection in patients with and without airflow limitation

BACKGROUND

The aim of the present study was to identify predictors of morbidity after major lung resection for non-small cell lung carcinoma in patients with forced expiratory volume in 1 second (FEV1) greater than or equal to 70% of predicted and in those with FEV1 less than 70% of predicted.

METHODS

Five hundred forty-four patients who underwent lobectomy or pneumonectomy from 1993 through 2000 were retrospectively analyzed. The patients were divided into two groups: group A (450 cases), with FEV1 greater than or equal to 70%, and group B (94 cases), with FEV1 less than 70%. Differences between complicated and uncomplicated patients were tested within each group.

RESULTS

Morbidity rate was not significantly different between group A and group B (20.4% and 24.5%, respectively; p = 0.4). In group A, multivariate analysis showed that predicted postoperative FEV1 was the only significant independent predictor of complications. In group B, no significant predictor was identified.

CONCLUSIONS

In patients with preoperative FEV1 less than 70% of predicted, predicted postoperative FEV1 was not predictive of postoperative morbidity. Thus, predicted postoperative FEV1 should not be used alone as a selection criteria for operation in these high-risk patients.

Risk factors for early mortality and major complications following pneumonectomy for non-small cell carcinoma of the lung

STUDY OBJECTIVES

To assess the mortality rate and the incidence of cardiopulmonary complications after pneumonectomy for non-small cell lung carcinoma (NSCLC) and to identify possible associated risk factors.

DESIGN

Observational study of patients who underwent pneumonectomy. Potential risk factors were analyzed from a local database including all thoracic surgical cases.

SETTING

A university hospital and a chest medical center.

PATIENTS AND METHODS

From January 1, 1990, to April 30, 2000, 193 consecutive pneumonectomies were performed for NSCLC in two affiliated institutions. The following information was recorded: demographic, clinical, functional, and surgical variables; as well as intraoperative and postoperative events. The risk of mortality and cardiopulmonary complications was evaluated using multiple logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

After undergoing pneumonectomy, all patients were successfully extubated in the operating room and then transferred to a postanesthesia care unit (126 patients) or ICU (67 patients). The 30-day mortality rate was 9.3%, and cardiovascular and/or pulmonary complications occurred in 47% of cases. Coronary artery disease (CAD) was a predictor of 30-day mortality (OR, 2.9; 95% CI, 1.1 to 8.9). Cardiac morbidity (mainly arrhythmias) was significantly related to advanced age (OR, 3.7; 95% CI, 1.6 to 8.6) and pathologic stages III/IV (OR, 1.4; 95% CI, 1.1 to 4.7), whereas continuous epidural analgesia was associated with a reduced incidence of respiratory complications (OR, 0.2; 95% CI, 0.1 to 0.6).

CONCLUSIONS

Pneumonectomy for lung cancer is a high-risk procedure, the risk for which is significantly related to the presence of CAD and advanced pathologic stages. Importantly, the provision of epidural analgesia contributes to lower the risk of respiratory complications.

Stair climbing test predicts cardiopulmonary complications after lung resection

STUDY OBJECTIVE

To evaluate the capability of the stair climbing test to predict cardiopulmonary complications after lung resection for lung cancer.

DESIGN

A prospective cohort of candidates for lung resection. Spirometric assessment and the stair climbing test were performed the day before operation. Univariate and multivariate analyses were performed to identify predictors of postoperative complications.

SETTING

Tertiary referral center.

PATIENTS

A consecutive series of 160 candidates for lung resection with lung carcinoma from January 2000 through March 2001.

RESULTS

At univariate analysis, the patients with complications were significantly older (p = 0.02), had a significantly lower FEV(1) percentage (p = 0.007) and predicted postoperative FEV(1) percentage (p = 0.01), had a greater incidence of a concomitant cardiac disease (p = 0.02), climbed a lower altitude at the stair climbing test (p < 0.0001), and had a lower calculated maximum oxygen consumption (O(2)max) [p = 0.03] and predicted postoperative O(2)max (p = 0.006) compared to the patients without complications. At multivariate analysis, the altitude reached at the stair climbing test remained the only significant independent predictor of complications.

CONCLUSIONS

The stair climbing test is a safe and economical exercise test, and it was the best predictor of cardiopulmonary complications after lung resection.

Lung cancer surgery--preoperative risk assessment and patient selection

Lung resection remains the therapy of choice offering the greatest potential for cure in non spread lung cancer. As these procedures have a significant rate of cardiopulmonary complications, risk assessment and evaluation of functional operability is essential for successful resectional surgery. The most valuable parameters for evaluation of lung function and risk assessment are FEV1, DLCO and VO2max as well as the calculation of predicted postoperative lung function. With preoperative preparatory physical therapy and treatment of comorbidities, also marginal patients may become operable for resectional surgery.