Perioperative mortality and major cardio-pulmonary complications after lung surgery for non-small cell carcinoma

Left ventricular stroke volume decreases due to surgical procedures of anatomical lung resection

OBJECTIVES

The influence of lung resection on cardiac function has been reported, and previous studies have mainly focused on right ventricular (RV) dysfunction. As few studies have analyzed changes in left ventricular hemodynamic variables caused by lung resection, we aimed to investigate the perioperative changes in left ventricular stroke volume (LVSV) caused by anatomical lung resection.

METHODS

We enrolled 61 patients who underwent anatomical lung resection and perioperative LVSV monitoring. The Flo Trac system was used for dynamic monitoring. We investigated changes in LVSV after lung resection and the factors that affected these changes. The operative procedures that contributed to these changes were also investigated.

RESULTS

LVSV decreased after anatomical lung resection in the majority of patients (n = 38, 62.2%). Operative procedures affecting this change were (a) taping the superior pulmonary vein (SPV; right: V1-3) before dorsal part procedure (e.g., major fissure division of right upper lobectomy, A1 + 2c, and A4 + 5 division of left upper lobectomy); (b) division of the SPV (right: V1-3, V4 + 5); (c) division of A6-10 (in lower lobectomy); and (d) finish division of all vessels.

CONCLUSIONS

LVSV decrease was caused by anatomical lung resection in the majority of patients owing to the intraoperative procedures described above.

Risk factors and prognostic significance of early postoperative complications for patients who underwent pneumonectomy for lung cancer

BACKGROUND

Although pneumonectomy has relatively high mortality and morbidity rates, it remains valid in the surgical treatment of lung cancer. This study aims to evaluate the prognostic significance of postoperative complications after pneumonectomy and demonstrate the risk factors related to early postoperative complications.

METHODS

Patients who underwent pneumonectomy for non-small cell lung cancer between January 2008 and May 2021 were included in the study. Factors related to the development of early postoperative complications and overall survival were evaluated by univariate and multivariate analyses.

RESULTS

A total of 136 patients were included in the study. Early postoperative complications were seen in 33 (24.3%) patients and late postoperative complications in 7 (5.1%) patients. The amount of cigarette smoking, and the operation side were the independent variables that affect the development of early postoperative complications. In multivariate analysis, smoking amount and pericardial invasion were associated with the development of postoperative hemorrhage, and advanced age was associated with the development of postoperative pneumonia.

CONCLUSIONS

Early postoperative complications have a negative effect on the prognosis after pneumonectomy therefore careful patient selection and preoperative risk assessment are essential to minimize the occurrence of complications and improve patient outcomes.

TRIAL REGISTRATION

This observational study was approved by the (Ethical Committee of Dr. Suat Seren Chest Diseases and Chest Surgery Education and Research Center) Institutional Review Board of our center (E-49109414-604.02.02-218625439).

Should cardiovascular comorbidities be a contraindication for pulmonary metastasectomy?

BACKGROUND

Limited information is available about the impact of cardiovascular comorbidities (CVC) on the postoperative course of patients undergoing pulmonary metastasectomy (PM). In this study, we aim to compare the postoperative morbidity, mortality, and the long-term survival of patients with and without CVC undergoing PM.

METHODS

A retrospective monocentric study was conducted including 760 patients who underwent PM in curative intention. Patients were divided into two groups depending on the presence of CVC.

RESULTS

The data from 164 patients with CVC (21.6%) and 596 patients without CVC (78.4%) were investigated. In both groups, zero in-hospital-mortality and limited 30-day mortality was detected. Postoperative complications occurred more often in patients with CVC (N=47, 28.7% vs. N=122, 20.5%, P=0.02). However, most of them were minor (N=37, 22.6% vs. N=93, 15.6%, P=0.03). The presence of multiple CVC (N=18 patients, 40% vs. N=28, 23.9%, P=0.04) and reduced left ventricular function (N=5, 62.5% vs. N=42, 27.1%, P=0.03) were identified as risk factors for postoperative morbidity. Patients with CVC showed reduced overall survival (5-year survival rate: 75.8% vs. 68%, P=0.03). In the multivariate analysis lobectomy [hazard ratio (HR) 0.3, 95% confidence interval (CI): 0.1-0.8, P=0.02] and general vascular comorbidities (HR 2.1, 95% CI: 1.1-3.9, P=0.01) were identified as independent negative prognostic factors.

CONCLUSIONS

Resection of pulmonary metastases can be performed safely in selected patients with stable CVC. The presence of CVC in patients undergoing PM is associated with reduced overall survival compared to patients without CVC in the long term follow up. However, a prolonged 5-year survival rate of 68% could be achieved.

Are cardiovascular comorbidities always associated with a worse prognosis in patients with lung cancer?

Many factors contribute to mortality in lung cancer, including the presence of concomitant cardiovascular disease. In the treatment of early stage of lung cancer, the presence of comorbidities and occurence of cardiotoxicity may be prognostic. The effect of cardiotoxicity of radiotherapy and chemoradiotherapy on overall survival has been documented. Acute arterial and venous thromboembolic events seem to correlate with the degree of the histological malignancy, its clinical advancement, and even with optimal cardiac treatment, they may influence the survival time. In the case of high-grade and advanced lung cancer stage especially in an unresectable stadium, the prognosis depends primarily on the factors related to the histopathological and molecular diagnosis. Electrocardiographic and echocardiographic abnormalities may be prognostic factors, as they seem to correlate with the patient's performance status as well as tumor localization and size.

Selection of preoperative stress electrocardiography test for appropriate patients with non-small cell lung cancer

OBJECTIVE

Lobectomy is an established surgical procedure for treating non-small cell lung cancer; however, it significantly impacts postoperative cardiac function. The stress electrocardiography test is relatively easy to perform and is used to confirm the presence of coronary artery stenotic lesions. However, it has a low pre-test probability and may yield many false positives. We examined the factors that would enable the appropriate selection of patients for stress electrocardiography as a preoperative cardiovascular examination preceding lobectomy for non-small cell lung cancer.

METHODS

From June 2016 to July 2018, 240 patients at our institution who underwent stress electrocardiography before lobectomy for primary lung cancer were included in this study. Clinical information was extracted from electronic medical records and evaluated retrospectively. Smoking history, diabetes, hypertension, dyslipidemia, and ischemic heart disease were considered risk factors for coronary artery stenosis. We determined the coronary risk factors that were applicable to each participant and calculated the total number of coronary risk factors as a risk score.

RESULTS

Patients with coronary risk factor scores of ≥ 3 were significantly more likely to have abnormal stress electrocardiography results. In addition, these patients also underwent more comprehensive examinations to identify coronary diseases. There were no patients with complications that could be attributed to ischemic heart disease.

CONCLUSION

Stress electrocardiography may be more useful before lobectomy in non-small cell lung cancer patients if the patients are appropriately selected, with the test utilized mainly in patients with coronary risk factor scores of ≥ 3.

[Pneumonectomy for Non-small Cell Lung Cancer: Predictors of Operative Mortality and Survival]

外科手术是目前根治非小细胞肺癌（non-small cell lung cancer, NSCLC）的最有效方式。全肺切除作为一种术式被应用于临床中。对于中央型肺癌，袖式肺叶切除术因其术后肺功能丧失少、术后并发症及死亡率低逐渐取代全肺切除术成为主流。然而为保证肿瘤学效果，当其他术式无法完全切除时，全肺切除术式仍是必要的。全肺切除术后主要发生心肺并发症，充分了解全肺切除术后相关并发症能帮助临床医师及时做出诊断，并进一步采取相关措施降低术后并发症对患者的不良影响。充分了解预后相关危险因素可帮助临床医师提前采取措施尽可能规避风险，从而改善患者预后。

Analysis of survival for lung cancer resections cases with fuzzy and soft set theory in surgical decision making

OBJECTIVE

Lung cancer is the most common type of cancer around the world, and it represents the main cause of death in the USA. Surgical treatment is the optimal therapeutic strategy for resectable non-small cell lung cancer. The principal factor for long-term survival after complete resection is the anatomic extension of the neoplasm. However, other factors also have adverse effects on operative mortality, and influence long-term outcome. In this paper we propose an algorithmic solution for the estimation of 5-years survival rate in lung cancer patients undertaking pulmonary resection.

MATERIALS AND METHODS

We address the issue of survival analysis through decision-making techniques based on fuzzy and soft set theories. We develop an expert system based on clinical and functional data of lung cancer resections in patients with cancer that can be used to predict the survival of patients.

RESULTS

The evaluation of surgical risk in patients undertaking pulmonary resection is a primary target for thoracic surgeons. Lung cancer survival is influenced by many factors. The computational performance of our algorithm is critically analyzed by an experimental study. The correct survival classification is achieved with an accuracy of 79.0%. Our novel soft-set based criterion is an effective and precise diagnosis application for the determination of the survival rate.

Routine intensive monitoring but not routine intensive care unit-based management is necessary in video-assisted thoracoscopic surgery lobectomy for lung cancer

Background

Evidence for immediate postoperative intensive care unit (ICU) care is still lacking in the era of minimally invasive video-assisted thoracic surgery (VATS). We evaluated the safety and feasibility of general ward (GW) care after VATS lobectomy for lung cancer.

Methods

A total of 451 patients who underwent VATS lobectomy for lung cancer between June 2012 and August 2017 were retrospectively studied. The patients were divided into two groups (ICU 344 vs. GW 107). We compared the postoperative complications and mortality between the two groups after propensity score matching. Furthermore, we evaluated the clinical factors associated with complications, and stratified patients according to the risk for complications.

Results

Immediate complications (within 24 hours after surgery) occurred in 0.4%. Non-immediate complications occurred in 18.8%. There were no differences in the incidence of complications and mortality between the two groups, after propensity matching. However, the length of postoperative stay (12.6±10.0 vs. 10.3±4.1 days, P=0.041) was significantly higher in the ICU group than in the GW group. Multivariate regression analyses revealed that chronic obstructive pulmonary disease (COPD) [odds ratio (OR) =3.00, 95% confidence interval (CI): 1.51-5.97, P=0.002], non-stage I cancer (OR =2.54, 95% CI: 1.39-4.62, P=0.002), multi-port surgery (OR =3.75, 95% CI: 2.18-6.44, P<0.001), and age ≥60 years (OR =2.12, 95% CI: 1.03-4.37, P=0.042) were associated with complications. Immediate postoperative care in GW had no influence on complications.

Conclusions

Immediate postoperative care after VATS lobectomy for lung cancer in GW was safe and feasible without poor outcomes. Therefore, selective intensive monitoring for high risk groups may offer cost-saving and efficient use of ICU resources.

The right ventricular response to lung resection

OBJECTIVES

Lung cancer is a leading cause of cancer death and in suitable cases the best chance of cure is offered by surgery. Lung resection is associated with significant postoperative cardiorespiratory morbidity, with dyspnea and reduced functional capacity as dominant features. These changes are poorly associated with deterioration in pulmonary function and a potential role of right ventricular (RV) dysfunction has been hypothesized. Cardiovascular magnetic resonance imaging is a reference method for noninvasive assessment of RV function and has not previously been applied to this population.

METHODS

We used cardiovascular magnetic resonance imaging to assess the RV response to lung resection. Cardiovascular magnetic resonance imaging with volume and flow analysis was performed on 27 patients preoperatively, on postoperative day 2 and at 2 months. Left ventricular ejection fraction and RV ejection fraction, the ratio of stroke volume to end systolic volume, pulmonary artery acceleration time, and distensibility of main and branch pulmonary arteries were studied.

RESULTS

Mean ± standard deviation RV ejection fraction deteriorated from 50.5% ± 6.9% preoperatively to 45.6% ± 4.5% on postoperative day 2 and remained depressed at 44.9% ± 7.7% by 2 months (P = .003). The ratio of stroke volume to end systolic volume deteriorated from median 1.0 (quartile 1, quartile 3: 0.9, 1.2) preoperatively to median 0.8 (quartile 1, quartile 3: 0.7, 1.0) on postoperative day 2 (P = .011). On postoperative day 2 there was a decrease in pulmonary artery acceleration time and operative pulmonary artery distensibility (P < .030 for both). There were no changes in left ventricular ejection fraction during the study period (P = .621).

CONCLUSIONS

These findings suggest RV dysfunction occurs following lung resection and persists 2 months after surgery. The deterioration in the ratio of stroke volume to end systolic volume suggests a mismatch between afterload and contractility. There is an increase in indices of pulsatile afterload resulting from the operative pulmonary artery.

Pain management and safety profiles after preoperative vs postoperative thoracic epidural insertion for bilateral lung transplantation

OBJECTIVE

Thoracic epidural analgesia provides effective pain control after lung transplantation; however, the optimal timing of placement is controversial. We sought to compare pain control and pulmonary and epidural morbidity between patients receiving preoperative vs postoperative epidurals.

METHODS

Institutional records were reviewed for patients undergoing a bilateral lung transplant via a bilateral anterior thoracotomy with transverse sternotomy incision between January 2014 and January 2017. Pain control was measured using visual analog scale pain scores (0-10). Pulmonary complications included a composite of pneumonia, prolonged intubation, and reintubation/tracheostomy.

RESULTS

Among 103 patients, 72 (70%) had an epidural placed preoperatively and 31 (30%) had an epidural placed within 72 hours posttransplant. There were no differences in the rates of cardiopulmonary bypass (3% vs 0%, P = 0.59); however, patients with a preoperative epidural were less likely to be placed on extracorporeal membrane oxygenation intraoperatively (25% vs 52%, P = 0.01). Pain control was similar at 24 hours (1.2 vs 1.7, P = 0.05); however, patients with a preoperative epidural reported lower pain scores at 48 (1.2 vs 2.1, P = 0.02) and 72 hours posttransplant (0.8 vs 1.7, P = 0.02). There were no differences in primary graft dysfunction (42% vs 56%, P = 0.28), length of mechanical ventilation (19.5 vs 24 hours, P = 0.18), or adverse pulmonary events (33% vs 52%, P = 0.12). No adverse events including epidural hematoma, paralysis, or infection resulted from epidural placement.

CONCLUSION

Preoperative thoracic epidural placement provides improved analgesia without increased morbidity following lung transplantation.

Patient and procedural features predicting early and mid-term outcome after radical surgery for non-small cell lung cancer

Background

Postoperative cardiovascular and pulmonary complications (PCVCs and PPCs) are frequent and result in prolonged hospital stay. The aim of this study was to update the risk factors associated with major complications and survival after lung cancer surgery.

Methods

This is a post-hoc analysis of a randomized controlled trial that was designed to assess the benefits of preoperative physical training. After enrollment, clinical, biological and functional data as well as intraoperative details were collected. In-hospital PCVCs and PPCs were recorded and survival data were adjudicated up to 4 years after surgery.

Results

Data from 151 patients were analyzed. Thirty-day mortality rate was 2.6% and the incidence of PCVCs and PPCs was 15% and 33%, respectively. Stepwise logistic regression analysis showed that, PCVCs were mainly related to elevated plasma levels of brain natriuretic peptides [odds ratios (ORs) =6.0; 95% confidence interval (CI), 1.3-27.3] and performance of a pneumonectomy (OR =9.6; 95% CI, 2.9-31.5) whereas PPCs were associated with the presence of COPD (OR =5.9; 95% CI, 2.4-14.8), current smoking (OR =2.6; 95% CI, 1.1-6.5) and the need for blood transfusion (OR =5.2; 95% CI, 1.2-23.3). Preoperative physical training was a protective factor regarding PPCs (OR =0.13; 95% CI, 0.05-0.34). Cox proportional hazards regression analysis showed that ventilatory inefficiency during exercise (expressed by a ratio >40 of ventilation to carbon dioxide elimination), coronary artery disease, elevated plasma levels of brain natriuretic peptides and the occurrence of PPCs were all predictive of poor survival after surgery.

Conclusions

Besides smoking and the extent of lung resection, preexisting cardiopulmonary disease as evidence by elevated levels of brain natriuretic peptides and inefficient ventilation are associated with poor clinical outcome after lung cancer surgery.

Role of pneumonectomy for lung cancer in current scenario: An Indian perspective

BACKGROUND

Surgical treatment for lung cancer has evolved from pneumonectomy to lobectomy/sleeve resection around the world. Although condemned for poor outcomes, pneumonectomy may still be required in a select group of patients in developing countries. With the better patient selection, optimization of medical comorbidities, better perioperative care; pneumonectomy may show better results. Thus, there is a need to reconsider the role of pneumonectomy in patients with locally advanced lung cancer in the current scenario.

PATIENTS AND METHODS

The aim of this study was to analyze the demographic and clinicopathologic profile of lung cancer patients and the role of pneumonectomy at a tertiary cancer center in India. The records of patients, who underwent surgery for lung cancer at our institute from January 2011 to April 2014, were analyzed retrospectively, and various parameters in pneumonectomy were compared to lobectomy patients.

RESULTS

Out of 48 patients undergoing major lung resections, nearly 80% patients were symptomatic at presentation and were mostly in advanced stages, thus requiring neoadjuvant chemotherapy in 45.8% cases and pneumonectomy in 41.6% patients. There was no difference in morbidity and mortality in pneumonectomy (25%, 5%) versus lobectomy (21.2%, 3.5%). Disease-free survival at 1, 2, and 3 years after pneumonectomy (71.8%, 51.4%, and 42.8%) was comparable to lobectomy (73.3%, 66.1%, and 55.6%). After neoadjuvant therapy, survival was not affected by the type of surgery.

CONCLUSIONS

In the Indian scenario, as the majority of lung cancer patients present at an advanced stage, pneumonectomy still plays a major role, and the acceptable postoperative outcome can be achieved with aggressive perioperative management.

Comparison between Thoracic Epidural Block and Thoracic Paravertebral Block for Post Thoracotomy Pain Relief

INTRODUCTION

Postoperative pain after thoracotomy is being considered one of the most severe pain and if not treated well, can result in various respiratory and other complications.

AIM

Present study was conducted with the aim to compare continuous thoracic epidural infusion with continuous paravertebral infusion for postoperative pain using Visual Analogue Scale (VAS) score and four point observer ranking. The secondary outcomes measured were pulmonary functions and any complication like hypotension, bradycardia, nausea, vomiting, urinary retention and neurological complications if any.

MATERIALS AND METHODS

Sixty patients of age group 18-60 years posted for anterolateral thoracotomy surgery for lung resection were randomised either to epidural or paravertebral group in this randomised prospective double blind study. In Epidural group 7.5ml bolus of 0.125% Bupivacaine with 50μg Fentanyl and in Paravertebral group 15ml bolus of 0.125% Bupivacaine with 50μg Fentanyl was given 30 minutes before the anticipated end of surgery. Bolus dose was followed by infusion of 0.125% Bupivacaine with 2μg/ml Fentanyl at the rate of 5 ml/hr in both groups. Parameters noted were Mean Arterial Pressure (MAP), Heart Rate (HR), Oxygen Saturation (SpO₂), Arterial Blood Gas (PaCO₂, P/F ratio), Visual Analogue Scale (VAS) and Four Point Observer Ranking Scale (FPORS) for pain, number of sensory segments blocked (by checking for pinprick sensation), requirement of infusion top ups and rescue analgesia (Tramadol), pre and postoperative pulmonary function test {(Forced Expiratory Volume (FEV)₁, Forced Vital Capacity (FVC), FEV₁/FVC, Peak Expiratory Flow Rate (PEFR)} and complications from start of infusion till 24 hours in the postoperative period.

RESULTS

Both the techniques were effective in relieving pain but pain relief was significantly better with epidural. Postoperatively, HR, SpO₂, P/F ratio and PaCO₂ were comparable between group E and P. There was significant decline in FeV₁, FVC, FeV₁/FVC and PEFR in postoperative period as compared to preoperative value in both the groups. Hypotension and bradycardia were more in group E.

CONCLUSION

Both the techniques, continuous thoracic epidural block and continuous thoracic paravertebral block were effective for post-thoracotomy pain relief; however, epidural block provides better pain relief. The incidence of sympatholytic complications was more in epidural group. The effect on respiratory mechanics was equivalent. Hence, paravertebral block can be used in post thoracotomy pain relief in those patients where thoracic epidural is contraindicated.

Surgery for non-small cell lung cancer in patients with a history of cardiovascular surgery

Purpose

To clarify if previous cardiovascular surgery (CVS) affects the postoperative outcome of surgery for non-small cell lung cancer (NSCLC).

Methods

We reviewed, retrospectively, the medical records of 36 patients with a history of CVS, who underwent lung cancer surgery at a single institution (study group; SG) and compared their characteristics and postoperative outcomes with those of patients without a history of CVS history (control group; CG), and also with those of patients with coexisting cardiovascular diseases in the CG (specified control group; SCG). Finally, we used a thoracic revised cardiac risk index (ThRCRI) to evaluate the risk of perioperative cardiovascular events.

Results

There was a significant difference in the ThRCRI classifications between the SG and the SCG (p < 0.0001). There were no significant differences in the incidence of intraoperative and postoperative complications between the SG and CG, or between the SG and SCG. The 5-year survival rates of the SG, CG, and SCG were 69.3, 73.9, and 65.4 % in all stages, and 83.5, 82.2, and 70.4 % in stage I, respectively.

Conclusions

Previous CVS did not increase the number of perioperative cardiovascular events in this study and had no significant influence on the prognosis of patients undergoing resection of NSCLC.

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.

Impact of thoracic epidural catheter threading distance on analgesia during the first 24 hours following thoracotomy: a randomized controlled trial

PURPOSE

The purpose of this prospective randomized controlled trial was to determine the impact of thoracic epidural catheter threading distance on analgesia quality after thoracotomy.

METHODS

We randomly assigned 120 elective thoracotomy patients to a thoracic epidural catheter threading distance of 3, 5, or 7 cm (groups 3CM, 5CM, and 7CM, respectively). Epidural bupivacaine 0.1% with fentanyl 2 µg·mL(-1) was administered according to a standardized protocol. Epidural analgesia quality was assessed at 60 min and 24 hr postoperatively for four measures: incidence of non-functioning epidurals; numerical rating score (NRS) < 4 at rest, while coughing, and during wound palpation; cold perception at the wound site; and cumulative dose of analgesic medication used. Our primary hypothesis was that, compared to threading distances of 3 and 5 cm, a threading distance of 7 cm was not inferior at providing an NRS < 4 while coughing at 60 min postoperatively, with a non-inferiority margin of 25% (absolute value) being significant.

RESULTS

The incidence of NRS < 4 while coughing at 60 min was 74% (29/39) in group 7CM compared with 68% (54/80) in the combined 3CM and 5CM groups (absolute difference 7%; 95% confidence interval -11 to 23; P = 0.29). At both 60 min and 24 hr, differences between groups were similar regarding the number of non-functioning epidurals, NRS < 4, and suppressed cold sensation. Analgesic doses were similar in the three groups.

CONCLUSIONS

This study found that a thoracic epidural catheter threading distance of 7 cm in the epidural space was not inferior to distances of 3 cm and 5 cm with respect to pain scores at 60 min postoperatively. This study was not powered to examine differences that could have clinical significance that were less than our a priori 25% non-inferiority margin.

Coadministration of intravenous remifentanil and morphine for post-thoracotomy pain: comparison with intravenous morphine alone

OBJECTIVES

In this double-blind, randomized study, the authors compared the effects of a patient-controlled remifentanil and morphine combination with morphine alone on post-thoracotomy pain, analgesic consumption, and side effects.

DESIGN

A prospective, randomized, double-blind clinical study.

SETTING

University hospital.

PARTICIPANTS

Volunteer patients at a university hospital undergoing elective thoracotomy surgery.

INTERVENTIONS

Patients were allocated randomly into 2 groups to receive patient-controlled analgesia: the morphine (M) group or the morphine plus remifentanil (MR) group. Pain, discomfort, sedation scores, cumulative patient-controlled morphine consumption, rescue analgesic (meperidine) requirement and side effects were recorded for 24 hours.

MEASUREMENTS AND MAIN RESULTS

Sixty patients were allocated randomly to receive intravenous patient-controlled analgesia with morphine alone (M) or morphine plus remifentanil (MR) in a double-blind manner. Patients were allowed to use bolus doses of morphine (0.02 mg/kg) or the same dose of a morphine plus remifentanil (0.2 µg/kg) mixture every 10 minutes without a background infusion. VAS scores were lower in the MR group than in the M group at 30 minutes (p = 0.04), 1 hour (p = 0.03), and 2 hours (p = 0.04). Mean cumulative doses of morphine were not significantly different at 27.8±15 mg for the M group and 21.9±10.5 mg for the MR group. Significantly more patients needed meperidine in the M group (p = 0.039); these also experienced more nausea (p = 0.01).

CONCLUSIONS

Coadministration of PCA remifentanil with morphine for the treatment of post-thoracotomy pain did not reduce morphine consumption but provided superior analgesia, less use of rescue analgesics, and fewer side effects compared to morphine alone.

Venous thromboembolism in patients undergoing operations for lung cancer: a systematic review

BACKGROUND

The risk of venous thromboembolism is perceived to be high in patients with lung cancer. However, existing studies in patients undergoing operations for lung cancer draw inconsistent conclusions and recommendations in terms of thromboprophylaxis. The aim of this study was to perform a systematic review of the risk of perioperative and postoperative venous thromboembolism for patients undergoing potential curative surgical procedures for primary lung cancer

METHODS

This was a systematic review including studies of patients with primary lung cancer undergoing operations with curative intent.

RESULTS

We included 19 studies with a total of 10,660 patients. All studies, except 1, were observational in design. Marked heterogeneity was found between the studies in terms of methodologic aspects, patient characteristics, and findings. The mean risk of venous thromboembolism (VTE) was estimated at 2.0% (range, 0.2%-19%), with a mean observation period of 16 months (range, 0.1-22), and the risk was nearly identical in studies with 1 month of follow-up and studies with a longer follow-up.

CONCLUSIONS

The evidence for using thromboprophylaxis after lung cancer operations is relatively sparse, and the use is based predominantly on clinical consensus. However, the risk of VTE seems to occur predominantly within the initial postoperative period, and subsequently the risk falls. Future research should focus on identifying patients and surgical procedures that increase the risk of VTE. This could be accomplished by large observational studies in addition to randomized controlled trials evaluating different thromboprophylaxis strategies.

Association between serum angiotensin-converting enzyme 2 level with postoperative morbidity and mortality after major pulmonary resection in non-small cell lung cancer patients

BACKGROUND

To explore the association between serum angiotensin-converting enzyme 2 (ACE2) levels and postoperative morbidity and mortality after major pulmonary resection in non-small cell lung cancer (NSCLC) patients.

METHODS

Preoperative and postoperative serum ACE2 levels in 320 NSCLC patients who underwent major pulmonary resection were measured. The serum ACE2 levels on postoperative day 1 were divided into quartile categories.

RESULTS

After adjustment for age, sex, body mass index, current smoking status, forced expiratory volume in 1 second, coronary heart disease, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and tumour clinical stages, the risk of developing postoperative morbidities was significantly higher in the lowest serum ACE2 level quartile than in the highest quartile (hazard ratio, 2.12; 95% CI, 1.57-6.23; p=0.008). NSCLC patients with a serum ACE2 level ≤3.21 ng/mL had significantly higher rates of pneumonia, pleural effusion, atrial fibrillation as well as higher in-hospital mortality after major pulmonary resection, compared with those with a serum ACE2 level >3.21 ng/mL.

CONCLUSIONS

The serum ACE2 level one day post surgery is an independent risk factor for postoperative morbidities after major pulmonary resection in NSCLC patients. Thus, it could be used as a prognostic factor for postoperative morbidities after major pulmonary resection in NSCLC patients.

From the Journal archives: Postoperative analgesia: effect on lung volumes

This study was undertaken to determine the contribution of postoperative pain to the known changes that occur to respiratory function in the postoperative period. The authors studied changes in functional residual capacity (FRC) and vital capacity (VC) either in the postanesthesia care unit or on postoperative day one in eight relatively healthy adult patients having upper abdominal surgery. These values were compared with measurements immediately before surgery. Variables were measured postoperatively during pain and then again after establishment of epidural analgesia. Epidural analgesia to a T4 sensory level resulted in a partial and statistically significant restoration of VC (from 37-55% of preoperative values) and a partial but statistically insignificant restoration of FRC (from 78-84% of preoperative values). The authors suggest that postoperative epidural analgesia may be able to decrease respiratory complications.

AUTHORS

Wahba MW, Don HF, Craig DB. Can Anaesth Soc J 1975; 22: 519-27.

PURPOSE

This study was undertaken to determine the contribution of postoperative pain to the known changes that occur to respiratory function in the postoperative period.

PRINCIPAL FINDINGS

Epidural analgesia to T4 resulted in a partial and statistically significant restoration of VC (from 37-55% of preoperative values) and a partial but statistically insignificant restoration of FRC (from 78-84% of preoperative values).

CONCLUSION

Epidural analgesia has more effect on the voluntary aspects of postoperative respiration (VC) than on the involuntary changes in respiration (FRC) after upper abdominal surgery.

Long-term survival after pneumonectomy for non-small-cell lung cancer

OBJECTIVE

to investigate long-term survival in patients who underwent pneumonectomy for non-small-cell lung cancer at the University of Kentucky Medical Center.

METHODS

we retrospectively reviewed 100 consecutive pneumonectomy cases from 1998 to 2009 at the University of Kentucky. We were able to obtain follow-up data on 99 of 100 patients.

RESULTS

overall 1-, 2-, and 5-year survival was 66%, 48%, and 32%, respectively. The 1-, 2-, and 5- survival for left pneumonectomy was 76%, 55%, and 40%, respectively, compared to 56%, 44%, and 22%, respectively, for right pneumonectomy. The median survival for left pneumonectomy was 2.4 years compared to 1.2 years for right pneumonectomy (p = 0.056). The 5-year survival for patients diagnosed with stage I disease was 34%, compared to 19% for stage II disease, and 38% for stage III disease. The 5-year survival for patients who underwent neoadjuvant therapy was 31% compared to 39% for patients who received adjuvant therapy and 29% for patients who received surgery alone. These results were also not statistically significant.

CONCLUSION

neoadjuvant therapy did not adversely affect long-term survival in our study. When compared to left pneumonectomy, right pneumonectomy for non-small-cell lung cancer is associated with adverse postoperative outcomes as well as poorer long-term survival.

Acute respiratory distress syndrome after pulmonary resection

Postoperative acute respiratory distress syndrome (ARDS) is a recognized complication of pulmonary resection. It is characterized by the acute onset of hypoxemia with radiographic infiltrates consistent with pulmonary edema, without elevations in the pulmonary capillary wedge pressure. Many studies suggest that around 2-5 % of patients develop some degree of lung injury, and the mortality from ARDS following pulmonary resection remains high. ARDS following thoracotomy and lung resection has a miserable prognosis, with overall hospital mortality rates over 25 %. The present review evaluates the evidence available in the literature tracking perioperative mortality and morbidity as well as the pathogenesis and management of ARDS in patients undergoing pulmonary resection.

Impact of previous cardiovascular surgery on postoperative morbidity and mortality after major pulmonary resection for non-small cell lung cancer

PURPOSE

The aim of this study was to evaluate the impact of previous cardiovascular surgery on the postoperative morbidity and mortality following major pulmonary resection for non-small cell lung cancer (NSCLC).

METHODS

Medical records of 227 patients, who underwent major pulmonary resection for NSCLC from 2003 to 2012 at our department, were reviewed retrospectively. Thirty-one patients with a mean age of 65.8 years had previous cardiovascular surgery (group A) including coronary artery revascularization in 11 patients, peripheral arterial revascularization in 6 patients, carotis endarterectomy in 9 patients, and combined coronary artery revascularization and carotis endarterectomy in 5 patients, whereas 167 patients (mean age = 62.0 years) had no cardiovascular comorbidity (group B). Twenty-nine patients with nonsurgically treated cardiovascular comorbidity were excluded from this study.

RESULTS

There were no significant differences in overall postoperative morbidity (22.6 % in group A vs. 19.2 % in group B) and mortality (no mortality in group A vs. 2.4 % in group B) between both groups.

CONCLUSIONS

Major pulmonary resections for NSCLC can be performed safely in patients with previous cardiovascular surgical history who are fulfilling the common cardiopulmonary criteria of operability. Operative risk in this subpopulation is comparable to that in patients without cardiovascular comorbidity.

CT Densitometry as a Predictor of Pulmonary Function in Lung Cancer Patients

Purpose:

Preoperative pulmonary assessment is undertaken in patients with resectable lung cancer to identify those at increased risk of perioperative complications. Guidelines from the American College of Chest Physicians indicate that if the FEV¹ and DLCO are ≥60% of predicted, patients are suitable for resection without further evaluation.

The aim of our study is to determine if quantitative measures of lung volume and density obtained from pre-operative CT scans correlate with pulmonary function tests. This may allow us to predict pulmonary function in patients with lung cancer and identify patients who would tolerate surgical resection.

Materials and Methods:

Patients were identified retrospectively from the lung cancer database of a tertiary hospital. Image segmentation software was utilized to estimate total lung volume, normal lung volume (values -500 HU to -910 HU), emphysematous volume (values less than -910 HU), and mean lung density from pre-operative CT studies for each patient and these values were compared to contemporaneous pulmonary function tests.

Results:

A total of 77 patients were enrolled. FEV1 was found to correlate significantly with the mean lung density (r=.762, p<.001) and the volume of emphysema (r= -.678, p<.001). DLCO correlated significantly with the mean lung density (r =.648, p<.001) and the volume of emphysematous lung (r= -.535, p<.001).

Conclusion:

The results of this study suggest that both FEV1 and DLCO correlate significantly with volume of emphysema and mean lung density. We now plan to prospectively compare these CT parameters with measures of good and poor outcome postoperatively to identify CT measures that may predict surgical outcome preoperatively

The impact of cardiovascular comorbidities on the outcome of surgery for non-small-cell lung cancer

OBJECTIVE

The presence of cardiovascular comorbidity in non-small-cell lung cancer (NSCLC) patients increases with age. Therefore, the influence of cardiovascular comorbidity in NSCLC patients on their short- or long-term prognosis remains controversial. This study evaluated the possible risk factors related to the short-term and long-term survivals in NSCLC patients with cardiovascular comorbidity.

METHODS

One thousand one hundred and sixty-two consecutive patients with NSCLC who had undergone a surgical resection between 1984 and 2010 were enrolled in this study. A total of 360 (31%) patients with cardiovascular comorbidities were analysed to identify the risk factors for postoperative complications and prognostic factors.

RESULTS

The patients with cardiovascular comorbidity included 301 with hypertension, 28 with coronary artery disease, 35 with peripheral vascular disease, 23 with arrhythmia and 11 with abdominal aortic aneurysm. Eighty-three patients exhibited more than one type of comorbidity. The postoperative cardiovascular morbidity rates were 3.6% in the cardiovascular comorbidity patients and 3.3% among patients without cardiovascular comorbidity (P = 0.73). No correlation was observed between preoperative cardiovascular comorbidity and postoperative pulmonary complications (P = 0.52). The operative mortality rates were 1.0% for the cardiovascular comorbidity patients and 0.8% for the other patients (P = 0.51). No difference in the postoperative outcomes was observed between the patients with and without cardiovascular comorbidity. The 5-year survival rates were 62.5% in comparison with 65.4% among patients without cardiovascular comorbidity (P = 0.48).

CONCLUSIONS

Patients with cardiovascular comorbidity were not found to be at increased risk of mortality and morbidity following surgery for NSCLC. In addition, cardiovascular comorbidity did not influence the long-term outcomes of patients after a pulmonary resection for NSCLC.

Selective Neurogenic Blockade and Perioperative Immune Reactivity in Patients Undergoing Lung Resection

OBJECTIVE: This double-blind, prospective, randomized, controlled trial examined the effects of thoracic epidural block and intravenous clonidine and opioid treatment on the postoperative Th1/Th2 cytokine ratio after lung surgery. The primary endpoint was the interferon γ (IFN-γ; Th1 cytokine)/interleukin 4 (IL-4; Th2 cytokine) ratio. Secondary endpoints were reductions in pain and incidence of pneumonia. METHODS: Sixty patients were randomized into three groups to receive remifentanil intravenously (remifentanil group, n = 20), remifentanil and clonidine intravenously (clonidine group, n = 20), or ropivacaine epidurally (ropivacaine group, n = 20). Pain was assessed using a numerical rating scale (NRS). Cytokines were measured using a cytometric bead array. RESULTS: Patients in the ropivacaine group (thoracic epidural block) had a significantly lower IFN-γ/IL-4 ratio at the end of surgery than those in the remifentanil group and clonidine group. There were no significant between-group differences in the IFN-γ/IL-4 ratio at other time-points. There were no differences in NRS scores at any time-point. No patient developed pneumonia. CONCLUSION: Intraoperative thoracic epidural block decreased the IFN-γ/IL-4 ratio immediately after lung surgery, indicating less inflammatory stimulation during surgery.

Immediate Postoperative Care in the General Thoracic Ward Is Safe for Low-risk Patients after Lobectomy for Lung Cancer

Background

Following major lung resection, patients have routinely been monitored in the intensive care unit (ICU). Recently, however, patients are increasingly being placed in a general thoracic ward (GTW). We investigated the safety and efficacy of the GTW care after lobectomy for lung cancer.

Materials and Methods

316 patients who had undergone lobectomy for lung cancer were reviewed. These patients were divided into two groups: 275 patients were cared for in the ICU while 41 patients were care for in the GTW immediately post-operation. After propensity score matching, postoperative complications and hospital costs were analyzed. Risk factors for early complications were analyzed with the whole cohort.

Results

Early complications (until the end of the first postoperative day) occurred in 11 (3.5%) patients. Late complications occurred in 42 patients (13.3%). After propensity score matching, the incidence of early complications, late complications, and mortality were not different between the two groups. The mean expense was higher in the ICU group. Risk factors for early complications were cardiac comorbidities and low expected forced expiratory volume in one second. The location of postoperative care had no influence on outcome.

Conclusion

Immediate postoperative care after lobectomy for lung cancer in a GTW was safe and cost-effective without compromising outcomes in low-risk patients.

Emergency thoracic surgery in elderly patients

OBJECTIVES

Emergency thoracic surgery in the elderly represents an extreme situation for both the surgeon and patient. The lack of an adequate patient history as well as the inability to optimize any co-morbidities, which are the result of the emergent situation, are the cause of increased morbidity and mortality. We evaluated the outcome and prognostic factors for this selected group of patients.

DESIGN

Retrospective chart review.

SETTING

Academic tertiary care referral center.

PARTICIPANTS

Emergency patients treated at the Department of Thoracic Surgery, University Hospital of Luebeck, Germany.

MAIN OUTCOME MEASURES

Co-morbidities, mortality, risk factors and hospital length of stay.

RESULTS

A total of 124 thoracic procedures were performed on 114 patients. There were 79 men and 36 women (average age 72.5 ±6.4 years, range 65-94). The overall operative mortality was 25.4%. The most frequent indication was thoracic/mediastinal infection, followed by peri- or postoperative thoracic complications. Risk factors for hospital mortality were a high ASA score, pre-existing diabetes mellitus and renal insufficiency.

CONCLUSIONS

Our study documents a perioperative mortality rate of 25% in patients over 65 who required emergency thoracic surgery. The main indication for a surgical intervention was sepsis with a thoracic/mediastinal focus. Co-morbidities and the resulting perioperative complications were found to have a significant effect on both inpatient length of stay and outcome. Long-term systemic co-morbidities such as diabetes mellitus are difficult to equalize with respect to certain organ dysfunctions and significantly increase mortality.

Postresectional lung injury in thoracic surgery pre and intraoperative risk factors: a retrospective clinical study of a hundred forty-three cases

Introduction

Acute respiratory dysfunction syndrome (ARDS), defined as acute hypoxemia accompanied by radiographic pulmonary infiltrates without a clearly identifiable cause, is a major cause of morbidity and mortality after pulmonary resection. The aim of the study was to determine the pre and intraoperative factors associated with ARDS after pulmonary resection retrospectively.

Methods

Patients undergoing elective pulmonary resection at Adnan Menderes University Medical Faculty Thoracic Surgery Department from January 2005 to February 2010 were included in this retrospective study. The authors collected data on demographics, relevant co-morbidities, the American Society of Anesthesiologists (ASA) Physical Status classification score, pulmonary function tests, type of operation, duration of surgery and intraoperative fluid administration (fluid therapy and blood products). The primary outcome measure was postoperative ARDS, defined as the need for continuation of mechanical ventilation for greater than 48-hours postoperatively or the need for reinstitution of mechanical ventilation after extubation. Statistical analysis was performed with Fisher exact test for categorical variables and logistic regression analysis for continuous variables.

Results

Of one hundred forty-three pulmonary resection patients, 11 (7.5%) developed postoperative ARDS. Alcohol abuse (p = 0.01, OR = 39.6), ASA score (p = 0.001, OR: 1257.3), resection type (p = 0.032, OR = 28.6) and fresh frozen plasma (FFP)(p = 0.027, OR = 1.4) were the factors found to be statistically significant.

Conclusion

In the light of the current study, lung injury after lung resection has a high mortality. Preoperative and postoperative risk factor were significant predictors of postoperative lung injury.

Perioperative tidal volume and intra-operative open lung strategy in healthy lungs: where are we going?

Tidal volumes have tremendously decreased over the last decades from <15 ml kg(-1) to approximately 6 ml kg(-1) actual body weight. Guidelines, widely agreed and used, exist for patients with acute lung injury or acute respiratory distress syndrome (ARDS). However, it is questionable if data created in patients with acute lung injury or ARDS from ventilation on intensive care units can be transferred to healthy patients undergoing surgery. Consensus criteria regarding this topic are still missing because only a few randomised controlled trials have been performed to date, focussing on the use of the best intra-operative tidal volume. The same problem has been observed regarding the application of positive end-expiratory pressure (PEEP) and intra-operative lung recruitment. This article provides an overview of the current literature addressing the size of tidal volume, the use of PEEP and the application of the open-lung concept in patients without acute lung injury or ARDS. Pathophysiological aspects of mechanical ventilation are elucidated.

Acute lung injury after thoracic surgery

In this review, the authors discussed criteria for diagnosing ALI; incidence, etiology, preoperative risk factors, intraoperative management, risk-reduction strategies, treatment, and prognosis. The anesthesiologist needs to maintain an index of suspicion for ALI in the perioperative period of thoracic surgery, particularly after lung resection on the right side. Acute hypoxemia, imaging analysis for diffuse infiltrates, and detecting a noncardiogenic origin for pulmonary edema are important hallmarks of acute lung injury. Conservative intraoperative fluid administration of neutral to slightly negative fluid balance over the postoperative first week can reduce the number of ventilator days. Fluid management may be optimized with the assistance of new imaging techniques, and the anesthesiologist should monitor for transfusion-related lung injuries. Small tidal volumes of 6 mL/kg and low plateau pressures of < or =30 cmH2O may reduce organ and systemic failure. PEEP may improve oxygenation and increases organ failure-free days but has not shown a mortality benefit. The optimal mode of ventilation has not been shown in perioperative studies. Permissive hypercapnia may be needed in order to reduce lung injury from positive-pressure ventilation. NO is not recommended as a treatment. Strategies such as bronchodilation, smoking cessation, steroids, and recruitment maneuvers are unproven to benefit mortality although symptomatically they often have been shown to help ALI patients. Further studies to isolate biomarkers active in the acute setting of lung injury and pharmacologic agents to inhibit inflammatory intermediates may help improve management of this complex disease.

Update on one-lung ventilation: the use of continuous positive airway pressure ventilation and positive end-expiratory pressure ventilation--clinical application

PURPOSE OF REVIEW

The purpose of this review is to examine the evidence for and the clinical use of continuous positive airway pressure (CPAP) and positive end-expiratory pressure (PEEP) for the management of one-lung ventilation during thoracic surgery. CPAP and PEEP use are important as we are increasingly challenged with patients with less respiratory reserve and greater comorbidity leading to the need for greater clinical management and more interventions during one-lung ventilation for thoracic surgery to prevent perioperative complications.

RECENT FINDINGS

The focus of this article is on the most recent literature with selected classic articles. First, the supportive literature and rationale for application of PEEP, CPAP or both during thoracic surgery are reviewed, relative to the threats of hypoxemia, hyperoxia and mechanical lung injury. The second part of the article focuses on the clinical use of PEEP and CPAP. Algorithms for the application of CPAP and PEEP to patients both at risk and not at risk of acute lung injury are presented.

SUMMARY

CPAP and PEEP are useful not only to treat hypoxia and atelectasis as the consequence of one-lung ventilation, perhaps more importantly, also as part of a protective lung-ventilation strategy to ameliorate mechanical stress and prevent acute lung injury.