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

Association Between Preoperative COVID-19 Infection and Postoperative Outcomes in Patients with Obstructive Sleep Apnea Undergoing Metabolic Surgery: A Retrospective Analysis

BACKGROUND

Obstructive sleep apnea (OSA) is highly prevalent in patients undergoing metabolic surgery and can complicate recovery. While OSA and COVID-19 share common pathophysiological mechanisms involving systemic inflammation and respiratory dysfunction, their combined impact on surgical outcomes remains poorly understood.

METHODS

Using TriNetX data from June 2022 to December 2024, we retrospectively analyzed adult patients with OSA undergoing metabolic surgery. Patients were divided into two groups: those with COVID-19 infection within 4 weeks before surgery and controls without infection in the preceding 8 weeks. After propensity score matching, 8,733 pairs were analyzed. The primary outcomes included postoperative pneumonia and respiratory failure within 30 days. The secondary outcomes included acute kidney injury (AKI), intensive care unit (ICU) admission, mortality, surgical site infection (SSI), emergency department (ED) visit, and deep vein thrombosis (DVT).

RESULTS

No significant differences were found between the COVID-19 and control groups in postoperative pneumonia (0.28% vs. 0.32%, p = 0.5785) or respiratory failure (0.30% vs. 0.38%, p = 0.3613). Secondary outcomes, including the incidence of AKI, ICU admission, mortality, SSI, ED visit, and DVT, showed no significant differences. Chronic obstructive pulmonary disease (COPD) emerged as the strongest risk factor for both pneumonia (odds ratio 6.06, p = 0.002) and respiratory failure (odds ratio 4.22, p = 0.013).

CONCLUSION

Recent preoperative COVID-19 infection did not significantly impact postoperative outcomes in patients with OSA undergoing metabolic surgery. However, the presence of COPD substantially increases the risk of respiratory complications, suggesting the need for additional preoperative optimization in these patients.

Effect of pulmonary rehabilitation on lung cancer surgery outcomes: a matched-case analysis

Pulmonary rehabilitation programs for COPD patients are extensively accessible throughout the UK and have demonstrated efficacy in enhancing outcomes, including recovery from exacerbations. Numerous lung cancer surgery patients possess COPD, and the surgery may be regarded as a definitive aggravation of COPD. It is ambiguous in practical application whether referral to pulmonary rehabilitation programs enhances surgical and patient-reported results. We want to address this topic by conducting a propensity-score analysis (PSA) of participants in an enriched cohort trial. Methods An enriched cohort research was conducted, providing rehabilitation both pre- and post-surgery pragmatically through local pulmonary rehabilitation providers for patients undergoing lung cancer resection, and compared to a contemporaneous control group receiving standard treatment. The study enrolled 873 participants (pulmonary rehabilitation (PR) n = 135, non-intervention or control (NG) n = 738). Regression analyses for exposed and unexposed matching, effect estimation, and standard error estimations were conducted.Results A total of 114 participants were matched PR (n = 57) and NG (n = 57). The multivariate-linear regression indicated a reduction in length of stay (LOS) of 0.2 days of LOS compared to the usual care group (EE = - 0.20), and that reduction could potentially go up to 1.8 days (95% CI = - 1.8-1.6). The multivariate log-binomial regression revealed that PR had a reduction of 60% postoperative pulmonary complications (PPC) rate (EE = - 0.60, 95% CI = - 1.8-0.5). Lastly, the multivariate-linear regression showed an improvement in quality of life 6 weeks and 6 months after surgery (QoL) in patients in PR, especially in the physical functioning score in which an improvement of 6.6% was noted for the PR group compared to the NG group following surgery (EE = 6.6). Conclusion Participation in "real world" pulmonary rehabilitation prior to and following surgery seems to yield improved patient and clinical results post-lung cancer surgery. Nonetheless, prompt access to pulmonary rehabilitation may be a significant challenge following COVID.

Smoking and Complications After Cancer Surgery: A Systematic Review and Meta-Analysis

Importance

Surgical cancer treatments may be delayed for patients who smoke over concerns for increased risk of complications. Quantifying risks for people who had recently smoked can inform any trade-offs of delaying surgery.

Objective

To investigate the association between smoking status or smoking cessation time and complications after cancer surgery.

Data Sources

Embase, CINAHL, Medline COMPLETE, and Cochrane Library were systematically searched for studies published from January 1, 2000, to August 10, 2023.

Study Selection

Observational and interventional studies comparing the incidence of complications in patients undergoing cancer surgery who do and do not smoke.

Data Extraction and Synthesis

Two reviewers screened results and extracted data according to the Meta-Analyses of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Data were pooled with a random-effects model and adjusted analysis was performed.

Main Outcomes and Measures

The odds ratio (OR) of postoperative complications (of any type) for people who smoke currently vs in the past (4-week preoperative cutoff), currently smoked vs never smoked, and smoked within shorter (2-week cutoff) and longer (1-year cutoff) time frames.

Results

The meta-analyses across 24 studies with a pooled sample of 39 499 participants indicated that smoking within 4 weeks preoperatively was associated with higher odds of postoperative complications compared with ceasing smoking for at least 4 weeks (OR, 1.31 [95% CI, 1.10-1.55]; n = 14 547 [17 studies]) and having never smoked (OR, 2.83 [95% CI, 2.06-3.88]; n = 9726 [14 studies]). Within the shorter term, there was no statistically significant difference in postoperative complications between people who had smoked within 2 weeks preoperatively and those who had stopped between 2 weeks and 3 months in postoperative complications (OR, 1.19 [95% CI, 0.89-1.59]; n = 5341 [10 studies]), although the odds of complications among people who smoked within a year of surgery were higher compared with those who had quit smoking for at least 1 year (OR, 1.13 [95% CI, 1.00-1.29]; N = 31 238 [13 studies]). The results from adjusted analyses were consistent with the key findings.

Conclusions and Relevance

In this systematic review and meta-analysis of smoking cessation and complications after cancer surgery, people with cancer who had stopped smoking for at least 4 weeks before surgery had fewer postoperative complications than those smoking closer to surgery. High quality, intervention-based evidence is needed to identify the optimal cessation period and inform clinicians on the trade-offs of delaying cancer surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perioperative Challenges: Analysis of Surgical Complications in Screening Lung Carcinoma Patient

Introduction In September 2020, the Institute for Pulmonary Diseases of Vojvodina (IPBV) started a lung cancer screening program using low-dose computed tomography (LDCT). Video-assisted thoracic surgery (VATS) lobectomy is the most effective treatment for early-stage lung cancer. However, the frequency of postoperative complications in VATS anatomical lung resections among patients enrolled in the screening program has not been adequately studied. This study aims to compare the frequency of surgical complications and length of hospital stay between patients enrolled in the screening program and a control group. Methods Retrospective, observational, monocentric, non-randomized study was conducted at the IPBV in Sremska Kamenica. The study included patients with a confirmed diagnosis of lung cancer who underwent anatomic pulmonary resection with mediastinal lymphadenectomy for therapeutic purposes. The patients were divided into two groups: the first group consisted of 34 patients who participated in the lung carcinoma screening program, while the second control group consisted of 102 patients. Over the past three years, all patients identified with nodules suspicious of malignancy during the screening program were sequentially enrolled in the screening group. For the control group, patients were selected based on a matching process to ensure valid statistical comparisons with the screening group. They were matched in a 3:1 ratio with patients from the screening group based on criteria including gender, disease stage, pathohistological type of cancer, tumor, node, and metastasis (TNM) stage of the disease, and degree of surgical resection. Patients were monitored for demographic parameters, smoking status, presence of comorbidities and prior oncological diseases, pulmonary function parameters, level of pre-operational risk, the number of lymph nodes removed by biopsies, spread through alveolar spaces (STAS), and the occurrence of complications after surgery (infection, bleeding, air leak, presence of adhesions), re-drainage, and length of hospital stay. Results The patients in the screening group had a higher incidence of infections, bleeding, prolonged air leak, and required re-drainage after surgery compared to the control group. Patients from the screening program with a high operative risk, prolonged air leak, and pleural adhesions had a statistically significant higher hospital stay longer than the control group. Conclusions This research emphasizes the importance of screening programs for detecting lung cancer in the early stages. However, it also highlights the need for further research to reduce surgical complications and improve therapeutic interventions for patients in the screening program.

Exploring Inflammatory Parameters in Lung Cancer Patients: A Retrospective Analysis

Inflammation-related parameters serve as pivotal indicators in the prognosis and management of lung cancer. This retrospective investigation aimed to explore the relationship between inflammatory markers and diverse clinical variables in non-small-cell lung cancer patients. A cohort of 187 individuals undergoing elective lobectomy for lung cancer was retrospectively analyzed, spanning an 11-year data collection period. Six inflammation ratios derived from complete peripheral blood counts were assessed. Significantly elevated levels of neutrophil-to-lymphocyte ratio (NLR) (p = 0.005), platelet-to-lymphocyte ratio (PLR) (p = 0.001), Aggregate Index of Systemic Inflammation (AISI) (p = 0.015), Systemic Inflammation Response Index (SIRI) (p = 0.004), and Systemic Immune Inflammation Index (SII) (p = 0.004) were observed in patients with advanced T stages. Significantly, elevated values (p < 0.05) of these parameters were observed in the study's smoker patients compared to non-smokers. A statistically significant correlation was identified between the NLR parameter and tumor size (p = 0.07, r = 0.204), alongside a significant elevation in SIRI (p = 0.041) among patients experiencing postoperative complications. Inflammatory biomarkers emerge as invaluable prognostic indicators for patients with non-small-cell lung cancer, offering potential utility in forecasting their prognosis.

Comparison of the effect between cefazolin/cefuroxime and broad-spectrum antibiotics in preventing post-operative pulmonary infections for smoking patients receiving video-assisted thoracoscopic lung surgery: a propensity score-matched retrospective cohort study

BACKGROUND

The selection of prophylactic antibiotics for preventing post-operative pulmonary infections in smoking patients undergoing video-assisted thoracoscopic lung surgery (VATLS) is not clear.

METHODS

In this retrospective cohort study, the outcomes of 572 smoking patients undergoing VATLS with prophylactic cefazolin/cefuroxime or other antibiotics were analyzed. Patients were classified as cefazolin/cefuroxime group and the control group. A 1:1 propensity score matching was also performed.

RESULTS

The primary outcome of the incidence of post-operative pulmonary infection did not differ significantly between the two groups (23.7% vs 30.5%, RR = 0.777, 95%CI 0.564 ~ 1.070 p = 0.113). Similarly, secondary outcomes including the incidence of post-operative fever, the white blood cell count and neutrophils on the 3rd day after the surgery, and time for blood routine test recovery were all found without significant difference between the two groups. In the multivariate logistic regression model, no association was found between prophylactic use of cefazolin/cefuroxime and post-operative pulmonary infections after controlling other possible confounding factors (OR = 0.685, 95%CI 0.441 ~ 1.065, p = 0.093).

CONCLUSIONS

Prophylactic use of cefazolin/cefuroxime was not associated with more adverse clinical outcomes among smoking populations undergoing VATLS when compared with broad-spectrum antibiotics and the two drugs are still feasible for peri-operative prophylactic use for smoking population before the surgery.

The Effect of Albuterol Spray on Hypoxia and Bronchospasm in Patients with Chronic Obstructive Pulmonary Disease (COPD) under General Anesthesia: A bouble-Blind Randomized Clinical Trial

Background

Patients with chronic obstructive pulmonary disease (COPD) experience an increased risk of perioperative pulmonary complications. The aim of this study was to evaluate the effect of albuterol spray on hypoxia and bronchospasm in patients with COPD under general anesthesia.

Methods

This single-center, double-blind, parallel-group, randomized clinical trial was performed on 120 smoking patients with COPD who were referred to 5 Azar Educational Hospital in Gorgan, Northern Iran, in 2021. Twenty minutes before general anesthesia and also after completion of surgery and before extubation, 60 patients in the intervention group were inhaled with 2 puffs of albuterol spray. In the control group, patients were inhaled with 2 puffs of placebo spray. In perioperative period, the occurrence of wheezing, bronchospasm, coughing, hemodynamic changes, postoperative shivering, dyspnea, and nausea and vomiting were evaluated in all patients. The Consolidated Standards of Reporting Trials (CONSORT) checklist was used to report important aspects of this study.

Results

The mean age of the patients was 52.34 ±8.95 years, and 115 (95.8%) of them were males while the rest were females. The difference between systolic blood pressure before induction of anesthesia (after administration of albuterol spray) between the group receiving albuterol spray and the group not receiving it was statistically significant (p=0.04). Also, the difference between the mean arterial oxygen saturation before tracheal extubation (after re-administration of albuterol spray) between the albuterol spray group and the non-albuterol group was statistically significant (p = 0.03). Wheezing and recurrent cough after induction of anesthesia and after extubation (after albuterol spray administration) was lower in the albuterol group than in the control group (p<0.05). No significant side effects were detected in the albuterol-treated group.

Conclusion

According to the results of this study, it seems that the prophylactic use of albuterol spray is useful in reducing the incidence of wheezing and recurrent cough before induction of anesthesia in COPD patients with smoking.

Biological and Genetic Mechanisms of COPD, Its Diagnosis, Treatment, and Relationship with Lung Cancer

Chronic obstructive pulmonary disease (COPD) is one of the most prevalent chronic adult diseases, with significant worldwide morbidity and mortality. Although long-term tobacco smoking is a critical risk factor for this global health problem, its molecular mechanisms remain unclear. Several phenomena are thought to be involved in the evolution of emphysema, including airway inflammation, proteinase/anti-proteinase imbalance, oxidative stress, and genetic/epigenetic modifications. Furthermore, COPD is one main risk for lung cancer (LC), the deadliest form of human tumor; formation and chronic inflammation accompanying COPD can be a potential driver of malignancy maturation (0.8-1.7% of COPD cases develop cancer/per year). Recently, the development of more research based on COPD and lung cancer molecular analysis has provided new light for understanding their pathogenesis, improving the diagnosis and treatments, and elucidating many connections between these diseases. Our review emphasizes the biological factors involved in COPD and lung cancer, the advances in their molecular mechanisms' research, and the state of the art of diagnosis and treatments. This work combines many biological and genetic elements into a single whole and strongly links COPD with lung tumor features.

New Implications of Patients’ Sex in Today’s Lung Cancer Management

Simple Summary

We aim to raise awareness that sex is an important factor to take into account in modern-day thoracic oncology practice. Summarized, women should be specifically targeted in smoking cessation campaigns and sex-specific barriers should be addressed. Women present more often with adenocarcinoma histology and EGFR/ALK alterations, as lung cancer in never-smokers is more common in women compared to men. Lung cancer in female patients may show a poorer response to immune checkpoint inhibition; therefore, the addition of chemotherapy should be considered. On the other hand, women experience more benefits from targeted therapy against EGFR. In general, prognosis for women is better compared to that in men. Lung cancer screening trials report that women derive more benefit from screening, although they have not been designed for women. Future trial designs should take this into account and encourage participation of women.

Abstract

This paper describes where and how sex matters in today’s management of lung cancer. We consecutively describe the differences between males and females in lung cancer demographics; sex-based differences in the immune system (including the poorer outcomes in women who are treated with immunotherapy but no chemotherapy); the presence of oncogenic drivers and the response to targeted therapies according to sex; the greater benefit women derive from lung cancer screening and why they get screened less; and finally, the barriers to smoking cessation that women experience. We conclude that sex is an important but often overlooked factor in modern-day thoracic oncology practice.

Establishment of Thoracic Surgical Difficulty Assessment Scale based on Delphi method

OBJECTIVES

The difficulty of surgery, which is related to surgical safety, has only been mentioned as a subjective perception for a long time. There are few studies to quantitatively and systematically evaluate the difficulty of thoracic surgery. This study aims to establish a quantitative evaluation index system for thoracic surgical difficulty, and to evaluate its reliability and validity.

METHODS

During the 2 national thoracic surgery academic conferences, the factors that may affect the difficulty of thoracic surgery were evaluated by the thoracic surgeons via semi open questionnaires, and then the evaluation item pool of thoracic surgery difficulty was established. The importance of each indicator in the evaluation item pool was graded by 2 rounds of Delphi method. The average score, full score rate and coefficient of variation of each index were calculated, and the composite index method was used to decide whether to delete the indicator.Finally, the difficulty evaluation scale of thoracic surgery was constructed. The surgical data of patients with thoracic tumors were collected. The scale was used to evaluate the difficulty of thoracic surgery for lung, esophageal, and mediastinal tumors. The reliability and validity of the scale were evaluated by the commonly used difficulty evaluation indexes: Operation time, intraoperative estimated blood loss, Visual Analog Scale (VAS), side injury rate, and blood transfusion rate as standards.

RESULTS

A total of 230 questionnaires were distributed in the 2 rounds of survey, and 149 valid questionnaires were collected after eliminating duplicate questionnaires. Through 2 rounds of Delphi consultation with 20 experts, the difficulty evaluation indexes were scored and screened, and the difficulty evaluation scale of thoracic surgery was established. It included 5 main indexes (surgical decision-making, operation space, separation interface, reconstruction method, and surgical materials) and 16 secondary indexes [American Society of Anesthesiologists (ASA) classification, surgical trauma, operator experience, space size, space depth, space source, space adjacent, interface content, anatomical gap, visual field, interface size, reconstruction complexity, reconstruction scope, autologous materials, artificial biomaterials and instruments]. After weighting, the total score of Thoracic Surgery Difficulty Evaluation Scale was from 1 to 3. A Score at 1 standed for simplicity, and score at 3 standed for difficulty. Further data were collected for 127 cases of thoracic tumor surgery. The difficulty scores of surgery for lung, esophageal, and mediastinal tumor were 1.69±0.26, 1.86±0.18, and 1.56±0.31, respectively, and the Cronbach's α coefficients of the scale in 3 tumor surgeries were 0.993, 0.974, and 0.989, repectively, and the Spearman Brown coefficients were 0.996, 0.984, and 0.996, respectively. The Spearman correlation coefficients of operation difficulty score with operation time, estimated blood loss, and VAS were 0.360 and 0.634, 0.632 and 0.578, 0.696 and 0.875, respectively (all P<0.05). The incidence of postoperative complications in the difficult operation group (difficulty score >1.85) was higher than that in the non-difficult operation group (P=0.02).

CONCLUSIONS

The quantitative Thoracic Surgical Difficulty Assessment Scale has been successfully established, which shows good reliability and validity in thoracic tumor surgery. The Thoracic Surgical Difficulty Assessment Scale has broad application prospects in reducing the difficulty of the surgery, controlling surgical complications, and training surgeons.