Pneumonectomy for lung cancer in the elderly: lessons learned from a multicenter study

The Impact of Postoperative Pulmonary Complications on Perioperative Outcomes in Patients Undergoing Pneumonectomy: A Multicenter Retrospective Cohort Study of the German Thorax Registry

Postoperative pulmonary complications have a deleterious impact in regards to thoracic surgery. Pneumonectomy is associated with the highest perioperative risk in elective thoracic surgery. The data from 152 patients undergoing pneumonectomy in this multicenter retrospective study were extracted from the German Thorax Registry database and presented after univariate and multivariate statistical processing. This retrospective study investigated the incidence of postoperative pulmonary complications (PPCs) and their impact on perioperative morbidity and mortality. Patient-specific, preoperative, procedural, and postoperative risk factors for PPCs and in-hospital mortality were analyzed. A total of 32 (21%) patients exhibited one or more PPCs, and 11 (7%) died during the hospital stay. Multivariate stepwise logistic regression identified a preoperative FEV1 < 50% (OR 9.1, 95% CI 1.9-67), the presence of medical complications (OR 7.4, 95% CI 2.7-16.2), and an ICU stay of more than 2 days (OR 14, 95% CI 3.9-59) as independent factors associated with PPCs. PPCs (OR 13, 95% CI 3.2-52), a preoperative FEV1 < 60% in patients with previous pulmonary infection (OR 21, 95% CI 3.2-52), and continued postoperative mechanical ventilation (OR 8.4, 95% CI 2-34) were independent factors for in-hospital mortality. Our data emphasizes that PPCs are a significant risk factor for morbidity and mortality after pneumonectomy. Intensified perioperative care targeting the underlying risk factors and effects of PPCs, postoperative ventilation, and preoperative respiratory infections, especially in patients with reduced pulmonary reserve, could improve patient outcomes.

Artificial Intelligence-Based Hazard Detection in Robotic-Assisted Single-Incision Oncologic Surgery

THE PROBLEM

Single-incision surgery is a complex procedure in which any additional information automatically collected from the operating field can be of significance. While the use of robotic devices has greatly improved surgical outcomes, there are still many unresolved issues. One of the major surgical complications, with higher occurrence in cancer patients, is intraoperative hemorrhages, which if detected early, can be more efficiently controlled.

AIM

This paper proposes a hazard detection system which incorporates the advantages of both Artificial Intelligence (AI) and Augmented Reality (AR) agents, capable of identifying, in real-time, intraoperative bleedings, which are subsequently displayed on a Hololens 2 device.

METHODS

The authors explored the different techniques for real-time processing and determined, based on a critical analysis, that YOLOv5 is one of the most promising solutions. An innovative, real-time, bleeding detection system, developed using the YOLOv5 algorithm and the Hololens 2 device, was evaluated on different surgical procedures and tested in multiple configurations to obtain the optimal prediction time and accuracy.

RESULTS

The detection system was able to identify the bleeding occurrence in multiple surgical procedures with a high rate of accuracy. Once detected, the area of interest was marked with a bounding box and displayed on the Hololens 2 device. During the tests, the system was able to differentiate between bleeding occurrence and intraoperative irrigation; thus, reducing the risk of false-negative and false-positive results.

CONCLUSION

The current level of AI and AR technologies enables the development of real-time hazard detection systems as efficient assistance tools for surgeons, especially in high-risk interventions.

[Surgery of old people-Thoracic surgery]

Background

The incidence of a large number of diseases relevant to thoracic surgery increases with age; however, old age is still frequently considered a contraindication per se for curative interventions and extensive surgical procedures.

Objective

Overview of the current relevant literature, derivation of recommendations for patient selection as well as preoperative, perioperative and postoperative optimization.

Material and methods

Analysis of the current study situation.

Results

Recent data show that for most thoracic diseases, age alone is not a reason to withhold surgical treatment. Much more important for the selection are comorbidities, frailty, malnutrition and cognitive impairment. A lobectomy or segmentectomy for stage I non-small cell lung cancer (NSCLC) in carefully selected octogenarians can provide acceptable to even comparably good short-term and long-term results as in younger patients. Selected > 75-year-old patients with stages II-IIIA NSCLC even benefit from adjuvant chemotherapy. With appropriate selection high-risk interventions, such as pneumonectomy in > 70-year-old patients and pulmonary endarterectomy in > 80-year-old patients can be performed without an increase in mortality rates. Even lung transplantation can lead to good long-term results in carefully selected > 70-year-old patients. Minimally invasive surgical techniques and nonintubated anesthesia contribute to risk reduction in marginal patients.

Discussion

In thoracic surgery the biological age rather than the chronological age is decisive. In view of the increasingly older population, further studies are urgently needed to optimize patient selection, type of intervention, preoperative planning and postoperative treatment as well as the quality of life.

[Surgery of old people-Thoracic surgery]

BACKGROUND

The incidence of a large number of diseases relevant to thoracic surgery increases with age; however, old age is still frequently considered a contraindication per se for curative interventions and extensive surgical procedures.

OBJECTIVE

Overview of the current relevant literature, derivation of recommendations for patient selection as well as preoperative, perioperative and postoperative optimization.

MATERIAL AND METHODS

Analysis of the current study situation.

RESULTS

Recent data show that for most thoracic diseases, age alone is not a reason to withhold surgical treatment. Much more important for the selection are comorbidities, frailty, malnutrition and cognitive impairment. A lobectomy or segmentectomy for stage I non-small cell lung cancer (NSCLC) in carefully selected octogenarians can provide acceptable to even comparably good short-term and long-term results as in younger patients. Selected > 75-year-old patients with stages II-IIIA NSCLC even benefit from adjuvant chemotherapy. With appropriate selection high-risk interventions, such as pneumonectomy in > 70-year-old patients and pulmonary endarterectomy in > 80-year-old patients can be performed without an increase in mortality rates. Even lung transplantation can lead to good long-term results in carefully selected > 70-year-old patients. Minimally invasive surgical techniques and nonintubated anesthesia contribute to risk reduction in marginal patients.

DISCUSSION

In thoracic surgery the biological age rather than the chronological age is decisive. In view of the increasingly older population, further studies are urgently needed to optimize patient selection, type of intervention, preoperative planning and postoperative treatment as well as the quality of life.

Pneumonectomy in an elderly patient with congenital unilateral lung hypoplasia and recurrent Aspergillus: a case report

Background

Congenital lung disorders encompass a spectrum of several conditions, one of which is lung hypoplasia. While hypoplasia is typically identified and intervened upon in the neonatal period, some patients can remain asymptomatic or even be diagnosed as adults. Given the rarity of the condition persisting in adults though, it is not clear what medical or surgical interventions may be helpful if respiratory status declines.

Case Description

In this report, we describe an elderly man with a history of right lung hypoplasia, pulmonary artery agenesis, and bronchial atresia who developed progressive dyspnea and worsening cough. His condition was complicated by multiple Aspergillus infections for which he received prolonged courses of anti-fungal therapy. He was also treated for bacterial pneumonia many times over a 10-year period. However, as his symptoms remained refractory to medical management, he underwent pneumonectomy, which revealed diffuse cystic changes in the right lung. He is currently doing well post-operatively with resolution of his dyspnea.

Conclusions

Although hypoplastic lung disorders have been described in asymptomatic adults, this report highlights the successful utilization of pneumonectomy in an individual with refractory symptoms much later in adulthood. This case additionally describes possible complications of cystic lung disease in this patient population, serving as further rationale for aggressive intervention.

Clinical characteristics and survival outcomes of patients with pneumonectomies: A population-based study

BACKGROUND

Prognostic factors in a pneumonectomy (PN) are not yet fully defined. This study sought to analyze and evaluate long-term survival after pneumonectomies (PNs) for patients with non-small cell lung cancer (NSCLC).

METHODS

We obtained data from the Surveillance, Epidemiology, and End Results (SEER) database for patients who underwent PNs between 2004 and 2015. Propensity score matching (PSM) analysis and Kaplan-Meier curves were used to estimate overall survival (OS), while univariate and multivariable Cox proportional hazards regression analyses were applied to create a forest plot.

RESULTS

In total, 1,376 patients were grouped according to right/left PNs. Before matching, OS was worse after a right PN [hazard ratio (HR): 1.459; 95% CI 1.254-1.697; P < 0.001] and after matching, survival differences between groups were not significant (HR: 1.060; 95% CI 0.906-1.240; P = 0.465). Regression analysis revealed that age, gender, grade, lymph node dissection, N-stage, and chemotherapy were independent predictors of OS (P < 0.05). Chemotherapy was associated with improved OS (P < 0.001).

CONCLUSIONS

Laterality was not a significant prognostic factor for long-term survival after a PN for NSCLC. Chemotherapy was a significant independent predictor of improved OS. Long-term survival and outcomes analyses should be conducted on larger numbers of patients.