Minimal-invasive approach reduces cardiopulmonary complications in elderly after lung cancer surgery

[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.

Improvements in perioperative outcomes for non-small cell lung cancer: a decade-long analysis

BACKGROUND

Video-assisted thoracic surgery (VATS) procedures for non-small cell lung cancer (NSCLC) have steadily increased and have become the gold standard, but their prognostic advantage compared with thoracotomy has not been elucidated. This study retrospectively evaluated perioperative characteristics of VATS for NSCLC over time.

METHODS

We collected the clinical data of 760 patients with NSCLC who underwent pulmonary resection over the past decade, classifying patients into early (2011-2015) and late (2016-2020) periods. Changes in NSCLC patient characteristics, surgical approaches, perioperative factors, postoperative morbidities, and prognoses were analyzed.

RESULTS

Patients in the late period were older (p = 0.01), had more comorbidities (p = 0.01), and had earlier-stage cancer (p < 0.01) than those in the early period. The late period had significantly fewer surgical procedures for lobectomy or extended resection beyond lobectomy (p < 0.01), open thoracotomies (p < 0.01), postoperative (p = 0.02) and severe morbidities (p < 0.01), and a significantly shorter postoperative hospital stay than the early period. Surgical procedures of lobectomy or extended resection beyond lobectomy (p < 0.01) were significant risk factors for postoperative morbidity, and being in the early period (p < 0.01) and surgical procedures of lobectomy or extended resection beyond lobectomy (p < 0.01) were significant risk factors for severe postoperative morbidities. The overall survival prognosis significantly differed between the groups (p = 0.02) but progression-free survival did not (p = 0.89).

CONCLUSIONS

The incidence of postoperative morbidities decreased over time in older patients and patients with more comorbidities. The prognosis of patients with NSCLC did not change with increasing VATS or sublobar resection.

The nomograms for predicting overall and cancer-specific survival in elderly patients with early-stage lung cancer: A population-based study using SEER database

Purpose

Lung cancer is the leading cause of death from cancer and the number of operable elderly lung cancer patients is increasing, with advanced age being associated with a poorer prognosis. However, there is no easy and comprehensive prognostic assessment method for these patients.

Methods

Clinicopathological data of patients aged 65 years or older with TNM stage I-II lung cancer from 2004 to 2018 were downloaded from the SEER database. Patients from 2004 to 2015 were randomized into a training group (n = 16,457) and a validation group (n = 7,048). Data from 2016 to 2018 (n = 6,231) were used for external validation. Two nomogram prognostic models were created after independent prognostic factors connected to both overall survival (OS) and cancer-specific survival (CSS) in the training set by using univariate and multivariate Cox proportional hazards regression analysis. In turn, overall survival (OS) and cancer-specific survival (CSS) were predicted for patients at 1, 3, and 5 years. Based on the concordance index (C-index), calibration curves, area under the receiver operating characteristics (ROC) curve (AUC), the time-dependent area under the ROC curve, the validity, accuracy, discrimination, predictive ability, and clinical utility of the models were evaluated. Decision curve analysis (DCA) was used to assess the clinical value of the models.

Results

A total of 29,736 patients were included. Univariate and multivariate analyses suggested that age, race, gender, marriage, disease grade, AJCC stage, T-stage, surgery, radiotherapy, chemotherapy, and tumor size were independent risk factors for patient prognosis. These 11 variables were included in nomogram to predict OS and CSS of patients. C-indexes of OS for the training, validation and external validation sets were 0.730 (95% CI, 0.709-0.751), 0.734 (95% CI, 0.722-0.746), and 0.750 (95% CI, 0.734-0.766), respectively. The AUC results for the training and validation sets indicated good accuracy for this nomogram. The calibration curves demonstrated a high degree of concordance between actual and anticipated values, and the DCA demonstrated that the nomograms had better clinical application than the traditional TNM staging approach.

Conclusion

This study identified risk factors for survival in operable elderly lung cancer patients and established a new column line graph for predicting OS and CSS in these patients. The model has good clinical application and can be a good clinical decision-making tool for physicians and patients.

Non-Intubated Versus Intubated Video-Assisted Thoracic Surgery in Patients Aged 75 Years and Older: A Propensity Matching Study

Introduction

In most developed countries, lung cancer is associated with the highest mortality rate among all cancers. The number of elderly patients with lung cancer is increasing, reflecting the global increase in aging population. Patients with impaired lung or cardiac function are at a high risk during intubated general anesthesia, which may preclude them from surgical lung cancer treatment. We evaluated the safety and survival of non-intubated video-assisted thoracoscopic surgery (VATS) versus those of intubated thoracoscopic surgery for surgical resection for lung cancer in older patients.

Methods

Patients aged ≥75 years who underwent non-intubated and intubated VATS resection with pathologically confirmed non-small cell lung cancer, using a combination of thoracic epidural anesthesia or intercostal nerve block and intra-thoracic vagal block with target-controlled sedation, from January 2011 to December 2019 were included. Ultimately, 79 non-intubated patients were matched to 158 patients based on age, sex, body mass index, family history, comorbidity index, pulmonary function (forced expiratory volume in one second/ forced vital capacity [%]), and disease stage. The endpoints were overall survival and recurrence progression survival.

Results

All patients had malignant lung lesions. Data regarding conversion data and the postoperative result were collected. Both groups had comparable preoperative demographic and cancer staging profiles. The anesthetic duration in the non-intubated group was shorter than that in the intubated group, which showed a significantly higher mean number of lymph nodes harvested (intubated vs non-intubated, 8.3 vs. 6.4) and lymph stations dissected (3.0 vs. 2.6). Intensive care unit (ICU) admission rate and postoperative ICU stay were significantly longer in the intubated group. The complication rate was higher and hospital stay were longer in the intubated group, but these differences were not significant (12% vs. 7.6%; p = .07, respectively).

Conclusions

In the elderly, non-intubated thoracoscopic surgery provides similar survival results as the intubated approach, although fewer lymph nodes are harvested. Non-intubated surgery may serve as an alternative to intubated general anesthesia in managing lung cancer in carefully selected elderly patients with a high risk of impaired pulmonary and cardiac function.

Continuous serratus anterior plane block improved early pulmonary function after lung cancer surgery

BACKGROUND

Serratus anterior plane block (SAPB) has been proven to be an efficient way to control postoperative pain. This study explored whether the use of continuous SAPB in combination with flurbiprofen could improve early pulmonary function in lung cancer patients undergoing video-assisted thoracoscopic surgery (VATS).

METHODS

From July 2019 to April 2020, patients who scheduled for elective lung resection undergoing thoracoscopic surgery were randomly allocated to receive patient-controlled SAPB in combination with intravenous flurbiprofen or patient-controlled intravenous analgesia. Postoperative pulmonary function parameters, including forced expiratory volume in 1 second, and forced vital capacity were collected before and 24, 48, and 72 hours after surgery. Pain intensity was measured at rest and on coughing. Comfort score during breathing exercises, postoperative pulmonary complications and adverse events were recorded.

RESULTS

A substantial reduction in lung function was exhibited in both groups after surgery (P < 0.001), but lung function parameters in continuous SAPB group were significantly higher (P < 0.001) throughout postoperative period up to 72 hours, regardless of the surgery type. Meanwhile, there were significant differences of pain intensity at rest and on coughing between both groups (P < 0.001). The incidence of pneumonia, pulmonary atelectasis, hypoxemia, vomiting and the comfort score in continuous SAPB group was significantly lower (P< 0.05).

CONCLUSIONS

Postoperative acute pain treatment with continuous SAPB in combination with flurbiprofen enhanced pulmonary function and reduced postoperative pulmonary complications in lung cancer patients undergoing VATS.