[Influencing factor of postoperation fast-track recovery and in hospital cost after lobctomy for lung cancer]

[Analysis on the Incidence and Economic Burden of Patients with Lung Cancer]

BACKGROUND

The previous study has indicated that lung cancer has a high incidence and mortality in China, and has caused a large economic burden. The purpose of this study was to analyze the incidence and economic burden of lung cancer by analyzing the information on the home page of discharge history of lung cancer patients in Hebei Tumor Hospital, and to provide scientific basis for the prevention and treatment of lung cancer.

METHODS

The information of all of the discharges, new cases, surgical patients, age, gender, length of stay and hospitalization cost of lung cancer patients in Hebei Tumor Hospital from January 2012 to December 2019 were retrieved based on the medical record management system, and the incidence trend, gender and age distribution as well as the economic burden of the disease were statistically described.

RESULTS

The number of new cases of lung cancer increased year by year, from 2,235 cases in 2012 to 5,012 cases in 2019. The number of males always outnumbered females, but the gender ratio decreased year by year, from 2.25 in 2012 to 1.56 in 2019. Among new cases of lung cancer, the proportion of surgical treatment increased year by year, from 28.14% in 2012 to 44.83% in 2019. Except for 2012, the proportion of surgical operations in female patients was higher than that in male patients from 2013 to 2019. The proportion of surgical operations in male and female patients was 23.52% and 28.07% in 2013, and 36.14% and 58.37% in 2019, respectively. The median age at the onset of lung cancer has increased year by year, from 61 years old in 2012 to 63 years old in 2019. The median age of onset in all lung cancer patients was higher in males than in females. The number of new lung cancer patients and surgical patients both showed an increasing trend with the increase of age, and both reached the maximum value in the age group of 60-69 years old. With the increase of age, the number of patients gradually decreased. The median length of hospital stay for all discharged lung cancer patients or surgical patients decreased year by year, from 10 d and 19 d in 2012 to 8 d and 17 d in 2019, respectively, while the median hospitalization cost increased year by year. It increased from 10,611.46 yuan and 38,750.13 yuan in 2012 to 17,187.15 yuan and 84,030.16 yuan in 2019, respectively.

CONCLUSIONS

Lung cancer is still one of the main cancers endangering the health of Chinese residents. The incidence of lung cancer is increasing year by year, and the distribution of gender and age has certain characteristics. In order to reduce the number of cases and the economic burden, effective prevention and control measures should be formulated and medical reform should be strengthened.

[Application of Single-hole Thoracoscopic Surgery Combined with ERAS Concept for Respiratory Function Exercise in Perioperative Period of Lung Cancer]

背景和目的

肺癌是当前国内和国外发病率和死亡率均排名前列的恶性肿瘤, 手术治疗为肺癌治疗的主要治疗方案。本研究旨在探讨快速康复外科(enhanced recovery after surgery, ERAS)理念的呼吸功能锻炼联合单孔胸腔镜手术对肺癌患者术后肺部并发症、术后疼痛、下床时间、拔管时间以及住院时间的影响。

方法

选择2017年10月-2019年10月在扬州大学附属医院和盐城市第一人民医院行胸腔镜肺癌手术的240例患者, 随机分为四组, 每组60例。A组患者采用单孔胸腔镜手术, 术前进行ERAS理念宣教和呼吸功能锻炼; B组采用常规3孔胸腔镜手术, 术前进行ERAS理念宣教和呼吸功能锻炼; C组采用常规3孔胸腔镜手术, 进行常规入院宣教和护理指导, 常规的呼吸功能锻炼, 无术前ERAS理念宣教; D组采用单孔胸腔镜手术, 进行常规入院宣教和护理指导以及常规的呼吸功能锻炼, 无术前ERAS理念宣教。记录四组患者术后肺部并发症的发生数量、术后疼痛、下次时间、拔管时间及住院时间。

结果

A组分别与B组、C组、D组三组比较, 肺部并发症发生率明显降低, 下床时间、拔管时间和住院时间明显缩短; 与B组、C组两组比较, 术后疼痛明显减轻; B组与C组比较, B组肺部并发症显著降低, 下床时间、拔管时间和住院时间明显缩短, 差异均有统计学意义(P < 0.05)。术后疼痛在A组和D组比较以及B组和C组比较中均未见明显差异(P > 0.05)。

结论

对于单孔胸腔镜肺癌手术患者, ERAS理念指导可有效降低肺部并发症的发生率和术后疼痛, 缩短下床时间、拔管时间以及住院时间。

[What is Enhanced Recovery After Surgery: Humanity or Technology?]

The development of surgical techniques and the innovation of surgical instruments promote the changes in surgical methods, which in turn, leads to the reforms of surgical idea. The concept of enhanced recovery after surgery (ERAS) results in the surgery connotation switching from "to treat an illness" to "to save patients". ERAS also causes the change of surgery denotation from "only operation" to "enhance recovery". The concept of ERAS is derived from but not only restricted to the development of surgical techniques. Also, ERAS pays more attention to patients than disease and thinks more about patient safety and recovery than surgical technique. Specifically, ERAS has three advantages: first, ERAS attaches importance to multidisciplinary assessment (patient-oriented) and select appropriate (personalized) treatment and tries to decrease the rate of complication and mortality. Second, ERAS pays attention to preoperative preparation and high-risk prevention performed by multi-disciplinary collaboration in order to prevent complication and save cost for patients. Third, ERAS always focus on optimizing the process of perioperative period and trying to change the working habits of surgeons and the old cooperation mode among doctors, nurses and rehabilitation physicians. To sum up, the goal is to apply the concept of ERAS to all the links of perioperative period and try hard to decrease patients' stress and pain, which finally helps doctors fulfill the ultimate aims of "no pain and no risk".
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[Establishment and Optimization of Enhanced Recovery after Surgery System for Lung Cancer]

加速康复外科（enhanced recovery after surgery, ERAS）理念应用于不同疾病及学科均有其相应的关键技术及流程与体系。肺癌微创外科的核心是加速肺康复（enhanced lung recovery after surgery, ELRAS），而加速肺康复的关键技术是气道管理和肺保护。气道管理和肺保护的实现需要医、护、康一体及多学科协作，从而形成肺癌患者加速肺康复的完整体系。主要包括以下几方面：一是ERAS方案实施的各个环节均有准确、客观的评估体系；二是ERAS方案简单、易行且具有可重复性；三是ERAS方案临床应用效果具有精准严谨评价体系；四是以问题为导向的团队架构。总之，加速肺康复外科体系需要在临床实践中不断优化与完善。

[Can Preoperative Peak Expiratory Flow Predict Postoperative Pulmonary Complications in Lung Cancer Patients Undergoing Lobectomy?]

BACKGROUND

Postoperative pulmonary complications (PPCs), especially postoperative pneumonia (POP), directly affect the rapid recovery of lung cancer patients after surgery. Peak expiratory flow (PEF) can reflect airway patency and cough efficiency. Moreover, cough impairment may lead to accumulation of pulmonary secretions which can increase the risk of PPCs. The aim of this study is to investigate the effect of preoperative PEF on PPCs in patients with lung cancer.

METHODS

Retrospective research was conducted on 433 lung cancer patients who underwent lobectomy at the West China Hospital of Sichuan University from January 2014 to December 2015. The associations between preoperative PEF and PPCs were analyzed based on patients' basic characteristics and clinical data in hospital.

RESULTS

Preoperative PEF value in PPCs group (280.93±88.99) L/min was significantly lower than that in non-PPCs group (358.38±93.69) L/min (P<0.001). According to the binary logistics regression analysis, PEF and operative time were independent risk factors for PPCs. Further, ROC curve showed that PEF=320 L/min was the cut-off value for predicting the occurrence of PPCs (AUC=0.706, 95%CI: 0.661-0.749). The incidence of PPCs in PEF≤320 L/min group (26.6%) was significantly higher than that in PEF>320 L/min group (9.4%)(P<0.001).

CONCLUSIONS

Preoperative PEF and PPCs are correlated, and PEF may be used as a predictor of PPCs.

[Enhanced Lung Recovery after Surgery, Is It A Necessary for Precision Therapy?]

背景与目的

绿原酸类物质可通过调节细胞周期、诱导凋亡、抑制细胞生长等途径产生抗癌作用，Notch信号通路与人类许多肿瘤都存在密切的关系，本研究旨在探讨绿原酸通过Notch1信号通路控制非小细胞肺癌细胞凋亡的作用机制，为临床应用以及Notch1靶向药物的研究提供依据。

方法

MTT法检测不同浓度的绿原酸对非小细胞肺癌细胞系A549细胞形态和细胞增殖的影响；流式细胞仪检测绿原酸对A549细胞的凋亡和细胞周期的影响；建立A549细胞的裸鼠荷瘤模型；测量肿瘤大小和重量；实时荧光定量PCR法检测Notch信号通路相关因子的mRNA表达水平；免疫印迹法检测Notch信号通路相关因子的蛋白表达水平。

结果

绿原酸抑制A549细胞增殖，诱导A549细胞凋亡，增加细胞G₂期/M期细胞百分比增加（P < 0.05），并且呈现剂量依赖趋势。在A549细胞的裸鼠荷瘤模型中，实验组肿瘤大小和体积明显小于对照组，差异具有统计学意义（P < 0.01）。试验组Notch1、VEGF、Delta4、HES1、HEY1 mRNA表达量较对照组明显减少（P < 0.05）。实验组Notch1蛋白明显减少，PTEN、p-PTEN、p-AKT明显增加（P < 0.05）。

结论

在动物水平，绿原酸可能通过Notch1信号通路调控非小细胞肺癌的凋亡，可能是通过减少VEGF的表达，下调Delta 4水平，从而抑制Notch1信号通路的活化。Notch1信号通路可能通过PTEN与PI3K/AKT通路存在交叉调控作用。

[Evidence and Practice of Enhanced Lung Recovery after Surgery in Patients Undergoing Lung Surgery]

加速康复外科（enhanced recovery after surgery, ERAS）方案临床应用的多样性，取决于病种和团队而不同。肺术后都有哪些证据有利于加速肺康复（enhanced lung recovery after surgery, ELRAS）的临床实践呢？本文主要从围手术期可采用的措施及方法进行回顾性分析：术前强调教育及高危因素的评估及预防，术中微创手术及流程优化，术后关注以疼痛为主的症状管理。

[Enhanced Recovery after Surgery from Theory to Practice What do We Need to Do?]

Enhanced recovery after surgery (ERAS) is a paradigm shift in perioperative care, resulting in substantial improvements in clinical outcomes, shorter length of hospital stay and cost savings. But the current ERAS either by application of breadth or depth is not enough, why? The main reason is the lack of "operability, evaluation, repetition" ERAS protocol and suitable for clinical extensive application protocol. How to form the clinical available protocol? Operational mainly refers to the clinical scheme is simple and feasible, and protocol compliance is good; Evaluate refers to the methods used before, during and after are the objective evaluation criteria and plan; Repeatable is clinical scheme repeatability in the process of single or multiple center.

[Impact and Effect of Preoperative Short-term Pulmonary Rehabilitation Training on Lung Cancer Patients with Mild to Moderate Chronic Obstructive Pulmonary Disease: A Randomized Trial]

BACKGROUND

Pulmonary rehabilitation (PR) is proposed as an effective strategy to decrease surgical morbidity. However, appropriate rehabilitation plan, initiation time, and optimal duration of PR remain unclear. Lung cancer patients with chronic obstructive pulmonary disease (COPD) are considered high-risk population for postoperative pulmonary complications (PPCs) because of poor lung fitness and cardiopulmonary endurance. This study aims to assess the impact of a one-week, systematic and highly-intensive rehabilitation on surgical lung cancer patients with mild to moderate COPD.

METHODS

A randomized controlled trial with 48 subjects was conducted (24 patients each for the intervention and groups). The intervention group received seven days of systematic, integrated and highly-intensive PR before surgical treatment, including: pharmacotherapy with atomizing terbutaline, pulmicort and infusion of ambroxol; and physical rehabilitation with respiratory training and endurance training. The control group underwent standard preoperative care.

RESULTS

For the intervention group, the postoperative length of stay was shorter [(6.17±2.91) d vs (8.08±2.21) d; P=0.013]; likewise for the duration of antibiotics use [(3.61±2.53) d vs (5.36±3.12) d; P=0.032]. No significant difference was found between the groups in total in-hospital cost [(46,455.6±5,080.9) ¥ vs (45,536.0±4,195.8) ¥, P=0.498], medicine cost [(7,760.3±2,366.0) vs (6,993.0±2,022.5), P=0.223], and material cost [(21,155.5±10,512.1) ¥ vs (21,488.8±3,470.6) ¥, P=0.883]. In the intervention group, peak expiratory flow [(268.40±123.94) L/min vs (343.71±123.92) L/min; P<0.001], 6-min walk distance (6-MWD) [(595.42±106.74) m vs (620.90±99.27) m; P=0.004], and energy consumption [(59.93±10.61) kcal vs (61.03±10.47) kcal; P=0.004] were statistically different after the seven-day exercise, compared with those on the first day. Finally, for the intervention group the incidence of PPCs (8.3%, 2/24 vs 20.8%, 5/24, 20.8%; P=0.416) were lower.

CONCLUSIONS

The systematic and highly-intensive pulmonary rehabilitation combining abdominal respiration training, respiratory exercise with incentive spirometry, and aerobic exercise could improve the cardiorespiratory endurance of lung cancer patients with mild to moderate COPD. The proposed program may be a practicable preoperative strategy.
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[Status of perioperative airway management in patients with chronic obstructive pulmonary disease and lung cancer]

肺癌患者均合并不同程度的慢性阻塞性肺疾病（chronic obstructive pulmonary disease, COPD），而COPD导致的肺功能降低对其能否手术治疗及术后并发症发生具有重要的影响。研究证明围手术期气道管理可以有效改善患者肺功能且减少术后并发症。本文针对近年来气道管理的临床应用现状及进展进行综述，主要有以下几方面：①围手术期气道管理的必要性；②围手术期气道管理的药物治疗现状与特点；③围手术期应用气道管理在改善肺功能中的价值；④围手术期需要气道管理的最佳人群；⑤围手术期气道管理应用存在的问题。