[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]

Relationship between gender and perioperative clinical features in lung cancer patients who underwent VATS lobectomy

OBJECTIVES

Compare the differences in perioperative clinical characteristics of lung cancer patients of different genders who have undergone VATS lobectomy, and explore the impact of these differences on the short-term prognosis of patients.

METHODS

A total of 338 consecutive patients with lung cancer who underwent VATS lobectomy in our hospital from August 2021 to August 2022 were retrospectively analyzed, they were divided into male group and female group. The perioperative characteristics and short-term prognosis of different groups were compared. The multivariate binary logistic regression analysis was used to analyze the risk factors.

RESULTS

There were statistically significant differences between male and female patients in age of onset, body surface area (BSA), smoking rate, alcohol consumption rate, hypertension incidence, pulmonary function and clinical stage. There were statistically significant differences between male and female patients in operation time and lymph node dissection. The probability of postoperative complications, such as pulmonary infection, persistent air leakage and severe subcutaneous emphysema, in male patients was significantly higher than that in female patients. The average daily postoperative thoracic drainage volume in male patients was considerably higher than that in female patients, and the postoperative duration of thoracic drainage tube and hospital stay in male patients were significantly longer than those in female patients. After multiple regression analysis, low FEVI values in males was found to be an independent risk factor for postoperative complications.

CONCLUSIONS

Compared with female patients, male patients with lung cancer are more likely to have unfavorable factors such as older age, higher smoking rate, poor pulmonary function and late clinical stage of tumors when they undergoing VATS surgery treatment. The appropriate thoracic drainage time can be selected according to gender differences to shorten the length of hospital stay. The incidence of postoperative complications is higher in male patients, especially those with poor pulmonary function, and active perioperative intervention is required to reduce the incidence of postoperative complications.

Preoperative exercise training for people with non-small cell lung cancer

BACKGROUND

Surgical resection for early-stage non-small cell lung cancer (NSCLC) offers the best chance of cure, but it is associated with a risk of postoperative pulmonary complications. It is unclear if preoperative exercise training, and the potential resultant improvement in exercise capacity, may improve postoperative outcomes. This review updates our initial 2017 systematic review.

OBJECTIVES

1. To evaluate the benefits and harm of preoperative exercise training on postoperative outcomes, such as the risk of developing a postoperative pulmonary complication and the postoperative duration of intercostal catheter, in adults scheduled to undergo lung resection for NSCLC. 2. To determine the effect on length of hospital stay (and costs associated with postoperative hospital stay), fatigue, dyspnoea, exercise capacity, lung function and postoperative mortality.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was from 28 November 2016 to 23 November 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which study participants who were scheduled to undergo lung resection for NSCLC were allocated to receive either preoperative exercise training or no exercise training.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. risk of developing a postoperative pulmonary complication; 2. postoperative duration of intercostal catheter and 3.

SAFETY

Our secondary outcomes were 1. postoperative length of hospital stay; 2. postintervention fatigue; 3. postintervention dyspnoea; 4. postintervention and postoperative exercise capacity; 5. postintervention lung function and 6. postoperative mortality. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

Along with the five RCTs included in the original version, we identified an additional five RCTs, resulting in 10 RCTs involving 636 participants. Preoperative exercise training results in a large reduction in the risk of developing a postoperative pulmonary complication compared to no preoperative exercise training (risk ratio (RR) 0.45, 95% CI 0.33 to 0.61; I2 = 0%; 9 studies, 573 participants; high-certainty evidence). The evidence is very uncertain about its effect on postoperative intercostal catheter duration (MD -2.07 days, 95% CI -4.64 to 0.49; I2 = 77%, 3 studies, 111 participants; very low-certainty evidence). Preoperative exercise training is likely safe as studies reported no adverse events. Preoperative exercise training likely results in a reduction in postoperative length of hospital stay (MD -2.24 days, 95% CI -3.64 to -0.85; I2 = 85%; 9 studies, 573 participants; moderate-certainty evidence). Preoperative exercise training likely increases postintervention exercise capacity measured by peak oxygen consumption (MD 3.36 mL/kg/minute, 95% CI 2.70 to 4.02; I2 = 0%; 2 studies, 191 participants; moderate-certainty evidence); but the evidence is very uncertain about its effect on postintervention exercise capacity measured by the 6-minute walk distance (MD 29.55 m, 95% CI 12.05 to 47.04; I2 = 90%; 6 studies, 474 participants; very low-certainty evidence). Preoperative exercise training may result in little to no effect on postintervention lung function (forced expiratory volume in one second: MD 5.87% predicted, 95% CI 4.46 to 7.28; I2 = 0%; 4 studies, 197 participants; low-certainty evidence).  AUTHORS' CONCLUSIONS: Preoperative exercise training results in a large reduction in the risk of developing a postoperative pulmonary complication compared to no preoperative exercise training for people with NSCLC. It may also reduce postoperative length of hospital stay, and improve exercise capacity and lung function in people undergoing lung resection for NSCLC. The findings of this review should be interpreted with caution due to risk of bias. Research investigating the cost-effectiveness and long-term outcomes associated with preoperative exercise training in NSCLC is warranted.

Effect of Pulmonary Rehabilitation on Postoperative Clinical Status in Patients with Lung Cancer and Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Pulmonary rehabilitation (PR) has a curative effect in patients undergoing pneumonectomy for lung cancer. Nevertheless, the contribution of PR to the clinical status of patients with chronic obstructive pulmonary disease (COPD) undergoing lung resection has not been adequately elucidated. The aim of this systematic review of randomized and nonrandomized controlled trials was to appraise the impact of PR compared to conventional treatment based on postoperative clinical status in patients with lung cancer and COPD. Literature in English from PubMed, Cochrane Library, Science Citation Index, and Embase databases and in Chinese from the Chinese National Knowledge Infrastructure and the WANFANG Database was retrieved from inception to November 2021, employing the keywords "Pulmonary Neoplasms," "Chronic Obstructive Pulmonary Diseases," "Physical Therapy Modalities," and "pulmonary rehabilitation." Only studies that reported PR results were included. This review was registered in the International Prospective Register of Systematic Reviews (number: CRD42021224343). A total of nine controlled trials with 651 patients were included. Postoperative pulmonary complications (PPCs) were the primary outcome measure. PR decreased the risk of complications after surgery compared to regular treatment (odds ratio (OR) 0.21, 95% confidence interval (CI) 0.12-0.37, P < 0.01). PR reduced the risk of pneumonia after surgery compared to regular treatment (OR 0.36, 95% CI 0.15-0.86, P=0.02). There was a significant difference in the postoperative length of stay (mean difference -2.13 days, 95% CI -2.65 to -1.61 days, P < 0.05). PR was an effective intervention that decreased PPCs in patients suffering from lung cancer and COPD. However, due to the limitations of the available data, the results should be interpreted with caution.

[Study on the Benefit of Postoperative Exercise Rehabilitation in Patients with Lung Cancer Complicated with Chronic Obstructive Pulmonary Disease]

BACKGROUND

Chronic obstructive pulmonary diseases (COPD) affects 45%-63% of lung cancer patients worldwide. Lung cancer patients complicated with COPD have decreased cardiopulmonary function and increased perioperative risk, and their postoperative exercise endurance and lung function are significantly lower than those with conventional lung cancer. Previous studies have shown that postoperative exercise training can improve the exercise endurance of unselected lung cancer patients, but it is unclear whether lung cancer patients with COPD can also benefit from postoperative exercise training. This study intends to explore the effects of postoperative exercise training on exercise endurance, daily activity and lung function of lung cancer patients with COPD.

METHODS

Seventy-four patients with non-small cell lung cancer (NSCLC) complicated with COPD who underwent pneumonectomy in the lung cancer center of West China Hospital of Sichuan University from August 5, 2020 to August 25, 2021 were prospectively analyzed. They were randomly divided into exercise group and control group; The patients in the two groups received routine postoperative rehabilitation in the first week after operation, and the control group was given routine nursing from the second week. On this basis, the exercise group received postoperative exercise rehabilitation training for two weeks. Baseline evaluation was performed 3 days before operation and endpoint evaluation was performed 3 weeks after operation.

RESULTS

The exercise endurance, daily activity and pulmonary function test results of the two groups decreased from baseline to the end point. However, after the operation and intervention program, the maximum oxygen consumption of Cardiopulmonary Exercise Test and the walking distance of 6-Minute Walking Test in the exercise group were significantly better than those in the control group [(13.09±1.46) mL/kg/min vs (11.89±1.38) mL/kg/min, P=0.033; (297±46) m vs (243±43) m, P=0.041]. The average number of we-chat steps in the exercise group was also significantly better than that in the control group (4,381±397 vs 3,478±342, P=0.035). Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) in the exercise group were better than those in the control group, but the difference did not reach a statistically significant level [(1.76±0.19) L vs (1.60±0.28) L, P=0.084; (1.01±0.17) L vs (0.96±0.21) L, P=0.467].

CONCLUSIONS

Postoperative exercise rehabilitation training can improve exercise endurance and daily activity ability of patients with lung cancer complicated with COPD and promote postoperative rehabilitation.

Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis

OBJECTIVE

To determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished). We searched Medline, Embase, CENTRAL, DARE, HTA and NHS EED, The Cochrane Library, CINAHL, PsychINFO and ISI Web of Science (June 2020).

SETTING

Secondary care.

PARTICIPANTS

Patients (≥18 years) undergoing major elective surgery (curative or palliative).

INTERVENTIONS

Any intervention administered in the preoperative period with the aim of improving postoperative outcomes.

OUTCOMES AND MEASURES

Primary outcomes were 30-day mortality, hospital length of stay (LoS) and postoperative complications. Secondary outcomes included LoS in intensive care unit or high dependency unit, perioperative morbidity, hospital readmission, postoperative pain, heath-related quality of life, outcomes specific to the intervention, intervention-specific adverse events and resource use.

REVIEW METHODS

Two authors independently extracted data from eligible RCTs and assessed risk of bias and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Random-effects meta-analyses were used to pool data across trials.

RESULTS

178 RCTs including eight types of intervention were included. Inspiratory muscle training (IMT), immunonutrition and multimodal interventions reduced hospital LoS (mean difference vs usual care: -1.81 days, 95% CI -2.31 to -1.31; -2.11 days, 95% CI -3.07 to -1.15; -1.67 days, 95% CI -2.31 to -1.03, respectively). Immunonutrition reduced infective complications (risk ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise reduced postoperative pulmonary complications (RR 0.55, 95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75, respectively). Smoking cessation interventions reduced wound infections (RR 0.28, 95% CI 0.12 to 0.64).

CONCLUSIONS

Some prehabilitation interventions may reduce postoperative LoS and complications but the quality of the evidence was low.

PROSPERO REGISTRATION NUMBER

CRD42015019191.

Effect of cardiopulmonary rehabilitation nursing on exercise endurance and quality of life of stable COPD patients

OBJECTIVE

To investigate the effect of cardiopulmonary rehabilitation nursing on exercise endurance and quality of life (QOL) of patients with stable chronic obstructive pulmonary disease (COPD).

METHODS

This randomized trial was conducted on 84 subjects with stable COPD recruited in our hospital from March 2018 to December 2019 and they were divied into the observation group (n=42) and the control group (n=42) based on nursing methods. The control group adopted conventional nursing, and the observation group received cardiopulmonary rehabilitation nursing in addition to conventional method. The exercise endurance, cardiopulmonary function, psychological state, QOL and nursing satisfaction were compared at pre- and post-nursing care.

RESULTS

Before nursing, no notable difference was observed in 6 min walking distance (6MWD), deep inspiratory volume (IC), left ventricular ejection fraction (LVEF), forced vital capacity (FVC), Forced expiratory volume in one second (FEV1), FEV1/FVC, Self-Rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS) score, QOL, scores of symptoms, activities and impact in these two groups (P>0.05). After nursing, 6MWD and IC of observation group were remarkably higher (P<0.05); LVEF, FVC, FEV1 and FEV1/FVC in the observation group were remarkably higher (P<0.05); SAS and SDS scores of two groups decreased, and the observation group was notably lower (P<0.05); the QOL scores of symptoms, activities and effects of two groups were notably reduced, and the observation group was remarkably lower (P<0.05). The nursing satisfaction of the observation group was considerably higher than the control group (95.23% vs 76.19%) (P<0.05).

CONCLUSION

Cardiopulmonary rehabilitation nursing has a remarkable effect on COPD patients in stable stage, which can enhance patients' exercise endurance and lung function, reduce adverse emotions, and improve patients' QOL and nursing satisfaction.

[The Present Situation and Prospect of Day Surgery and Enhanced Recovery after Surgery in Thoracic Surgery]

The good results of enhanced recovery after surgery (ERAS) combined with minimally invasive surgery are reflected in reducing the incidence of perioperative complications and shortening the length of hospitalization (LOS). It has been widely used in surgical fields of different specialties. The implementation of the day surgery mode can shorten the waiting time for patients and reduce the financial burden. Especially in thoracic surgery, the shorter the waiting time in the hospital, the more beneficial for the patient's physical and psychological recovery. With the widespread implementation of minimally invasive technology and accelerated rehabilitation procedures, the application of ERAS in thoracic surgery has made it possible for some thoracic surgery to be completed in the day surgery. This article summarizes the current application of ERAS in the field of thoracic surgery and the development prospects of day surgery models in China.

Systematic Review and Meta-Analysis of Randomized, Controlled Trials on Preoperative Physical Exercise Interventions in Patients with Non-Small-Cell Lung Cancer

Preoperative physical exercise protocols prior to cancer surgery increased in popularity over recent years; however, the beneficial effect of such protocols is not well established, with conflicting results reported. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the effects of different modalities or combinations of preoperative exercise interventions and/or prehabilitation multicomponent training in patients with non-small-cell lung cancer (NSCLC) after surgery on the outcomes related to functional capacity, mental wellness and medical care. We searched in OVID Embase, Pubmed, Cochrane Library, CINAHL, Scopus, and Web of Science. Characteristics of studies and program results and outcome data were extracted. Changes between the intervention and control groups, from baseline to follow-up (standardized mean difference (SMD) or relative risk (RR) with 95% confidence interval (CI) for each intervention was pooled using weighted random-effects models). A total of 676 participants from 10 RCTs were included in the final analysis (aerobic training + inspiratory muscle training, n = 5; aerobic training + strength training + inspiratory muscle training, n = 2; aerobic training + strength training, n = 1; multicomponent training, n = 1; aerobic training alone, n = 1). The results showed intervention-induced improvement in walking endurance (SMD = 0.27; 95% CI, 0.11 to 0.44; I² = 0.0%), peak exercise capacity (SMD = 0.78; 95% CI, 0.35 to 1.21; I² = 76.7%), dyspnoea (SMD = −0.30; 95% CI, −0.51 to −0.10; I² = 0.0%), risk of hospitalization (SMD = −0.58; 95% CI, −0.97 to −0.20; I² = 70.7%), and postoperative pulmonary complications (relative risk (RR) = 0.50; 95% CI, 0.39 to 0.66; I² = 0.0%). For the functional capacity and medical care parameters, preoperative combined aerobic, resistance, and inspiratory muscle training was shown to be effective if comprising one to four weeks, performing 1–3 sessions per week, with moderate intensity (50% for endurance capacity). Further studies with larger samples and higher methodological quality are needed to clarify the potential benefits of preoperative exercise training for patients with NSCLC.

Integrating perioperative medicine with anaesthesia in India: Can the best be achieved? A review

Integrating perioperative medicine with anaesthesia is the need of the hour. Evolution of a new superspeciality called perioperative anaesthesia can improve surgical outcomes by quality perioperative care and guarantee imminent escalation of influence and power for anaesthesiologists. All original peer-reviewed manuscripts pertaining to surgery-specific perioperative surgical home models involving preoperative, intraoperative and postoperative initiatives spanning the past 5 years have been reviewed using PubMed and Google Scholar. Whether the perioperative surgical home model is feasible or still a distant dream in the Indian perspective has been analysed.

Impact of preoperative exercise therapy on surgical outcomes in lung cancer patients with or without COPD: a systematic review and meta-analysis

Objectives

This meta-analysis aimed to demonstrate the impact of preoperative exercise therapy on surgical outcomes in patients with lung cancer and COPD. Pulmonary function and muscle capacity were investigated to explore their potential links with outcome improvements after exercise.

Methods

Articles were searched from PubMed, Embase, and the Cochrane Library with criteria of lung cancer patients with or without COPD, undergoing resection, and receiving preoperative exercise training. Key outcomes were analyzed using meta-analysis.

Results

Seven studies containing 404 participants were included. Patients receiving preoperative exercise training had a lower incidence of postoperative pulmonary complications (PPCs; OR 0.44, 95% CI 0.27-0.71) and shorter length of hospital stay (standardized mean difference -4.23 days, 95% CI -6.14 to -2.32 days). Exceptionally, pneumonia incidence remained unchanged. Patients with COPD could not obviously benefit from exercise training to reduce PPCs (OR 0.44, 95% CI 0.18-1.08), but still might achieve faster recovery. No significant difference in pulmonary function was observed between the two groups. However, 6MWD and VO₂ peak were significantly improved after exercise training.

Conclusion

Preoperative exercise training may reduce PPCs for lung cancer patients. However, for patients with COPD undergoing lung cancer resection, the role of exercise is uncertain, due to limited data, which calls for more prospective trials on this topic. Rehabilitation exercise strengthens muscle capacity, but does not improve impaired pulmonary function, which emphasizes the possible mechanism of the protocol design.

[Effect of A High Intensive Preoperative Rehabilitation on the Perioperative Complications in Patients with Chronic Obstructive Pulmonary Disease Eligible for Lung Cancer Surgery]

背景与目的

慢性阻塞性肺病(chronic obstructive pulmonary diseases, COPD)降低患者心肺功能，可导致患者围手术期风险增加。本研究拟探讨术前短期高强度肺康复训练对肺癌合并COPD患者肺功能及术后并发症的影响。

方法

分析2016年6月-2016年12月101例肺癌合并COPD患者的临床资料，其中肺康复训练组43例，常规治疗组58例，比较两组患者肺功能、术后肺部并发症、住院时间等指标，同时比较肺康复训练组训练前后肺功能相关指标。

结果

两组患者术前一般资料及肺功能无显著差异，康复训练组住院时间更长[(17.23±4.18) d vs (14.41±4.03) d]，但术后住院时间与常规治疗组无显著差异[(8.93±3.78) d vs (9.62±3.98) d]，两组患者术后肺部感染[8例(18.6%) vs 17例(29.3%)]、肺不张[1例(2.3%) vs 1例(1.7%)]、呼吸衰竭[1例(2.3%) vs 2例(3.4%)]等无显著差异。肺康复训练组训练前后FEV₁[(2.06±0.45) L vs (2.15±0.45) L, P < 0.001]、PEF[(4.32±0.90) L/s vs (5.15±1.05) L/s, P < 0.001]、PCO₂[(42.42±2.79) mmHg vs (41.58±2.98) mmHg, P=0.009]改善明显，按亚组分析，康复训练后中-重度COPD亚组FEV₁[(0.16±0.05) L (8.6%) vs (0.06±0.05) L (2.8%)]增加值较轻度COPD亚组更明显。

结论

术前短期肺康复训练可改善肺癌合并COPD患者肺功能，其中中-重度COPD患者肺功能改善更明显。

[Effect of A High Intensive Preoperative Rehabilitation on the Perioperative Complications in Patients with Chronic Obstructive Pulmonary Disease Eligible for Lung Cancer Surgery]

BACKGROUND

Chronic obstructive pulmonary disease (COPD) will reduce the cardiopulmonary function and increase perioperative risk. The aim of this study is to investigate the effect of preoperative short-term high intensity lung rehabilitation training on lung function and postoperative complications in patients with COPD who are eligible for lung cancer surgery.

METHODS

We analysis of 101 patients with COPD and a diagnosis of lung cancer, with 43 patients in pulmonary rehabilitation group and 58 patients in conventional group. The pulmonary function, postoperative pulmonary complications (PPCs) and length of stay (LOS) will be compared between the two groups, the lung function will be compared before and after the rehabilitation at the same time.

RESULTS

There were no significant difference between the two groups in general information, lung function before surgery, postoperative pulmonary infection [8 (18.6%) vs 17 (29.3%)], atelectasis [1 (2.3%) vs 1 (1.7%)], respiratory failure [1 (2.3%) vs 2 (3.4%)] and postoperative LOS [(8.93±3.78) d vs (9.62±3.98) d, P>0.05]. In the rehabilitation group, the FEV1 [(2.06±0.45) L vs (2.15±0.45) L, P<0.001] and PEF [(4.32±0.90) L/s vs (5.15±1.05) L/s, P<0.001) were higher, and PCO2 [(42.42±2.79) mmHg vs (41.58±2.98) mmHg, P=0.009] was lower after rehabilitation, significantly. The increase value of FEV1 in moderate to severe COPD group was higher than that of the mild COPD group after the rehabilitation [(0.16±0.05) L, 8.6% vs (0.06±0.05) L, 2.8%, P<0.001).

CONCLUSIONS

The short-term highly-intensity lung rehabilitation can improve lung function in lung cancer patients with COPD, and the improvement of pulmonary function in moderate to severe COPD patients is more obviously.

[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。

Enhanced recovery programs in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials

Background

Enhanced recovery after surgery (ERAS) program is an effective evidence-based multidisciplinary protocol of perioperative care, but its roles in thoracic surgery remain unclear. This systematic review of randomized controlled trials (RCTs) aims to investigate the efficacy and safety of the ERAS programs for lung cancer surgery.

Materials and methods

We searched the PubMed and EMBASE databases to identify the RCTs that implemented an ERAS program encompassing more than four care elements within at least two phases of perioperative care in lung cancer surgery. The heterogeneity levels between studies were estimated by the Cochrane Collaborations. A qualitative review was performed if considerable heterogeneity was revealed. Relative risk (RR) and weighted mean difference served as the summarized statistics for the meta-analyses. Additional analyses were also performed to perceive potential bias risks.

Results

A total of seven RCTs enrolling 486 patients were included. The meta-analysis indicated that the ERAS group patients had significantly lower morbidity rates (RR=0.64; p<0.001), especially the rates of pulmonary (RR=0.43; p<0.001) and surgical complications (RR=0.46; p=0.010), than those of control group patients. No significant reduction was found in the in-hospital mortality (RR=0.70; p=0.58) or cardiovascular complications (RR=1.46; p=0.25). In the qualitative review, most of the evidence reported significantly shortened length of hospital and intensive care unit stay and decreased hospitalization costs in the ERAS-treated patients. No significant publication bias was detected in the meta-analyses.

Conclusion

Our review demonstrates that the implementation of an ERAS program for lung cancer surgery can effectively accelerate postoperative recovery and save hospitalization costs without compromising patients’ safety. A worldwide consensus guideline is urgently required to standardize the ERAS protocols for elective lung resections in the future.

[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.

[Analysis of Postoperative Complications and Risk Factors of Patients with Lung Cancer through Clavien-Dindo Classification]

背景与目的

术后并发症是肺切除术后患者死亡的重要原因。在本研究中，我们应用Clavien-Dindo并发症分级系统对肺癌术后并发症按照严重程度进行分级，并分析术后并发症的发生率，探讨不同分级术后并发症的危险因素。

方法

回顾性分析2013年6月-2014年12月四川大学华西医院胸外科966例行肺叶切除术的肺癌患者，依据术后30 d内是否发生并发症将此966例患者分为并发症组与无并发症组；同时根据Clavien-Dindo分级系统将并发症分为4级，并针对不同分级的并发症进行危险因素分析。

结果

966例患者中，并发症组占15.0%（145/966），发生总数380次；依据Clavien-Dindo分级系统将此380次并发症进行分级，其中Ⅰ级、Ⅱ级、Ⅲ级、Ⅳ级及以上分别占6.8%、75.3%、15.0%和2.9%。Logistic回归分析结果显示术前第1秒用力呼气容积（forded expiratory volume in one second, FEV₁）、肺一氧化碳弥散量（diffusion capacity for carbon monoxide of the lung single breath, DLco SB）及术前合并慢性阻塞性肺疾病（chronic obstructive pulmonary disease, COPD）是术后并发症的独立危险因素；其中术前FEV₁是Ⅰ级、Ⅱ级、Ⅲ级及以上并发症的独立危险因素。

结论

在Clavien-Dindo分级系统下，Ⅱ级并发症在术后30天内最常见；FEV₁与术后并发症的发生密切相关，可作为评估术后并发症发生风险的可靠指标之一。