Predictive factors of prolonged postoperative length of stay after anatomic pulmonary resection

INTRODUCTION

The objective of this study is to create a predictive model of prolonged postoperative length of stay (PLOS) in patients undergoing anatomic lung resection, to validate it in an external series and to evaluate the influence of PLOS on readmission and 90-day mortality.

METHODS

All patients registered in the GEVATS database discharged after the intervention were included. We define PLOS as the postoperative stay in days above the 75th percentile of stay for all patients in the series. A univariate and multivariate analysis was performed using logistic regression and the model was validated in an external cohort. The possible association between PLOS and readmission and mortality at 90 days was analyzed.

RESULTS

3473 patients were included in the study. The median postoperative stay was 5 days (IQR: 4-7). 815 patients had PLOS (≥8 days), of which 79.9% had postoperative complications. The final model included as variables: age, BMI, male sex, ppoFEV1%, ppoDLCO% and thoracotomy; the AUC in the referral series was 0.684 (95% CI: 0.661-0.706) and in the validation series was 0.73 (95% CI: 0.681-0.78). A significant association was found between PLOS and readmission (p < .000) and 90-day mortality (p < .000).

CONCLUSIONS

The variables age, BMI, male sex, ppoFEV1%, ppoDLCO% and thoracotomy affect PLOS. PLOS is associated with an increased risk of readmission and 90-day mortality. 20% of PLOS are not related to the occurrence of postoperative complications.

Predictive factors of pathological complete response after induction (ypT0N0M0) in non-small cell lung cancer and short-term outcomes: Results of the Spanish Group of Video-assisted Thoracic Surgery (GE-VATS)

INTRODUCTION

To analyze the predictors of pCR in NSCLC patients who underwent anatomical lung resection after induction therapy and to evaluate the postoperative results of these patients.

METHODS

All patients prospectively registered in the database of the GE-VATS working group undergone anatomic lung resection by NSCLC after induction treatment and recruited between 12/20/2016 and 3/20/2018 were included in the study. The population was divided into two groups: patients who obtained a complete pathological response after induction (pCR) and patients who did not obtain a complete pathological response after induction (non-pCR). A multivariate analysis was performed using a binary logistic regression to determine the predictors of pCR and the postoperative results of patients were analyzed.

RESULTS

Of the 241 patients analyzed, 36 patients (14.9%) achieved pCR. Predictive factors for pCR are male sex (OR: 2.814, 95% CI: 1.015-7.806), histology of squamous carcinoma (OR: 3.065, 95% CI: 1.233-7.619) or other than adenocarcinoma (OR: 5.788, 95% CI: 1.878-17.733) and induction therapy that includes radiation therapy (OR: 4.096, 95% CI: 1.785-9.401) and targeted therapies (OR: 7.625, 95% CI: 2.147-27.077). Prevalence of postoperative pulmonary complications was higher in patients treated with neoadjuvant chemo-radiotherapy (p = 0.032).

CONCLUSIONS

Male sex, histology of squamous carcinoma or other than ADC, and induction therapy that includes radiotherapy or targeted therapy are positive predictors for obtaining pCR. Induction chemo-radiotherapy is associated with a higher risk of postoperative pulmonary complications.

Mortality predictors in complicated patients after anatomical lung resection

INTRODUCTION

Failure to rescue (FTR), defined as the mortality rate among patients suffering from postoperative complications, is considered an indicator of the quality of surgical care. The aim of this study was to investigate the risk factors associated with FTR after anatomical lung resections.

METHOD

Patients undergoing anatomical lung resection at our center between 1994 and 2018 were included in the study. Postoperative complications were classified as minor (grade I and II) and major (grade IIIA to V), according to the standardized classification of postoperative morbidity. Patients who died after a major complication were considered FTR. A stepwise logistic regression model was created to identify FTR predictors. Independent variables included in the multivariate analysis were age, body mass index, cardiac, renal, and cerebrovascular comorbidity, ppoFEV1%, VATS approach, extended resection, pneumonectomy, and reintervention. A non-parametric ROC curve was constructed to estimate the predictive capacity of the model.

RESULTS

A total of 2.569 patients were included, of which 223 (8.9%) had major complications and 49 (22%) could not be rescued. Variables associated with FTR were: age (OR: 1.07), history of cerebrovascular accident (OR: 3.53), pneumonectomy (OR: 6.67), and reintervention (OR: 12.26). The area under the ROC curve was 0.82 (95% CI: 0.77-0.88).

CONCLUSIONS

Overall, 22% of patients with major complications following anatomical lung resection in this series did not survive until discharge. Pneumonectomy and reintervention are the most significant risk factors for FTR.

Robotic anatomical lung resections: Analysis of the learning curve

INTRODUCTION

Robotic surgery has become a safe and effective approach for the treatment of pulmonary surgical pathology. However, the adoption of new surgical techniques requires the evaluation of the learning curve. The objective of this study is to analyze the learning curve of robotic anatomical lung resections.

METHODS

Retrospective analysis of all robotic anatomical lung resections performed by the same surgeon between June 2018 and March 2020. The learning curve was evaluated using CUSUM charts to estimate trend changes in surgical time, surgical failure and the occurrence of post-operative cardiorespiratory complications throughout the sequence of cases.

RESULTS

The study included a total of 73 cases. The median duration of all complications was 120 min (interquartile range: 90-150 min), the prevalence of surgical failure was 23.29%, while 4/73 patients had any postoperative cardiorespiratory complication. Based on the CUSUM analysis, the learning curve was divided into 3 different phases: phase i (from the first to the 14th intervention), phase ii (between the 15th and 30th intervention) and phase iii (from the 31st intervention).

CONCLUSIONS

The learning curve for robotic anatomical lung resections can be divided into 3 phases. The technical competence that guarantees satisfactory perioperative outcomes was achived in phase iii from the 31st intervention.

Predictive factors of pathological complete response after induction (ypT0N0M0) in non-small cell lung cancer and short-term outcomes: results of the Spanish Group of Video-assisted Thoracic Surgery (GE-VATS)

INTRODUCTION

To analyze the predictors of pathological complete response (pCR) in not small cells lung carcinoma (NSCLC) patients who underwent anatomical lung resection after induction therapy and to evaluate the postoperative results of these patients.

METHODS

All patients prospectively registered in the database of the GE-VATS working group undergone anatomic lung resection by NSCLC after induction treatment and recruited between December 20th 2016, and March 20th 2018, were included in the study. The population was divided into two groups: patients who obtained a complete pathological response after induction (pCR) and patients who did not obtain a complete pathological response after induction (non-pCR). A multivariate analysis was performed using a binary logistic regression to determine the predictors of pCR and the postoperative results of patients were analyzed.

RESULTS

Of the 241 patients analyzed, 36 patients (14.9%) achieved pCR. Predictive factors for pCR are male sex (OR 2.814, 95% CI 1.015-7.806), histology of squamous carcinoma (OR 3.065, 95% CI 1.233-7.619) or other than adenocarcinoma (ADC) (OR 5.788, 95% CI 1.878-17.733) and induction therapy that includes radiation therapy (OR 4.096, 95% CI 1.785-9.401) and targeted therapies (OR 7.625, 95% CI 2.147-27.077). Prevalence of postoperative pulmonary complications was higher in patients treated with neoadjuvant chemo-radiotherapy (p = 0.032).

CONCLUSIONS

Male sex, histology of squamous carcinoma or other than ADC, and induction therapy that includes radiotherapy or targeted therapy are positive predictors for obtaining pCR. Induction chemo-radiotherapy is associated with a higher risk of postoperative pulmonary complications.

The «Weekday Effect» Does Not Have an Impact on the Development of Complications or Mortality After Pulmonary Resection: Retrospective Cohort Study

OBJECTIVE

To determine whether elective anatomic pulmonary resection surgery carried out at the end of the week is associated with a higher mortality and postoperative morbidity than surgery performed at the beginning of the week.

METHOD

Historical cohort study. All patients undergoing anatomical pulmonary resection between January 2013 and November 2018 in our center were included. Patients operated at the end of the week (Thursday or Friday) were considered «not exposed» and patients operated at the beginning of the week (Monday, Tuesday or Wednesday) were considered «exposed». The likelihood of cardiorespiratory complications and operative death (30days) was compared in the two cohorts calculated using the Eurolung1 and2 risk models. 30-day mortality and the occurrence of cardiorespiratory and technical complications were studied as outcome variables. The incidence of these adverse effects was calculated for the overall series and for both cohorts, and the relative risk (RR) and its 95% confidence interval (95%CI) were determined.

RESULTS

The overall mortality of the series was 0.9% (10/1172), the incidence of cardiorespiratory complications was 10.2% (120/1172) and that of technical complications was 20.6% (242/1172). The RR calculated for cardiorespiratory, technical complications and mortality in exposed and unexposed subjects was: 0.914 (95%CI: 0.804-1.039), 0.996 (95%CI: 0.895-1.107) and 0.911 (95%CI: 0.606-1.37), respectively.

CONCLUSIONS

Patients operated at the end of the week do not present a higher risk of postoperative adverse effects.

Mortality Predictors In Complicated Patients After Anatomical Lung Resection

INTRODUCTION

Failure to rescue (FTR), defined as the mortality rate among patients suffering from postoperative complications, is considered an indicator of the quality of surgical care. The aim of this study was to investigate the risk factors associated with FTR after anatomical lung resections.

METHOD

Patients undergoing anatomical lung resection at our center between 1994 and 2018 were included in the study. Postoperative complications were classified as minor (grade I and II) and major (grade IIIA to V), according to the standardized classification of postoperative morbidity. Patients who died after a major complication were considered FTR. A stepwise logistic regression model was created to identify FTR predictors. Independent variables included in the multivariate analysis were age, body mass index, cardiac, renal, and cerebrovascular comorbidity, ppoFEV1%, VATS approach, extended resection, pneumonectomy, and reintervention. A non-parametric ROC curve was constructed to estimate the predictive capacity of the model.

RESULTS

A total of 2,569 patients were included, of which 223 (8.9%) had major complications and 49 (22%) could not be rescued. Variables associated with FTR were: age (OR: 1.07), history of cerebrovascular accident (OR: 3.53), pneumonectomy (OR: 6.67), and reintervention (OR: 12.26). The area under the ROC curve was 0.82 (95% CI: 0.77-0.88).

CONCLUSIONS

Overall, 22% of patients with major complications following anatomical lung resection in this series did not survive until discharge. Pneumonectomy and reintervention are the most significant risk factors for FTR.

Changes in the Risk of Mortality and Morbidity After Lung Resection in the Last 20 Years

INTRODUCTION

The aim of this study is to evaluate changes in the risk of cardiorespiratory mortality and morbidity calculated by Eurolung risk models 1 and 2 in the last 20 years, and to identify variations in patient selection or surgical practice that might have altered the risk of death and complications after anatomical lung resections.

METHOD

This was a retrospective analysis of a series of 2,435 consecutive patients who underwent anatomical lung resection. The population was divided into three time periods: 1994-2006 (976 cases), 2007-2015 (945 cases), and 2016-2017 (420 cases). Eurolung models 1 and 2 were applied to the series, and the individual probability of adverse effects was calculated. We compared this mean probability, and the prevalence or means of each of the variables included in the models in each period and plotted the evolution of the risk.

RESULTS

A progressive decrease was observed in both adverse effects over time. The prevalence of the binary variables, except for coronary heart disease, was higher in the last period. The percentage of pneumonectomies and extended resections fell in the last two periods and the number of cases treated with VATS increased substantially in 2016-2017.

CONCLUSIONS

The decline in the number of pneumonectomies and the increase in the rate of minimally invasive procedures appear to be the variables most closely associated with decreased risk. Other changes in the clinical characteristics of the patients do not seem to have influenced the outcomes.

e-Consultation Improves Efficacy in Thoracic Surgery Outpatient Clinics

OBJECTIVE

The aim of this study is analysing the impact of the systematic versus occasional videoconferencing discussion of patients with two respiratory referral units along 6 years of time over the efficiency of the in-person outpatient clinics of a thoracic surgery service.

METHOD

Retrospective and comparative study of the evaluated patients through videoconferencing and in-person first visits during two equivalents periods of time: Group A (occasional discussion of cases) between 2008-2010 and Group B (weekly regular discussion) 2011-2013. Data were obtained from two prospective and electronic data bases. The number of cases discussed using e-consultation, in-person outpatient clinics evaluation and finally operated on under general anaesthesia in each period of time are presented. For efficiency criteria, the index: number of operated on cases/number of first visit outpatient clinic patients is created. Non-parametric Wilcoxon test is used for comparison.

RESULTS

The mean number of patients evaluated at the outpatient clinics/year on group A was 563 versus 464 on group B. The median number of cases discussed using videoconferencing/year was 42 for group A versus 136 for group B. The mean number of operated cases/first visit at the outpatient clinics was 0.7 versus 0.87 in group B (P=.04).

CONCLUSIONS

The systematic regular discussion of cases using videoconferencing has a positive impact on the efficacy of the outpatient clinics of a Thoracic Surgery Service measured in terms of operated cases/first outpatient clinics visit.

SEPAR guidelines for lung cancer staging

The latest tumour, lymph node and metastasis (TNM) classification by the International Association for the Study of Lung Cancer (IASLC), based on the analysis of patients from all over the world, has incorporated changes in the descriptors, especially those regarding tumor size, while proposing new group staging. A new lymph node map has also been developed with the intention of facilitating the classification of the "N" component. SEPAR recommends using this new classification. As for the procedures recommended for staging, in addition to the generalized use of computed tomography (CT), it points to the role of positron emission tomography (PET) or image fusion methods (PET/CT), which provide a better evaluation of the mediastinum and extrathoracic metastases. Endobronchial ultrasound (EBUS) and esophageal ultrasound (EUS) for obtaining cytohistological samples have been incorporated in the staging algorithm, and it emphasizes the importance of precise re-staging after induction treatment in order to make new therapeutic decisions. Comment is made on the foreseeable incorporation in the near future of molecular staging, and systematic lymph node dissection is recommended with the intention of making a more exact surgical-pathological classification.

[Guidelines for the diagnosis and treatment of spontaneous pneumothorax]

This is the fourth update of the guidelines for the diagnosis and treatment of pneumothorax published by the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). Spontaneous pneumothorax, or the presence of air in the pleural space not caused by injury or medical intervention, is a significant clinical problem. We propose a method for classifying cases into 3 categories: partial, complete, and complete with total lung collapse. This classification, together with a clinical assessment, would provide sufficient information to enable physicians to decide on an approach to treatment. This update introduces simple aspiration in an outpatient setting as a treatment option that has yielded results comparable to conventional drainage in the management of uncomplicated primary spontaneous pneumothorax; this technique is not, as yet, widely used in Spain. For the definitive treatment of primary spontaneous pneumothorax, the technique most often used by thoracic surgeons is video-assisted thoracoscopic bullectomy and pleural abrasion. Hospitalization and conventional tube drainage is recommended for the treatment of secondary spontaneous pneumothorax. This update also has a new section on catamenial pneumothorax, a condition that is probably underdiagnosed. The definitive treatment for a recurring or persistent air leak is usually surgery or the application of talc through the drainage tube when surgery is contraindicated. Our aim in proposing algorithms for the management of pneumothorax in these guidelines was to provide a useful tool for clinicians involved in the diagnosis and treatment of this disease.