The Society of Thoracic Surgeons and The European Society of Thoracic Surgeons General Thoracic Surgery Databases: Joint Standardization of Variable Definitions and Terminology

Comparative outcomes of robot-assisted minimally invasive versus open esophagectomy in patients with esophageal squamous cell carcinoma: a propensity score-weighted analysis

Robots are increasingly used in minimally invasive surgery. We evaluated the clinical benefits of robot-assisted minimally invasive esophagectomy (RAMIE) in comparison with the conventional open esophageal surgery. From 2012 to 2016, 371 patients with esophageal squamous cell carcinoma underwent an Ivor Lewis or McKeown procedure at our institution. Of these, 130 patients underwent laparoscopic gastric conduit formation followed by RAMIE, whereas 241 patients underwent conventional esophageal surgery, including laparotomy and open esophagectomy (OE). We compared the short- and long-term clinical outcomes of these patients using the propensity score-based inverse probability of treatment weighting technique (IPTW). Among the early outcomes, the OE group showed a higher incidence of pneumonia (P = 0.035) and a higher requirement for vasopressors (P = 0.001). Regarding the long-term outcomes, all-cause mortality was significantly higher (P = 0.001) and disease-free survival was lower (P = 0.006) in the OE group. Wound-related problems also occurred more frequently in the OE group (P = 0.020) during the long-term follow-up. There was no statistical intergroup difference in the recurrence rates (P = 0.191). The Cox proportional-hazard analysis demonstrated that wound problems (HR 0.16, 95% CI 0.02-0.57; P = 0.017), pneumonia (HR 0.23, 95% CI 0.06-0.68; P = 0.019), and use of vasopressors (HR 0.14, 95% CI 0.08-0.25; P = 0.001) were independent predictors of mortality. RAMIE could be a better surgical option for selected patients with esophageal squamous cell carcinoma.

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

Background

The number of elderly patients undergoing lung resection for lung cancer is continuously increasing. This study investigates the risk factors for postoperative complications in elderly lung cancer patients and the role of surgical approach in early postoperative outcome.

Methods

We reviewed all consecutive patients who underwent anatomical resection for early stage T1/2 lung cancer in a curative intent between January 2016 and November 2018 at our institution. Clinical data, postoperative complications, hospital stay and 30- and 90-day mortality were prospectively collected.

Results

A total of 505 (278 male) patients were included. One hundred ninety patients (38%) were ≥70 years of age. Forty-eight percent (n=241) had thoracotomy, 52% (n=264) were operated with video-assisted or robot-assisted thoracoscopy. Major cardiopulmonary complications were observed in 4.2% (n=21) patients. There was no significant difference in major cardiopulmonary complication rate following minimally invasive surgery between patients above or below 70 years of age (4.3% vs. 2.5%, P=0.47). In contrast, major cardiopulmonary complication rate was significantly higher in elderly thoracotomy patients than in patients below 70 years of age (9.9% vs. 2.6%, P=0.035). Elderly patients operated minimally invasive had a significantly shorter hospital stay compared to open approach (8.1 vs. 11.9 days, P<0.0001). Thirty- and 90-day mortality was comparable with 1.4% and 1.5%, respectively.

Conclusions

Pulmonary resection for lung cancer in elderly patients is safe and can be performed with a low morbidity and mortality. However, our results indicate that minimal invasive surgery leads to reduced postoperative complications especially in elderly and should be the preferred approach.

Postoperative Elevations of Neutrophil-to-lymphocyte and Platelet-to-lymphocyte Ratios Predict Postoperative Pulmonary Complications in Non-small Cell Lung Cancer Patients: A Retrospective Cohort Study

The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) are found to increase in patients who develop postoperative complications (PCs). The aim of the present study was to explore the association of the perioperative changes of NLR (ΔNLR) and PLR (ΔPLR) with PCs in non-small cell lung cancer (NSCLC). Clinical data of 509 patients, who were diagnosed with NSCLC and underwent thoracoscopic radical resection between January 1, 2014 and July 31, 2016 at the Department of Thoracic Surgery, West China Hospital, were reviewed. Patients were divided into PC and non-PC groups, and clinical characteristics including ΔNLR and ΔPLR were compared between them. The optimal cut-off values of ΔNLR and ΔPLR were determined by receiver operating characteristics (ROC) curves and patients were assigned to high ΔNLR/ΔPLR and low ΔNLR/ΔPLR groups in terms of the cut-off values. Clinicopathologic characteristics and the incidence of different PCs were compared between the dichotomized groups. Univariate and multivariate logistic regression analyses were performed to identify the independent risk factors for PCs. The results showed that the ΔNLR and ΔPLR in the PC group were signifcantly higher than those in the non-PC group (P<0.001 for both). The optimal cutoff values of ΔNLR and ΔPLR were 6.6 and 49, respectively. Patients with ΔNLR>6.6 or ΔPLR>49 were more likely to experience postoperative pulmonary complications (PPCs) (P<0.001 for both). Multivariate logistic regression analysis demonstrated that smoking [odds ratio (OR): 2.450, 95% confdence interval (95% CI): 1.084-5.535, P=0.031)], tumor size (OR: 1.225, 95% CI: 1.047-1.433, P=0.011), ΔNLR>6.6 (OR: 2.453, 95% CI: 1.224-4.914, P=0.011) and ΔPLR>49 (OR: 2.231, 95% CI: 1.182-4.212, P=0.013) were predictive of PPCs. In conclusion, the ΔNLR and ΔPLR may act as novel predictors for PPCs in NSCLC patients undergoing thoracoscopic radical lung resection, and patients with ΔNLR>6.6 or ΔPLR>49 should be treated more actively to prevent or reduce PPCs.

A risk model to predict 2-year survival after video-assisted thoracoscopic surgery lobectomy for non-small-cell lung cancer

OBJECTIVES

We sought to identify the risk factors associated with mortality post-video-assisted thoracoscopic surgery (VATS) lobectomy over a 2-year period.

METHODS

Analysis was performed using a sample from an institutionally maintained database. All lobectomies for non-small-cell lung cancer from April 2014 to March 2018 started with VATS approach and with a complete follow-up were included (n = 732). Several clinical variables were screened using the Cox univariate analysis for their association with 2-year survival. Those with a P-value <0.1 were included in a Cox proportional hazard model.

RESULTS

After multivariable analysis, the following variables showed significant association with 2-year survival: age >75 [hazard ratio (HR) 1.527, P = 0.043], carbon monoxide lung diffusion capacity <70 (HR 1.474, P = 0.061), body mass index (BMI) <18.5 (HR 2.628, P = 0.012), American Society of Anesthesiologist Physical Status >2 (HR 1.518, P = 0.047), performance status >1 (HR 1.822, P = 0.032) and male gender (HR 2.700, P < 0.001). A score of 2 was assigned to the male gender and BMI <18.5, with all other variables assigned a score of 1. Each patient was scored and placed into their risk class. A Kaplan-Meier estimate for 2-year survival was calculated for each class. These were collapsed into the following 3 classes of risk based on their similar 2-year survival: class A (score 0) 97%, 95% CI 88-99, class B (score 1-3) 84%, 95% CI 80-88, class C (score > 3) 66%, 95% CI 57-74.

CONCLUSION

Our scoring system can serve as an adjunct to a clinician's experience in risk-stratifying patients during multidisciplinary tumour board discussion and the shared decision-making process.

Parsimonious Eurolung risk models to predict cardiopulmonary morbidity and mortality following anatomic lung resections: an updated analysis from the European Society of Thoracic Surgeons database

OBJECTIVES

To develop a simplified version of the Eurolung risk model to predict cardiopulmonary morbidity and 30-day mortality after lung resection from the ESTS database.

METHODS

A total of 82 383 lung resections (63 681 lobectomies, 3617 bilobectomies, 7667 pneumonectomies and 7418 segmentectomies) recorded in the ESTS database (January 2007-December 2018) were analysed. Multiple imputations with chained equations were performed on the predictors included in the original Eurolung models. Stepwise selection was then applied for determining the best logistic model. To develop the parsimonious models, different models were tested eliminating variables one by one starting from the less significant. The models' prediction power was evaluated estimating area under curve (AUC) with the 10-fold cross-validation technique.

RESULTS

Cardiopulmonary morbidity model (Eurolung1): the best parsimonious Eurolung1 model contains 5 variables. The logit of the parsimonious Eurolung1 model was as follows: -2.852 + 0.021 × age + 0.472 × male -0.015 × ppoFEV1 + 0.662×thoracotomy + 0.324 × extended resection. Pooled AUC is 0.710 [95% confidence interval (CI) 0.677-0.743]. Mortality model (Eurolung2): the best parsimonious model contains 6 variables. The logit of the parsimonious Eurolung2 model was as follows: -6.350 + 0.047 × age + 0.889 × male -0.055 × BMI -0.010 × ppoFEV1 + 0.892 × thoracotomy + 0.983 × pneumonectomy. Pooled AUC is 0.737 (95% CI 0.702-0.770). An aggregate parsimonious Eurolung2 was also generated by repeating the logistic regression after categorization of the numeric variables. Patients were grouped into 7 risk classes showing incremental risk of mortality (P < 0.0001).

CONCLUSIONS

We were able to develop simplified and updated versions of the Eurolung risk models retaining the predictive ability of the full original models. They represent a more user-friendly tool designed to inform the multidisciplinary discussion and shared decision-making process of lung resection candidates.

Databases in tracheal diseases

During the last two decades surgery has considerably changed not only under the pressure of technological advances but also for the wide dissemination of a clinical practice based on the data driven approach. In fact, surgeons became increasingly used to analyze and to review their own result in order to optimize the subsequent clinical management with the aim of offering a better quality of care to their patients. Obviously, this virtuous process must be founded on reliable and comprehensive collections of clinical data. The detailed storage of information about patients, treatments and results is even more important for those categories of disease that are less common and where the standardization of practice is poor. Tracheal diseases submitted to surgical treatment are indeed rare and the description of different aspect of clinical practice is fragmented within the scientific literature. For this reason, the needs exist of a standardized and shared data repository with a multi-institutional and international connotation that could represent a benchmark for collecting data about tracheal diseases surgery and at the same time a valuable instrument for improving the quality of care in this field.

Fibrosis independent atrial fibrillation in older patients is driven by substrate leukocyte infiltration: diagnostic and prognostic implications to patients undergoing cardiac surgery

Background

The objectives of the study were to characterize and quantify cellular inflammation and structural remodeling of human atria and correlate findings with molecular markers of inflammation and patient surrogate outcome.

Methods

Voluntary participants undergoing heart surgery were enrolled in the study and blood samples were collected prior to surgery, and right atrium samples were harvested intraoperatively. Blood samples were analyzed by flow cytometry and complete blood counts. Atrial samples were divided for fixed fibrosis analysis, homogenized for cytokine analysis and digested for single cell suspension flow cytometry.

Results

A total of 18 patients were enrolled and samples assessed. Isolated cells from the atria revealed a CD45+ population of ~ 20%, confirming a large number of leukocytes. Further characterization revealed this population as 57% lymphocytes and 26% monocyte/macrophages (MoΦ), with the majority of the latter cells being classical (CD14++/CD16−). Interstitial fibrosis was present in 87% of samples and correlated significantly with patient age. Older patients (> 65) had significantly more atrial fibrosis and cellular inflammation. AFib patients had no distinguishing feature of atrial fibrosis and had significantly greater CD45+ MoΦ, increased expression of MMP9 and presented with a significant correlation in length of stay to CCL-2/MCP-1 and NLR (neutrophil-to-lymphocyte ratio).

Conclusion

Atrial fibrosis is correlated with age and not determinate to AFib. However, severity of atrial leukocyte infiltration and markers of matrix degradation are determinant to AFib. This also correlated with CCL2 (or MCP-1) and NLR-indicative of marked inflammation. These data show the potential importance of diagnostic and prognostic assessments that could inform clinical decision making in regard to the intensity of AFib patient management.

Effect of postoperative haemoglobin variation on major cardiopulmonary complications in high cardiac risk patients undergoing anatomical lung resections

OBJECTIVES

Recent evidence shows that permissive anaemia strategies are safe in different surgical settings. However, effects of variations in haemoglobin (Hb) levels could have a negative impact in high-risk patients. We investigated the combined effect of postoperative Hb concentration and cardiac risk status on major cardiopulmonary complications after anatomical lung resections.

METHODS

We retrospectively analysed the records, collected in a prospective clinical database, of 154 consecutive patients undergoing anatomical lung resections at our institution (February 2017-February 2019). Hb levels were displayed as preoperative concentration, nadir Hb level before onset of complications and delta Hb (ΔHb). Cardiac risk was stratified according to the Thoracic Revised Cardiac Risk Index (ThRCRI). Univariable and multivariable logistic regression analyses were used to test the associations between patients, surgical variables and cardiopulmonary complications according to the European Society of Thoracic Surgeons definitions.

RESULTS

Cardiopulmonary complications occurred in 63 patients (17%). In the fully adjusted multivariable model, higher values of ΔHb were associated with increased risk of complications [odds ratio (OR) 1.07; P < 0.001], along with higher ThRCRI classes (classes A-B versus C-D: OR 0.09; P < 0.001). Interaction terms with transfusion were not statistically significant, indicating that the harmful effect of ΔHb was independent. According to receiver operating characteristic curve analysis, a ΔHb of 29 g/l was found to be the best cut-off value for predicting complications.

CONCLUSIONS

In our series, ΔHb, rather than nadir Hb, was associated with an increased risk of complications, particularly in patients with higher cardiac risk. Restrictive transfusion strategies should be carefully applied in patients undergoing lung resections and balanced according to individual clinical status.

Recent Trends in Demographics, Surgery, and Prognosis of Patients with Surgically Resected Lung Cancer in a Single Institution from Korea

BACKGROUND

Over the past few decades, demographics information has changed significantly in patients with surgically resected lung cancer. Herein, we evaluated the recent trends in demographics, surgery, and prognosis of lung cancer surgery in Korea.

METHODS

Patients with surgically resected primary lung cancer from 2002 to 2016 were retrospectively analyzed. Multivariable Cox regression analysis was conducted to identify prognostic factors for overall survival. The annual percent change (APC) and statistical significance were calculated using the Joinpoint software.

RESULTS

A total of 7,495 patients were enrolled. Over the study period, the number of lung cancer surgeries continued to increase (P < 0.05). The proportion of women to total subjects has also increased (P < 0.05). The proportion of elderly patients (≥ 70 years) as well as those with tumors measuring 1-2 cm and 2-3 cm significantly increased in both genders (all P < 0.05). The proportion of patients with adenocarcinoma, video-assisted thoracic surgery, sublobar resection, and pathological stage I significantly increased (P < 0.05). The 5-year overall survival rate of lung cancer surgery increased from 61.1% in 2002-2006 to 72.1% in 2012-2016 (P < 0.001). The operative period was a significant prognostic factor in multivariable Cox analysis (P < 0.001).

CONCLUSION

The mean age of patients with lung cancer surgery increased gradually, whereas tumor size reduced. Prognosis of lung cancer surgery improved with recent increases in the frequency of adenocarcinoma, video-assisted thoracic surgery, sublobar resection, and pathological stage I. The operation period itself was also an independent prognostic factor for overall survival.

Systemic inflammation score: a novel risk stratification tool for postoperative outcomes after video-assisted thoracoscopic surgery lobectomy for early-stage non-small-cell lung cancer

Objectives

To evaluate whether the systemic inflammation score (SIS) could predict postoperative outcomes for patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for early-stage non-small-cell lung cancer (NSCLC).

Methods

This retrospective study was conducted on the prospectively maintained database in our institution between January 2016 and December 2017. Preoperative SIS comprising serum albumin (sALB) and lymphocyte-to-monocyte ratio (LMR) was graded into 0, 1 and 2, and then utilized to distinguish patients at high surgical risks. Multivariable logistic-regression analysis was conducted to determine independent risk factors for postoperative outcomes.

Results

There were 1,025 patients with TNM-stage I-II NSCLC included, with an overall morbidity rate of 31.1% and mortality rate of 0.3%. We applied the sALB at 40 g/L and the median LMR of our series at 4.42 as dichotomized cutoffs for modified SIS scoring criteria. Both minor and major morbidity rates in patients with SIS=2 were significantly higher than those in patients with SIS=0 and with SIS=1 (P<0.001). No difference was found in overall morbidity rate between patients with SIS=1 and with SIS=0 (P=0.20). No significant difference was found in the mortality rate between these 3 groups. Patients with SIS=2 had the highest probability to experience most of individual complications. Finally, multivariable logistic-regression analysis suggested that preoperative SIS=2 could independently predict the morbidity risks following VATS lobectomy (OR=1.73; 95% CI=1.11–2.71; P=0.016).

Conclusions

The SIS scoring system can be employed as a simplified, effective and routinely operated risk stratification tool in patients undergoing VATS lobectomy.

Application of full lateral decubitus position with cephalic parallel approach in robotic-assisted minimally invasive esophagectomy

Background

To overcome the technical shortcomings of robot-assisted minimally invasive esophagectomy (RAMIE), we designed an optimized approach called full lateral position with cephalic-parallel approach for this technique.

Methods

We described and demonstrated the details regarding the full lateral position with cephalic-parallel approach for mobilization of the esophagus and mediastinal lymphadenectomy. On the basis of the location and T stage of esophageal cancer, a disease-specific resection process was also designed and introduced. Ten of our latest RAMIE procedures were performed using this approach. Perioperative data were collected and analyzed.

Results

The mean duration of the entire RAMIE procedure was 381.0±57.5 min. Two (20%) patients suffered from postoperative hoarseness. The mean total number of lymph nodes dissected was 22.4±4.0, and the mean number of positive lymph nodes dissected was 2.0±2.7.

Conclusions

The newly designed full lateral position with cephalic-parallel approach, which makes the procedure highly convenient, is technically feasible for RAMIE.

External suction versus simple water-seal on chest drainage following pulmonary surgery: an updated meta-analysis

OBJECTIVES

The decision to apply simple water-seal drainage or the addition of an external suction to the simple water-seal drainage following pulmonary surgery is made based on the surgeon's experience or preference and has remained controversial. This meta-analysis aimed to assess the effects of the addition of suction to simple water-seal on the postoperative outcomes.

METHODS

PubMed, EMBASE and Web of Science were searched from their inception to 30 August 2017. The risk ratio and the weight mean difference were calculated for dichotomous and continuous outcomes, respectively, each with 95% confidence intervals (CIs). The heterogeneity and risk of bias were also assessed.

RESULTS

A total of 10 randomized controlled trials enrolling 1601 patients were included. Overall, compared with simple water-seal, the addition of external suction reduced the occurrence of postoperative pneumothorax (risk ratio 0.35, 95% CI 0.13-0.93; P = 0.04) and other cardiopulmonary complications (risk ratio 0.65, 95% CI 0.48-0.89; P = 0.008), and increased the duration of chest tube drainage (weight mean difference 0.92 days, 95% CI 0.04-1.81, P = 0.04). However, the effect difference between the 2 groups was not significant regarding air leak duration, length of hospital stay and the occurrence of prolonged air leak. The stability of these studies was strong. No evidence of publication bias was detected.

CONCLUSIONS

The addition of suction to simple water-seal made no difference to air leak duration, hospital stay or the occurrence of prolonged air leak following pulmonary surgery. In patients where there is concern about a residual or increasing pneumothorax, the addition of suction may be applied selectively.

Albumin-to-alkaline phosphatase ratio as a novel prognostic indicator for patients undergoing minimally invasive lung cancer surgery: Propensity score matching analysis using a prospective database

OBJECTIVES

To evaluate prognostic significance of albumin-to-alkaline phosphatase ratio (AAPR) for patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for non-small-cell lung cancer (NSCLC) by a propensity score-matching (PSM) analysis.

METHODS

This PSM study was conducted on the prospectively-maintained database in our institution between December 2013 and March 2015. Overall survival analyses and further subgroup analyses were both performed to distinguish the differences in postoperative survival between patients stratified by an optimal cutoff of AAPR. Multivariable Cox proportional hazards regression models were established to determine the independent prognostic factors.

RESULTS

There were 390 patients with operable NSCLCs included. An AAPR of 0.57 was identified as the optimal cutoff regarding to postoperative survival. Both overall survival (OS) and disease-free survival (DFS) in patients with AAPR≤0.57 were significantly shortened compared to those in patient with AAPR>0.57 (Log-rank P < 0.001). Patients with AAPR≤0.57 had significantly lower rates of OS and DFS than those of patients with AAPR>0.57 (P < 0.001). These differences still remained significant after subgroup analyses and PSM analyses. Multivariate analyses on the entire cohort and the PSM cohort commonly indicated that low preoperative AAPR could be an independent prognostic factor for unfavorable OS and DFS of resected NSCLCs.

CONCLUSIONS

AAPR can serve as a novel risk stratification tool to refine prognostic prediction for surgical NSCLC. It may help surgeons to screen high-surgical-risk patients and further formulate individualized treatment schemes.

Systemic Inflammation Score as a Novel Prognostic Indicator for Patients Undergoing Video-Assisted Thoracoscopic Surgery Lobectomy for Non-Small-Cell Lung Cancer

BACKGROUND

To evaluate the prognostic significance of systemic inflammation score (SIS) for patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for non-small-cell lung cancers (NSCLCs). Methods: This retrospective cohort study was conducted on the prospectively maintained database in our institution during the study period. Preoperative SIS comprising serum albumin (sALB) and lymphocyte-to-monocyte ratio (LMR) was graded into 0, 1 and 2. Survival analysis was performed to distinguish differences in postoperative survival between three groups of SIS. Finally, multivariate Cox proportional hazards regression analyses were conducted to determine independent prognostic factors. Results: There were 390 patients with operable NSCLCs included. We applied sALB at 40 g/L and our median LMR at 3.91 as the cutoffs for modified SIS scoring criteria. Both overall survival (OS) and disease-free survival (DFS) were significantly shortened in a step-wise fashion with each 1-point increase in SIS (Log-rank p < .001). There was a significant step-wise decline in both OS and DFS rates in proportion to SIS (p < .001). No difference was found in postoperative complications between three groups of SIS. Multivariate analyses finally demonstrated that both SIS = 1 and SIS = 2 could be independent prognostic factors for unfavorable OS and DFS of NSCLCs. Conclusions: SIS can serve as a novel risk stratification tool to refine the prognostic prediction for surgical NSCLCs.

Chest Trauma Scoring Systems for Predicting Respiratory Complications in Isolated Rib Fracture

BACKGROUND

We retrospectively compared chest trauma scoring systems in patients with rib fractures without major extrathoracic injury for predicting respiratory complications. We also evaluated the predictive power according to the presence or absence of pulmonary contusion.

MATERIALS AND METHODS

Data from 177 patients with isolated rib fractures were included (December 2013 to April 2018). The primary outcome was respiratory complications (pneumonia, respiratory failure, or empyema). The Abbreviated Injury Scale (AIS), Thoracic Trauma Severity Score (TTSS), Chest Trauma Score (CTS), Rib Fracture Score (RFS), and RibScore were evaluated using univariate and receiver operating characteristic (ROC) analyses to determine their predictive value for pulmonary complications. We divided patients into two groups according to the presence or absence of pulmonary contusion, and constructed ROC curves for both groups.

RESULTS

Twenty-eight patients (15.8%) had ≥1 respiratory complication, with significantly higher numbers of standard, segmental, and displaced rib fractures as well as significantly higher TTSS, CTS, RFS, and AIS scores. In all patients, the TTSS (0.723, 95% confidence interval [CI] 0.651-0.788) showed the highest area under the ROC curve (AUROC), followed by the CTS, RFS, AIS, and RibScore. In patients with pulmonary contusion, TTSS also showed the highest AUROC (0.704, 95% CI 0.613-0.784). In patients without pulmonary contusion, RFS showed the highest AUROC (0.759, 95% CI 0.630-0.861).

CONCLUSIONS

TTSS was the most useful system for predicting respiratory complications in isolated rib fracture patients with pulmonary contusion. By contrast, RFS was the most useful in patients without pulmonary contusion.

Does robot-assisted minimally invasive esophagectomy really have the advantage of lymphadenectomy over video-assisted minimally invasive esophagectomy in treating esophageal squamous cell carcinoma? A propensity score-matched analysis based on short-term outcomes

This study aims to investigate advantages of robot-assisted minimally invasive esophagectomy (RAMIE) over video-assisted minimally invasive esophagectomy (VAMIE) in treating esophageal squamous cell carcinoma by applying propensity score-matched analysis. From April 2016 to January 2018, consecutive patients undergoing a McKeown RAMIE or VAMIE for esophageal squamous cell carcinoma were prospectively included for analysis. Baseline data, pathological findings, and short-term outcomes of the two groups (RAMIE group and VAMIE group) were collected and compared. Propensity score-matched analysis was applied to generate matched pairs for further comparison. Finally, we included a total of 151 patients (RAMIE group: 79 patients, VAMIE group: 72 patients) for analysis. In the analysis of unmatched cohort, RAMIE yielded a significantly larger number of total dissected lymph nodes (mean: 20.6 ± 8.8 vs. 17.9 ± 7.7; P = 0.048) and abdominal lymph nodes (mean: 9.5 ± 6.8 vs. 7.4 ± 5.1; P = 0.039) than VAMIE. However, there was no significantly different risk of major complications between the two groups. In the analysis of matched cohort, RAMIE still yielded a significantly larger number of total dissected lymph nodes (P = 0.006) and abdominal lymph nodes (P = 0.042) than VAMIE. There was still no increased risk of postoperative major complications in the RAMIE group compared to the VAMIE group. Moreover, RAMIE was found to yield significantly more left recurrent laryngeal nerve lymph nodes (mean: 1.0 ± 1.8 vs. 0.4 ± 0.8; P = 0.033) than VAMIE without increasing the risk of recurrent laryngeal nerve paralysis. Therefore, RAMIE may have the advantage of lymphadenectomy over VAMIE without increasing any risk of postoperative major complications. Further well-conducted studies, however, are needed to confirm our conclusions.

Clinical utility of robot-assisted transthoracic esophagectomy in advanced esophageal cancer after neoadjuvant chemoradiation therapy

Background

Although robot-assisted minimally-invasive esophagectomy (RAMIE) surgeries are expanding clinically, few studies have reported patients with locally-advanced esophageal cancer who underwent neoadjuvant chemoradiation therapy (nCRT).

Methods

From 2013 to 2017, 219 patients with esophageal squamous cell carcinoma underwent RAMIE and 35 of them received nCRT at our institution. During the period, 289 patients underwent conventional open esophagectomy (OE) and 111 patients underwent nCRT. We compared postoperative mortality and morbidity of RAMIE and OE patients after nCRT.

Results

In patients who received nCRT, the RAMIE and OE groups had similar operative time, estimated blood loss, early-period mortality, and recurrence rate (≤1 year) and both groups showed a high rate of complete resection. With respect to postoperative morbidities, such as anastomotic leakage, chylothorax, postoperative bleeding, and wound infection, only vasopressor use was significantly higher in the OE group (P<0.001). The RAMIE group had a lower, but not statistically significant, postoperative pneumonia incidence than the OE group (5.7% vs. 13.5%, P=0.341).

Conclusions

In patients who received nCRT for locally-advanced esophageal cancer, RAMIE is safe and feasible with comparable postoperative mortality and morbidity to conventional OE. Patients with advanced-stage esophageal cancer who received nCRT may be surgical candidates for RAMIE.

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.

An aggregate score to stratify the technical complexity of video-assisted thoracoscopic lobectomy

OBJECTIVES

The purpose of this study was to develop a score to predict the complexity of video-assisted thoracoscopic surgery (VATS) lobectomies preoperatively.

METHODS

One hundred and thirty-nine consecutive patients undergoing VATS lobectomy operated on by a single surgeon as the first operator were included. Complex operations were defined as: operation time >180 min (corresponding to the 75th percentile) or a conversion to thoracotomy. Several patient-related baseline and radiological variables were tested for a possible association with surgical complexity by logistic regression analysis. An aggregate score was created by weighing the regression estimates of the significant predictors. Patients were then grouped in classes of risk according to their scores. Finally, the score was validated in an external population of 154 VATS lobectomy patients.

RESULTS

Twenty-nine VATS lobectomies (21%) were classified as complex. The following variables were found to be significantly associated with a complex operation and were used to calculate the risk score in each patient (1 point each): male (P = 0.006), presence of thick pleura (P = 0.003), presence of emphysema (P = 0.001), enlarged hilar nodes (P = 0.003). Patients were grouped in 4 classes showing an incremental incidence of complex operations (P < 0.0001): score 0, 7.4%; score 1, 18%; score 2, 27%; score >2, 67%. In the external validation set, the score confirmed its association with the incidence of complex operations (P < 0.001): score 0, 7.3%; score 1, 10%; score 2, 16%; score >2 50%.

CONCLUSIONS

The complexity score appeared to be reproducible in an external setting and can be used to preoperatively identify appropriate candidates for VATS lobectomies to improve the efficiency and safety of the training phase.

Fat-free mass index is superior to body mass index as a novel risk factor for prolonged air leak complicating video-assisted thoracoscopic surgery lobectomy for non-small-cell lung cancer

Background

To evaluate whether fat-free mass index (FFMI) could be predictive of prolonged air leak (PAL) complicating video-assisted thoracoscopic (VATS) lobectomy for non-small-cell lung cancer (NSCLC).

Methods

A retrospective study was conducted on the prospectively-maintained database in our institution between January 2015 and July 2017. The gender-specific median values of FFMI for males and females were applied as their respective cutoffs to stratify patients into low-FFMI group and high-FFMI group in initial univariable analyses. An effective multivariable logistic-regression analysis was then performed to demonstrate the predictive value of dichotomized FFMI.

Results

There were 1,091 surgical patients with NSCLC included (616 males and 475 females), with a PAL incidence of 14.6%. The median FFMI values among males and females were 17.3 and 14.6 kg/m², respectively. PAL cases in both male (16.9±1.5 vs. 17.4±1.5 kg/m²; P=0.002) and female (14.0±0.9 vs. 14.6±1.1 kg/m²; P<0.001) groups had a significantly lower mean FFMI than that of non-PAL cases. The incidence of PAL was significantly increased in male patients with FFMI <17.3 kg/m² (23.7% vs. 14.3%; P=0.003) and female patients with FFMI <14.6 kg/m² (12.7% vs. 5.0%; P=0.003). Lower dichotomized FFMI was also significantly associated with prolonged time to air leak cessation and length of stay (LOS). Finally, multivariable logistic-regression analysis indicated that lower dichotomized FFMI [odds ratio (OR) =1.98; 95% confidence interval (CI): 1.33-2.96; P=0.001] could independently predict the occurrence of PAL.

Conclusions

FFMI acts as an excellent categorical risk factor for PAL complicating VATS lobectomy and shows a much superior significance than body mass index (BMI) in terms of the prediction of PAL.

The Association of Angiogenesis Markers With Acute Kidney Injury and Mortality After Cardiac Surgery

RATIONALE & OBJECTIVE

The process of angiogenesis after kidney injury may determine recovery and long-term outcomes. We evaluated the association of angiogenesis markers with acute kidney injury (AKI) and mortality after cardiac surgery.

STUDY DESIGN

Prospective cohort.

SETTING & PARTICIPANTS

1,444 adults undergoing cardiac surgery in the TRIBE-AKI (Translational Research Investigating Biomarker Endpoints for Acute Kidney Injury) cohort.

EXPOSURES

Plasma concentrations of 2 proangiogenic markers (vascular endothelial growth factor A [VEGF] and placental growth factor [PGF]) and 1 antiangiogenic marker (soluble VEGF receptor 1 [VEGFR1]), measured pre- and postoperatively within 6 hours after surgery.

OUTCOMES

AKI, long AKI duration (≥7 days), and 1-year all-cause mortality.

ANALYTICAL APPROACH

Multivariable logistic regression.

RESULTS

Following cardiac surgery, plasma VEGF concentrations decreased 2-fold, and PGF and VEGFR1 concentrations increased 1.5- and 8-fold, respectively. There were no meaningful associations of preoperative concentrations of angiogenic markers with outcomes of AKI and mortality. Higher postoperative VEGF and PGF concentrations were independently associated with lower odds of AKI (adjusted ORs of 0.89 [95% CI, 0.82-0.98] and 0.69 [95% CI, 0.55-0.87], respectively), long AKI duration (0.65 [95% CI, 0.49-0.87] and 0.48 [95% CI, 0.28-0.82], respectively), and mortality (0.74 [95% CI, 0.62-0.89] and 0.46 [95% CI, 0.31-0.68], respectively). In contrast, higher postoperative VEGFR1 concentrations were independently associated with higher odds of AKI (1.56; 95% CI, 1.31-1.87), long AKI duration (1.75; 95% CI, 1.09-2.82), and mortality (2.28; 95% CI, 1.61-3.22).

LIMITATIONS

Angiogenesis markers were not measured after hospital discharge, so we were unable to determine long-term trajectories of angiogenesis marker levels during recovery and follow-up.

CONCLUSIONS

Higher levels of postoperative proangiogenic markers, VEGF and PGF, were associated with lower AKI and mortality risk, whereas higher postoperative antiangiogenic VEGFR1 levels were associated with higher risk for AKI and mortality.

Aspirin for patients undergoing major lung resections: hazardous or harmless?†

OBJECTIVES

Acetylsalicylic acid (ASA, aspirin) is a medication widely used for primary and secondary prevention of cardiovascular diseases, which are the leading cause of morbidity and mortality worldwide. Whether aspirin should be continued or paused in the perioperative period remains controversial, especially in thoracic surgical settings.

METHODS

A single-centred retrospective study comprised 486 patients. Of these, 329 patients did not use aspirin (group ASA-0) and 157 did (group ASA-1) during the perioperative period after anatomical lung resection at our hospital from January 2013 to December 2016. Major outcome measures were the amount of blood loss during the operation and during the first 5 days postoperatively (per Mercuriali's formula), as well as the amount and proportion of the blood transfusion (packed red cells) received. The need for reoperation due to a postoperative haemothorax and/or bleeding was recorded. The groups were also compared according to their rates of morbidity and mortality. Inferential statistical methods with bootstrap analysis using 1000 samples and the Mersenne Twister, a random number generator, were used.

RESULTS

There were no significant differences between the 2 groups in intraoperative bleeding [ASA-0M = 418.69 ml, standard deviation (SD) ± 364.87; ASA-1M = 399.8 ml, SD ± 323.84; P = 0.58] or in total blood loss according to Mercuriali's formula (ASA-0M = 1111.62 ml, SD ± 816.69; ASA-1M = 1115.08 ml, SD ± 682.12; P = 0.95). A total of 104 patients received transfusions up to postoperative day 5: 71 patients in the ASA-0 group received 151 blood transfusions, whereas 33 patients in the ASA-1 group received 65 blood transfusions (P = 0.66). The indication for reoperation due to bleeding (ASA-1 = 3, ASA-0 = 4; P = 0.69) was similar between the groups. There was a trend towards higher rates of postoperative complications in the ASA-1 group (risk ratio (RR) = 1.28; P = 0.055); neither cardiovascular complications nor deaths were more frequent in either of the 2 groups (P = 0.73).

CONCLUSIONS

Patients taking aspirin therapy and undergoing anatomical lung resection seem not to be at any disadvantage regarding bleeding. However, a trend towards a higher rate of postoperative complications indicates a basically increased risk for operations due to comorbidities in these patients.

Refined risk stratification for thoracoscopic lobectomy or segmentectomy

Background

Given the wide adoption of thoracoscopic lobectomy and positive effect of the thoracoscopic approach for improving postoperative outcomes, questions have arisen regarding the validity of previously published risk assessment models. We sought to review the reliability of the established predictors for patients undergoing thoracoscopic lobectomy.

Methods

From January 2009 to May 2017, 606 patients (275 women, 331 men; median age 67 years) underwent thoracoscopic lobectomy or segmentectomy for confirmed or suspected early-stage lung cancer or metastasis at our institution. Logistic regression analyses were performed to determine the predictors of postoperative complications, followed by assessments of causal inference.

Results

The postoperative mortality, pulmonary complication, cardiovascular complication and overall morbidity rates were 1.0%, 8.9%, 5.8% and 18.0%, respectively. While the American Society of Anesthesiologists physical status (ASA-PS) emerged as an independent morbidity predictor, only a slightly significant association between lung function determinants and overall morbidity was found in the univariable regression analyses. Regarding causal inference, inverse probability of treatment weighting using propensity scores revealed 2- and 1.7-fold increases in the odds of cardiopulmonary complications and overall morbidity in patients with ASA-PS grade 3 or 4 compared with those with ASA-PS grade 1 or 2 (OR =2.116, 95% CI: 1.252-3.577, P=0.005; OR =1.740, 95% CI: 1.095-2.765, P=0.019, respectively).

Conclusions

Our results suggested that the current physiologic evaluation algorithm is also applicable to major lung resection via thoracoscopic approach. ASA-PS is an easily assessable factor capable of predicting major complications following thoracoscopic lobectomy in patients properly selected in compliance with the current guideline. It is recommended to incorporate the ASA-PS into the existing algorithm for more accurate risk stratification in this patient population.

Preoperative serum lactate dehydrogenase level as a predictor of major complications following thoracoscopic lobectomy: a propensity-adjusted analysis

OBJECTIVES

Despite the positive effects of a thoracoscopic approach on improving postoperative outcomes, the risk of major complications following thoracoscopic lobectomy is not negligible. We sought to assess the usefulness of the preoperative determination of serum biomarkers to refine risk stratification in this patient population.

METHODS

From 2009 to 2017, 626 patients (285 women, 341 men; median age: 67 years) underwent thoracoscopic lobectomy or anatomical segmentectomy for confirmed or suspected early-stage lung cancer or metastasis at our institution. Preoperative serum biomarkers, including albumin, C-reactive protein, haemoglobin and lactate dehydrogenase (LDH), were examined as predictors of postoperative cardiopulmonary complications using logistic regression analyses followed by causal inference.

RESULTS

The 90-day mortality, cardiopulmonary complication and overall morbidity rates were 1.0%, 13.1% and 18.1%, respectively. Although serum albumin, C-reactive protein and haemoglobin were not associated with cardiopulmonary complications in regression analyses, preoperative serum LDH level emerged as an independent morbidity predictor (odds ratio 1.008, 95% confidence interval 1.002-1.013; P = 0.006). The causal inference using the covariate balancing generalized propensity score methodology demonstrated similar results and an approximately positive linear relationship between the odds of cardiopulmonary complications and preoperative serum LDH level. For every 100 U/l increase in preoperative serum LDH, a 2-fold increase in the odds of cardiopulmonary complications was observed.

CONCLUSIONS

Our results suggest that the preoperative serum LDH level is an independent predictor of 90-day cardiopulmonary complications following thoracoscopic lobectomy or segmentectomy, even in properly selected patients. Therefore, we recommend incorporating early serum LDH measurements as a readily available method into the risk assessment process prior to major lung resection.

[Can Perioperative Oscillating Positive Expiratory Pressure Practice Enhance Recovery in Lung Cancer Patients Undergoing Thorascopic Lobectomy?]

背景与目的

振动正压呼气（oscillatory positive expiratory pressure, OPEP）训练是一种通过正压呼气装置（acapella）进行的呼吸训练。OPEP在慢性阻塞性肺疾病、支气管扩张症、肺囊肿等疾病的临床价值已经得到广泛探讨，但其在肺癌手术患者围术期的应用价值尚有待探索。本研究旨在探索围术期进行振动正压呼气训练对胸腔镜肺癌患者术后并发症发生率、肺功能、生活质量的影响。

方法

前瞻性收集2017年9月15日-2018年1月15日四川大学华西医院胸外科单个医疗组行胸腔镜肺叶切除的原发性非小细胞癌患者69例，随机分成实验组（35例）和对照组（34例）。实验组（acapella group, AG）围手术期采用振动正压呼气训练，对照组（control group, CG）进行常规围术期处理。对比分析两组在术后并发症发生率、肺功能、生活质量方面的差异。

结果

术后肺部并发症和肺不张在AG（2.9%, 0.0%）显著低于CG（20.6%, 14.7%）（P=0.03, P=0.03）；平均住院日和术后住院日在AG（10.86±5.64, 5.09±4.55）d显著短于CG（14.41±4.58, 7.59±3.21）d（P=0.01, P=0.01）；住院药物费用在AG（4, 413.60±1, 772.35）￥显著低于CG（6, 490.35±3, 367.66）￥（P=0.01）。出院当日第1秒用力呼气容积（forced expiratory volume in the first second, FEV₁）和呼气峰流速（peak expiratory flow, PEF）在AG[(1.50±0.32) L, (252.06±75.27) L/min]显著高于CG[(1.34±0.19) L, (216.94±49.72) L/min]（P=0.03, P=0.03）。

结论

肺癌患者围手术期使用振动正压呼气训练有助于降低肺部并发症，同时能够加速患者康复。

Blazing new trails: initial efforts to create a joint Society of Thoracic Surgeons-European Society of Thoracic Surgeons (STS-ESTS) dataset

Over the past 5 years, there has been an increased focus on international database collaboration between the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) and European Society of Thoracic Surgeons (ESTS) Registry Task Forces. To this end, a joint STS-ESTS database Task Force meeting is held each year at the STS annual meeting, during which current and future projects are discussed. As this relationship has evolved, various issues have been encountered that must be overcome to maximize the potential of this collaborative effort. This article provides an overview of the STS GTSD and ESTS Registry, past projects, and the challenges faced by the Societal Task Forces as future projects are envisioned.

Focus on specific disease-part 2: the European Society of Thoracic Surgery chest wall database

Background

Data collection has gained a great importance in numerous areas in the last years and also in the medical field. Collecting data is the key to knowledge and consequently improving data quality is fundamental, as the results of the data analysis can have a large impact on the clinical practice.

Methods

Collected data can be employed to assess the performance of surgeons or institutions and to implement hospital´s performance and productivity. The chest wall database is one of the satellites composing the European Society of Thoracic Surgery (ESTS) database and includes data on risk factors, surgical techniques, processes of care and outcomes related to chest wall pathologies. The participation to the registry is free and voluntary for the ESTS members. The ESTS chest wall database includes data on risk factors, surgical techniques, processes of care and outcomes related to chest wall pathologies. The collected data are designed for quality control and performance audit. Acquired data are anonymous, independently accessed and encrypted on a Dendrite platform, which provides data security and regular backups. The registry is managed by an external company (KData Clinicak Srl), which works together with the database committee in revising and updating periodically the database.

Results

The ESTS chest wall database is structured in four main sections: preoperative, intraoperative, postoperative and follow up. For each procedure registered in the database are collected a number of different variables regarding the patients' characteristics, the surgical technique, the postoperative course until the discharge and also follow up data. Correction of pectus excavatum is the most common procedures registered in 2017 (392 patients, 67% of all data), followed by pectus bar removal (159 patients, 27% of all procedures).

Conclusions

The ESTS chest wall database is an ambitious European project, which aims to standardize all chest wall procedures in all their aspects.

Degree of pulmonary fissure completeness can predict postoperative cardiopulmonary complications and length of hospital stay in patients undergoing video-assisted thoracoscopic lobectomy for early-stage lung cancer

OBJECTIVES

To estimate the effects of pulmonary fissure completeness on postoperative cardiopulmonary complications (PCCs) and hospital stay in patients undergoing video-assisted thoracoscopic surgery lobectomy for early-stage non-small-cell lung cancer.

METHODS

We performed a single-centre retrospective analysis based on the prospectively maintained data of our institution during the study period. Demographic differences between the PCC group and the non-PCC group were initially examined. Then, the patients were classified into 3 groups according to their fissure sum averages (FSAs: 0 ≤ FSA ≤ 1, 1 < FSA ≤ 2, 2 < FSA ≤ 3) calculated by fissure development scores. The differences in PCC incidences and hospital stay between these 3 groups were further evaluated. Finally, FSA > 1 was determined as the cut-off to indicate the degree of pulmonary fissure completeness and involved into a multivariate logistic regression model to identify the predictors for PCCs.

RESULTS

In total, 528 patients with Stage I to Stage II non-small-cell lung cancer were enrolled. There were 343 patients with 0 ≤ FSA ≤ 1, 105 patients with 1 < FSA ≤ 2 and 80 patients with 2 < FSA ≤ 3. Pulmonary complication rate in patients with 1 < FSA ≤ 2 (25.7% vs 14.3%; P = 0.006) and with 2 < FSA ≤ 3 (33.8% vs 14.3%; P < 0.001) was significantly higher than that in patients with 0 ≤ FSA ≤ 1. No difference was found in cardiovascular complication rate between these groups (P = 0.22). The Kaplan-Meier analysis showed that the length of hospital stay and the length of chest tube drainage in patients with 1 < FSA ≤ 2 and with 2 < FSA ≤ 3 were significantly longer than those in patients with 0 ≤ FSA ≤ 1. Incomplete pulmonary fissure (FSA > 1) was a strong independent predictor for PCCs (odds ratio = 2.12; P = 0.002) in the multivariate analysis.

CONCLUSIONS

The degree of pulmonary fissure completeness can predict the PCCs and the length of hospital stay following video-assisted thoracoscopic surgery lobectomy for early-stage non-small-cell lung cancer.

The everlasting issue of prolonged air leaks after lobectomy for non-small cell lung cancer: A data-driven prevention planning model in the era of minimally invasive approaches

BACKGROUND AND OBJECTIVES

Prolonged air leaks (PAL) are the most frequent complication after lobectomy for non-small cell lung cancer, even in case of minimally invasive approaches. We developed a novel score to identify high-risk patients for PAL during minimally invasive lobectomy.

METHODS

A dedicated database was created. We investigated preoperative candidate features and specific intraoperative variables. Univariate and subsequent logistic regression analysis with bootstrap resampling have been used. Model performance has been assessed by reckoning the area under the receiver operating characteristics curve and the Hosmer-Lemeshow goodness of fit.

RESULTS

PAL (>5 days) occurred in 72 (15.69%) patients. Five variables emerged from the model. Each one was assigned a score to provide a cumulative scoring system: forced expiratory volume in 1 second below 86% (P = 0.004, 1.5 points), body mass index <24 ( P = 0.002, 1 point), active smoking ( P = 0.001, 1.5 points), incomplete fissures ( P = 0.004, 1.5 points), and adhesions ( P = 0.0001, 1 point). The new score provided a stratification into four risk classes.

CONCLUSIONS

The risk score incorporates either general or more specific variables, providing a risk stratification that could be readily applied intra- and postoperatively. Henceforth, specific technical and management measures could be properly allocated to curb PAL.

Body surface area as a novel risk factor for chylothorax complicating video-assisted thoracoscopic surgery lobectomy for non-small cell lung cancer

Background

The study was conducted to demonstrate the predictive value of body surface area (BSA) for chylothorax complicating video‐assisted thoracoscopic surgery (VATS) lobectomy for non‐small cell lung cancer (NSCLC).

Methods

Large‐scale retrospective analysis was conducted on the data of 1379 patients who underwent VATS lobectomy between January 2014 and October 2017 at our institution. Receiver operating characteristic analysis was conducted to determine a threshold BSA value for the prediction of chylothorax. This optimal BSA cutoff, other clinicopathological variables, and P < 0.15 were included into a multivariable logistic regression model to determine the risk factors for chylothorax.

Results

Twenty‐six patients (1.9%) developed postoperative chylothorax. The mean BSA in patients with chylothorax was significantly higher than in patients without (1.84 ± 0.14 vs. 1.73 ± 0.16 m²; P = 0.001). A BSA of 1.69 m² was identified as the threshold value with maximum joint sensitivity (96.2%) and specificity (43.8%). Patients with BSA > 1.69 m² had a significantly higher incidence of chylothorax (3.0% vs. 0.3%; P < 0.001) and a longer hospital stay (log rank P < 0.001) than patients with BSA ≤ 1.69 m². Multivariable logistic regression analysis suggested that BSA > 1.69 m² (odds ratio 7.35, 95% confidence interval 1.54–35.71; P = 0.013) was predictive of postoperative chylothorax.

Conclusions

BSA can serve as a novel categorical predictor for chylothorax complicating VATS lobectomy for NSCLC. It may be more helpful to incorporate a BSA cutoff into routine risk stratification tools for lung cancer surgery.

Minute ventilation-to-carbon dioxide slope is associated with postoperative survival after anatomical lung resection

OBJECTIVES

The aim of the study was to identify whether ventilation-to-carbon dioxide output (V_E/V _CO2) slope obtained from cardiopulmonary exercise test (CPET) as part of the preoperative functional workup was an independent prognostic factor for short and long-term survival after major lung resection.

PATIENTS AND METHODS

974 consecutive patients undergoing lobectomy (n = 887) or segmentectomy (n = 87) between April 2014 to March 2018 were included. 209 (22%) underwent CPET, and pulmonary function tests and several clinical factors including age, sex, performance status and comorbidities were retrospectively investigated to identify the prognostic factors with a multivariable Cox regression analysis.

RESULTS

Among the patients with measured V_E/V _CO2, the incidence of cardiopulmonary complications in patients with high V_E/V _CO2 slope (>40) was 37% (19 of 51) vs. 27% (33 of 121) in those with lower slope values (p = 0.19). The 90-day mortality in patients with high V_E/V _CO2 slope (n = 8) was 16% vs. 5% (n = 6) in those with lower slope values (p = 0.03). No overall difference in 2-year mortality was identified between the two groups (VE/VCO2 > 40: 70% (54-80) vs. VE/VCO2 ≤ 40: 72% (63-80), log-rank test, p = 0.39). In a Cox regression analysis V_E/V_CO2 values were associated with poorer 2-year survival (HR 1.05, 95% CI 1.01-1.10, p = 0.030).

CONCLUSIONS

We found that V_E/V _CO2 slope was an independent prognostic factor for the 90-day mortality and 2-year survival after anatomic pulmonary resection. This finding may assist during the multidisciplinary treatment decision-making process in high-risk patients with lung cancer.

Perioperative changes of serum albumin are a predictor of postoperative pulmonary complications in lung cancer patients: a retrospective cohort study

Background

A decrease in serum albumin is commonly observed after lung cancer surgery, however, whether it is associated with postoperative outcomes is unknown. The objective of this study was to evaluate whether the reduction of serum albumin (ΔALB) on postoperative day one could serve as a predictor of postoperative pulmonary complications (PPCs) after thoracoscopic anatomical resection in lung cancer patients.

Methods

Patients characteristics were compared between groups of whether they experienced PPCs or not. The cutoff value of ΔALB was examined by receiver operating characteristic curve to find out the threshold value of ΔALB in predicting PPCs. Logistic regression analysis was conducted to identify potential risk factors for PPCs.

Results

Totally 533 patients were included into analysis, and among them, 52 experienced PPCs. The ΔALB was significant in the PPCs group than in the non-PPCs group (P<0.001), and ΔALB was observed an independent risk factor for PPCs (OR =2.268, 95% CI: 1.153-4.460). The cutoff value of ΔALB in predicting PPCs was 14.97%. Patients with ΔALB ≥14.97% were more likely to have PPCs (P<0.001).

Conclusions

A reduction of serum albumin with a cut-off value of 14.97% can be served as a predictor to identify patients at high risk of developing PPCs following thoracosopic anatomical lung cancer surgery.

Beyond borders-international database collaboration in thoracic surgery

Thoracic surgery databases continue to emerge as pillars for institutional quality improvement and research endeavors. This paper reviews the current state of the largest thoracic surgery databases: the Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD) and the European Society of Thoracic Surgery Database (ESTSD). In addition, we utilize these as a platform to evaluate the role and key ingredients for successful international database collaborations. Ultimately, collaborative efforts among large databases unify research efforts, foster cohesion, serve as benchmarks for quality improvement locally, nationally and internationally, promote comparative innovation, and ultimately improve patient outcomes.

Comparison of short-term outcomes between robot-assisted minimally invasive esophagectomy and video-assisted minimally invasive esophagectomy in treating middle thoracic esophageal cancer

Whether the robot-assisted minimally invasive esophagectomy (RAMIE) has any advantages over the video-assisted minimally invasive esophagectomy (VAMIE) remains controversial. In this study, we tried to compare the short-term outcomes of RAMIE with that of VAMIE in treating middle thoracic esophageal cancer from a single medical center. Consecutive patients undergoing RAMIE or VAMIE for middle thoracic esophageal cancer from April 2016 to April 2017 were prospectively included for analysis. Baseline data and pathological findings as well as short-term outcomes of these two group (RAMIE group and VAMIE group) patients were collected and compared. A total of 84 patients (RAMIE group: 42 patients; VAMIE group: 42 patients) were included for analysis. The baseline characteristics between the two groups were comparable. RAMIE yielded significantly larger numbers of total dissected lymph nodes (21.9 and 17.8, respectively; P = 0.042) and the right recurrent laryngeal nerve (RLN) lymph nodes (2.1 and 1.2, respectively; P = 0.033) as well as abdominal lymph nodes (10.8 and 7.7, respectively; P = 0.041) than VAMIE. Even though RAMIE may consume more overall operation time, it could significantly decrease total blood loss compared to VAMIE (97 and 161 mL, respectively; P = 0.015). Postoperatively, no difference of the risk of major complications or hospital stay was observed between the two groups. In conclusion, RAMIE had significant advantage of lymphadenectomy especially for dissecting RLN lymph nodes over VAMIE with a comparable rate of postoperative complications. Further randomized controlled trials are badly needed to confirm and update our conclusions.

EORTC QLQ-C30 summary score reliably detects changes in QoL three months after anatomic lung resection for Non-Small Cell Lung Cancer (NSCLC)

INTRODUCTION

We tested the European Organization for Research and Treatment of Cancer Quality of Life (EORTC QLQ-C30) summary score (SumSC) to detect changes in the HRQOL after Non-small-cell lung cancer (NSCLC) surgery and compared its performance to the traditional scales.

METHOD

EORTC QLQ-C30 data was obtained from 326 consecutive pre-operative patients submitted for anatomical lung resections for NSCLC.66 patients completed post-operative assessments 3 months after surgery. The data was analysed to evaluate the ability of the SumSC compared to the traditional scales to [1] preoperatively differentiate between clinical groups [2]; detect post-op changes and to [3] compare pre and post-op changes in clinically different groups.The importance of perioperative changes was measured by calculating the effect size (ES).

RESULTS

Of the 326 patients, those older than 70 years, with higher DLCO value and Performance Status (PS) ≤1 had a significantly better preoperative SumScore. Physical function (PF) showed a large and significant decline (ES 0.91). Role and social function also showed a significant and medium decline (ES 0.62 and 0.41). Postoperatively some symptoms scales showed significant increases in the values, implying worse symptoms with the largest increase in dyspnoea (ES -0.88). The change in General Health score (GH) was not significant after surgery (ES 0.26, p = 0.062). The SumSc, decreased significantly postoperatively. In particular, medium or large postoperative declines of SumSc were observed in both males and females, in patients with lower FEV1, lower performance score, and in those older than 70 years. Interestingly the decline of SumSc was observed irrespective of the preoperative DLCO level.

DISCUSSION

The Summary Score was more sensitive to changes in subjects' HRQOL, than the GH score. The SumSc can be used as a parsimonious and easy to interpreted patient-reported-outcome measure in multi-institutional database and future clinical trials.

Is it safe and practical to use a Foley catheter as a chest tube for lung cancer patients after lobectomy? A prospective cohort study with 441 cases

OBJECTIVE

This study was conducted to explore the feasibility and safety of postoperative chest drainage with a Foley catheter for lung cancer patients undergoing a video-assisted thoracoscopic surgery (VATS) lobectomy.

METHODS

Data from lung cancer patients who underwent a VATS lobectomy with insertion of a catheter (Foley catheter or 28-F chest tube) were analysed. A total of 441 patients were included preoperatively for participation, with 208 patients in the Foley catheter group and 233 in the 28-F group.

RESULTS

In the Foley catheter group, a shorter mean number of days was required until chest tube removal after lobectomy (2.6 ± 1.3 vs. 3.5 ± 2.0 d, P < 0.001) and postoperative length of stay was shorter (3.8 ± 2.5 vs. 5.2 ± 4.1 d, P < 0.001); The 28-F group had a higher average VAS score than did the Foley catheter group at 6 h (P = 0.025), and 48 h (P < 0.001) after VATS lobectomy as well as at 6 h, 24 h, 48 h, 72 h, 30 days and 90 days after chest tube removal (P < 0.001). Regarding postoperative pulmonary complications (PPCs) and chest tube removal-related complications, the rate of PPCs was not found to be significant, and a significantly higher proportion of disordered wound healing at the drainage site was observed in the 28-F group (5.8%, 12/208 vs. 11.6%, 27/233; P = 0.043).

CONCLUSION

The study indicated that placement of Foley catheter vs. 28-F chest tube was associated with a statistically significant but clinically modest reduction in pain, with shorter mean days until chest tube removal after lobectomy, shorter in-hospital stay, and a smaller proportion of disordered wound healing at the drainage site. These results indicate the feasibility and safety of postoperative chest drainage with a Foley catheter for lung cancer patients undergoing VATS lobectomy.

CLINICAL REGISTRATION NUMBER

ChiCTR1800014816.

Estimated intraoperative blood loss correlates with postoperative cardiopulmonary complications and length of stay in patients undergoing video-assisted thoracoscopic lung cancer lobectomy: a retrospective cohort study

Background

The purpose of our study was to estimate the influence of estimated intraoperative blood loss (EIBL) on postoperative cardiopulmonary complications (PCCs) in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for non-small-cell lung cancer (NSCLC).

Methods

We conducted a single-center retrospective analysis on the clinical data of consecutive patients in our institution between April 2015 and February 2016. Demographic differences between PCC group and non-PCC group were initially assessed. Receiver operating characteristic (ROC) analysis was performed to determine the threshold value of EIBL for the prediction of PCCs. Demographic differences in the PCC rates and length of stay between two groups of patients divided by this cutoff were further evaluated. A multivariable logistic-regression model involving the clinicopathological parameters with P-value< 0.05 was finally established to identify independent risk factors for PCCs.

Results

A total of 429 patients with operable NSCLC were included and 80 of them developed PCCs (rate = 18.6%). The mean EIBL in PCC group was significantly higher than that in non-PCC group (133.3 ± 191.3 vs. 79.1 ± 107.1 mL; P < 0.001). The ROC analysis showed an EIBL of 100 mL as the threshold value at which the joint sensitivity (50.0%) and specificity (73.4%) was maximal. The PCC rate in patients with EIBL≥100 mL was significantly higher than that in patients with EIBL< 100 mL (30.1 vs. 13.5%; P < 0.001). Both the length of stay and chest tube duration were significantly prolonged in the patients with EIBL≥100 mL. Finally, EIBL≥100 mL was identified to be predictive of PCCs by multivariable logistic-regression analysis (odds ratio = 3.01; 95% confidence interval = 1.47–6.16; P = 0.003).

Conclusions

EIBL serves as a significant categorical predictor for cardiopulmonary complications following VATS lobectomy for NSCLC. Thoracic surgeons should minimize the EIBL and strive for the ‘bloodless’ goal to optimize surgical outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0360-0) contains supplementary material, which is available to authorized users.

Impact of comorbidity burden on morbidity following thoracoscopic lobectomy: a propensity-matched analysis

Background

Given the positive effect of a thoracoscopic approach on improving postoperative outcomes, it is reasonable to speculate whether an increased comorbidity burden is related to higher morbidity following thoracoscopic lobectomy. We sought to evaluate the impact of comorbidity burden on adverse postoperative outcomes in this patient population.

Methods

A retrospective review of our institutional database included 512 patients undergoing thoracoscopic lobectomy for early-stage non-small cell lung cancer (NSCLC) from 2009 through 2016. Comorbidity burden was assessed by the Charlson comorbidity index (CCI) and classified as high (CCI ≥3) or low (CCI <3) grade. Propensity score matching and random effects model were performed.

Results

Patients included 228 women and 284 men with a median age of 67 years. High and low comorbidity burdens were found in 193 and 319 patients, respectively. The postoperative mortality, pulmonary and cardiovascular complication rates and overall morbidity in patients with high comorbidity burden were comparable to those with low comorbidity burden (1.6% vs. 0.6%, 9.3% vs. 8.5%, 6.2% vs. 6.0%, 24.4% vs. 22.9%, respectively). Similar results were seen after propensity score matching, which balanced differences in demographics and preoperative characteristics between the comorbidity groups. On the analyses of propensity-matched data using generalized linear mixed model, a high comorbidity burden was not related to greater postoperative complication rates.

Conclusions

Our results suggest that thoracoscopic lobectomy can be performed with low mortality and reasonable morbidity in lung cancer patients presenting with multiple comorbid diseases. The presence of a high comorbidity burden measured by CCI does not have a perceptible impact on adverse postoperative outcomes following thoracoscopic lobectomy.

Effects of degree of pulmonary fissure completeness on major in-hospital outcomes after video-assisted thoracoscopic lung cancer lobectomy: a retrospective-cohort study

Background

To evaluate the clinical significance of degree of pulmonary fissure completeness (PFC) on major in-hospital outcomes following video-assisted thoracoscopic (VATS) lobectomy for non-small-cell lung cancer (NSCLC).

Materials and methods

We carried out a single-center retrospective analysis on the prospectively maintained database at our unit between August 2014 and October 2015. Patients were divided into two groups based on their fissure sum average (FSA). Patients with FSA >1 (1< FSA ≤3) were considered to have incomplete pulmonary fissures (group A), while patients with FSA of 0–1 were considered to have complete pulmonary fissures (group B). Demographic differences in perioperative characteristics and surgical outcomes between these two groups were initially assessed. Then, a multivariate logistic-regression analysis was further conducted to identify the independent predictors for major in-hospital outcomes.

Results

A total of 563 patients undergoing VATS lobectomy for NSCLC were enrolled. There were 190 patients in group A and 373 patients in group B. The overall morbidity and mortality rates of our cohort were 30.6% and 0.5%, respectively. Group A patients had a significantly higher overall morbidity rate than group B patients (42.1% vs 24.7%, P<0.001). Both minor morbidity (40.5% vs 22%, P<0.001) and major morbidity (11.1% vs 5.6%, P=0.021) rates in group A patients were also significantly higher than group B patients. No significant difference was observed in mortality rate between these two groups (1.1% vs 0.3%, P=0.26). The incomplete degree of PFC was significantly correlated with length of stay and chest-tube duration (log-rank P<0.001) after surgery. Finally, the incomplete degree of PFC was found to be predictive of overall morbidity (OR 2.08, P<0.001), minor morbidity (OR 2.39, P<0.001), and major morbidity (OR 2.06, P=0.031) by multivariate logistic-regression analyses.

Conclusion

Degree of PFC is an excellent categorical predictor for both major and minor morbidity after VATS lobectomy for NSCLC.

Surgery for lung tumors in the elderly: A retrospective cohort study on the influence of advanced age (over 80 years) on the development of complications by using a multivariate risk model

BACKGROUND

The prevalence of lung cancer and other tumors is increasing among the elderly people. The purpose of this study was to examine the influence of advanced age (80 + years) on the immediate perioperative outcome as well as to define potential risk factors that may lead to increasing morbidity and mortality after lung resections.

METHODS

A retrospective cohort analysis of the data from an electronic database of 208 elderly patients (165 patients ≥70 years, 45 patients ≥80 years) undergoing pulmonary anatomical resection for lung tumors during January 2013-December 2016 was conducted. The patients were initially observed and then divided into two groups: septuagenarians and octogenarians. The risk of developing postoperative complications in association with the numerous observed factors, which appeared significant in univariate tests, was assessed using univariate and multivariate logistic regression analyses to construct a risk model that assesses the highest chance of developing complications. Readmission rate and mortality within 90 days were recorded.

RESULTS

There were 140 men and 68 women with the mean age of 76 ± 4 years. A total of 15 pneumonectomies (7.2%), 11 bilobectomies (5.3%), 27 segmentectomies (13%), and 155 lobectomies (74.5%) were performed through 84 thoracotomies (40.4%) and 124 video-assisted thoracoscopic surgery (VATS) procedures (59.6%). Ninety-one patients (44%) exhibited at least one of 113 postoperative complications. There were four deaths (1.9%). Readmission rate was 12%, and 90-day mortality was 5.3%. There was no difference in postoperative morbidity among the groups according to their age (RR = 0.95; p = 78). According to multivariate logistic regression, adjusted Charlson Comorbidity Index≥11, FEV₁≤0.72, DLCO≤0.57, male gender, and nonsegmentectomies appeared to be strong predictors for the development of complications.

CONCLUSIONS

In this cohort, age more than 80 years was not found to be significant for the development of complications, when compared to the septuagenarians. Female gender, better lung function (FEV1>72%, DLCO>57%), less comorbidities (ACCI<11), and segmentectomy type of lung resection were associated with improved outcomes.