Pulmonary complications following lung resection: a comprehensive analysis of incidence and possible risk factors

Experimental evaluation of a new system for laser tissue welding applied on damaged lungs

OBJECTIVES

Alveolar air leaks represent a challenging problem in thoracic surgery, leading to increased patient morbidity and prolonged hospitalization. Several methods have been used, but no ideal technique exists yet. We investigated the lung-sealing capacity of an experimental kit for laser tissue welding.

METHODS

The kit is composed of a semiconductor laser system applied on a protein substrate associated with a chromophore that increases absorption. In vitro tests on porcine lung tissue were done to define ideal laser parameters (power 100 Å, frequency 50 Hz, pulse duration 400 µs) and protein substrate dilution (50%). For in vivo tests, through a left thoracotomy, 14 pigs received two different lung damages: a linear incision and a circular incision. Protein substrate applied on damaged areas was treated with laser to obtain a layer that reconstituted the integrity of the visceral pleura. Air leaks were intraoperatively evaluated by water submersion test with an airway pressure of 20 cmH2O. Animals were sacrificed at postoperative days 0 and 7 to study early and late pathological features.

RESULTS

After applying laser treatment, no air leaks were seen in all proofs except in 2 cases in which a second application was required. At time 0, pathological damage mostly consisted of superficial alveolar necrotic tissue covered by protein membrane. At time 7, a complete recovery of lung lesions by fibrous scar with slight inflammatory reaction of adjacent lung tissue was seen.

CONCLUSIONS

This experimental study demonstrated the effectiveness of laser tissue welding applied to seal air leaks after lung surgery. Further studies are needed to verify acceptability for human application.

Postoperative outcomes following preoperative inspiratory muscle training in patients undergoing open cardiothoracic or upper abdominal surgery: protocol for a systematic review

BACKGROUND

In patients undergoing open cardiothoracic and upper abdominal surgery, postoperative pulmonary complications remain an important cause of postoperative morbidity and mortality, impacting upon hospital length of stay and health care resources. Adequate preoperative respiratory muscle strength may help protect against the development of postoperative pulmonary complications and therefore preoperative inspiratory muscle training has been suggested to be of potential value in improving postoperative outcomes.

METHODS/DESIGN

A systematic search of electronic databases will be undertaken to identify randomized trials of preoperative inspiratory muscle training in patients undergoing elective open cardiothoracic and upper abdominal surgery. From these trials, we will extract available data for a list of predefined outcomes, including postoperative pulmonary complications, hospital length of stay and respiratory muscle strength. We will meta-analyze comparable results where possible, and report a summary of the available pool of evidence.

DISCUSSION

This review will provide the most comprehensive answer available to the question of whether preoperative inspiratory muscle training is clinically useful in improving postoperative outcomes in patients undergoing cardiothoracic and upper abdominal surgery. It will help inform clinicians working in the surgical arena of the likely effectiveness of instituting preoperative inspiratory muscle training programs to improve postoperative outcomes.

Prophylactic use of noninvasive positive pressure ventilation in post-thoracic surgery patients: A prospective randomized control study

OBJECTIVE

Prospective randomized controlled study was conducted to explore the effects and safety of prophylactic use of noninvasive positive pressure ventilation (NPPV) in post-thoracic surgery (PTS) patients, especially on the lung re-expansion, lung function change and postoperative pulmonary complications (PPCs).

METHODS

Fifty PTS patients met the inclusion criterion were enrolled in the study. All subjects were randomly divided into conventional treatment (control) group and NPPV group. NPPV group received intermittent NPPV therapy in first three days of PTS. BiPAP ventilator was used with S/T mode in the study. The average IPAP was (13±3.2)cmH(2)O (ranged from 7 to 18 cmH(2)O) and EPAP was 4cmH(2)O. Total ventilation time was (13.5±4.9) hours (ranged from 6.5 to 23 hours). PPCs rate, lung re-expansion, the volume of residual cavity, lung function and tolerance to NPPV were assessed with chest roentgenography, CT scan, lung function testing and clinical evaluation before and one week after surgery.

RESULTS

1. There was no significant difference of total PPCs rate during hospitalization between the two groups (5/23 in NPPV group vs 6/27 in control group, P= 0.967). Multiple factorial logistic regression analysis showed that COPD was a risk factor for PPCs (B=1.705, P=0.027). 2. Compared with control group, NPPV therapy reduced inadequate lung expansion rate (3/23 vs 13/27, P=0.008) and volume of residual cavity calculated with CT scan [(31.9±71.7)ml vs (63.6±78.3)ml, P=0.02]. However, there were no significant difference in the change of lung function parameters after operation between the two groups (all P>0.05). No significant adverse effects of NPPV were found in the present study.

CONCLUSIONS

In the current study of prophylactic application of NPPV in post-thoracic surgery patients, the use of NPPV resulted in improved lung re-expansion, but had no significant effects on post-operative pulmonary complications and lung functions.

A novel approach to control air leaks in complex lung surgery: a retrospective review

Background

Intra-operative air leaks (IOAL) are common complications of pulmonary surgery. The post-operative management of air leaks requires a chest tube which may lead to longer hospitalization, further medical complications, and increased costs. Sealants have been shown to help control intra-operative air leaks and studies have demonstrated a reduction in chest tube duration and/or length of hospital stay. Nevertheless, systematic reviews have not presented sufficient evidence to recommend their general use in lung resection.

Methods

One hundred and twenty-one consecutive patients who underwent pulmonary surgery with and without Progel® Pleural Air Leak Sealant were reviewed retrospectively. Intra-operative and 3-months postoperative data were assessed for the presence and persistence of air leaks, chest tube duration, the length of hospital stay, and complications.

Results

Seventy patients (57.9%) had IOAL. Thirty-six were treated with Progel in addition to standard intra-operative technique (pleural-sealant group; PSG) and 34 patients were treated only with standard technique (control group; CG). The percentage of post-operative air leaks in the PSG was 11% (1.2% >Grade 2 air leak) compared with 58.8% (6% >Grade 2 air leak) in the CG (p <0.0001, Leaks graded from 1 = small air leak to 7 = large air leak). The median chest tube duration was significantly shorter in the PSG compared with the controls (1.0 versus 2.5 days; p < 0.0001). The median length of hospital stay was 50% lower in the PSG compared with the control group (1.5 versus 3.0 days; p = 0.047). There were no significant differences in complications between the two groups.

Conclusions

The results of this single-center, single surgeon, retrospective review demonstrate a significant reduction in IOAL, chest tube duration, and length of hospital stay in the in patients treated with Progel when compared with standard intra-operative closure management alone. They suggest that the use of a pleural sealant is more effective in reducing alveolar air leaks associated with lung resection compared with standard closure techniques alone and may result in both an improved surgical outcome and a reduction in costs associated with prolonged hospital stay.

Impact of previous gastrectomy on postoperative pneumonia after pulmonary resection in lung cancer patients

Postoperative pneumonia is a serious complication following pulmonary resection. Aspiration of oesophageal reflux contents is known to cause pulmonary complications in patients with a history of gastrectomy. In this study, we compared the incidence of postoperative pneumonia in patients with or without previous gastrectomy. A retrospective review was conducted of clinical charts for patients who underwent radical pulmonary resection for non-small cell lung cancer from January 2006 to December 2010. Pneumonia was diagnosed with chest computed tomography findings in all cases. A total of 333 patients underwent pulmonary resections during the study period. Twenty-seven patients (8.1%) had a history of gastrectomy. Eight patients (2.2%) had postoperative pneumonia. All eight patients who developed postoperative pneumonia did not have pneumonia before pulmonary resection. Of the aforementioned 27 patients, five (18.5%) developed pneumonia postoperatively, whereas only three of 325 patients who did not have a history of gastrectomy (0.9%) had pneumonia (P < 0.001). In multivariate analysis, a history of gastrectomy had the highest impact on the odds ratio (8.81) for postoperative pneumonia. A significantly higher incidence of postoperative pneumonia was found in patients with a history of gastrectomy. Prophylactic treatment, such as premedication with ranitidine, should be considered in those patients.

Early respiratory acidosis is a new risk factor for pneumonia after lung resection

Postoperative pneumonia (POP) is a life-threatening complication of lung resection (LR). Its risk factors, bacteriological profile and outcome are not well known. The aims of this study were to describe the outcome and causal bacteria and to identify risk factors for POP. We reviewed all cases admitted to intensive care after LR. Clinical parameters, operative and postoperative data were recorded. POP was suspected on the basis of fever, radiographic infiltrate, and either leucocytosis or purulent sputum. The diagnosis was confirmed by culture of a respiratory sample. Risk factors for POP were identified by univariate and multivariate analysis. We included 159 patients in this study. POP was diagnosed in 23 patients (14.4%) and was associated with a higher hospital mortality rate (30% versus 5%, P = 0.0007) and a longer hospital stay. Members of the Enterobacteriaceae and Pseudomonas species were the most frequently identified pathogens. Early respiratory acidosis (ERA; OR, 2.94; 95% CI, 1.1-8.1), blood transfusion (OR, 3.8; 95% CI, 1.1-13.1), bilobectomy (OR, 7.26; 95% CI, 1.2-43.1) and smoking history (OR, 1.84; 95% CI, 1.1-3) were identified as independent risk factors. ERA may be a risk factor for POP and could serve as a target for therapeutic interventions.

Predicting risk of intensive care unit admission after resection for non-small cell lung cancer: a validation study

A model for predicting the risk of emergency, unplanned intensive care unit (ICU) admission after lung resection for lung cancer has been reported. However, it has not been validated outside of the derivation cohort, and the aim of our study was to undertake external validation at our institution. We reviewed a series of consecutive patients who underwent major lung resection for non-small cell lung cancer over a 6-year period. Test performance was evaluated by area under the receiver operator characteristic (ROC) curve. Between 2003 and 2008, 425 patients underwent major lung resections for lung cancer. The mean age (SD) was 65 (10) years and 241 (57%) were men. A total of 77 (18%) patients were admitted to ICU, 47 for elective admission and 30 (7%) for treatment of post-procedure complications. Of the 30 patients admitted for complications, the median length of ICU (interquartile range) stay was 3 days (1-15 days). The mortality rate among these patients was 17%. The area under the ROC curve was 0.66 (95% CI 0.53-0.79). The Brunelli scoring system had moderate discriminating ability to predict the risk of ICU admission after lung resection in our institution.

Risk factors of postoperative pneumonia after lung cancer surgery

The purpose of this study was to investigate risk factors of postoperative pneumonia (POP) after lung cancer surgery. The 417 lung cancer patients who underwent surgical resection in a tertiary referral hospital were included. Clinical, radiological and laboratory data were reviewed retrospectively. Male and female ratio was 267:150 (median age, 65 yr). The incidence of POP was 6.2% (26 of 417) and in-hospital mortality was 27% among those patients. By univariate analysis, age ≥ 70 yr (P < 0.001), male sex (P = 0.002), ever-smoker (P < 0.001), anesthesia time ≥ 4.2 hr (P = 0.043), intraoperative red blood cells (RBC) transfusion (P = 0.004), presence of postoperative complications other than pneumonia (P = 0.020), forced expiratory volume in 1 second/forced vital capacity (FEV(1)/FVC) < 70% (P = 0.002), diffusing capacity of the lung for carbon monoxide < 80% predicted (P = 0.015) and preoperative levels of serum C-reactive protein ≥ 0.15 mg/dL (P = 0.001) were related with risk of POP. Multivariate analysis showed that age ≥ 70 yr (OR = 3.563, P = 0.014), intraoperative RBC transfusion (OR = 4.669, P = 0.033), the presence of postoperative complications other than pneumonia (OR = 3.032, P = 0.046), and FEV(1)/FVC < 70% (OR = 3.898, P = 0.011) were independent risk factors of POP. In conclusion, patients with advanced age, intraoperative RBC transfusion, postoperative complications other than pneumonia and a decreased FEV(1)/FVC ratio have a higher risk for pneumonia after lung cancer surgery.

Immediate Postoperative Care in the General Thoracic Ward Is Safe for Low-risk Patients after Lobectomy for Lung Cancer

Background

Following major lung resection, patients have routinely been monitored in the intensive care unit (ICU). Recently, however, patients are increasingly being placed in a general thoracic ward (GTW). We investigated the safety and efficacy of the GTW care after lobectomy for lung cancer.

Materials and Methods

316 patients who had undergone lobectomy for lung cancer were reviewed. These patients were divided into two groups: 275 patients were cared for in the ICU while 41 patients were care for in the GTW immediately post-operation. After propensity score matching, postoperative complications and hospital costs were analyzed. Risk factors for early complications were analyzed with the whole cohort.

Results

Early complications (until the end of the first postoperative day) occurred in 11 (3.5%) patients. Late complications occurred in 42 patients (13.3%). After propensity score matching, the incidence of early complications, late complications, and mortality were not different between the two groups. The mean expense was higher in the ICU group. Risk factors for early complications were cardiac comorbidities and low expected forced expiratory volume in one second. The location of postoperative care had no influence on outcome.

Conclusion

Immediate postoperative care after lobectomy for lung cancer in a GTW was safe and cost-effective without compromising outcomes in low-risk patients.

A postoperative shoulder exercise program improves function and decreases pain following open thoracotomy: a randomised trial

QUESTION

Does a postoperative physiotherapy exercise program incorporating shoulder exercises improve shoulder function, pain, range of motion, muscle strength, and health-related quality of life in patients undergoing elective pulmonary resection via open thoracotomy?

DESIGN

Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

76 patients who underwent pulmonary resection via open thoracotomy.

INTERVENTION

All participants received standard medical and nursing care involving a clinical pathway. The experimental group also received physiotherapy interventions that included daily supervised, progressive exercises until discharge and a postoperative exercise booklet on discharge.

OUTCOME MEASURES

Preoperatively and up to 3 months postoperatively pain was measured with a numerical rating scale, shoulder function with the Shoulder Pain and Disability Index, and quality of life with the Short Form-36. Shoulder range of motion and muscle strength were measured in a subgroup.

RESULTS

The experimental group had 1.3 units (95% CI 0.3 to 2.2) less shoulder pain (scored /10) and 2.2 units (95% CI 0.2 to 4.3) less total pain (scored /30) at discharge, and 7.6% (95% CI 1.7 to 13.6) better function at 3 months. The Short Form-36 physical component score was 4.8 points (95% CI -0.3 to 10.0) better for the experimental group than the control group at 3 months. Differences between groups in all range of motion and strength measures were small and statistically non-significant.

CONCLUSION

A physiotherapist-directed postoperative exercise program resulted in significant benefits in pain and shoulder function over usual care for patients following open thoracotomy.

TRIAL REGISTRATION

ANZCTRN 12605000201673.

Emergency thoracic surgery in elderly patients

OBJECTIVES

Emergency thoracic surgery in the elderly represents an extreme situation for both the surgeon and patient. The lack of an adequate patient history as well as the inability to optimize any co-morbidities, which are the result of the emergent situation, are the cause of increased morbidity and mortality. We evaluated the outcome and prognostic factors for this selected group of patients.

DESIGN

Retrospective chart review.

SETTING

Academic tertiary care referral center.

PARTICIPANTS

Emergency patients treated at the Department of Thoracic Surgery, University Hospital of Luebeck, Germany.

MAIN OUTCOME MEASURES

Co-morbidities, mortality, risk factors and hospital length of stay.

RESULTS

A total of 124 thoracic procedures were performed on 114 patients. There were 79 men and 36 women (average age 72.5 ±6.4 years, range 65-94). The overall operative mortality was 25.4%. The most frequent indication was thoracic/mediastinal infection, followed by peri- or postoperative thoracic complications. Risk factors for hospital mortality were a high ASA score, pre-existing diabetes mellitus and renal insufficiency.

CONCLUSIONS

Our study documents a perioperative mortality rate of 25% in patients over 65 who required emergency thoracic surgery. The main indication for a surgical intervention was sepsis with a thoracic/mediastinal focus. Co-morbidities and the resulting perioperative complications were found to have a significant effect on both inpatient length of stay and outcome. Long-term systemic co-morbidities such as diabetes mellitus are difficult to equalize with respect to certain organ dysfunctions and significantly increase mortality.

Comparison of recognition tools for postoperative pulmonary complications following thoracotomy

OBJECTIVES

To evaluate the recognition of postoperative pulmonary complications (PPC) following thoracotomy and lung resection using three PPC scoring tools.

DESIGN

Prospective observational study.

SETTING

Regional thoracic centre.

PARTICIPANTS

One hundred and twenty-nine consecutive thoracotomy and lung resection patients (October 2007 and April 2008).

MAIN OUTCOME MEASURES

PPC assessment was performed on a daily basis using three sets of criteria described by Brooks-Brunn, Gosselink et al. and Reeve et al.: the Brooks-Brunn Score (BBS), Gosselink Score (GS) and Melbourne Group Scale (MGS), respectively. The results were compared with treatment for PPC and clinical outcomes including mortality, postoperative length of stay and high dependency unit length of stay.

RESULTS

PPC frequency was 13% (17/129) with the MGS, 6% (8/129) with the GS and 40% (51/129) with the BBS. The clinically observed incidence of treated (requiring antibiotic therapy or bronchoscopy) PPC was 12% (16/129).

CONCLUSION

PPC treatment following thoracotomy is common. Of the three scoring tools, the MGS outperforms the BBS and the GS in terms of PPC recognition following thoracotomy and lung resection. Patients with a PPC-positive MGS score have a worse outcome as defined by mortality, high dependency unit length of stay and postoperative length of stay. The MGS is an easy-to-use multidisciplinary scoring tool, but further work is required into its use in minimally invasive surgery and in targeting high-risk groups for therapy.

Initial experience with a synthetic sealant PleuraSeal after pulmonary resections: a prospective study with retrospective case matched controls

The objective of this study was to evaluate postoperative outcome and efficacy of a hydrogel tissue sealant for prevention of alveolar leakage after open lung resections. 20 consecutive patients were enrolled in the PleuraSeal sealant group (PSG) and case matched with 20 retrospective controls (CG) with standard treatment. Assessment of postoperative air leakage was performed until chest tube removal. Patients were followed until 30 days after discharge. At end of surgery, 100% in the PSG and 0% in the CG were air leak free (p < 0.001). Duration of postoperative chest tube suction was shorter in PSG (p < 0.001), and air leak chest tube was removed earlier (p = 0.03). Limitation for chest tube removal due to a pulmonary leak was 35% in CG and 5% in PSG (p = 0.04). Patients remaining air leak free thru discharge was 95% and 15% for PSG and CG (p < 0.001). The study demonstrated a superior efficacy of PleuraSeal sealant compared with standard surgical treatment for sustained sealing of postoperative air leakage and causes shorter air leak chest tube duration.

Risk and protective factors for major complications after pneumonectomy for lung cancer

Pneumonectomy carries a high-risk for postoperative complications. The aim of the study was to identify factors that may predispose to the development of major postoperative complications after pneumonectomy for lung cancer. All consecutive patients from January 2000 to December 2005 were retrospectively studied. Major postoperative complications were defined by respiratory failure, pulmonary embolism, pneumonia, shock, cardiogenic pulmonary oedema, myocardial ischaemia or symptomatic cardiac arrhythmia. One hundred and twenty-nine patients were included. The overall hospital mortality rate was 10.8%, and complications occurred in 42.6%. Multivariate analysis revealed that patients with American Society of Anesthesiologist (ASA) class >2 [odds ratio (OR) 8.26; 95% confidence interval (CI), 3.19-36.55] and liberal fluid administration during surgery (OR, 1.96 for each litre; 95% CI, 1.45-3.16) to be risk factor for major cardiopulmonary complication or mortality. Preoperative haemoglobin > or =10 g/dl (OR, 0.19; 95% CI, 0.01-0.91) and low tidal volume administrated during surgery (< or =7.35 ml/kg; OR, 0.36; 95% CI, 0.10-0.92) were identified as protective factors. Pneumonectomy remains a high-risk surgery. Postoperative complications may be influenced by the comorbidities but also the management of fluid infusion and mechanical ventilation during the surgical procedure.

Anesthetic considerations in 65 patients undergoing unilateral pneumonectomy: problems related to fluid therapy and hemodynamic control

STUDY OBJECTIVE

To examine perioperative management and complications in patients undergoing pneumonectomy.

DESIGN

Observational cohort study.

SETTING

University-affiliated city hospital.

MEASUREMENTS

65 patients who underwent unilateral pneumonectomy for resection of lung cancer between March 1997 and October 2007 were included in this study. Patients who underwent pneumonectomy were then classified into two groups: Group C patients had signs of postoperative acute right heart failure, and Group N patients had no signs of postoperative acute right heart failure.

MAIN RESULTS

In the pneumonectomy patients, extubation did not occur in 8 patients (12%) and postoperative death occurred in 4 patients (6%), compared with no such occurrences among patients who underwent lobectomy. Perioperative respiratory function was significantly lower in Group C (P < 0.05) than Group N. Fluid infusion volume, fluid balance volume, intraoperative total fluid balance, urine output volume, blood loss volume, blood transfusion volume, times of administration of vasopressors intraoperatively, and number of patients requiring intraoperative administration of catecholamines were significantly greater in Group C (P < 0.05) than Group N.

CONCLUSIONS

Fluid infusion volume, fluid balance volume, intraoperative total balance, blood loss volume, and blood transfusion volume were important intraoperative risk factors in the development of postoperative right-sided heart failure.

Risk factor analysis for postoperative acute respiratory distress syndrome and early mortality after pneumonectomy: the predictive value of preoperative lung perfusion distribution

OBJECTIVES

This study aims to establish the preoperative risk factors in the development of acute respiratory distress syndrome (ARDS) and early mortality after pneumonectomy for lung cancer and to examine the influence of reduced pulmonary perfusion on outcomes.

METHODS

Between 1994 and 2009, of 425 patients who underwent simple pneumonectomy for primary lung cancer, 164 who were preoperatively evaluated with lung perfusion scanning formed the population of this study.

RESULTS

Of 30 (18.3%) patients who had major pulmonary complications, 17 (10.4%) progressed to ARDS, 15 of whom subsequently died. On multivariable logistic regression analyses, lower predicted postoperative forced expiratory volume in 1 second (ppo-FEV(1); relative risk of 0.93 [P = .020] for ARDS and 0.94 [P = .027] for mortality) and greater perfusion fraction of resected lung (relative risk of 1.10 [P = .003] for ARDS and 1.09 [P = .002] for mortality) were found to be independent factors associated with ARDS and early mortality. With a cut-off value of 35% for perfusion fraction of resected lung, patients with a perfusion fraction of greater than 35% had a greater incidence of ARDS (17.3% vs 3.3%, P = .005) and early mortality (19.8% vs 6.0%, P = .010) than those with a perfusion fraction of 35% or less.

CONCLUSIONS

Patients with a low ppo-FEV(1), a high perfusion fraction of resected lung, or both had a higher incidence of ARDS and early mortality after pneumonectomy. Therefore, although the ppo-FEV(1) appears to be within an acceptable limit for pneumonectomy, much attention should be given to patients with a high perfusion fraction of resected lung.

Perioperative management of patients who have pulmonary disease

The identification of risk factors and optimization of respiratory status are crucial to the successful management of patients who have pulmonary disease and are undergoing a surgical procedure. This article explores the approach to pulmonary patients, from the preoperative assessment to the intraoperative and postoperative periods. The management of specific pulmonary disorders in the perioperative period is discussed.

Impact of smoking cessation before resection of lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database study

BACKGROUND

Smoking cessation is presumed to be beneficial before resection of lung cancer. The effect of smoking cessation on outcome was investigated.

METHODS

From January 1999 to July 2007, in-hospital outcomes for 7990 primary resections for lung cancer in adults were reported to the Society of Thoracic Surgeons General Thoracic Surgery Database. Risk of hospital death and respiratory complications was assessed according to timing of smoking cessation, adjusted for clinical confounders.

RESULTS

Hospital mortality was 1.4% (n = 109), but 1.5% in patients who had smoked (105 of 6965) vs 0.39% in those who had not (4 of 1025). Compared with the latter, risk-adjusted odds ratios were 3.5 (p = 0.03), 4.6 (p = 0.03), 2.6 (p = 0.7), and 2.5 (p = 0.11) for those whose timing of smoking cessation was categorized as current smoker, quit from 14 days to 1 month, 1 to 12 months, or more than 12 months preoperatively, respectively. Prevalence of major pulmonary complications was 5.7% (456 of 7965) overall, but 6.2% in patients who had smoked (429 of 6941) vs 2.5%% in those who had not (27 of 1024). Compared with the latter, risk-adjusted odds ratios were 1.80 (p = 0.03), 1.62 (p = 0.14), 1.51 (p = 0.20), and 1.29 (p = 0.3) for those whose timing of smoking cessation was categorized as above.

CONCLUSIONS

Risks of hospital death and pulmonary complications after lung cancer resection were increased by smoking and mitigated slowly by preoperative cessation. No optimal interval of smoking cessation was identifiable. Patients should be counseled to stop smoking irrespective of surgical timing.

UK pneumonectomy outcome study (UKPOS): a prospective observational study of pneumonectomy outcome

Background

In order to assess the short term risks of pneumonectomy for lung cancer in contemporary practice a one year prospective observational study of pneumonectomy outcome was made. Current UK practice for pneumonectomy was observed to note patient and treatment factors associated with major complications.

Methods

A multicentre, prospective, observational cohort study was performed. All 35 UK thoracic surgical centres were invited to submit data to the study. All adult patients undergoing pneumonectomy for lung cancer between 1 January and 31 December 2005 were included. Patients undergoing pleuropneumonectomy, extended pneumonectomy, completion pneumonectomy following previous lobectomy and pneumonectomy for benign disease, were excluded from the study.

The main outcome measure was suffering a major complication. Major complications were defined as: death within 30 days of surgery; treated cardiac arrhythmia or hypotension; unplanned intensive care admission; further surgery or inotrope usage.

Results

312 pneumonectomies from 28 participating centres were entered. The major complication incidence was: 30-day mortality 5.4%; treated cardiac arrhythmia 19.9%; unplanned intensive care unit admission 9.3%; further surgery 4.8%; inotrope usage 3.5%. Age, American Society of Anesthesiologists physical status ≥ P3, pre-operative diffusing capacity for carbon monoxide (DLCO) and epidural analgesia were collectively the strongest risk factors for major complications. Major complications prolonged median hospital stay by 2 days.

Conclusion

The 30 day mortality rate was less than 8%, in agreement with the British Thoracic Society guidelines. Pneumonectomy was associated with a high rate of major complications. Age, ASA physical status, DLCO and epidural analgesia appeared collectively most associated with major complications.

Predictors of prolonged postoperative endotracheal intubation in patients undergoing thoracotomy for lung resection

OBJECTIVE

The aim of this study was to identify predictors of delayed endotracheal extubation defined as the need for postoperative ventilatory support after open thoracotomy for lung resection.

DESIGN

An observational cohort investigation.

SETTING

A tertiary referral center.

PARTICIPANTS

The study population consisted of 2,068 patients who had open thoracotomy for pneumonectomy, lobectomy, or segmental lung resection between January 1996 and December 2005.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

Preoperative and intraoperative variables were collected concurrently with the patient's care. Risk factors were identified using logistic regression with stepwise variable selection procedure on 1,000 bootstrap resamples, and a bagging algorithm was used to summarize the results. Intraoperative red blood cell transfusion, higher preoperative serum creatinine level, absence of a thoracic epidural catheter, more extensive surgical resection, and lower preoperative FEV(1) were associated with an increased risk of delayed extubation after lung resection.

CONCLUSION

Most predictors of delayed postoperative extubation (ie, red blood cell transfusion, higher preoperative serum creatinine, lower preoperative FEV(1), and more extensive lung resection) are difficult to modify in the perioperative period and probably represent greater severity of underlying lung disease and more advanced comorbid conditions. However, thoracic epidural anesthesia and analgesia is a modifiable factor that was associated with reduced odds for postoperative ventilatory support. Thus, the use of epidural analgesia may reduce the need for post-thoracotomy mechanical ventilation.

Thoracic surgery in the elderly--co-morbidity is the limit

A retrospective chart review was performed in 242 consecutive patients aged 65 years or older who were treated in an academic surgical centre between January 2004 and July 2007. A total of 249 thoracic procedures were performed in 242 patients, of whom 143 were men and 99 women with a mean age of 69.9 years (range 65-92). Overall operative mortality was 2.4%, rising to 26.4% in emergency patients. Negative predictors for perioperative mortality were: American Society of Anesthesiology (ASA) class 4, pre-existing kidney failure, leucocytosis, low haemoglobin, elevated C-reactive protein, diabetes mellitus and emergency surgery. In addition, the risk of major and minor complications resulting in a prolonged hospital stay was increased in emergency patients, patients with multiple co-morbidities and ASA class 3 or 4. Appropriate thoracic surgery can be offered to the elderly with an acceptable level of perioperative morbidity and mortality. Regardless of age, a high degree of co-morbidity or emergency surgery are the main risk factors for perioperative mortality and/or prolonged hospital stay.

Complications related to lobectomy in living lobar lung transplant donors

OBJECTIVE

To evaluate post-operative complications in living lobar lung transplant donors.

METHODS

Between September of 1999 and May of 2005, lobectomies were performed in 32 healthy lung transplant donors for 16 recipients. The medical charts of these donors were retrospectively analyzed in order to determine the incidence of postoperative complications and alterations in pulmonary function after lobectomy.

RESULTS

Twenty-two donors (68.75%) presented no complications. Among the 10 donors presenting complications, the most frequently observed complication was pleural effusion, which occurred in 5 donors (15.6% of the sample). Red blood cell transfusion was necessary in 3 donors (9.3%), and 2 donors underwent a second surgical procedure due to hemothorax. One donor presented pneumothorax after chest tube removal, and one developed respiratory infection. There were two intra-operative complications (6.25%): one donor required bronchoplasty of the middle lobe; and another required lingular resection. No intra-operative mortality was observed. Post-operative pulmonary function tests demonstrated an average reduction of 20% in forced expiratory volume in one second (p < 000.1) compared to pre-operative values.

CONCLUSIONS

Lobectomy in living lung transplant donors presents high risk of post-operative complications and irreversible impairment of pulmonary function. Careful pre-operative evaluation is necessary in order to reduce the incidence of complications in living lobar lung transplant donors.

Predictors of atelectasis after pulmonary lobectomy

PURPOSE

To define the incidence of and factors predisposing to postlobectomy atelectasis (PLA).

METHODS

The subjects were 412 patients who underwent pulmonary lobectomy at our hospital between January 2004 and April 2007. This study was performed as a retrospective analysis of our prospective database. Postlobectomy atelectasis was defined as ipsilateral opacification of the involved lobe or segment with an ipsilateral shift of the mediastinum on chest radiograph, requiring bronchoscopy.

RESULTS

Postlobectomy atelectasis developed in 27 patients (6.6%), accounting for 29% of all postoperative pulmonary complications. There were no significant differences between the PLA and no-PLA groups in age, sex, American Society of Anesthesiology performance status, cardiovascular comorbidity, or operation time. Chronic obstructive pulmonary disease (COPD) was the only preoperative variable predictive of PLA (P<0.05). Right upper lobectomy (RUL), either alone or in combination with right middle lobectomy, was associated with a significantly higher incidence of PLA than any other type of resection (P<0.05).

CONCLUSIONS

Postlobectomy atelectasis is an important postoperative complication. Patients with COPD and those undergoing RUL are at higher risk of this complication. Although often isolated, PLA is associated with longer hospital stay.

Predictors of long time survival after lung cancer surgery: a retrospective cohort study

BACKGROUND

There have been few reports regarding long time survival after lung cancer surgery. The influence of age and pulmonary function on long time survival is still not fully discovered. Some reports suggest that hospitals with a high surgical volume have better results. The aim of this study was to evaluate lung cancer surgery performed in a county hospital in terms of 30 days mortality, complications and predictors of long time survival.

METHODS

All patients operated with non-small cell lung cancer in the period 1993-2006 were reviewed, and 148 patients were included in the study. 30 days mortality and complications were analyzed by univariate analysis. Kaplan Meier plots were performed to display some of the univariate variables. Cox regression analysis was performed to find Hazard Ratios (HR) that predicted long time survival in univariate and multivariate analysis.

RESULTS

The overall 30 days mortality rate was 2.7%, whereas 36.3% had one or more complications after surgery. The median survival time was 3.4 years. In multivariate Cox regression analysis advanced preoperative stage predicted reduced long time survival with HR (95%CI) 1.63 (0.92, 2.89) and 4.16 (1.92, 9.05) for patients in stage IB and II-IV respectively, when compared to patients in stage IA. Age >or= 70 years and FEV1<80% predicted reduced long time survival with HR (95%CI) 2.23 (1.41, 3.54) and 1.93 (1.14, 3.28) respectively, compared to age<70 years and FEV1 >or= 80%.

CONCLUSION

Thirty days mortality and complication rate showed that lung cancer surgery can be performed safely in a county hospital with experienced thoracic surgeons. Early preoperative stage, age below 70 years and normal pulmonary function predicted long time survival.

Noninvasive ventilation for acute respiratory failure after lung resection: an observational study

BACKGROUND

A single prospective randomized study found that, in selected patients with acute respiratory failure (ARF) following lung resection, noninvasive ventilation (NIV) decreases the need for endotracheal mechanical ventilation and improves clinical outcome.

METHOD

We prospectively evaluated early NIV use for ARF after lung resection during a 4-year period in the setting of a medical and a surgical ICU of a university hospital. We documented demographics, initial clinical characteristics and clinical outcomes. NIV failure was defined as the need for tracheal intubation.

RESULTS

Among 690 patients at risk of severe complications following lung resection, 113 (16.3%) experienced ARF, which was initially supported by NIV in 89 (78.7%), including 59 with hypoxemic ARF (66.3%) and 30 with hypercapnic ARF (33.7%). The overall success rate of NIV was 85.3% (76/89). In-ICU mortality was 6.7% (6/89). The mortality rate following NIV failure was 46.1%. Predictive factors of NIV failure in univariate analysis were age (P = 0.046), previous cardiac comorbidities (P = 0.0075), postoperative pneumonia (P = 0.0016), admission in the surgical ICU (P = 0.034), no initial response to NIV (P < 0.0001) and occurrence of noninfectious complications (P = 0.037). Only two independent factors were significantly associated with NIV failure in multivariate analysis: cardiac comorbidities (odds ratio, 11.5; 95% confidence interval, 1.9-68.3; P = 0.007) and no initial response to NIV (odds ratio, 117.6; 95% confidence interval, 10.6-1305.8; P = 0.0001).

CONCLUSION

This prospective survey confirms the feasibility and efficacy of NIV in ARF following lung resection.

Morbidity and mortality after pneumonectomy in smokers with NSCLC

OBJECTIVE

Perioperative morbidity and mortality in patients receiving pneumonectomy because of non-small cell lung cancer (NSCLC) remains quite high. The aim of this study is to identify risk factors to minimize perioperative mortality and morbidity.

PATIENTS AND METHOD

The results of 156 Patients who received pneumonectomy between 1995 and 2004 were reviewed retrospectively. All patients had stage I or II NSCLC. In 81 cases a right sided and in 75 a left sided pneumonectomy was performed. Cardiopulmonary function tests were sufficient for pneumonectomy.

RESULTS

Overall perioperative 30-day mortality was 7.1% (n=11), in hospital mortality 8.3% (n=13). The cause was sepsis in 6 cases, cardiac failure in 4 cases, and respiratory insufficiency in 3 cases. In univariable and multivariable regression analysis considering mortality, none of the prognostic factors reached significance. The odds ratio for postoperative death was 1.6 fold for smokers in comparison to non smokers. Complications after pneumonectomy were seen in 34.6%, with arrhythmia in 16.0%, sepsis in 1.9% and bronchopleural fistula (BPF) occurring in 6.4%. Smoking and intraoperative blood loss >500 ml were highly significant perioperative risk factors.

CONCLUSION

Smoking until operation and intraoperative blood loss were independent postoperative risk factors leading to complications after pneumonectomy for NSCLC. The risk for complications was 2.8-fold higher for smokers.

Does physiotherapy reduce the incidence of postoperative complications in patients following pulmonary resection via thoracotomy? a protocol for a randomised controlled trial

BACKGROUND

Postoperative pulmonary and shoulder complications are important causes of postoperative morbidity following thoracotomy. While physiotherapy aims to prevent or minimise these complications, currently there are no randomised controlled trials to support or refute effectiveness of physiotherapy in this setting.

METHODS/DESIGN

This single blind randomised controlled trial aims to recruit 184 patients following lung resection via open thoracotomy. All subjects will receive a preoperative physiotherapy information booklet and following surgery will be randomly allocated to a Treatment Group receiving postoperative physiotherapy or a Control Group receiving standard care nursing and medical interventions but no physiotherapy. The Treatment Group will receive a standardised daily physiotherapy programme to prevent respiratory and musculoskeletal complications. On discharge Treatment Group subjects will receive an exercise programme and exercise diary to complete. The primary outcome measure is the incidence of postoperative pulmonary complications, which will be determined on a daily basis whilst the patient is in hospital by a blinded assessor. Secondary outcome measures are the length of postoperative hospital stay, severity of pain, shoulder function as measured by the self-reported shoulder pain and disability index, and quality of life measured by the Medical Outcomes Study Short Form 36 v2 New Zealand standard version. Pain, shoulder function and quality of life will be measured at baseline, on discharge from hospital, one month and three months postoperatively. Additionally a subgroup of subjects will have measurement of shoulder range of movement and muscle strength by a blinded assessor.

DISCUSSION

Results from this study will contribute to the increasing volume of evidence regarding the effectiveness of physiotherapy following major surgery and will guide physiotherapists in their interventions for patients following thoracotomy.

TRIAL REGISTRATION

The study protocol is registered with the Australian and New Zealand Clinical Trials registry (ANZCTRN12605000201673).