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

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).

Predicting the need for intensive care following lung resection

On the basis of the evidence available, the authors would suggest a decision making algorithm to determine the need for ICU admission postoperatively similar to that shown in Fig. 1. First, patients should quit smoking at least 1 month and preferably 2 months before surgery. Those over the age of 70 years should receive elective ICU admission. Second, those at increased risk of general anesthesia, as judged by ASA and performance status scores and cardiovascular risk assessment, should be prebooked into the ICU in the postoperative period. A ppo FEV1 of less than 44% should warrant additional monitoring rather than mandate ICU admission. Pre-existing fibrotic lung disease mandates ICU admission. Third, perioperatively, protective (low tidal volume) ventilatory strategies should be applied during one lung ventilation. Patients undergoing one lung ventilation, and especially those undergoing extensive lymphatic dissection, should be monitored closely for signs of ALI in the first 5 days postoperatively. This, together with any indication of postoperative complications such as POP, BPF or empyema, should mandate immediate transfer to the ICU.

Bronchopleural fistula after lobectomy for lung cancer

Bronchopleural fistula after lung resection is a fatal complication. The aim of this study was to determine the risk factors for bronchopleural fistula after lobectomy for lung cancer. Clinical records of 767 patients who underwent lobectomy or bilobectomy for lung cancer in our institution were reviewed. Twelve patients (1.6%) suffered a bronchopleural fistula, of whom 5 died because of this complication (mortality rate, 41.7%). Multivariate analysis revealed squamous cell carcinoma, preoperative chemotherapy, lower lobectomy, and middle and lower lobectomy were risk factors for bronchopleural fistula. In such cases, particular care must be exercised to maintain blood flow through the bronchial stump during surgery, and reinforcement, such as stump coverage, must be employed.

Abscess of residual lobe after pulmonary resection for lung cancer

Abscess of the residual lobe after lobectomy is a rare but potentially lethal complication. Between January 1975 and December 2006, 1,460 patients underwent elective pulmonary lobectomy for non-small-cell lung cancer at our institution. Abscess of the residual lung parenchyma occurred in 5 (0.3%) cases (4 bilobectomies and 1 lobectomy). Postoperative chest radiography showed incomplete expansion and consolidation of residual lung parenchyma. Flexible bronchoscopy revealed persistent bronchial occlusion from purulent secretions and/or bronchial collapse. Computed tomography in 3 patients demonstrated lung abscess foci. Surgical treatment included completion right pneumonectomy in 3 patients and a middle lobectomy in one. Complications after repeat thoracotomy comprised contralateral pneumonia and sepsis in 1 patient. Residual lobar abscess after lobectomy should be suspected in patients presenting with fever, leukocytosis, bronchial obstruction and lung consolidation despite antibiotic therapy, physiotherapy and bronchoscopy. Computed tomography is mandatory for early diagnosis. Surgical resection of the affected lobe is recommended.

Patterns of first-coded complications in acute episodes of lung cancer care

The objective of this research was to document the most common first-recorded adverse events of inpatient care for lung cancer in Victoria, Australia. The sample comprised record abstracts for 3642 admissions (overnight or longer) of adult patients with lung cancer, extracted from the Victorian Admitted Episodes Database for 2000-2001. The method involved analysis of diagnoses prefixed with "C" (an indicator for diagnoses which arose only after hospitalisation), calculation of complication rates by intervention type, and analysis of complication type by intervention. Overall, 23% of episodes recorded at least one in-hospital complication, with highest rates for radiotherapy and surgical interventions. The highest surgical complication rates were for pneumonectomies, lobectomies, and lung resections. Nausea and vomiting were the most common first-recorded complications for both chemotherapy and radiotherapy. It was concluded that complications through the use of morbidity data may offer a timely and economical method for health care organisations to screen large numbers of patient episodes.

The physiotherapy management of patients undergoing thoracic surgery: a survey of current practice in Australia and New Zealand

BACKGROUND AND PURPOSE

Physiotherapy is considered an essential component of the management of patients after thoracotomy, yet the type of interventions utilized, and evidence for their efficacy, has not been established. The aim of the present study was to ascertain the current physiotherapy management of patients undergoing thoracotomy and the factors influencing practice among different providers.

METHOD

A purpose-designed postal questionnaire was distributed to senior physiotherapists in all thoracic surgical units throughout Australia and New Zealand (n=57).

RESULTS

A response rate of 81% was obtained (n=46). Pre-operatively, 16 respondents (35%) reported assessing all thoracotomy patients. The majority of respondents (n=44; 96%) indicated that all patients were seen by physiotherapists after surgery, with 29 respondents (63%) performing prophylactic physiotherapy interventions to prevent post-operative pulmonary complications. Respondents reported that physiotherapy treatment was usually commenced on day one post-operatively (n=37; 80%) with the most commonly used treatment interventions being deep breathing exercises, the active cycle of breathing techniques, cough, forced expiration techniques and sustained maximal inspirations. Most respondents reported that patients first sat out of bed (n=41; 89%), commenced shoulder range of movement (n=23; 50%) and walking (n=32; 70%) on day one post-operatively. The majority of respondents reported that they offered no post-operative pulmonary rehabilitation (n=25; 54%), outpatient follow-up (n=43; 94%) orpost-thoracotomy pain management (n=40; 87%). Respondents indicated that personal experience, literature recommendations and established practice were the factors which most influenced physiotherapy practice. Conclusion. Most patients after thoracotomy receive physiotherapy assessment and/or treatment in the immediate post-operative period, but only one-third were routinely seen pre-operatively and relatively few were reviewed following discharge from hospital. Further studies are required to guide physiotherapists in determining the efficacy of their practices for patients undergoing thoracotomy.

Influence de la stratégie analgésique sur la fonction respiratoire après chirurgie thoracique pour lobectomie

OBJECTIVE

To compare the influence of thoracic epidural analgesia (TEA) with intravenous patient-controlled analgesia with morphine (PCA) on the early postoperative respiratory function after lobectomy.

STUDY DESIGN

Prospective and comparative observational study.

PATIENTS AND METHODS

Fourty-four patients scheduled for lobectomy (n=22 per group) were studied on the evolution of the postoperative respiratory function assessed by the forced vital capacity (FVC) and the forced expired volume (FEV(1)) during the first two postoperative days and the analysis of noctural arterial desaturation during the three first postoperative nights.

RESULTS

The use of TEA resulted in fewer decrease both in FEV(1) (1.01+/-0.34 versus 1.31+/-0.51 l/s for Day 1, P=0.03; 1.13+/-0.37 versus 1.53+/-0.59 l/s for Day 2, P=0.01) and in FVC (1.23 [1.05-1.51] versus 1.57 [1.38-2.53] l for day 1, P=0.008; 1.33+/-0.43 versus 2.24+/-0.87 l for day 2, P<0.001). Moreover, the duration of arterial desaturation<90% were longer in the PCA group during the first (8.6 [0.8-28.2] versus 1.3 [0-2.6] min, P=0.02) and the second postoperative night (13.5 [3.5-54] versus 0.4 [0-2.6] min, P=0.025).

CONCLUSION

The results of this study suggest that the use of TEA is associated with a better preservation of respiratory function assessed by spirometric data and noctural arterial desaturation recording after thoracic surgery for lobectomy.

[Risk factors in bronchogenic carcinoma surgery]

OBJECTIVE

To analyze the factors that determine the risk of morbidity and mortality associated with lung resection in patients with bronchogenic carcinoma.

PATIENTS AND METHODS

Prospective multicenter study conducted between October 1, 1993 and September 30, 1997 in the 19 hospitals that make up the Bronchogenic Carcinoma Cooperative Group. During the study period, 2994 patients with bronchogenic carcinoma underwent surgery. The morbidity and mortality data at 30 days from all centers were recorded in a single registry.

RESULTS

Major resection was performed in 2491 patients, whereas 212 underwent minor resection. The resection had to be extended in 296 and exploratory thoracotomy was carried out in 291. Postoperative complications were reported in 1057 patients (35.2%). Complications directly related to surgery were the most common (22.9%), followed by respiratory (19.5%) and cardiovascular (10.7%) complications. Of the patients with complications, 654 patients (21.8%) had only 1, whereas 403 (13.4%) had more than 1. After classification of complications, 21% were found to be minor and 14.2% were major. Mortality at 30 days was 6.8% (204 patients), and strongly linked to the presentation of major complications--40.8% of those with such complications died.

CONCLUSIONS

Surgical treatment of bronchogenic carcinoma in Spain is associated with high morbidity and mortality. The morbidity reported in the present study lies in the middle of the ranges found in the literature, whereas mortality lies at the high end of the range. The presence of major complications and/or multiple complications should be considered as strong risk factors.

Genetics of postoperative complications following thoracic surgery

The field of complex trait-gene interaction research has expanded exponentially in recent years, and new insights into the ways patients respond to surgical stimuli have arisen from this body of work. From a physiological systems perspective, thoracic surgical procedures (thoracotomy in particular) represent a massive input stimulus, and it is, therefore, not surprising that approximately 30% of these patients experience an adverse postoperative event. The best risk prediction models have typically explained about 60% to 70% of the risk, leaving a large residual component unaccounted for. It is quite possible that there is a genetic (heritable) component to this residual risk. This article explores some of the concepts underlying gene-disease interactions, the preliminary work that has been done to date in this area, and finally discusses some of the more important methodological issues involved in complex trait association study design.

The acute physiology and chronic health evaluation III outcome prediction in patients admitted to the intensive care unit after pneumonectomy

PURPOSE

The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after pneumonectomy. The purpose of this study was to determine if the APACHE III predicts hospital mortality after pneumonectomy.

METHODS

A retrospective review of all adult patients admitted to a single thoracic surgical intensive care unit after pneumonectomy between October 1994 and December 2004. Patient demographics, ICU admission day APACHE III score, actual and predicted hospital mortality, and length of hospital and ICU stay data were collected. Data on preoperative pulmonary function tests and smoking habits were also collected. Univariate statistical methods and logistic regression were used. The performance of the APACHE III prognostic system was assessed by the Hosmer-Lemeshow statistic for calibration and area under receiver operating characteristic curve (AUC) for discrimination.

RESULTS

There were 417 pneumonectomies performed during the study period, of which 281 patients were admitted to the ICU. The mean age was 61.1 years, and 67.2% were men; 88.2% were smokers with a median of 40.0 (interquartile range, 18-62) pack-years of tobacco use. The mean APACHE III score on the day of ICU admission was 37.7 (+/- standard deviation 17.8), and the mean predicted hospital mortality rate was 6.4% (+/-10.4). The median (and interquartile range) lengths of ICU and hospital stay were 1.7 (0.9-3.1) and 9.0 (7.0-17.0) days, respectively. The observed ICU and hospital mortality rates were 4.6% (13/281 patients) and 8.2% (23/281), respectively. The standardized ICU and hospital mortality ratios with their 95% confidence intervals (CIs) were 1.55 (0.71-2.39) and 1.27 (0.75-1.78), respectively. There were significant differences in the mean APACHE III score (p < 0.001) and the predicted mortality rate (p < .001) between survivors and nonsurvivors. In predicting mortality, the AUC of APACHE III prediction was 0.801 (95% CI, 0.711-0.891), and the Hosmer-Lemeshow statistic was 9.898 with a p value of 0.272. Diffusion capacity of the lung for carbon monoxide (DLCO) and percentage predicted DLCO were higher in survivors, but the addition of either of these variables to a logistic regression model did not improve APACHE III mortality prediction.

CONCLUSIONS

In patients admitted to the ICU after pneumonectomy, the APACHE III discriminates moderately well between survivors and nonsurvivors. The calibration of the model appears to be good, although the low number of deaths limits the power of the calibration analysis. The use of APACHE III data in outcomes research involving patients who have undergone pneumonectomy is acceptable.

Increased Risk of Aspiration and Pulmonary Complications After Lung Resection in Head and Neck Cancer Patients

BACKGROUND

Patients with head and neck cancers (HNCs) may have impaired deglutition and airway protection. The risk of pulmonary complications after lung resection has not been evaluated in HNC patients. We therefore reviewed the risk of aspiration-related pulmonary complications in HNC patients after pulmonary resection.

METHODS

Retrospective review of a prospectively collected database from a single institution identified 1633 patients who underwent pulmonary resection for suspected primary lung cancer from 1997 to 2004. Of these, 76 patients had a history of HNC. The remaining 1557 patients were defined as controls. Categoric variables were analyzed with the chi2 test. Univariate and multivariate logistic regression analyses determined the variables related to aspiration pneumonia after pulmonary resection.

RESULTS

Aspiration pneumonia occurred in 7 HNC patients (9.2%) versus 10 patients (0.6%) in the control group (p < 0.001). In the entire population with pulmonary resection, HNC history (p < 0.001; odds ratio (OR), 17.5; 95% confidence interval (CI), 6.0 to 50.6), and postoperative recurrent laryngeal nerve paralysis (p < 0.001; OR, 27.8; 95% CI, 5.2 to 148) were independent risk factors for aspiration pneumonia after pulmonary resection. Length of stay was longer in patients with aspiration pneumonia, with a median of 30 days (range, 10 to 258) versus 6 days (range, 0 to 374; p = 0.021). In the HNC patients, prior recurrent laryngeal nerve paralysis was predictive of aspiration pneumonia (p = 0.034; OR, 8.8; 95% CI, 1.1 to 65.4).

CONCLUSIONS

Patients with HNC have an increased risk of aspiration pneumonia after pulmonary resection. Evaluation of swallowing function to identify aspiration is indicated in HNC patients before pulmonary resection to avoid the morbidity and prolonged hospitalization associated with aspiration pneumonia.

Usefulness of lung perfusion scintigraphy before lung cancer resection in patients with ventilatory obstruction

BACKGROUND

The study was conducted to evaluate the efficacy of preoperative lung perfusion scintigraphy performed by planar acquisition and single-photon emission computed tomography (SPECT) in predicting postoperative pulmonary function of patients with resectable lung cancer and obstructive ventilatory defect.

METHODS

The study enrolled 39 patients (mean age, 67 +/- 2.1 years). All patients underwent preoperative and postoperative pulmonary function tests. Cut-off values for postoperative forced expiratory volume in 1 second (FEV1) were 65% of the predicted value for pneumonectomy and 45% for lobectomy. A semiquantitative analysis of planar and SPECT lung perfusion scintigraphy images was performed preoperatively to estimate postoperative predicted FEV1 (FEV1ppo). Relationships between FEV1ppo and measured postoperative FEV1 were tested by the Pearson correlation and Bland Altman agreement tests.

RESULTS

Twenty-eight lobectomies and 11 pneumonectomies were performed. The FEV1ppo estimated by mean planar lung scintigraphy was 1.85 +/- 0.38 L, with a Pearson correlation coefficient to the measured FEV1 of 0.8632 (p < 0.001). The mean FEV1ppo estimated by SPECT was 1.78 +/- 0.31 L, with a Pearson coefficient to the measured FEV1 of 0.8527 (p < 0.001). Both values showed a more significant correlation with postoperative measured FEV1 after lobectomy (p < 0.001) than after pneumonectomy (p = 0.045). The Bland Altman test confirmed satisfactory agreement of FEV1ppo estimated by both planar lung scintigraphy and SPECT with FEV1 measured by spirometry.

CONCLUSIONS

Both planar lung scintigraphy and SPECT can accurately predict postoperative FEV1 and can therefore be considered reliable tools in establishing operability of patients with lung cancer and ventilatory obstruction.

Trends in Lung Surgery

BACKGROUND

Reports on the temporal evolution in lung resection are limited. To elucidate temporal changes in the demographics of lung resections, we analyzed nationally representative data that were collected for the National Hospital Discharge Survey from 1988 to 2002.

METHODS

Data collected between 1988 and 2002 were analyzed. Patients with International Classification of Diseases, ninth revision, clinical modification, procedure codes for lung resection were included in the sample. Three 5-year time periods were created (1988 to 1992, 1993 to 1997, and 1998 to 2002) to simplify the temporal analysis. Changes in the prevalence of procedures, age, gender, race, length of care, mortality, disposition status, and distribution by hospital size were evaluated. Trends in procedure-related complications were analyzed.

RESULTS

Between 1988 and 2002, a total of 512,758 lung resections were performed. Comparing the earliest to the most recent time period, we found increases in the average age (61.1 years [range, 1 to 89 years] vs 63.2 years [range, 1 to 91 years], respectively), in the proportion of patients who were female (40.1% vs 49.6%, respectively), and in the proportion of Medicare/Medicaid patients (43.8% vs 49%/4.7% vs 6.7%, respectively). Decreases in the average length of stay (12.9 days [range, 1 to 358 days] vs 9.1 days [range, 1 to 175 days], respectively) and in the proportion of patients discharged to their primary residence (86% vs 79.5%, respectively) were seen. The proportion of patients who had undergone lobectomies compared to other types of lung resection increased. Mortality rates were 5% vs 5.4%, respectively, while the frequency of complications decreased.

CONCLUSION

We identified temporal changes in lung resection surgery that may help in the construction of health-care policies to address the changing needs of and financial burdens on the health-care system.

Autologous blood patch in persistent air leaks after pulmonary resection

OBJECTIVE

Persistent air leak is among the most common complications after pulmonary resection, leading to prolonged hospitalization and increased costs. At present there is not yet a consensus on their treatment.

METHODS

During a 7-year experience, 21 patients submitted to pulmonary resection were postoperatively treated with an autologous blood patch for persistent air leaks. Persistent air leaks were catalogued twice daily according to the classification previously reported by Cerfolio and associates. Chest radiographs showed a fixed pleural space deficit in 18 (86%) patients. A total of 50 to 150 mL of autologous blood was drawn from the patient and injected into the chest tube, which was removed 48 hours after cessation of the air leak.

RESULTS

We observed a 4% incidence of persistent air leaks after pulmonary resection in our series. Persistent air leaks were categorized as follows: 14% forced expiratory, 57% expiratory, 29% continuous, and 0% inspiratory. The mean duration of prolonged air leaks was 11 days after surgery. In 81% of the cases examined, a blood patch was only carried out once and gave successful results within 24 hours. In the remaining 19% of cases, the air leak ceased within 12 hours after the second procedure. Mean hospital stay was 15 days. In our experience this procedure had a 100% success rate.

CONCLUSIONS

Pleurodesis with an autologous blood patch is well tolerated, safe, and inexpensive. This procedure is an effective technique for treatment of postoperative persistent air leaks, even in the presence of an associated fixed pleural space deficit.

Prospective Study of Infection Risk Factors in 988 Lung Resections

PURPOSE

To evaluate the incidence of surgical site infections (SSI), as related to risk factors, in patients undergoing lung resections (LR).

METHODS

We evaluated 988 consecutive patients prospectively who underwent LR between 1996 and 2005 at the Center for Thoracic Surgery of the University of Insubria, Varese, Italy. Patients were divided into four groups: Pneumonectomy (n=104), lobectomy/bi-lobectomy (n=438), wedge resection by thoracotomy (n=155), and wedge resection by video-thoracoscopy (VATS) (n=291). The recorded risk factors for SSI were hemoglobin concentration, serum albumin concentration, lymphocyte count, percentage of predicted forced expiratory volume in 1 sec (FEV1), duration of surgery, blood transfusion, age>70 years, and comorbidity. The postoperative SSIs (superficial and deep incisional SSI, pneumonia, empyema) were recorded in they occurred within 30 days, and the final outcome was recorded.

RESULTS

Postoperative infections were found in 141 patients (14.3%) and included 166 thoracic infections, among them 32 incisional SSIs (3.2%), 103 cases of pneumonia (10.4%); and 24 empyemas (2.4%). The overall incidence of SSI was significantly lower in patients having wedge resections by VATS (5.5%) than in the other three groups (17.9%) (p<0.001). The overall mortality rate was 1.2% (12/988), of which six deaths (0.6%) were caused by complications of infection. The infection rate correlated with duration of surgery>180 min, age>70 years, serum albumin<3.5 g/dL, and the presence of any comorbidity. Moreover, 18% of patients with FEV1>70% had postoperative pneumonia, a significant increase (p<0.01) compared with patients with FEV1>or=70%.

CONCLUSIONS

In this prospective study, the SSI rate after LR was 14.3%, and the 30-day operative mortality rate was 1.2%, with most of the deaths caused by pneumonia. After VATS LR procedures, the incidence of SSI was lower at 5.5%. Finally, SSI correlated with the duration of surgery, serum albumin, concurrent comorbidity, age, and FEV1.

Postoperative Pneumonia after Major Lung Resection

BACKGROUND

Postoperative pneumonia (POP) is a life-threatening complication of lung resection. The incidence, causative bacteria, predisposing factors, and outcome are poorly understood.

DESIGN

Prospective observational study.

METHODS

A prospective study of all patients undergoing major lung resections for noninfectious disease was performed over a 6-mo period. Culture of intraoperative bronchial aspirates was systematically performed. All patients with suspicion of pneumonia underwent bronchoscopic sampling and culture before antibiotherapy.

RESULTS

One hundred and sixty-eight patients were included in the study. Bronchial colonization was identified in 31 of 136 patients (22.8%) on analysis of intraoperative samples. The incidence of POP was 25% (42 of 168). Microbiologically documented and nondocumented pneumonias were recorded in 24 and 18 cases, respectively. Haemophilus species, Streptococcus species, and, to a much lesser extent, Pseudomonas and Serratia species were the most frequently identified pathogens. Among colonized and noncolonized patients, POP occurred in 15 of 31 and 20 of 105 cases, respectively (p = 0.0010; relative risk, 2.54). Death occurred in 8 of 42 patients who developed POP and in 3 of 126 of patients who did not (p = 0.0012). Patients with POP required noninvasive ventilation or reintubation more frequently than patients who did not develop POP (p < 0.0000001 and p = 0.00075, respectively). POP was associated with longer intensive care unit and hospital stay (p < 0.0000001 and p = 0.0000005, respectively). Multivariate analysis showed that chronic obstructive pulmonary disease, extent of resection, presence of intraoperative bronchial colonization, and male sex were independent risk factors for POP.

CONCLUSIONS

Pneumonia acquired in-hospital represents a relatively frequent complication of lung resections, associated with an important percentage of postoperative morbidity and mortality.

Operative Mortality and Respiratory Complications After Lung Resection for Cancer: Impact of Chronic Obstructive Pulmonary Disease and Time Trends

BACKGROUND

Smoking is a common risk factor for chronic obstructive pulmonary disease (COPD), cardiovascular disease, and lung cancer. In this observational study, we examined the impact of COPD severity and time-related changes in early outcome after lung cancer resection.

METHODS

Over a 15-year period, we analyzed an institutional registry including all consecutive patients undergoing surgery for lung cancer. Using the receiver-operating characteristic (ROC) curve, we analyzed the relationship between forced expiratory volume in 1 second (FEV1) and postoperative mortality and respiratory morbidity. Multiple regression analysis has also been applied to identify other risk factors.

RESULTS

A preoperative FEV1 less than 60% was a strong predictor for respiratory complications (odds ratio [OR] = 2.7, confidence interval [CI]: 1.3 to 6.6) and 30-day mortality (OR = 1.9, CI: 1.2 to 3.9), whereas thoracic epidural analgesia was associated with lower mortality (OR = 0.4; CI: 0.2 to 0.8) and respiratory complications (OR = 0.6; CI: 0.3 to 0.9). Mortality was also related to age greater than 70 years, the presence of at least three cardiovascular risk factors, and pneumonectomy. From the period 1990 to 1994, to 2000 to 2004, we observed significant reductions in perioperative mortality (3.7% versus 2.4%) and in the incidence of respiratory complications (18.7% versus 15.2%), that was associated with a higher rate of lesser resection (from 11% to 17%, p < 0.05) and increasing use of thoracic epidural analgesia (from 65% to 88%, p < 0.05).

CONCLUSIONS

Preoperative FEV1 less than 60% is a main predictor of perioperative mortality and respiratory morbidity. Over the last 5-year period, diagnosis of earlier pathologic cancer stages resulting in lesser pulmonary resection as well as provision of continuous thoracic epidural analgesia have contributed to improved surgical outcome.

Systemic inflammatory response syndrome and surgical stress in thoracic surgery

PURPOSE

To evaluate the clinical usefulness of postoperative systemic inflammatory response syndrome (SIRS) as an index of surgical stress in patients undergoing thoracic surgery.

METHODS

Forty-five consecutive patients who underwent thoracic surgery with thoracotomy were enrolled. The SIRS criteria were examined daily during the first 7 postoperative days. The serum interleukin-6 (IL-6) level, operation time, intraoperative blood loss, amount of thoracic drainage, and C-reactive protein levels were also measured.

RESULTS

Sixteen cases were categorized into the SIRS group, whereas 29 cases were categorized into the non-SIRS group. Among the patients who underwent thoracic surgery, the physiological responses of the patients to the surgery, such as serum IL-6 levels and C-reactive protein levels, were significantly higher in the SIRS group than in the non-SIRS group (P = .002 and .024, respectively). The serum IL-6 level on the first postoperative day was an independent factor associated with SIRS (95% CI 1.002-1.041; P = .030). Furthermore, there was a correlation between the number of SIRS days and the duration of the postoperative hospital stay (r = 0.379, P = .012).

CONCLUSIONS

Our results demonstrated that SIRS reflected the degree of surgical stress, especially thoracotomic procedures, through the IL-6 levels, and affected the postoperative hospital stay. Systemic inflammatory response syndrome can be useful for the postoperative management of patients undergoing thoracic surgery.

Concordance of antibiotic prophylaxis, direct Gram staining and protected brush specimen culture results for postoperative patients with suspected pneumonia

BACKGROUND AND OBJECTIVES

Antibiotic therapy alters the diagnostic value of protected brush specimens. With protected brush specimens alone, diagnosing pneumonia requires 24 or 48 h. Addition of direct Gram staining shortens this delay. Antibiotic prophylaxis, recommended after major surgery, may influence the contribution of Gram staining to diagnosing postoperative pneumonia.

METHODS

During a 1-yr period, we retrospectively studied all patients on mechanical ventilation suspected of having postoperative pneumonia who had undergone fibreoptic bronchoscopy with protected brush specimens. Postoperative pneumonia was diagnosed when quantitative protected brush specimens culture results yielded 103 colony-forming units mL-1.

RESULTS

Fifty patients were clinically suspected of having postoperative pneumonia after cardiac (n=42), vascular (n=5) or thoracic (n=3) surgery. Eleven (22%) samples were obtained during antibiotic prophylaxis. Twenty-two (44%) episodes were microbiologically proven. Gram-stain sensitivity was 95.5%, with 82.1% specificity, 80.7% positive-predictive value and 95.8% negative-predictive value. Concordance between direct Gram-stain-identified pathogens and Gram stain of cultured pathogens was significantly less frequent during antibiotic prophylaxis (63.6%) than afterwards (94.9%) (P<0.05).

CONCLUSION

Antibiotic prophylaxis diminished the diagnostic value of Gram staining of protected brush specimens. When protected brush specimens was performed during antibiotic prophylaxis, Gram staining accurately enabled early exclusion of postoperative pneumonia because of its excellent negative-predictive value. After antibiotic prophylaxis, Gram staining permitted early diagnosis of postoperative pneumonia identification of the responsible pathogen.

Pulmonary complications following major lung resection for benign and malignant lung diseases

OBJECTIVE

To assess the incidence and to identify the possible associated risk factors for postoperative pulmonary complications after major lung resection.

SUBJECTS AND METHODS

One hundred and sixty-eight consecutive patients undergoing major lung resection for benign and malignant lung disease over a 3-year period were included in the study. Preoperative assessment clinical parameters, intraoperative and postoperative events were recorded. Pulmonary complications were noted according to a precise definition. The risk of complications associated with age, comorbidity, forced vital capacity (FVC), blood transfusion and extended operation was evaluated using logistic regression analysis.

RESULTS

The mean age of the patients was 47.1 years (range 16-80 years), 137 (77%) patients underwent lobectomy, 23 (14%) pneumonectomy, and 15 (9%) bilobectomy. Forty-six (27%) patients developed postoperative pulmonary complications and 2 (1.1%) died within 30 days following the operation. Age > or =65 years (OR 3.7, 95% CI: 1.5-8.6, p = 0.002), the presence of comorbid cardiopulmonary disease (OR 0.2, 95% CI: 0.1-0.5, p = 0.001), FVC <50% (OR 0.2, 95% CI: 0.1-0.8, p = 0.02), blood transfusion (OR 0.2, 95% CI: 0.1-0.4, p = 0.0001), and extended operation (OR 0.2, 95% CI: 0.07-0.6, p = 0.005) were the identified factors associated with the development of postoperative pulmonary complications, which necessitated an increased length of hospital stay.

CONCLUSION

Postoperative pulmonary complications are more likely to develop in patients with age > or =65 years with comorbid cardiopulmonary disease, FVC <50%, blood transfusion, and extended operation.

Nosocomial infection after lung surgery: incidence and risk factors

STUDY OBJECTIVES

To assess the incidence and risk factors for nosocomial infection after lung surgery.

DESIGN

Prospective cohort study.

SETTING

Service of thoracic surgery of an acute-care teaching hospital in Santander, Spain.

PATIENTS

Between June 1, 1999, and January 31, 2001, all consecutive patients undergoing lung surgery were prospectively followed up for 1 month after discharge from the hospital to assess the development of nosocomial infection, the primary outcome of the study.

INTERVENTIONS

During the hospitalization period, patients were visited on a daily basis. Postdischarge surveillance was based on visits to the surgeon.

MEASUREMENTS AND RESULTS

We studied 295 patients (84% men; mean age, 60.9 years), 89% of whom underwent resection operations. Ninety episodes of nosocomial infection were diagnosed in 76 patients, including pneumonia (n = 10), lower respiratory tract infection (n = 47), wound infection (n = 16; one third were detected after hospital discharge), urinary tract infection (n = 9), and bacteremia (n = 8; three fourths were catheter-related bacteremia). Twenty patients had severe infections (pneumonia or empyema), with a mortality rate of 60%. COPD (adjusted odds ratio [OR], 2.70; 95% confidence interval [CI], 1.52 to 4.84), duration of surgery with an increased risk for each additional minute (Mantel-Haenzel chi(2) test for trend, p = 0.037), and ICU admission (OR, 3.69; 95% CI, 1.94 to 7.06) were independent risk factors for nosocomial infection. The use of an epidural catheter was a protective factor (OR, 0.45; 95% CI, 0.22 to 0.95). There were no differences according to the use of amoxicillin/clavulanate or cefotaxime for surgical prophylaxis.

CONCLUSIONS

Nosocomial infections are common after lung surgery. One third of wound infections were detected after hospital discharge. The profile of a high-risk patient includes COPD as underlying disease, prolonged operative time, and postoperative ICU admission.

Bronchial colonization and postoperative respiratory infections in patients undergoing lung cancer surgery

STUDY OBJECTIVES

To evaluate the risk factors associated with postoperative respiratory infection in patients undergoing lung cancer surgery, with special emphasis on the perioperative pattern of airway colonization.

DESIGN

Prospective cohort study.

SETTING

Department of Pneumology and Thoracic Surgery of a tertiary hospital.

PATIENTS

Seventy-eight consecutive patients undergoing lung cancer surgery were evaluated. Patients were followed up until hospital discharge or death.

INTERVENTIONS

Fiberoptic bronchoscopies with bilateral protected specimen brush or bronchial aspirates were performed during anesthesia prior to the initiation of the surgical procedure.

RESULTS

Sixty-five patients (83%) had perioperative bronchial colonization by either potentially pathogenic microorganisms (PPMs) [28 patients, 36%] or non-potentially pathogenic microorganisms (56 patients, 72%). The 24 patients (31%) with a postoperative respiratory infection (pneumonia, purulent tracheobronchitis, or pleural empyema) had significantly higher perioperative bronchial colonization by PPMs (15 patients [63%] vs 13 patients [24%], p = 0.003) and a higher bacterial index (mean +/- SD, 3.6 +/- 3.3 vs 0.9 +/- 1.4; p = 0.003), compared to patients without infection. The agreement between pathogens found in perioperative evaluation and during postoperative infection was total in 5 patients (21%), partial in 5 patients (21%), and no concordance in 14 patients (58%). In the multivariate analysis, the presence of perioperative airway colonization by a PPM (odds ratio [OR], 6.9; p = 0.001) and a higher postoperative pain score (OR, 4.1; p = 0.014) were independent predictors of postoperative respiratory infection.

CONCLUSION

Adequate control of postoperative pain, as well as the conditions that potentially cause airway colonization by PPMs, could be beneficial in preventing postoperative respiratory infections after lung cancer surgery.

Pain and Physical Function Are Similar Following Axillary, Muscle-Sparing vs Posterolateral Thoracotomy

STUDY OBJECTIVES

We set out to determine whether there is a difference in postoperative pain and recovery after the patient undergoes the axillary muscle-sparing incision (ie, muscle-sparing thoracotomy [MT]) vs the modified posterolateral incision (ie, posterolateral thoracotomy [PT]).

DESIGN

Analysis of a database originally collected to determine the effect of the timing of epidural analgesia on long-term outcome after thoracotomy.

SETTING

The Hospital of the University of Pennsylvania.

PATIENTS

Patients presenting for lobectomy, segmentectomy, or bilobectomy.

MEASUREMENTS

Pain, physical activity, and the extent that pain interfered with activities following major thoracotomy were prospectively assessed with standard questionnaires (ie, the brief pain inventory and the Medical Outcomes Study 36-item short form) on postoperative days 1 to 5, and at postoperative weeks 4, 8, 12, 24, 36, and 48 by a blinded research assistant. Perioperative care was standardized and included patient-controlled thoracic epidural analgesia until thoracostomy tube removal.

RESULTS

Eighty-two subjects underwent MT and 38 subjects underwent PT during the 16-month accrual period. There were no significant differences in demographics. Pain reported during hospitalization and after hospital discharge did not differ with respect to incision type (p > or = 0.17). Postoperative physical activity levels were significantly less than those reported preoperatively, with a trend toward better functioning in the MT groups after 8 weeks. Incision type did not predict complications, morbidity, or mortality.

CONCLUSIONS

When comparing patients who had undergone vertical, axillary, wholly MT to those who had undergone modified serratus muscle-sparing PT, postoperative differences in pain were not apparent. One should not anticipate reduced pain or more rapid overall recovery following MT, at least when epidural analgesia is used aggressively for perioperative pain control.

[Bronchial fistula postpneumonectomy: predictive factors]

OBJECTIVE

To determine predictive factors of bronchial fistula following pneumonectomy.

PATIENTS AND METHODS

In 14 years (1989-2003), we collect 58 cases of bronchial fistula following 725 consecutive pneumonectomy in the service of thoracic surgery of the Sainte Marguerite Hospital in Marseilles. There were 53 cases (91.4%) of cancers and 5 cases (8.6%) of various pathology. The average age of the patients was of 61 +/- 10 years (range 24 to 80 years). The sex ratio M/F was 8.7. The software of regression SPSS (version11.5) was used to identify the factors risk of a bronchial fistula after a univariate and multivariate analysis.

RESULTS

The prevalence of the bronchial fistula after a pneumonectomy was 8%.The preoperative factors which increased to a significant degree the incidence of the bronchial dent to the univariate analysis were the chronic smoking (P < 0.001), the existence of COPD (P = 0.001) and of a previous thoracic surgery (P = 0.01). Operational data like a right- side pulmonary resection (P < 0.001), the type of bronchial stup carried out (P = 0.03) as and an extended pneumonectomy to the auricule (P = 0.03) were significant risk factors. With the logistic regression the significant risk factors were the chronic smoking (P = 0.002), the existence of COPD (P = 0.003), a previous pulmonary surgery (P = 0.03) and the right - side of the pneumonectomy (P < 0.001). The indication of the pneumonectomy was retained neither by the univariate analysis, nor by the logistic regression significant risk factors.

CONCLUSION

The predictive factors of a bronchial fistula after a pneumonectomy are dominated by respiratory co-morbidities. To prevent this complication, we insist on the stop of the tobacco, a better respiratory preparation and the acquisition of a protocol adapted of the bronchial stub after a pneumonectomy particularly on the right side.

Predictors of an appropriate admission to an ICU after a major pulmonary resection

BACKGROUND

There are no recommendations about admission to an ICU after a major lung resection and there are considerable differences among institutions in this respect.

OBJECTIVES

To audit the practice of admission to an ICU after a major lung resection and evaluate factors predicting the need for intensive care.

METHODS

Clinicalrecords of all patients who underwent major pulmonary resections in a 14-month period were reviewed retrospectively. The criteria for postoperative admission to the ICU were: (1) standard pneumonectomy if comorbidity index (CI) >0 and/or ASA score >1, and/or abnormal spirometry or arterial gas analysis; (2) extended pneumonectomy; (3) lobectomy if CI >or=4 and/or ASA >or=3; (4) lobectomy if FEV(1) <60% of predicted; (5) lobectomy if FEV(1) is between 60 and 80% and hypercapnia.

RESULTS

Among the 49 patients postoperatively admitted to the surgical ward, only 1 needed late intensive care. Among the 55 patients admitted to the ICU, 25 did not require specific intensive care and were discharged 24 h postoperatively, whereas the remaining 30 patients required specific intensive care. Multivariate analysis identified ASA score, predictive postoperative DL(CO), and predictive postoperative product (PPP) as independent predictors of a need for admission to an ICU.

CONCLUSION

This empirical protocol was useful in identifying patients not likely to need admission to the ICU. ASA score, predictive postoperative DL(CO), and PPP are independent predictors of a need for admission to an ICU.

Preoperative pulmonary evaluation of the thoracic surgical patient

Fig. 2 is an algorithm for the preoperative pulmonary evaluation of the lung resection candidate. Patients should undergo routine spirometry and diffusion capacity testing. If the FEV1 and DLCO are greater than 80% predicted, no further study is needed. When these parameters are less than 80%, some estimation of postoperative function is likely needed, taking into account the proposed resection. Patients with ppoFEV1 or ppoDLCO less than 40% are at increased risk of perioperative complications or death and should undergo formal exercise testing. A VO2max or ppoVO2max less than 10 mL/kg/min is associated with prohibitive risk for anatomic lung resection, and alternative treatment modalities should be considered.

Emergent bullectomy for acute respiratory failure in Ehlers-Danlos syndrome

A 49-year-old man with Ehlers-Danlos syndrome developed acute respiratory failure requiring mechanical ventilation. Chest computed tomography demonstrated giant right bulla extending into the contralateral hemithorax with mediastinal shift. Surgical bullectomy with pleurodesis relieved tension effects and allowed weaning.

Intérêt de la ventilation non invasive (VNI) systématique en post-opératoire immédiat d’une résection pulmonaire pour prévenir les complications pulmonaires chez les patients BPCO (essai POPVNI)

BACKGROUND

Respiratory complications are common following pulmonary resection and cause a significant mortality. The use of non-invasive ventilation (NIV) in acute respiratory insufficiency (ARI) is now well recognised. The prophylactic use of NIV in the absence of ARI and/or hypercapnia may be equally justified for the physiological benefits expected in the post-operative period following pulmonary surgery. The aim of our study therefore is to evaluate the effectiveness of NIV in the prevention of pulmonary complications in the immediate post-operative care of patients with moderate and severe COPD.

METHODS

It will be a multicentre, prospective, randomised, parallel, open ended study of patients with moderate and severe COPD admitted to hospital for pulmonary resection.

EXPECTED RESULTS

To determine whether the setting up of NIV immediately post-operatively reduces the incidence of acute respiratory events (acute respiratory insufficiency) and to identify any sub-groups who receive greater benefit from NIV. This study should establish the place of NIV in the immediate post operative care following pulmonary resection.

Respiratory risk factors in development of postoperative complications after the lung resection

The objectives of the study were to identify possible associated respiratory risk factors and to assess incidence of overall postoperative complications after the lung resection. We reviewed 110 patients who underwent lung resections due to malignant neoplasms or benign lung diseases. The risk of postoperative complications was evaluated using the univariate analysis. Results confirmed that low FEV1, postoperative high PaCO2, ASA-status and advanced age were factors associated with development of postoperative complications.

Optimization of lung function before pulmonary resection: pulmonologists' perspectives

Many risk factors for morbidity and mortality with lung resection have been identified. Factors such as age, gender, and cancer stage cannot be altered, but lung function can be optimized by treating COPD or asthma with bronchodilators, corticosteroids, or antibiotics (when indicated) and by inspiratory muscle training. Although smoking cessation 2 months in advance of surgery may not be feasible, cessation nevertheless should be encouraged because it may decrease postoperative inflammation and in the long-term may decrease the risk of recurrence. In addition, morbidity and mortality can be minimized by careful patient selection using lung scanning or CT to determine predicted postoperative functions (FEV1% and DLco%) and some form of exercise testing, such as cardiopulmonary exercise testing or simple stair climbing. When the risk of surgery is high, any benefit from possible cure must be weighed against the risk of long-term disability or death. Although much data are available to guide clinicians in these decisions, there still is no one test that provides the answer in individual cases. The art and science of medicine must merge at this point.

A decade of living lobar lung transplantation: perioperative complications after 253 donor lobectomies

Living lobar lung transplantation places two donors at risk for each recipient. We examined the perioperative outcomes associated with the 253 donor lobectomies performed at our institution during our first decade of living lobar lung transplantation. There have been no perioperative or long-term deaths. 80.2% of donors (n = 203) had no perioperative complications, while fifty (19.8%) had one or more complication. The incidence of intraoperative complications was 3.6%. Complications requiring reoperation occurred in 3.2% of donors. 15.0% of donors had other perioperative complications; the most serious were two donors who developed pulmonary artery thrombosis, while the most common was the need for an additional thoracostomy tube or a thoracostomy tube for >/=14 d for persistent air leaks and/or drainage. Right-sided donors were more likely to have a perioperative complication than left-sided donors (odd ratio 2.02, p = 0.04), probably secondary to right lower and middle lobe anatomy. This experience has shown donor lobectomy to be associated with a relatively low morbidity and no mortality, and is important if this procedure is to be considered an option at more pulmonary transplant centers, given continued organ shortages and differences in philosophical and ethical acceptance of live

Surgical lung cancer

STUDY OBJECTIVE

To identify those variables that are associated with operative morbidity or mortality in cases of thoracotomy in lung cancer.

SETTING

Third level university hospital.

PATIENTS

Consecutive patients with thoracotomy due to lung cancer operated on between 1994 and 1997 (n = 115).

METHODS

Pre- and postoperative variables potentially associated with operative morbidity or mortality were retrieved prospectively as follows: demographic and clinical characteristics of the patients, cardiopulmonary function characteristics, tumour characteristics, and treatment characteristics. A bivariate analysis of all variables under evaluation was carried out in order to identify those variables associated with operative morbidity and mortality. A multivariable analysis of the selected variables was then conducted using a logistic model.

RESULTS

The predicted postoperative product (predicted FEV1 x predicting diffusing capacity of carbon monoxide), the carbon monoxide diffusion coefficient (Kco) and the contralateral pulmonary perfusion are variables that relate to the overall morbidity or mortality (number of events 63, 55%) (-2 log likelihood chi2 = 22.9; R2 = 0.27). For variables associated with postoperative morbidity, the best associative model combines functional variables (diffusion, predicted FEV1), endoscopic variables (obstructed segments to be resected), clinical variables (comorbidity) and an important postoperative variable, the pathological tumoural staging (pN) (number of events 49, 43%) (-2 log likelihood chi2 = 32.9; R2 = 0.36).

CONCLUSION

The numerous variables under analysis are poorly associated with morbidity or mortality after thoracotomy in lung cancer. With regard to postoperative morbidity, the best associative models combine information that is known pre- and postoperatively and which is provided by both the patient and the tumour.

Anaesthesia and postoperative analgesia in older patients with chronic obstructive pulmonary disease: special considerations

Chronic obstructive pulmonary disease (COPD) and older age are known to be independent risk factors for severe perioperative adverse outcomes after surgery. A basic understanding of the disease, careful preoperative evaluation and preparation of the patient, as well as a tailored anaesthetic management plan might help to decrease complications in this patient population. Aging affects the pharmacokinetics and pharmacodynamics of almost all drugs and therefore the dosage must be adapted in older patients. The type of anaesthesia (general versus regional anaesthesia) has no substantial effect on perioperative morbidity and mortality. Most patients, even with severe COPD, tolerate general anaesthesia without major problems. One important goal of the anaesthetic management is to prevent reflex-induced bronchoconstriction, which can be accomplished by the use of volatile anaesthetics. Early recovery can be facilitated by the use of short-acting drugs, such as propofol and the new opioid remifentanil. Judicious use of neuromuscular blocking agents is necessary because of the risk of residual paralysis, and those agents associated with histamine liberation should be avoided. Ventilation requires long expiration times to avoid air trapping, and hyperinflation to avoid the possible threat of pneumothorax and a decrease in cardiac output. For postoperative analgesia, a balanced regimen consisting of regional analgesia with local anaesthetics and NSAIDs should be preferred. This will enhance analgesia and reduce opioid toxicity, which is important in patients with COPD, where respiratory depression is especially dangerous.

Infections in 346 consecutive video-assisted thoracoscopic procedures

BACKGROUND

Postoperative infections, as related to risk factors, in patients undergoing video-assisted thoracoscopic surgery (VATS) procedures have been studied infrequently.

MATERIALS AND METHODS

We evaluated 346 consecutive patients who underwent VATS procedures between October 1996 and June 2002 at our center. Patients preoperatively were free of chest infections and were divided into two groups: Group A (n = 139) who underwent lung wedge resection; group B (n = 207), who underwent pleural biopsy (n = 183) or biopsy of a mediastinal mass (n = 24). We recorded prospectively the following preoperative infection risk parameters: Hemoglobin concentration, hematocrit, serum albumin concentration, lymphocyte count, length of preoperative stay, duration of surgery, blood transfusion, age, comorbidity, and chronic obstructive pulmonary disease specifically (COPD, measured as FEV(1) <70% of expected). Short-term antibiotic prophylaxis was given to 94% of patients in group A and to 90% of patients in group B. As outcome measures we recorded the occurrence of postoperative infections within 30 days (surgical site infection, pneumonia, empyema) and the final patient outcome.

RESULTS

Patients who developed postoperative infections (all the above types included) were 17/346 (4.9%), the difference between group A (5.0%) and group B (4.8%) being not significant. The overall surgical site infection rate was 1.7%. Groups A and B showed a similar incidence of surgical site infection (2.8% vs. 1.0%; p = NS), of pneumonia (2.8% vs. 3.4%; p = NS), and of empyema (0.7% vs. 2.0%; p = NS). Among assessed infection risk parameters, a FEV(1) <70% of expected was the only parameter associated with a significantly increased incidence of surgical site infection (p < 0.05).

CONCLUSIONS

This prospective study confirms that the wound infection rate is low (1.7%) after minimally invasive VATS procedures. The cumulative incidence of postoperative infections (including wound infection, pneumonia, empyema) was similar after lung wedge resection and after pleural or mediastinal mass biopsy procedures. Among the infection risk parameters, COPD was the only parameter associated with a significantly increased incidence of postoperative infection. Our results suggest that patients with COPD who undergo VATS for lung wedge resections and for pleural/mediastinal biopsy should receive antibiotic prophylaxis to prevent surgical site infection.

Preoperative evaluation of patients undergoing lung resection surgery

Lung cancer continues to be the leading case of cancer deaths in the United States. In patients with resectable non-small cell lung cancer, surgical resection is the treatment of choice. An accurate preoperative general and pulmonary-specific evaluation is essential as postoperative complications and morbidity of lung resection surgery are significant. After confirming anatomic resectability, patients must undergo a thorough evaluation to determine their ability to withstand the surgery and the loss of the resected lung. The measurement of spirometric indexes (ie, FEV(1)) and diffusing capacity of the lung for carbon monoxide (DLCO) should be performed first. If FEV(1) and DLCO are > 60% of predicted, patients are at low risk for complications and can undergo pulmonary resection, including pneumonectomy, without further testing. However, if FEV(1) and DLCO are < 60% of predicted, further evaluation by means of a quantitative lung scan is required. If lung scan reveals a predicted postoperative (ppo) values for FEV(1) and DLCO of > 40%, the patient can undergo lung resection. If the ppo FEV(1) and ppo DLCO are < 40%, exercise testing is necessary. If this reveals a maximal oxygen uptake (O(2)max) of > 15 mL/kg, surgery can be undertaken. If the O(2)max is < 15 mL/kg, surgery is not an option. This review discusses the existing modalities for preoperative evaluation prior to lung resection surgery.

Clinical variables of preoperative risk in thoracic surgery

CONTEXT

Pulmonary complications are the most common forms of postoperative morbidity in thoracic surgery, especially atelectasis and pneumonia. The first step in avoiding these complications during the postoperative period is to detect the patients that may develop them.

OBJECTIVE

To identify risk variables leading to early postoperative pulmonary complications in thoracic surgery.

DESIGN

Prospective study.

SETTING

Hospital das Clínicas, Faculdade de Ciências Médicas, Universidade Estadual de Campinas.

PATIENTS

145 patients submitted to elective surgery were classified as low, moderate and high risk for postoperative pulmonary complications using a risk assessment scale.

PROCEDURES

The patients were followed up for 72 hours after the operation. Postoperative pulmonary complications were defined as atelectasis, pneumonia, tracheobronchitis, wheezing, prolonged intubation and/or prolonged mechanical ventilation.

MAIN MEASUREMENTS

Univariate analysis was applied in order to study these independent variables: age, nutritional status, body mass index, respiratory disease, smoking habit, spirometry and surgery duration. Multivariate logistic regression analysis was performed in order to evaluate the relationship between independent and dependent variables.

RESULTS

The incidence of postoperative complications was 18.6%. Multivariate logistic regression analysis showed that the variables increasing the chances of postoperative pulmonary complications were wheezing (odds ratio, OR = 6.2), body mass index (OR = 1.15), smoking (OR = 1.04) and surgery duration (OR = 1.007).

CONCLUSION

Wheezing, body mass index, smoking and surgery duration increase the chances of postoperative pulmonary complications in thoracic surgery

Risk factors for the development of postoperative complications after bronchial sleeve resection for malignancy: a univariate and multivariate analysis

BACKGROUND

This study was designed to identify risk factors responsible for postoperative complications after bronchoplastic procedures.

METHODS

Excluding sleeve pneumonectomies between January 1994 and December 2001, 108 patients underwent bronchoplastic procedures for bronchial malignancy. Prospectively documented data were age, gender, side, type of bronchial reconstruction, extended resection, histology, TNM stage, diseased lobe, and bronchial tumour occlusion. Cardiovascular (CV) risk factors included heart disease, arterial hypertension, cerebro-occlusive disease, peripheral artery disease of the lower extremities, diabetes mellitus, and abdominal aortic aneurysm. Patients were grouped according to the presence/absence of any CV risk factor and the absolute number of CV risk factors present (zero to four). Non-CV risk factors included neoadjuvant chemotherapy, alcoholism, lung disease, sleep apnea, history of recent pneumococcal sepsis, and repeat thoracotomy. Groups were assembled according to the presence or absence of any non-CV risk factor, neoadjuvant chemotherapy, and alcoholism. Respiratory risk factors included lung function and blood gas analysis. Groups were assembled according to the absolute number of respiratory risk factors in each person (zero to three) and the combination of respiratory and CV risk factors. Complications were defined as septic (pneumonia, empyema, brochopleural fistula, colitis) and aseptic. For univariate statistical analysis, t test, cross-tabulation, and chi2 test were used. All factors with a significance of p < 0.1 were entered into a binary backwards-stepwise logistic regression model.

RESULTS

The combination of respiratory and CV risk factors (p = 0.012, OR = 0.165) was predictive for overall complications. Coronary artery disease (p = 0.02, OR = 0.062) and the combination of two respiratory risk factors (p = 0.008, OR = 0.062) were predictive for septic complications. Peripheral artery disease (p = 0.024, OR = 0.28), moderate (p = 0.01, OR = 0.13) and severe chronic obstructive pulmonary disease (p = 0.018, OR = 0.11), and extended resections (p = 0.003, OR = 0.017.) were predictive for aseptic complications.

CONCLUSIONS

Comorbidity significantly influences the postoperative complication rate and is therefore crucial for evaluation of patients for bronchoplastic procedures. Different risk factors are responsible for the occurrence of septic and aseptic complications after bronchoplastic procedures.

Lung resection for cancer in patients with coronary arterial disease: analysis of short-term results

OBJECTIVE

Patients with lung cancer may present concomitant coronary arterial disease. Feasibility of lung resection is dependent on the severity of the cardiac impairment since it can increase operative morbidity and mortality. The aim of this study was to analyze the results of lung resection in patients with coronary arterial disease in terms of operative complications and hospital stay.

METHODS

Between January 1993 and March 2001, 50 patients with coronary arterial disease underwent lung resection for cancer at our department. Nineteen patients with a curable left-main or multiple-vessel disease first underwent surgical (six patients) or transluminal (13 patients) myocardial revascularization. Twenty-two of the 31 patients who did not require myocardial revascularization presented a medium-high cardiac risk. Univariate analysis determined the impact of coronary disease on operative complications and hospital stay.

RESULTS

Surgery consisted in 40 lobectomies, three pneumonectomies and seven wedge resections. The overall mortality and morbidity rates were 4% and 28%, respectively. Ten patients (22%) experienced postoperative cardiac complications such as arrhythmia and there was one intraoperative death, three suffered secretion retention and one patient died as a consequence of a stroke. Occurrence of postoperative complications was influenced by age (P=0.02) and the presence of medium-high cardiac risk (P=0.03). Hospital stay was longer for patients who did not have prior myocardial revascularization (11.7+/-4 vs. 8.1+/-3 days) and underwent more extensive pulmonary resection (10.6+/-5 vs. 7.4+/-2 days).

CONCLUSIONS

Lung resection in patients with coronary arterial disease is justified in selected cases. Previous myocardial revascularization and limited resections can decrease operative complications and hospital stay. Careful preoperative evaluation can identify patients who might benefit from myocardial revascularization prior to surgery.

Lung surgery: identifying the subgroup at risk for sputum retention

OBJECTIVES

Sputum retention after lung surgery is a potentially lethal condition, which can progress to atelectasis, pneumonia and respiratory failure requiring ventilatory support. Previous studies have concentrated on the treatment of postoperative respiratory complications but few have studied the risk factors for sputum retention. This prospective study was designed to identify the risk factors which may lead to the development of sputum retention after lung surgery.

METHODS

Three hundred sixty-one patients underwent lung surgery between January 1997 and December 1999 in a specialist Thoracic Surgery Unit (pneumonectomy, lobectomy, wedge or segmental resection, bullectomy, etc). Preoperative and intraoperative data collected prospectively included potential risk factors: chronic obstructive airway disease (COAD), forced expiratory volume in 1 s (FEV1)<50%, current smokers, ischaemic heart disease (IHD), cerebrovascular disease (CVA), resection of phrenic or recurrent laryngeal nerve, or absence of regional analgesia. Univariate and multivariate analysis was performed.

RESULTS

Sputum related complications occurred in 108 patients (30%). There were 17 deaths of which nine were due to complications related to sputum retention. Univariate analysis confirmed current smokers (n=128), COAD (n=103), IHD (n=41), prior history of CVA (n=16), FEV1<50% (n=48), and absence of regional anaesthesia as significant risk factors (P<0.01). The multivariate analysis confirmed current smokers, IHD and absence of regional anaesthesia as risk factors.

CONCLUSIONS

A subgroup of lung surgery patients at high risk for postoperative sputum retention can be predicted by the presence of one of the following criteria: current smokers, history of COAD, CVA, or IHD, and absence of regional analgesia. Prophylactic measures should be considered in this group to reduce the incidence of sputum retention.

Risk factors for early mortality and major complications following pneumonectomy for non-small cell carcinoma of the lung

STUDY OBJECTIVES

To assess the mortality rate and the incidence of cardiopulmonary complications after pneumonectomy for non-small cell lung carcinoma (NSCLC) and to identify possible associated risk factors.

DESIGN

Observational study of patients who underwent pneumonectomy. Potential risk factors were analyzed from a local database including all thoracic surgical cases.

SETTING

A university hospital and a chest medical center.

PATIENTS AND METHODS

From January 1, 1990, to April 30, 2000, 193 consecutive pneumonectomies were performed for NSCLC in two affiliated institutions. The following information was recorded: demographic, clinical, functional, and surgical variables; as well as intraoperative and postoperative events. The risk of mortality and cardiopulmonary complications was evaluated using multiple logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

After undergoing pneumonectomy, all patients were successfully extubated in the operating room and then transferred to a postanesthesia care unit (126 patients) or ICU (67 patients). The 30-day mortality rate was 9.3%, and cardiovascular and/or pulmonary complications occurred in 47% of cases. Coronary artery disease (CAD) was a predictor of 30-day mortality (OR, 2.9; 95% CI, 1.1 to 8.9). Cardiac morbidity (mainly arrhythmias) was significantly related to advanced age (OR, 3.7; 95% CI, 1.6 to 8.6) and pathologic stages III/IV (OR, 1.4; 95% CI, 1.1 to 4.7), whereas continuous epidural analgesia was associated with a reduced incidence of respiratory complications (OR, 0.2; 95% CI, 0.1 to 0.6).

CONCLUSIONS

Pneumonectomy for lung cancer is a high-risk procedure, the risk for which is significantly related to the presence of CAD and advanced pathologic stages. Importantly, the provision of epidural analgesia contributes to lower the risk of respiratory complications.

Pulmonary function tests in preoperative pulmonary evaluation

Pulmonary function testing (PFT) is used extensively by pulmonary specialists to address two common clinical questions: (1) What is the risk of a postoperative pulmonary complication in an individual with lung disease? and (2) Will the patient be able to tolerate lung resection surgery? Today, there are numerous tests available to measure pulmonary function; making judicious use of these tests essential. In this article, the authors describe significant postoperative pulmonary complications, and discuss the surgical and patient factors contributing to the risk of these complications. They provide an evidence-based approach using pulmonary function data to determine an individual patient's risk for pulmonary complications associated with three types of surgical procedures-upper abdominal, cardiac, and lung resection-and discuss recommendations for risk education.