Postoperative complications after pneumonectomy for treatment of lung cancer: multivariate analysis

The impact of preoperative serum lactate dehydrogenase on mortality and morbidity after noncardiac surgery

Preoperative serum lactate dehydrogenase (LDH) has been reported to be associated with adverse outcomes following thoracic surgery. However, its association with outcomes in noncardiac surgery as a whole has not been investigated. We conducted a retrospective cohort study at West China Hospital, Sichuan University, from 2018 to 2020, including patients undergoing noncardiac surgery. Multivariable logistic regression and propensity score weighting were employed to assess the link between LDH levels and postoperative outcomes. Preoperative LDH was incorporated into four commonly used clinical models, and its discriminative ability, reclassification, and calibration were evaluated in comparison to models without LDH. Among 130,879 patients, higher preoperative LDH levels (cut-off: 220 U/L) were linked to increased in-hospital mortality (4.382% vs. 0.702%; OR 1.856, 95% CI 1.620-2.127, P < 0.001), myocardial injury after noncardiac surgery (MINS) (3.012% vs. 0.537%; OR 1.911, 95% CI 1.643-2.223, P < 0.001), and ICU admission (15.010% vs. 6.414%; OR 1.765, 95% CI 1.642-1.896, P < 0.001). The inverse probability of treatment-weighted estimation supported these results. Additionally, LDH contributed significantly to four surgical prognostic models, enhancing their predictive capability. Our study revealed a significant association between preoperative LDH and in-hospital mortality, MINS, and ICU admission following noncardiac surgery. Moreover, LDH provided supplementary predictive information, extending the utility of commonly used surgical prognostic scores.

A Multiple-Center Nomogram to Predict Pneumonectomy Complication Risk for Non-Small Cell Lung Cancer Patients

OBJECTIVE

This study aimed to construct a nomogram to quantitatively predict pneumonectomy complication risks for non-small cell lung cancer (NSCLC) patients.

METHODS

Data from 1052 NSCLC patients who underwent pneumonectomy were retrospectively retrieved from the databases of three thoracic centers. Multivariable logistic regression was used to investigate postoperative morbidity predictors. Clinical parameters and operative features were analyzed using univariable and multivariable logistic regression analyses, and a nomogram to predict the risk of postoperative complications was constructed using bootstrap resampling. A receiver operating characteristic (ROC) curve was used to estimate the discrimination power for the nomogram.

RESULTS

A total of 212 patients (20.2%) had major complications. After regression analysis, forced expiratory volume in 1 s, Charlson Comorbidity Index score, male sex, and right-sided pneumonectomy were identified and entered into the nomogram. The nomogram showed a robust discrimination, with an area under the ROC curve of 0.753 (95% confidence interval 0.604-0.818). The calibration curves for the probability of postoperative complications showed optimal agreement between the nomogram and the actual probability.

CONCLUSIONS

Based on preoperative data, we developed a nomogram for predicting complication risks after pneumonectomy. This model may be helpful for thoracic surgeons in selecting appropriate patients for adopting prophylactic measures after surgery.

Combining Minimally Invasive Techniques in Managing a Frail Patient with Postpneumonectomy Bronchopleural Fistula

A postpneumonectomy bronchopleural fistula is a life-threatening complication requiring aggressive treatment and early repair. Reoperations are common due to initial treatment failure. Advanced bronchoscopic techniques are rapidly evolving, but permanent results are questionable. We report the minimally invasive management of a frail 79-year-old patient with postpneumonectomy fistula in respiratory failure due to repeated infections. Previous bronchoscopic closure attempts with fibrin failed. The multistep interdisciplinary management included airway surveillance by virtual bronchoscopy, percutaneous fibrin glue instillation under computed tomography, and awake thoracoscopic surgery to achieve temporary closure. This provided an acceptable long period of symptomatic and physical improvement. The bronchial stump failed again four months later, and the patient succumbed to pneumonia. Pneumonectomy has to be avoided unless strongly indicated. Complications are best managed with surgery for definite treatment. We emphasize our approach only when a patient declines surgery or is medically unfit as a temporary time-buying strategy in view of definite surgery in a high-volume center.

Extended Robotic Pulmonary Resections

While lung cancer remains the most common cause of cancer-related mortality in the United States, surgery for curative intent continues to be a mainstay of therapy. The robotic platform for pulmonary resection for non-small cell lung cancer (NSCLC) has been utilized for more than a decade now. With respect to more localized resections, such as wedge resection or lobectomy, considerable data exist demonstrating shorter length of stay, decreased postoperative pain, improved lymph node dissection, and overall lower complication rate. There are a multitude of technical advantages the robotic approach offers, such as improved optics, natural movement of the operator's hands to control the instruments, and precise identification of tissue planes leading to a more ergonomic and safe dissection. Due to the advantages, the scope of robotic resections is expanding. In this review, we will look at the existing data on extended robotic pulmonary resections, specifically post-induction therapy resection, sleeve lobectomy, and pneumonectomy. Additionally, this review will examine the indications for these more complex resections, as well as review the data and outcomes from other institutions' experience with performing them. Lastly, we will share the strategy and outlook of our own institution with respect to these three types of extended pulmonary resections. Though some controversy remains regarding the use and safety of robotic surgery in these complex pulmonary resections, we hope to shed some light on the existing evidence and evaluate the efficacy and safety for patients with NSCLC.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of postoperative lung volume and perfusion changes by dual-energy computed tomography in patients with lung cancer

PURPOSE

The aim of our study was to retrospectively evaluate postoperative physiologic changes in lung cancer patients using dual-energy CT (DECT), and develop modified methods reflecting postoperative change for predicting pulmonary function.

METHODS AND MATERIALS

88 patients (M:F=64:24; mean age, 63.5 years) with lung cancer who underwent DECT and pulmonary function tests before and after operation were included. Volume and iodine values for perfusion of each lobe were quantified. The predicted postoperative FEV1 using the current method was calculated by multiplying the preoperative FEV1 by the fractional contribution of perfusion of the remaining lung. The modified method reflecting postoperative volume change was compared to the current method.

RESULTS

Postoperative lung volume showed compensatory increases in the contralateral and remaining ipsilateral lobes, with a significantly greater increase in the ipsilateral lobe than contralateral lobe (21.8%±46.2% vs. 10.0%±20.8%, P=0.031). Perfusion analysis showed blood volume increases in both ipsilateral and contralateral lobes without statistical differences (blood volume ratio difference, 29.2%±26.7 vs. 24.6%±16.5, P=0.368). The performance of the modified method considering postoperative lung volume change was comparable to that of the current method in the development and validation datasets (95% CI, -24.5% to 37.1% vs. -33.3% to 22.2% and -23.6% to 32.0% vs. -31.9% to 16.0%, respectively).

CONCLUSIONS

Postoperative compensatory increases in lung volume and perfusion occur in different ways. Our modified method incorporating postoperative lung volume changes can be considered a comparable method for prediction of postoperative lung function.

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis

BACKGROUND

Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients.

METHODS

Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three- and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses.

RESULTS

The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68-5.95] (first meta-analysis) and 5.26% (95% CI: 3.47-7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P<0.001) thirty-day postoperative mortality, respectively (first meta-analysis). The pooled percentages for postoperative complications were 34.32% (95% CI: 24.59-44.75) (first meta-analysis) and 45.59% (95% CI: 35.62-55.74) (second meta-analysis). Higher percentages of squamous histology (P=0.001), lobectomy (P=0.002) and p-T1 or p-T2 (P=0.034) were associated with higher proportions of postoperative complications (second meta-analysis). The pooled three- and five- year survival probabilities were 68.25% (95% CI: 45.93-86.86) and 52.03% (95% CI: 34.71-69.11), respectively. Higher mean age (P=0.046) and percentage lobectomy (P=0.009) significantly reduced the five-year survival probability.

CONCLUSIONS

Lobectomy and age were both accompanied by reduced five-year survival rate. Also, combined aorto-coronary bypass grafting (CABG) with lobectomy for squamous pT1 or pT2 LC displayed a higher risk of postoperative complications. Moreover, medical decision between combined or staged surgery is suggested to be individualized based on adequacy of coronary arterial perfusion, age, patient's preoperative performance status (taking into account possible co-morbidities per patient), tumor's staging and extent of lung resection.

Predicting postoperative FEV1 using spiral computed tomography

RATIONALE AND OBJECTIVES

Lung resection for primary bronchogenic carcinoma in the setting of chronic obstructive pulmonary disease often requires a detailed assessment of lung function to avoid perioperative complications and long-term disability. The aim of this study was to test the hypothesis that a novel technique of spiral computed tomographic (CT) subtraction imaging provides accuracy equal to the current standard of radioisotope perfusion scintigraphy in predicting postoperative lung function.

METHODS AND MATERIALS

Preoperative lung function, radioisotope perfusion scintigraphy, spiral CT subtraction imaging, and assessment of postoperative lung function were performed in 25 patients with surgically resectable primary bronchogenic carcinoma. Comparisons of predicted postoperative lung function between the two modalities and to true postoperative lung function were performed using Pearson's correlation and linear regression analysis.

RESULTS

Among the 25 patients enrolled in the study, there was a high degree of agreement between the predicted value of postoperative forced expiratory lung volume in 1 second (FEV(1)) generated on novel contrast CT subtraction imaging and that on radioisotope perfusion scintigraphy (r = 0.96, P < .001). Furthermore, there was a strong correlation between the predicted and actual postoperative FEV(1) values for both imaging modalities (r = 0.87, P < .001, and r = 0.88, P < .001, respectively), among the 14 patients completing the study protocol.

CONCLUSION

A novel technique of CT subtraction imaging is equally accurate at predicting postoperative lung function as radioisotope perfusion scintigraphy, which may obviate the need for additional nuclear imaging in the context of the preoperative assessment of resectable lung cancer in high-risk patients.

Is age over 70 years a risk factor for pneumonectomy?

The lengthening of life expectancy has led to more surgical procedures in elderly patients. The aim of this work was to determine whether age >70 years is a risk factor for pneumonectomy. All cases of pneumonectomy from January 1999 to December 2006 were retrospectively reviewed. The 40 patients aged >70 years were compared with a group of 70 patients aged 40-68 years matched for sex, physical status, respiratory function, side of pneumonectomy, and pathologic stage. Postoperatively, significantly more older patients had atrial fibrillation (24% vs. 5.6%). There was a low incidence of respiratory complications in both groups, and reduced respiratory function did not increase respiratory morbidity. Thirty-day mortality was not significantly different (2.5% in older vs. 1.4% in younger patients), but long-term mortality rates evaluated at December 31, 2007 were 50% for those aged <70 years (35 patients) and 72.5% for the older group. Although age is a risk factor for morbidity and mortality in pneumonectomy, the risk is acceptable.

Pneumonectomy: Post-operative quality of life and lung function

BACKGROUND

Pneumonectomy is associated with high morbidity and mortality. After pneumonectomy, data on health-related quality of life (HRQoL) or its correlation with dyspnea and lung function are scarce. Our main aim was to evaluate long-term HRQoL after pneumonectomy.

METHODS

In a retrospective one-center cross-sectional study, we investigated 31 of 98 patients who underwent pneumonectomy between January 1997 and October 2003 due to primary lung cancer. Pre- or postoperative chemotherapy or radiotherapy was applied according to hospital protocol. In June 2004, all patients alive received the generic HRQoL instrument (15D), as well as the Baseline Dyspnea Index (BDI). Results of the 15D were compared with those for an age- and gender-standardized general population. In April 2005, 20 patients participated in follow-up spirometric pulmonary function tests.

RESULTS

The 15D total score and its various dimensions were significantly lower after pneumonectomy than in the general population. Females both in 15D score and in the BDI had more dyspnea (p<0.05). No difference appeared between right and left pneumonectomy patients, except for more prominent dyspnea in women with right-sided pneumonectomy.

CONCLUSIONS

Pneumonectomy had a negative impact on patients' HRQoL. The use of a broad HRQoL instrument like the 15D, which covers multiple dimensions of HRQoL, yields a more accurate evaluation than did a single-dimension HRQoL instrument. Possibilities for sleeve-resection should be considered thoroughly before any pneumonectomy.

SUMMARY

Quality of life (QoL) after pneumonectomy, as measured with a generic QoL instrument, the 15D, was compared in an age- and gender-standardized population. QoL after pneumonectomy was significantly lower, especially in women after right-sided pneumonectomy.

Influence of preoperative exercise capacity on length of stay after thoracic cancer surgery

BACKGROUND

Stress testing is frequently used to assess cardiac risk before thoracic surgery. However, the relationship between treadmill exercise capacity and length of stay (LOS) has not been investigated. We hypothesized that exercise capacity, a strong predictor of long-term prognosis, can also predict LOS after thoracic cancer surgery.

METHODS

Accordingly, 191 consecutive patients who had exercise stress testing before major thoracic cancer surgery were retrospectively grouped by poor (<4 metabolic equivalents [METs], n = 31), fair (4 to 7 METs, n = 107), good (7 to 10 METs, n = 30), and excellent (>10 METs, n = 23) exercise capacity. The relationship between exercise capacity and LOS was then determined.

RESULTS

Average LOS was inversely related to exercise capacity, with a nearly twofold increase in LOS between the excellent and poor exercise groups (4.8 versus 9.2 days). This relationship remained significant even after controlling for operation type, history of dyspnea, sex, and smoking history in analysis of covariance. Prolonged hospital stay (10 days or more) was strongly predicted by exercise capacity. Failure to exceed 4 METs was associated with a high risk of prolonged stay (9 of 31, 39%), whereas none of the 23 patients who exceeded 10 METs had a prolonged stay.

CONCLUSIONS

Treadmill exercise capacity has independent predictive value for LOS and risk of prolonged stay after thoracic cancer surgery. These findings have important implications for risk assessment and cost, suggesting that preoperative programs designed to improve exercise capacity may favorably influence LOS and associated costs.

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.

Radiographic and CT Findings of Thoracic Complications after Pneumonectomy

Pneumonectomy is the treatment of choice for bronchogenic carcinoma and intractable end-stage lung diseases such as tuberculosis and bronchiectasis, but it is often followed by postoperative complications, which account for significant morbidity and mortality. Knowledge of the radiologic features of such complications is of critical importance for their early detection and prompt management. Complications of pneumonectomy are classified as early or late, depending on when they occur in relation to the hospitalization period. Early complications of pneumonectomy include pulmonary edema, bronchopleural fistula, pneumonia of the contralateral lung, empyema, and adult respiratory distress syndrome, which may occur separately or in combination. Late postpneumonectomy complications include recurrent disease, infection, effects of radiation therapy or chemotherapy, and surgical complications such as late-onset bronchopleural fistula, postpneumonectomy syndrome, and esophagopleural fistula. Sequential examinations with chest radiography after pneumonectomy are an invaluable method of screening for these complications, especially in the early postoperative period. When the radiographic findings are inconclusive, computed tomography is helpful for establishing a diagnosis and obtaining detailed information about the disease process.

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.

One hundred consecutive pneumonectomies after induction therapy for non-small cell lung cancer: An uncertain balance between risks and benefits

OBJECTIVE

We sought to assess postoperative outcome after pneumonectomy after neoadjuvant therapy in patients with non-small cell lung cancer.

METHODS

This retrospective study included 100 patients treated from January 1989 through December 2003 for a primary lung cancer in whom pneumonectomy had been performed after an induction treatment. Surgical intervention had not been considered initially for the following reasons: N2 disease (stage IIIA, n = 79), doubtful resectability (stage IIIB [T4, N0], n = 19), and M1 disease (stage IV [T2, N0, M1, solitary brain metastasis], n = 2). All patients received a 2-drug platinum-based regimen with a median of 2.5 cycles (range, 2-4 cycles), and 30 had associated radiotherapy (30-45 Gy).

RESULTS

There were 55 right and 45 left resections. Overall 30-day and 90-day mortality rates were 12% and 21%, respectively. At multivariate analysis, one independent prognostic factor entered the model to predict 30-day mortality: postoperative cardiovascular event (relative risk, 45.7; 95% confidence interval, 3.7-226.7; P = .001). Four variables predicted 90-day mortality: age of more than 60 years (relative risk, 5.06; 95% confidence interval, 1.47-17.48; P = .01), male sex (relative risk, 8.25; 95% confidence interval, 1.01-67.34; P = .049), postoperative respiratory event (relative risk, 3.64; 95% confidence interval, 1.14-9.37; P = .007), and postoperative cardiovascular event (relative risk, 7.84; 95% confidence interval, 3.12-19.71; P < .001). Estimated overall survivals in 90-day survivors were 35% (range, 29%-41%) and 25% (range, 19.3%-30.7%) at 3 and 5 years, respectively. At multivariate analysis, one independent prognostic factor entered the model: pathologic stage III-IV residual disease (relative risk, 1.89; 95% confidence interval, 1.09-3.26; P = .022).

CONCLUSIONS

Pneumonectomy after induction therapy is a high-risk procedure, the survival benefit of which appears uncertain.

Pulmonary function tests in preoperative pulmonary evaluation

Pulmonary function testing (PFT) has been used to evaluate the risk for postoperative complications since the 1950s. PFT including spirometry, lung volumes, diffusing capacity, oximetry, and arterial blood gases has been used to assess the postoperative risk of lung resection. In selected cases, additional evaluation may include radionuclide lung scanning, exercise testing, invasive pulmonary hemodynamic measurements, and risk stratification analysis. A new index, predicted postoperative product (PPP), was found to have strong predictive ability for mortality. We defined a new useful index, measured product (MP), to predict postoperative complications; MP had similar advantages of PPP. Since diffusing capacity at rest has been shown to be a good predictor of postoperative complications following lung resection, and since exercise testing has been also useful in preoperative evaluation prior to lung resection, we reasoned that evaluation of the effect of exercise on diffusing capacity would be helpful to evaluate the ability of the pulmonary capillary bed to expand and increase its capacity to transfer gas during exercise.

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.

The use of surgery to treat lung cancer in elderly patients

Lung cancer is a leading cause of cancer death and its cure depends on an adequate surgical approach. More than half of all lung cancers are diagnosed in patients aged 65 years or over. However, surgical risk increases in patients over 65 years old. Therefore, surgical procedures for lung cancer are far less frequent in elderly patients. Many clinicians avoid surgery, or minimise surgical procedures on the basis of age but recent advances in preoperative risk assessment and surgical and anaesthetic techniques have resulted in a significant decrease in operative mortality and morbidity for older patients. The treatment of lung cancer in elderly patients should no longer be based on the premise that surgery is too risky for elderly patients. Every effort should be made to assess risk and optimise treatment for this large and expanding proportion of the population.

Postpneumonectomy empyema

Empyema is a serious complication after pneumonectomy. It is often associated with a bronchopleural fistula. Several risk factors have been associated with an increased incidence of these two challenging complications. Therapy aims at simultaneously treating the infected pleural space and the fistula. The authors describe their favorite methods which include repeated open debridements of the pleural space, primary closure of the fistula, and covering of the bronchial stump using intrathoracic transposition of extrathoracic skeletal muscle followed by delayed closure of the chest wall after instillation of an antibiotic solution (Clagett and modified Clagett procedures). The goals of treatment remain a healthy patient with a healed chest wall and no evidence of drainage or infection. Excellent results can be obtained in more than 80% of patients. Failure is often associated with a persistent or recurrent bronchopleural fistula.

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.

Incidence of major pulmonary morbidity after pneumonectomy: association with timing of smoking cessation

BACKGROUND

The prevention of major pulmonary events (MPEs) after pneumonectomy may minimize postoperative mortality rates. The purpose of this study was to identify preoperative and perioperative factors associated with the development of MPEs after pneumonectomy to help predict which patients are at increased risk for MPEs.

METHODS

We retrospectively reviewed the medical records of all patients (n = 261) who underwent pneumonectomies between January 1990 and May 1999. We analyzed preoperative and perioperative risk factors, the primary end point of an MPE and the secondary end points of mortality (in-hospital or 30 days postprocedure), length of stay, and hospital charges. A postoperative MPE included only pneumonia or acute respiratory distress syndrome as defined by the Centers for Disease Control and the American and European Consensus Conference's established criteria. Simple atelectasis that did not progress to pneumonia or a documented aspiration was not included.

RESULTS

Four patients died within 12 hours of operation; the records of the remaining 257 patients were analyzed. An MPE occurred in 33 (12.8%) of 257 patients; 16 (6.2%) of 257 patients died. A multivariate analysis performed on relevant variables showed that only the timing of smoking cessation (1 month or sooner before operation) was a significant predictor of an MPE. Age, side of pneumonectomy, and the use of preoperative chemotherapy or combined chemotherapy and radiation therapy were not significant predictors of an MPE. An MPE significantly increased the mortality rate 2.1% versus 39.3%, p < 0.001).

CONCLUSIONS

Mortality after pneumonectomy increased significantly with the development of an MPE. Patients who continue to smoke within 1 month of operation are at an increased risk for developing an MPE. Interventions to minimize MPEs may minimize the mortality rate after pneumonectomy.

Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence

BACKGROUND

Factors affecting the incidence of empyema and bronchopleural fistula (BPF) after pneumonectomy were analyzed.

METHODS

All patients who underwent pneumonectomy at the Mayo Clinic in Rochester, Minnesota, from January 1985 to September 1998 were reviewed. There were 713 patients (514 males and 199 females). Ages ranged from 12 to 86 years (median 64 years). Indication for resection was primary malignancy in 607 patients (85.1%), metastatic disease in 32 (4.5%), and benign disease in 74 (10.4%). One hundred fifteen patients (16.1%) underwent completion pneumonectomy. Factors affecting the incidence of postoperative empyema and BPF were analyzed using univariate and multivariate analysis.

RESULTS

Empyema was documented in 53 patients (7.5%; 95% confidence interval [CI], 5.7% to 9.7%) and a BPF in 32 (4.5%; 95% CI, 3.1% to 6.3%). Univariate analysis demonstrated that the development of empyema was adversely affected by benign disease (p = 0.0001), lower preoperative forced expiratory volume in 1 second (FEV1; p < 0.01) and diffusion capacity of lung to carbon monoxide (DLCO; p = 0.0001), lower preoperative serum hemoglobin (p = 0.05), right pneumonectomy (p = 0.0109), bronchial stump reinforcement (p = 0.007), completion pneumonectomy (p < 0.01), timing of chest tube removal (p = 0.01), and the amount of blood transfusions (p < 0.01). Similarly, the development of BPF was significantly associated with benign disease (p = 0.03), lower preoperative FEV1 (p = 0.03) and DLCO (p = 0.01), right pneumonectomy (p < 0.0001), bronchial stump reinforcement (p = 0.03), timing of chest tube removal (p = 0.004), increased intravenous fluid in the first 12 hours (p = 0.04), and blood transfusions (p = 0.04). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure (p = 0.009). No risk factors were identified as being jointly significant in multivariate analysis.

CONCLUSIONS

Multiple perioperative factors were associated with an increased incidence of empyema and BPF after pneumonectomy. Prophylactic reinforcement of the bronchial stump with viable tissue may be indicated in those patients suspected at higher risk for either empyema or BPF.

Perioperative Factors as Predictors of Operative Mortality and Morbidity in Pneumonectomy

Pneumonectomy for lung cancer is associated with significant morbidity and mortality. Risk factors for the morbidity and mortality have been reported, but consistent conclusive data are undetermined. Current accepted 30-day mortality rates for pneumonectomy range from 7 to 11 per cent. The objective of this study is to determine whether various perioperative factors can serve as predictors of morbidity and mortality in pneumonectomy patients and to review outcome data on patients undergoing pneumonectomy for lung cancer. A total of 105 patients undergoing pneumonectomy for lung cancer from 1988 through 1998 are studied in a retrospective chart review. The main outcome measure is the 30-day operative mortality and morbidity. Complications occurring in 10 per cent or more of the patients included atrial fibrillation (33.3%), respiratory failure (23.8%), pneumonia (21.9%), and bronchopleural fistula (12.4%). The 30-day mortality rate was 10.5 per cent (11 deaths). By Fisher's exact test for Chi-square only three statistically significant mortality factors were identified: respiratory failure ( P < 0.021), sepsis ( P < 0.008), and male sex ( P < 0.031); respiratory failure, sepsis, and sex were predictors of death. Significant correlation could not be made to predict postoperative morbidity. Overall long-term clinical outcome for pneumonectomy as lung cancer treatment was poor. Clinical judgment remains an essential factor when considering pneumonectomy as an option for lung cancer treatment.

Prediction of pulmonary complications after a lobectomy in patients with non-small cell lung cancer

BACKGROUND

Although the preoperative prediction of pulmonary complications after lung major surgery has been reported in various papers, it still remains unclear.

METHODS

Eighty nine patients with stage I-IIIA non-small cell lung cancer (NSCLC) who underwent a complete resection at our institute from 1994-8 were evaluated for the feasibility of making a preoperative prediction of pulmonary complications. All had either a predicted postoperative forced vital capacity (FVC) of >800 ml/m(2) or forced expiratory volume in one second (FEV(1)) of >600 ml/m(2).

RESULTS

Postoperative complications occurred in 37 patients (41.2%) but no patients died during the 30 day period after the operation. Pulmonary complications occurred in 20 patients (22.5%). Univariate analysis indicated that the factors significantly related to pulmonary complications were FVC <80%, serum lactate dehydrogenase (LDH) level > or =230 U/l, and arterial oxygen tension (PaO(2)) <10.6 kPa (80 mm Hg). In a multivariate analysis the three independent predictors of pulmonary complications were serum LDH > or =230 U/l (odds ratio (OR) 10.5, 95% CI 1.4 to 77.3), residual volume (RV)/total lung capacity (TLC) > or =30% (OR 6.0, 95% CI 1.1 to 33.7), and PaO(2) <10.6 kPa (OR 5.6, 95% CI 1.4 to 22.2).

CONCLUSIONS

The above findings indicate that three factors (serum LDH levels of > or =230 U/l, RV/TLC > or =30%, and PaO(2) <10.6 kPa) may be associated with pulmonary complications in patients undergoing a lobectomy for NSCLC, even though the patient group was relatively small for statistical analysis of such a diverse subject as pulmonary complications.

The incidence, etiology, and prevention of postresectional bronchopleural fistula

Bronchopleural fistula (BPF) is a life-threatening complication after pulmonary resection. The incidence varies from 4.5% to 20% after pneumonectomy and is only 0.5% after lobectomy. Certain patient characteristics increase this incidence. These include preoperative radiation to the chest, destroyed or infected lung from inflammatory disease, immunocompromised host, and insulin-dependent diabetes. Certain surgical techniques also increase the incidence. These include pneumonectomy, right-sided pneumonectomy, a long bronchial stump, residual cancer at the bronchial margin, devascularization of the bronchial stump, prolonged ventilation, or reintubation after resection and surgical inexperience. The best treatment of a BPF is prevention. Prevention centers around meticulous surgical technique and the liberal use of prophylactic, pedicled muscle flaps for the patient at increased risk. Survival of BPF depends on a high index of suspicion, early diagnosis, and aggressive surgical intervention.

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

STUDY OBJECTIVES

To assess the incidence and clinical implications of postoperative pulmonary complications (PPCs) after lung resection, and to identify possible associated risk factors.

DESIGN

Retrospective study.

SETTING

An 885-bed teaching hospital.

PATIENTS AND METHODS

We reviewed all patients undergoing lung resection during a 3-year period. The following information was recorded: preoperative assessment (including pulmonary function tests), clinical parameters, and intraoperative and postoperative events. Pulmonary complications were noted according to a precise definition. The risk of PPCs associated with selected factors was evaluated using multiple logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Two hundred sixty-six patients were studied (87 after pneumonectomy, 142 after lobectomy, and 37 after wedge resection). Sixty-eight patients (25%) experienced PPCs, and 20 patients (7.5%) died during the 30 days following the surgical procedure. An American Society of Anesthesiology (ASA) score > or= 3 (OR, 2.11; 95% CI, 1.07 to 4.16; p < 0.02), an operating time > 80 min (OR, 2.08; 95% CI, 1.09 to 3.97; p < 0.02), and the need for postoperative mechanical ventilation > 48 min (OR, 1.96; 95% CI, 1.02 to 3.75; p < 0.04) were independent factors associated with the development of PPCs, which was, in turn, associated with an increased mortality rate and the length of ICU or surgical ward stay.

CONCLUSIONS

Our results confirm the relevance of the ASA score in a selected population and stress the importance of the length of the surgical procedure and the need for postoperative mechanical ventilation in the development of PPCs. In addition, preoperative pulmonary function tests do not appear to contribute to the identification of high-risk patients.

Superphysiologic FDG Uptake in the Non-Paralyzed Vocal Cord Resolution of a False-Positive PET Result with Combined PET-CT Imaging

The application of positron emission tomography imaging with 18F-fluorodeoxyglucose (FDG) to the extracranial head and neck has been proven to be effective in the detection and staging of malignancy. The FDG uptake of normal laryngeal tissue is symmetric and low, while benign lesions typically have only slight increases in FDG uptake. We report a case of asymmetric, superphysiologic FDG uptake in the contralateral vocal cord of a patient with a unilateral vocal cord paralysis secondary to sacrifice of the recurrent laryngeal nerve during pneumonectomy for lung cancer. The FDG uptake of the non-paralyzed vocal cord was increased multiple-fold, placing it well within the range of malignancy. Use of unique, combined PET-CT imaging localized the high FDG uptake to the non-paralyzed vocal cord, and laryngoscopy confirmed no evidence of malignancy in the vocal cord. This case demonstrates that a benign cause of false-positive FDG-PET imaging may be encountered during evaluation of the extracranial head and neck for malignancy. We aim to alert the reader to this potential pitfall in the interpretation of FDG-PET imaging, which can be resolved with the use of combined PET-CT imaging and clinical correlation.

Incidence of arrhythmias after thoracic surgery: thoracotomy versus video-assisted thoracoscopy

PURPOSE

Atrial arrhythmias, especially supraventricular tachycardia (SVT) and atrial fibrillation, are common after thoracotomy and lung surgery. There are few existing data on the incidence of postoperative arrhythmias after video-assisted thoracoscopy (VAT). The purpose of the present investigation was to retrospectively determine the incidence of postoperative arrhythmias in patients who underwent VAT compared with those who underwent thoracotomy, and which factors are associated with an increased risk for arrhythmias in both groups.

DESIGN

A retrospective investigation.

SETTING

A metropolitan university hospital.

PARTICIPANTS

The medical records of 124 patients who underwent thoracotomy and 81 patients who underwent VAT over a 2-year period were reviewed.

MEASUREMENTS AND MAIN RESULTS

There was a 17% incidence of atrial arrhythmias after thoracotomy and 10% after VAT, but the difference was not statistically significant. In both groups, atrial fibrillation was the most common atrial arrhythmia.

CONCLUSION

Patients receiving digoxin were at higher risk for postoperative arrhythmias. Patients older than 65 years were at risk for arrhythmias after thoracotomy and patients older than 80 years were at risk for arrhythmias after VAT. Patients who had postoperative arrhythmias had prolonged hospital stays compared with patients who did not have arrhythmias.