Pulmonary function tests do not predict pulmonary complications after thoracoscopic lobectomy

Association between recovery from desaturation after stair climbing and postoperative complications in lung resection

OBJECTIVE

The stair-climbing test (SCT) is used as a surrogate for cardiopulmonary exercise testing, which measures maximal oxygen uptake, and considered a useful method for assessing exercise capacity in thoracic surgery. This study aims to investigate whether the recovery time of percutaneous oxygen saturation (SpO2) after stair climbing is a predictor of postoperative complications after lobectomy.

METHODS

We retrospectively identified 54 patients who performed SCT and underwent lobectomy between January 2015 and February 2023 at Shizuoka Cancer Center. The SpO2 recovery time was defined as the time required to recover from the minimum to resting value after stair climbing. The association between SpO2 recovery time and early postoperative pulmonary complications within 30 days after surgery was analyzed.

RESULTS

Eleven patients (20.4%) had postoperative pulmonary complications (≥ Clavien-Dindo Classification Grade 2). The cutoff value of SpO2 recovery time obtained from the receiver operating characteristic curve analysis was 90 s [sensitivity, 81.8%; specificity, 72.1%; AUC, 0.77 (95% confidence interval, 0.64-0.90)]. The occurrence of postoperative pulmonary complications was 42.9% in the delayed recovery time (DRT; SpO2 recovery time ≥ 90 s) group and 6.1% in the non-DRT (SpO2 recovery time < 90 s) group (p = 0.002). DRT was a predictor of postoperative pulmonary complications (odds ratio, 11.60; 95% CI 2.19-61.80).

CONCLUSIONS

DRT of SpO2 after stair climbing is a predictor of postoperative pulmonary complications following lobectomy in borderline patients who require exercise capacity assessment. SpO2 monitoring after stair climbing may be useful as one of the preoperative assessments in patients undergoing lobectomy.

Incidence and risk factors of pulmonary complications after lung cancer surgery: A systematic review and meta-analysis

Postoperative pulmonary complications (PPCs) are associated with high mortality rates after lung cancer surgery. Although some studies have discussed the different risk factors for PPCs, the relationship between these factors and their impact on PPCs remains unclear. Hence, this study aimed to systematically summarize the incidence and determine the risk factors for PPCs. We conducted a systematic search of five English and four Chinese databases from their inception to April 1, 2023. A total of 34 articles (8 cohort studies and 26 case-control studies) (n = 31696, 5833 with PPCs) were included in the analysis. The primary outcome was the incidence of PPC. The secondary outcome was the odds ratio (OR) of PPCs based on the identified risk factors calculated by RevMan 5.4. A narrative descriptive summary of the study results was presented when pooling the results or conducting a meta-analysis was not possible. The pooled incidence of PPCs was 18.4 %. This meta-analysis demonstrated that TNM staging (OR 4.29, 95 % CI 2.59-7.13), chronic obstructive pulmonary disease (COPD) (OR 2.47, 95 % CI 1.80-3.40), smoking history (OR 2.37, 95 % CI 1.33-4.21), poor compliance with respiratory rehabilitation (OR 1.64, 95 % CI 1.17-2.30), male sex (OR 1.62, 95 % CI 1.28-2.04), diabetes (OR 1.56, 95 % CI 1.07-2.27), intraoperative bleeding volume (OR 1.44, 95 % CI 1.02-2.04), Eastern Cooperative Oncology Group score (ECOG) > 1 (OR 1.37, 95 % CI 1.04-1.80), history of chemotherapy and/or radiotherapy (OR 1.32, 95 % CI 1.03-1.70), older age (OR 1.18, 95 % CI 1.11-1.24), and duration of surgery (OR 1.07, 95 % CI 1.04-1.10) were significantly associated with a higher risk of PPCs. In contrast, the peak expiratory flow rate (PEF) (OR 0.99, 95 % CI 0.98-0.99) was a protective factor. Clinicians should implement targeted and effective interventions to prevent the occurrence of PPCs.

Risk stratification of postoperative pulmonary complications in elderly patients undergoing lung cancer resection: a propensity score-matched study

BACKGROUND

In China, lung cancer mainly affects the elderly population. Surgery remains the standard treatment for lung cancer in elderly patients, however, postoperative pulmonary complications (PPCs) are major contributors to morbidity and mortality following lung resection. This study aimed to identify perioperative predictors of PPCs among elderly patients undergoing pulmonary resection for lung cancer to provide evidence for better prevention and intervention for PPCs.

METHODS

A retrospective study was conducted with 456 patients (age >65 years) undergoing pulmonary resection for lung cancer in Yunnan, China from January 2016 to March 2019. Propensity score matching (PSM) was performed to compare preoperative data and clinical characteristics between the PPC and non-PPC groups, followed by binary logistic regression to evaluate predictors of PPCs.

RESULTS

Pulmonary complications occurred in 142/456 (31.1%) patients age >65 years, with pneumonia being the most common event (21.7%). Both PSM and binary logistic regression analysis identified American Society of Anesthesiologists (ASA) class

CONCLUSIONS

PPCs following lung cancer resection in elderly patients were associated with a higher ASA classification and open thoracotomy. An adequate and comprehensive evaluation of the operative strategies and enhanced recovery methods should be implemented among elderly patients undergoing lung resection with an ASA class > II or those undergoing an open thoracotomy to help prevent the occurrence of PPCs.

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Key Words

• American Society of Anesthesiologists classification (ASA classification)
• Lung cancer surgery
• postoperative pulmonary complications (PPCs)
• thoracotomy

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MESH Headings Collapse

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Affiliation(s)

Qiubo Huang Department of Thoracic Surgery, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
Ritika Rauniyar Department of Thoracic Surgery, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
Jiao Yang Department of Nursing, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
Chen Zhou Department of Thoracic Surgery, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
Dezhong Cai Department of Thoracic Surgery, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
Toyofumi Fengshi Chen-Yoshikawa Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
Yojiro Yutaka Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
Riccardo Orlandi Department of Thoracic Surgery, IRCCS San Gerardo Hospital, ASST-Monza, Monza, Italy
Travis C. Geraci Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
Jules Lin Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
Huilian Hu Department of Thoracic Surgery, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
Ziqi Jiang Department of Thoracic Surgery, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
Guangqiang Zhao Department of Thoracic Surgery, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
Lianhua Ye Department of Thoracic Surgery, The Third Affiliated Hospital of Kunming Medical University, Kunming, China

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A machine learning approach for preoperatively assessing pulmonary function with computed tomography in patients with lung cancer

Background

It is clinically important to accurately assess the pulmonary function of patients with lung cancer, especially before surgery. This knowledge can help clinicians to monitor patients pre- and post-surgery, predict the impact of surgery on pulmonary function, and help to optimize postsurgical recovery. We used a deep learning approach for assessing pulmonary function on computed tomography (CT) scans in patients with lung cancer before they underwent surgery.

Methods

A total of 188 patients with lung cancer whose diagnoses had been pathologically confirmed were enrolled in this study. We used a software to automatically delineate regions of interest (ROIs) throughout the airways, lobes, and the whole lungs. We then used AK software to extract radiomics features of the 3 types of ROIs. We randomly separated these cases into a training cohort and a test cohort at a ratio of 7:3. We next constructed a logistic regression model to assess pulmonary function from the radiomics features. The machine learning outcomes were compared with established clinical criteria for pulmonary function. including forced expiratory volume in the first second/forced vital capacity (FEV1/FVC), FVC, and maximum vital capacity (VCmax) to evaluate the accuracy of the machine learning model.

Results

In the ROIs of the lobes, our results showed that the machine learning model had good performance in predicting FVC and VCmax, attaining a Spearman correlation r value of 0.714 with P<0.001 for FVC and a r value of 0.687 with P<0.001 for VCmax. Using the airway ROIs, our model achieved a r of 0.603 with P=0.001 for VCmax. Using the whole lung ROIs, our model achieved a r of 0.704 with P<0.001 for FVC and a r of 0.693 with P<0.001 for VCmax.

Conclusions

Preoperative CT may provide a means for evaluating pulmonary function in patients with lung cancer. With radiomics features extracted from the airway, lobes, and the whole lung region, and a properly trained machine learning model, it is possible to obtain accurate estimation for metrics used in clinical criteria and to offer clinicians imaging-based indicators for the status of pulmonary functions.

Lobectomías pulmonares en Colombia: una caracterización demográfica y clínico-patológica

Introducción. La lobectomía pulmonar es uno de los procedimientos más frecuentes en la cirugía torácica en Colombia y a nivel mundial. El objetivo de este estudio fue proporcionar información sobre el comportamiento clínico de los individuos sometidos a este tipo de cirugías. Métodos. Estudio observacional retrospectivo en un Hospital Universitario de Cali, Colombia, que incluyó todos los pacientes sometidos a lobectomía pulmonar, por causas benignas o malignas, entre los años 2010 y 2020. La información se extrajo del registro institucional de cirugía de tórax, obteniendo datos demográficos, clínicos y patológicos. Resultados. Se evaluaron los registros clínicos de 207 individuos. El 55,5 % eran mujeres, la edad promedio fue 58 años y el 41 % tuvieron antecedente de tabaquismo. En el 51,6 % de los casos se diagnosticaron neoplasias, de las cuales el 47,8 % eran primarias de pulmón, siendo el adenocarcinoma el subtipo más común. Las enfermedades benignas no tumorales representaron el 48,3 % de los casos y la causa más frecuente fueron las infecciones, dentro de las que se incluyeron 17 casos de tuberculosis pulmonar. La técnica más frecuente fue la cirugía toracoscópica video asistida (82,6 %). Presentaron un porcentaje de reintervención del 5,8 %, 10,6 % de complicaciones severas y una mortalidad hospitalaria del 4,3 %. Conclusión. La población evaluada muestra una carga alta de comorbilidades y riesgo operatorio elevado; de forma consecuente, al compararla con otras series internacionales, se encontró un porcentaje mayor de complicaciones perioperatorias y mortalidad.

Surgical Evaluation in Patients Undergoing Radiation Therapy for Early-Stage Lung Cancer

BACKGROUND

Stereotactic body radiation therapy (SBRT) is used to treat stage I non-small cell lung cancer (NSCLC) in nonsurgical candidates, although guidelines specify that inoperability be determined in multidisciplinary fashion. We characterized NSCLC patients treated with SBRT undergoing thoracic surgical evaluation (TSUe) and quantified TSUe's impact on time to treatment, receipt of diagnostic staging procedures, and health care costs.

METHODS

Adults with newly diagnosed NSCLC undergoing SBRT were identified in the MarketScan all-payer claims database (2014-2018). TSUe was defined as an outpatient encounter with a thoracic surgeon or multispecialty group. Time to treatment and total costs in the 6 months preceding treatment were examined using multivariable regression by receipt of TSUe, adjusting for demographic and clinical factors.

RESULTS

Of 1894 patients, 36.3% (n = 687) underwent TSUe. Compared with patients without TSUe, these patients were younger (mean age, 73.6 vs 76.3 years) and more likely to undergo invasive biopsy/staging procedures (90% vs 82%) or pulmonary function testing (80.6% vs 69.5%). Patients undergoing TSUe had a median time to treatment of 64 days (interquartile range, 43-98 days), compared with 44 days (interquartile range, 29-70 days) for no TSUe. Adjusted time to treatment was 43% longer (incident rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001) with TSUe. Patients undergoing TSUe also incurred 30% higher costs (adjusted cost ratio, 1.30; 95% CI, 1.20-1.41; P < .001).

CONCLUSIONS

Among patients with early-stage NSCLC undergoing SBRT as primary treatment, a minority are evaluated by a thoracic surgeon. Because they have a longer time to treatment, more invasive diagnostic procedures, and higher costs, this represents a targetable gap to make workup protocols more efficient.

The ARISCAT Risk Index as a Predictor of Pulmonary Complications After Thoracic Surgeries, Almoosa Specialist Hospital, Saudi Arabia

Background

Pulmonary complications after thoracic surgery are common and are associated with prolonged hospital stay, higher costs, and increased mortality. This study aimed to evaluate the value of The Assess Respiratory risk in Surgical Patients in Catalonia (ARISCAT) risk index in predicting pulmonary complications after thoracic surgery.

Methods

This retrospective study was conducted at Almoosa Specialist Hospital, Saudi Arabia, from August 2016 to August 2019 and included 108 patients who underwent thoracic surgery during the study period. Demographic data, ARISCAT risk index score, length of hospital stay, time of chest tube removal, postoperative complications, and time of discharge were recorded.

Results

The study involved 108 patients who met the inclusion criteria. Their mean age was 42.5 ± 18.9 years, and most of them were men (67.6%). Comorbid diseases were present in 53.7%, including mainly type 2 diabetes mellitus and hypertension. FEV1% was measured in 58 patients, with a mean of 71.1 ± 7.3%. The mean ARISCAT score was 39.3 ± 12.4 and ranged from 24 to 76, with more than one-third (35.2%) having a high score grade. The most common surgical procedures were thoracotomy in 47.2%, video-assisted thoracoscopic surgery (VATS) in 28.7%, and mediastinoscopy in 17.6%. Postoperative pulmonary complications (PPCs) occurred in 22 patients (20.4%), mainly pneumonia and atelectasis (9.2%). PPCs occurred most frequently during thoracotomy (68.2%), followed by VATS (13.6%), and mediastinoscopy (9.1%). Multinomial logistic regression of significant risk factors showed that lower FEV1% (OR = 0.88 [0.79-0.98]; p=0.017), longer ICU length of stay (OR = 1.53 [1.04-2.25]; p=0.033), a higher ARISCAT score (OR = 1.22 [1.02-1.47]; p=0.040), and a high ARISCAT grade (OR = 2.77 [1.06-7.21]; p=0.037) were significant predictors of the occurrence of postoperative complications.

Conclusion

ARISCAT scoring system, lower FEV1% score, and longer ICU stay were significant predictors of postoperative complications. In addition, thoracotomy was also found to be associated with PPCs.

Postoperative Patient-Reported Outcomes after Uniportal Video-Assisted Thoracoscopic Surgery Using the Perioperative Symptom Assessment for Lung Surgery Scale

This study aimed to use a new special inventory for lung surgery patients to evaluate postoperative symptoms and functional status and to identify factors that may affect these after uniportal video-assisted thoracoscopic surgery (VATS). In this single-center longitudinal cohort observational study, we used a new scale, the perioperative symptom assessment for lung surgery (PSA-Lung), to evaluate the recovery from symptoms and the functional status of patients undergoing uniportal VATS. We divided patients into two groups, according to patients' symptom scores, and compared the clinical characteristics between the two groups under each item. Then, we conducted a qualitative interview regarding coughing in postoperative week 4. Exactly 104 patients were enrolled in this study. The two highest-scoring patient-reported outcome (PRO) items were "shortness of breath" and "coughing" in the fourth week after surgery. Thirty-one patients reported that "coughing" severely influenced their lives in postoperative week 4. Using the PSA-Lung inventory, we found that "shortness of breath" was the worst symptom in postoperative week 4. Although "coughing" was not the most important symptom in the early postoperative period, it affected some patients' lives in postoperative week 4. Therefore, further research is required to determine the optimal cut-off point for coughing.

Exercise testing and postoperative complications after minimally invasive lung resection: A cohort study

Background: Peak oxygen uptake (V˙O2) during cardiospulmonary exercise testing (CPET) is used to stratify postoperative risk following lung cancer resection but peak V˙O2 thresholds to predict post-operative mortality and morbidity were derived mostly from patients who underwent thoracotomy.

Objectives: We evaluated whether peak V˙O2 or other CPET-derived variables predict post-operative mortality and cardiopulmonary morbidity after minimally invasive video-assisted thoracoscopic surgery (VATS) for lung cancer resection.

Methods: A retrospective analysis of patients who underwent VATS lung resection between 2002 and 2019 and in whom CPET was performed. Logistic regression models were used to determine predictors of postoperative outcomes until 30 days after surgery. The ability of peak V˙O2 to discriminate between patients with and without post-operative complications was evaluated using Receiver operating characteristic (ROC) analysis.

Results: Among the 593 patients, postoperative cardiopulmonary complications occurred in 92 (15.5%) individuals, including three deaths. Mean peak V˙O2 was 18.8 ml⋅kg⁻¹⋅min⁻¹, ranging from 7.0 to 36.4 ml⋅kg⁻¹⋅min⁻¹. Best predictors of postoperative morbidity and mortality were peripheral arterial disease, bilobectomy or pneumonectomy (versus sublobar resection), preoperative FEV₁, peak V˙O2 , and peak V˙E/V˙CO2. The proportion of patients with peak V˙O2 of < 15 ml⋅kg⁻¹⋅min⁻¹, 15 to < 20 ml⋅kg⁻¹⋅min⁻¹ and ≥ 20 ml⋅kg⁻¹⋅min⁻¹ experiencing at least one postoperative complication was 23.8, 16.3 and 10.4%, respectively. The area under the ROC curve for peak V˙O2 was 0.63 (95% CI: 0.57–0.69).

Conclusion: Although lower peak V˙O2 was a predictor of postoperative complications following VATS lung cancer resection, its ability to discriminate patients with or without complications was limited.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 3: systematic review of evidence regarding surgery in compromised patients or specific tumors

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in older patients, patients with limited pulmonary reserve and favorable tumors is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons (NRCs) with adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In older patients, perioperative mortality is minimally altered by resection extent and only slightly affected by increasing age; sublobar resection may slightly decrease morbidity. Long-term outcomes are worse after lesser resection; the difference is slightly attenuated with increasing age. Reported short-term outcomes are quite acceptable in (selected) patients with severely limited pulmonary reserve, not clearly altered by resection extent but substantially improved by a minimally invasive approach. Quality-of-life (QOL) and impact on pulmonary function hasn't been well studied, but there appears to be little difference by resection extent in older or compromised patients. Patient selection is paramount but not well defined. Ground-glass and screen-detected tumors exhibit favorable long-term outcomes regardless of resection extent; however solid tumors <1 cm are not a reliably favorable group.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in compromised patients and favorable tumors with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.

Role of stereotactic body radiotherapy for early-stage non-small-cell lung cancer in patients borderline for surgery due to impaired pulmonary function

AIM

Stereotactic body radiotherapy (SBRT) is recommended only for inoperable patients with early-stage (e-stage) non-small-cell lung cancer (NSCLC). We compared outcomes between surgery and SBRT in patients borderline for surgery due to impaired pulmonary function (PF).

METHODS

We reviewed single-institution retrospective data of 578 patients with clinically T1-2N0M0 NSCLC treated by surgery or SBRT between 2004 and 2014, and extracted a cohort with borderline impaired PF for surgery, which was defined as predicted postoperative (PPO) forced expiratory volume in 1 s (FEV₁ ) of <50% and ≥30%. Overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS) were compared between surgery and SBRT using propensity score-matching (PSM) to avoid bias.

RESULTS

Among a total of 116 eligible patients with a median PPO FEV₁ of 45%, PSM identified 25 patients from each group with similar characteristics. The median age, pretreatment FEV₁ , and follow-up durations for the surgery and SBRT groups were 75 and 74 years, 58% and 56%, and 56 and 60 months, respectively. The 5-year OS, CSS, and DFS rates of the surgery versus SBRT groups were 60% versus 63%, 76% versus 81%, and 52% versus 48%, respectively (p = 0.97, 0.81, and 0.99). The surgical mortality was 4.0%, but no treatment-related death was observed after SBRT. The incidence of ≥ grade 2 adverse events after surgery was double that after SBRT (40% versus 20%, p = .22).

CONCLUSION

Our study suggests that SBRT is a reasonable option for patients with e-stage NSCLC and impaired PF who are considered borderline candidates for surgery.

The impact of marginal lung function on outcomes in the era of minimally invasive thoracic surgery

Background

The effect of marginal lung function on outcomes after lung resection has traditionally been studied in the context of open thoracic surgery. Its impact on postoperative outcomes in the era of minimally invasive lung resection is unclear.

Methods

In this retrospective cohort study, we included adult patients who underwent minimally invasive lung resection at our institution between January 2017 and May 2020 for known malignancy or lung nodule. Marginal lung function was defined as pre-operative forced expiratory volume in 1 second (FEV1) and/or diffusion lung capacity of carbon monoxide <60% of predicted. Our outcomes included a composite outcome of pulmonary morbidity and/or 30- and 90-day mortality, and hospital length of stay. We used multivariable logistic and Poisson regression models to identify associations with outcomes, and Kaplan-Meier and Cox models to estimate survival.

Results

Of 300 patients, 88 (29%) had marginal lung function. Patients in the marginal group were more likely to be female (69% vs. 56%; P=0.028), and more likely to have: hypertension (HTN) (83% vs. 71%; P=0.028), chronic obstructive pulmonary disease (COPD) (38% vs. 12%; P<0.001), interstitial lung disease (ILD) (9% vs. 3%; P<0.019), and ischemic heart disease (28% vs. 18%; P=0.033). Patients were similar in terms of age (68±8 vs. 68±10 years; P=0.932), and other comorbidities. Anatomic lung resection comprised 56.8% of the marginal group vs. 74% in the non-marginal group (P=0.003). The most common complication was prolonged air leak (18.2% vs. 11.8%; P=0.479). Marginal lung function had a trend toward increased composite respiratory complications (22.7% vs. 15.1%; P=0.112) and 90-day mortality (5.7% vs. 4.2%; P=0.591), although they did not reach statistical significance. There was a statistically significant 1-day average increase in length of stay in the marginal lung function cohort (4.6 vs. 3.4 days; P<0.015) with a stronger association with diffusion lung capacity of carbon monoxide than FEV1. Survival was similar (marginal function HR =1.0; P=0.994).

Conclusions

In the era of minimally invasive thoracic surgery, lung resection in patients with marginal lung function may be considered in select patients. These findings aid in the selection consideration and counseling of this patient population.

The impact of pulmonary function tests on early postoperative complications in open lung resection surgery: an observational cohort study

We investigated whether pulmonary function tests (PFTs) can predict pulmonary complications and if they are, to find new cutoff values in current open lung resection surgery. In this observational study, patients underwent open lung resection surgery at a tertiary hospital were analyzed (n = 1544). Various PFTs were tested by area under the receiver-operating characteristic curve (AUC_ROC) to predict pulmonary complications until 30 days postoperatively. In results, PFTs were generally not effective to predict pulmonary complications (AUC_ROC: 0.58-0.66). Therefore, we could not determine new cutoff values, and used previously reported cutoffs for post-hoc analysis [predicted postoperative forced expiratory volume in one second (ppoFEV₁) < 40%, predicted postoperative diffusing capacity for carbon monoxide (ppoDL_CO) < 40%]. In multivariable analysis, old age, male sex, current smoker, intraoperative transfusion and use of inotropes were independent risk factors for pulmonary complications (model 1: AUC_ROC 0.737). Addition of ppoFEV₁ or ppoDL_CO < 40% to model 1 did not significantly increase predictive capability (model 2: AUC_ROC 0.751, P = 0.065). In propensity score-matched subgroups, patients with ppoFEV₁ or ppoDL_CO < 40% showed higher rates of pulmonary complications [13% (21/160) vs. 24% (38/160), P = 0.014], but no difference in in-hospital mortality [3% (8/241) vs. 6% (14/241), P = 0.210] or mean survival duration [61 (95% CI 57-66) vs. 65 (95% CI 60-70) months, P = 0.830] compared to patients with both > 40%. In conclusion, PFTs themselves were not effective predictors of pulmonary complications. Decision to proceed with surgical resection of lung cancer should be made on an individual basis considering other risk factors and the patient's goals.

Exploring the 175-year history of spirometry and the vital lessons it can teach us today

175 years have elapsed since John Hutchinson introduced the world to his version of an apparatus that had been in development for nearly two centuries, the spirometer. Though he was not the first to build a device that sought to measure breathing and quantify the impact of disease and occupation on lung function, Hutchison coined the terms spirometer and vital capacity that are still in use today, securing his place in medical history. As Hutchinson envisioned, spirometry would become crucial to our growing knowledge of respiratory pathophysiology, from Tiffeneau and Pinelli's work on forced expiratory volumes, to Fry and Hyatt's description of the flow-volume curve. In the 20th century, standardization of spirometry further broadened its reach and prognostic potential. Today, spirometry is recognized as essential to respiratory disease diagnosis, management and research. However, controversy exists in some of its applications, uptake in primary care remains sub-optimal and there are concerns related to the way in which race is factored into interpretation. Moving forward, these failings must be addressed, and innovations like Internet-enabled portable spirometers may present novel opportunities. We must also consider the physiologic and practical limitations inherent to spirometry and further investigate complementary technologies such as respiratory oscillometry and other emerging technologies that assess lung function. Through an exploration of the storied history of spirometry, we can better contextualize its current landscape and appreciate the trends that have repeatedly arisen over time. This may help to improve our current use of spirometry and may allow us to anticipate the obstacles confronting emerging pulmonary function technologies.

VATS lobectomy morbidity and mortality is lower in patients with the same ppoDLCO: Analysis of the database of the Spanish Video-Assisted Thoracic Surgery Group

INTRODUCTION

Measuring predicted post-operative diffusion capacity of the lung for carbon monoxide (ppoDLCO) is essential to determine patient operability and to stratify the risk of patients who are candidates for major lung cancer surgery. Studies that established surgical risk variables were based on open surgery series. The aim of our study was to analyze morbidity and mortality as a function of ppoDLCO and to compare its behavior in open and video-assisted thoracic surgery (VATS).

METHODS

We compared 90-day mortality and morbidity in patients undergoing open surgery versus VATS as a function of decline in ppoDLCO. Propensity score matching (using age, ASA, arterial vascular disease, BMI, gender, stage, ppoDLCO, and ppoFEV₁) was applied to create comparable open surgery and VATS groups.

RESULTS

Of 2,530 patients with lung cancer and ppoDLCO values, a sample of 1,624 (812 per group) was obtained after score matching. The relative risk of mortality associated with thoracotomy in patients with ppoDLCO < 60 is 2.66 (p < 0.02) compared to VATS. The risk of thoracotomy in terms of overall and cardiac and respiratory morbidity is higher than that of VATS for almost all ppoDLCO values.

CONCLUSIONS

Major resection by VATS shows lower morbidity and mortality in patients with the same ppoDLCO. A steady rise in the risk of mortality begins to occur at higher ppoDLCO values in thoracotomy (∼60) than in VATS (∼45).

Impact of pulmonary function on pulmonary complications after robotic-assisted thoracoscopic lobectomy

OBJECTIVES

Percentage-predicted forced expiratory volume in 1 s (FEV1) and diffusing capacity for carbon monoxide (DLCO), and their predicted postoperative (ppo) values are established prognostic factors for postoperative pulmonary complications after thoracotomy. However, their predictive value for minimally invasive pulmonary resections remains controversial. This study assessed the incidence of pulmonary complications after robotic lobectomy for primary lung cancer and analysed the predictive significance of FEV1 and DLCO.

METHODS

This was a retrospective analysis of patients who underwent robotic lobectomy from 4 institutions. Descriptive and comparative analyses were performed for patients who experienced pulmonary complications versus patients who did not, in relation to FEV1 and DLCO values. To identify thresholds for increased complications, patients were categorized into groups of 10% incremental increases in FEV1 and DLCO, and their ppo values.

RESULTS

From November 2002 to April 2018, 1088 patients underwent robotic lobectomy. Overall, 169 postoperative pulmonary complications occurred in 141 patients. Male gender and Eastern Cooperative Oncology Group grade ≥1 were associated with increased pulmonary complications on univariable analysis. Patients who experienced pulmonary complications had increased mortality (2.1% vs 0.2%, P = 0.017) and longer hospitalizations (9 vs 4 days, P < 0.001). Pulmonary complications were associated when FEV1 ≤60% and DLCO ≤50%, and when ppo FEV1 or DLCO was ≤50%; ppo FEV1 ≤50% (P < 0.001) and ppo DLCO ≤50% (P = 0.031) remained statistically significant on multivariable analysis.

CONCLUSIONS

Both FEV1 and DLCO were shown to be significant predictors of pulmonary complications. Furthermore, thresholds of percentage-predicted and ppo FEV1 and DLCO values were identified, below which pulmonary complications occurred significantly more frequently, suggesting their predictive values are particularly useful in patients with poorer pulmonary function.

Video-assisted thoracoscopic surgery for primary lung cancer resections in patients with moderate to severe chronic obstructive pulmonary diseases

Background

Lung cancer patients with chronic obstructive pulmonary disease (COPD) are considered a high-risk population to receive radical surgical treatment due to the high incidence of cardiopulmonary complications. The aim of this study was to evaluate the clinical factors associated with postoperative complications in primary lung cancer patients with moderate to extremely severe grades of COPD.

Methods

From December 2015 to June 2020, 138 patients with moderate to extremely severe COPD who underwent video-assisted thoracoscopic surgery (VATS) lung cancer resection (lobectomy or sublobar resection) were retrospectively reviewed. Patients' postoperative complications were collected from clinical records. Clinical factors (such as COPD severity or surgical approaches, etc.) were evaluated to investigate the association with postoperative complications.

Results

Of the 138 patients included in the study, the mean age was 67 (63-74) years, the mean preoperative forced expiratory volume in one second (FEV1) was 1.33±0.39 L, the mean FEV1% was 51.23% (41.43-60.00%). 33% patients (46/138) had postoperative complications, and no mortality occurred. Univariate analysis revealed that incidence of overall complications (OCs) and respiratory complications (RCs) was markedly higher in extremely severe COPD patients compared to moderate (OCs, P=0.033; RCs, P=0.050) and severe (OCs, P=0.015; RCs, P=0.008) COPD patients, respectively. Multivariate analysis showed that COPD grade was an independent risk factor of RCs (P=0.024). Furthermore, the grades of COPD (moderate, P=0.029; severe, P=0.028; extremely severe, P=0.019) and the surgical procedure (lobectomy or sublobar resection, P=0.043) were independent risk factors for atelectasis, which was the most common postoperative complication.

Conclusions

The aggravation of COPD was accompanied by an increase in the incidence of respiratory system complications postoperatively, especially atelectasis. For patients with moderate to extremely severe grades of COPD, careful perioperative evaluation should be performed to identify the indicators that influence the surgical choice between lobectomy and sublobar resection.

Cluster analysis of emphysema for predicting pulmonary complications after thoracoscopic lobectomy

 

OBJECTIVES

Despite significant advances in surgical techniques, including thoracoscopic approaches and perioperative care, the morbidity rate remains high after lung resection. This study focused on a low attenuation cluster analysis, which represented the size distribution of pulmonary emphysema and assessed its utility for predicting postoperative pulmonary complications after thoracoscopic lobectomy.

METHODS

From April 2013 to September 2018, lung cancer patients who received spirometry and computed tomography (CT) before surgery and underwent thoracoscopic lobectomy were included. The cumulative size distribution of the low attenuation area (LAA, defined as ≤-950 Hounsfield unit on CT) clusters followed a power-law characterized by an exponent D-value, a measure of the complexity of the alveolar structure. D-value and LAA% (LAA/total lung volume) were calculated using preoperative 3-dimensional CT software. The relationship between pulmonary complications and patient characteristics, including D-value and LAA%, was investigated.

RESULTS

Among 471 patients, there were 61 respiratory complication cases (12.9%). Receiver operation characteristic curve analysis revealed that the best predictive cut-off value of D-value and LAA% for pulmonary complications was 2.27 and 16.5, respectively, with an area under the curve of 0.72 and 0.58, respectively. D-value was significantly correlated with % forced expiratory volume in 1 s. Per univariate analysis, gender, smoking history, forced expiratory volume in 1 s/forced vital capacity, LAA% and D-value were risk factors for predicting postoperative pulmonary complications. In the multivariate analysis, D-value remained a significant predictive factor.

CONCLUSION

Preoperative assessment of emphysema cluster analysis may represent the vulnerability of the operated lung and could be the novel predictor for pulmonary complications after thoracoscopic lobectomy.

VATS Lobectomy Morbidity and Mortality is Lower in Patients with the Same ppoDLCO: Analysis of the Database of the Spanish Video-Assisted Thoracic Surgery Group

INTRODUCTION

Measuring predicted post-operative diffusion capacity of the lung for carbon monoxide (ppoDLCO) is essential to determine patient operability and to stratify the risk of patients who are candidates for major lung cancer surgery. Studies that established surgical risk variables were based on open surgery series. The aim of our study was to analyze morbidity and mortality as a function of ppoDLCO and to compare its behavior in open and video-assisted thoracic surgery (VATS).

METHODS

We compared 90-day mortality and morbidity in patients undergoing open surgery versus VATS as a function of decline in ppoDLCO. Propensity score matching (using age, ASA, arterial vascular disease, BMI, sexo, stage, ppoDLCO, and ppoFEV1) was applied to create comparable open surgery and VATS groups.

RESULTS

Of 2,530 patients with lung cancer and ppoDLCO values, a sample of 1,624 (812 per group) was obtained after score matching. The relative risk of mortality associated with thoracotomy in patients with ppoDLCO<60 is 2.66 (P<.02) compared to VATS. The risk of thoracotomy in terms of overall and cardiac and respiratory morbidity is higher than that of VATS for almost all ppoDLCO values.

CONCLUSIONS

Major resection by VATS shows lower morbidity and mortality in patients with the same ppoDLCO. A steady rise in the risk of mortality begins to occur at higher ppoDLCO values in thoracotomy (∼60) than in VATS (∼45).

Post-operative outcomes and quality of life assessment after thoracoscopic lobectomy for Non-small-cell lung cancer in octogenarians: Analysis from a national database

BACKGROUND

Thoracoscopic lobectomy (VATS-L) for non-small-cell lung cancer (NSCLC) is a well-established option for early stage NSCLC, but the evidences are limited for octogenarians.

OBJECTIVE

The objectives of this multi-institutional study were to evaluate the post-operative outcomes of VATS-L in octogenarians and to estimate the post-operative quality of life (QoL) using a validated questionnaire (EuroQoL5D).

METHODS

Data from patients underwent VATS-L between 2014 and 2019 were analysed and divided into two groups: Group A (younger patients) and Group B (octogenarians). To define predictors for complications, univariate and multivariable logistic regression analysis were performed.

RESULTS

7023 patients underwent VATS-L and 329 (4.6%) were octogenarians. 30-day and 90-day post-operative mortality were similar (0.95% vs 0.91%, p = 0.84 and 1.3% vs 1.2%, p = 0.58), whereas the percentage of patients who suffered from any complication (25.5% vs 31.9%, p = 0.012) and the complication rate (31.6% vs 45.2%, p=<0.01) were higher for octogenarians. At discharge, the values of EuroQoL5D were worse in group B, but after one month these levels became similar. Age >80 years had a significant influence on morbidity on both univariate and multivariable analyses (p = 0.025).

CONCLUSIONS

VATS-L for NSCLC can be performed in selected octogenarians without increased risk of post-operative death, acceptable not-life-threatening complications and a moderate impact on QoL.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

INTRODUCTION

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.

METHODS

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.

RESULTS

Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).

CONCLUSIONS

These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

"Fit for Surgery? What's New in Preoperative Assessment of the High-Risk Patient Undergoing Pulmonary Resection"

Advances in perioperative assessment and diagnostics, together with developments in anesthetic and surgical techniques, have considerably expanded the pool of patients who may be suitable for pulmonary resection. Thoracic surgical patients frequently are perceived to be at high perioperative risk due to advanced age, level of comorbidity, and the risks associated with pulmonary resection, which predispose them to a significantly increased risk of perioperative complications, increased healthcare resource use, and costs. The definition of what is considered "fit for surgery" in thoracic surgery continually is being challenged. However, no internationally standardized definition of prohibitive risk exists. Perioperative assessment traditionally concentrates on the "three-legged stool" of pulmonary mechanical function, parenchymal function, and cardiopulmonary reserve. However, no single criterion should exclude a patient from surgery, and there are other perioperative factors in addition to the tripartite assessment that need to be considered in order to more accurately assess functional capacity and predict individual perioperative risk. In this review, the authors aim to address some of the more erudite concepts that are important in preoperative risk assessment of the patient at potentially prohibitive risk undergoing pulmonary resection for malignancy.

Pulmonary lobectomy for cancer: Systematic review and network meta-analysis comparing open, video-assisted thoracic surgery, and robotic approach

BACKGROUND

Although minimally invasive lobectomy has gained worldwide interest, there has been debate on perioperative and oncological outcomes. The purpose of this study was to compare outcomes among open lobectomy, video-assisted thoracic surgery lobectomy, and robotic lobectomy.

METHODS

PubMed, EMBASE, and Web of Science databases were consulted. A fully Bayesian network meta-analysis was performed.

RESULTS

Thirty-four studies (183,426 patients) were included; 88,865 (48.4%) underwent open lobectomy, 79,171 (43.2%) video-assisted thoracic surgery lobectomy, and 15,390 (8.4%) robotic lobectomy. Compared with open lobectomy, video-assisted thoracic surgery, lobectomy and robotic lobectomy had significantly reduced 30-day mortality (risk ratio = 0.53; 95% credible intervals, 0.40-0.66 and risk ratio = 0.51; 95% credible intervals, 0.36-0.71), pulmonary complications (risk ratio = 0.70; 95% credible intervals, 0.51-0.92 and risk ratio = 0.69; 95% credible intervals, 0.51-0.88), and overall complications (risk ratio = 0.77; 95% credible intervals, 0.68-0.85 and risk ratio = 0.79; 95% credible intervals, 0.67-0.91). Compared with video-assisted thoracic surgery lobectomy, open lobectomy, and robotic lobectomy had a significantly higher total number of harvested lymph nodes (mean difference = 1.46; 95% credible intervals, 0.30, 2.64 and mean difference = 2.18; 95% credible intervals, 0.52-3.92) and lymph nodes stations (mean difference = 0.37; 95% credible intervals, 0.08-0.65 and mean difference = 0.93; 95% credible intervals, 0.47-1.40). Positive resection margin and 5-year overall survival were similar across treatments. Intraoperative blood loss, postoperative transfusion, hospital length of stay, and 30-day readmission were significantly reduced for minimally invasive approaches.

CONCLUSION

Compared with open lobectomy, video-assisted thoracic surgery lobectomy, and robotic lobectomy seem safer with reduced 30-day mortality, pulmonary, and overall complications with equivalent oncologic outcomes and 5-year overall survival. Minimally invasive techniques may improve outcomes and surgeons should be encouraged, when feasible, to adopt video-assisted thoracic surgery lobectomy, or robotic lobectomy in the treatment of lung cancer.

Evaluation of Risk for Thoracic Surgery

Modern surgical practice places increased emphasis on treatment outcomes. There has been a paradigm shift from paternalistic ways of practicing medicine to patients having a major involvement in decision making and treatment planning. The combination of these two factors undoubtedly leaves the surgeon open to greater scrutiny in respect of results and outcomes. In dealing with this it is important that the surgeon, wider multidisciplinary team, and patient appreciate the idea of surgical risk. This article reviews the latest evidence relating to risk assessment in thoracic surgery and suggests how this should be incorporated into clinical practice.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk factors for the development of complications after surgical treatment for bronchopulmonary carcinoma

INTRODUCTION

The most suitable treatment in most early-stage lung cancer patients is surgical resection. Despite previously assessing each patient's status being relevant to detect possible complications inherent to surgery, no consensus has been reached on which factors are "high risk" in such patients. Our study aimed to analyse the morbidity and the mortality incidence associated with this surgery in our setting with a multicentre study and to detect risk parameters.

METHODS

A prospective analysis study with 3,307 patients operated for bronchopulmonary carcinoma in 24 hospitals. Study variables were age, TNM, gender, stage, smoking habit, surgery approach, surgical resection, ECOG, neoadjuvant therapy, comorbidity, spirometric values, and intraoperative and postoperative morbidity and mortality. A multivariate logistic regression analysis of the morbidity and mortality predictor factors was done.

RESULTS

We recorded 34.2% postoperative morbidity and 2.1% postoperative mortality. Gender, myocardial infarction, angina, ECOG ≥1, COPD, DLCO <60%, clinical pathological status, surgical resection and surgery approach were shown as morbidity and mortality predictor factors in lung cancer surgery in our series.

CONCLUSIONS

The main variables to consider when assessing the lung cancer patients to undergo surgery are gender, myocardial infarction, angina, ECOG, COPD, DLCO, clinical pathological status, surgical resection and surgery approach.

Comparison of postoperative complications between segmentectomy and lobectomy by video-assisted thoracic surgery: a multicenter study

BACKGROUND

Compared to lobectomy by video-assisted thoracic surgery (VATS), segmentectomy by VATS has a potential higher risk of postoperative atelectasis and air leakage. We compared postoperative complications between these two procedures, and analyzed their risk factors.

METHODS

We reviewed the records of all patients who underwent anatomical pulmonary resections by VATS from January 2014 to March 2018 in two Swiss university hospitals. All complications were reported. A logistic regression model was used to compare the risks of complications for the two interventions. Adjustment for patient characteristics was performed using a propensity score, and by including risk factors separately.

RESULTS

Among 690 patients reviewed, the major indication for lung resection was primary lung cancer (86.4%) followed by metastasis resection (5.8%), benign lesion (3.9%), infection (3.2%) and emphysema (0.7%). Postoperatively, there were 80 instances (33.3%) of complications in 240 segmentectomies, and 171 instances (38.0%) of complications in 450 lobectomies (P = 0.73). After adjustment for the patient's propensity to be treated by segmentectomy rather than lobectomy, the risks of a complication remained comparable for the two techniques (odds ratio for segmentectomy 0.91 (0.61-1.30), p = 0.59). Length of hospital stay and drainage duration were shorter after segmentectomy. On multivariate analysis, an American Society of Anesthesiologists score above 2 and a forced expiratory volume in one second below 80% of predicted value were significantly associated with the occurrence of complications.

CONCLUSIONS

The rate of complications and their grade were similar between segmentectomy and lobectomy by VATS.

[Preconditioning of the lungs and circulation before visceral and thoracic surgical interventions]

BACKGROUND

Estimation of the perioperative risk plays a decisive role in the surgical indications, particularly in view of the demographic change. For this reason, prehabilitation concepts for reducing perioperative risk nowadays play an increasingly important role.

OBJECTIVE

Presentation of the current recommendations for preoperative diagnostics in thoracic surgical interventions as well as existing prehabilitation concepts and their practical applicability.

MATERIAL AND METHODS

A selective review of the literature was carried out by searching the electronic databases PubMed, Cochrane Library and ISRCTN, including the guidelines of the American College of Chest Physicians (ACCP) and the European Society of Thoracic Surgery (ESTS).

RESULTS

Preconditioning includes the conservative treatment of underlying diseases, smoking cessation and prehabilitation. Prehabilitation is an increasingly pressing concept in routine clinical practice, even though the evidence is limited due to the very heterogeneous study situation. Overall, however, there is a tendency for positive effects on the quality of life and postoperative complications as well as convalescence.

CONCLUSION

In addition to preoperative diagnostics to assess the perioperative risk, effective preconditioning of patients is also necessary. For this an interdisciplinary approach including anesthesia, pneumology, psychotherapy and physiotherapy is necessary. In addition to the conservative medicinal optimization, prehabilitation concepts are gaining in importance and will certainly become established in routine clinical practice. From the surgical perspective, minimally invasive approaches and parenchyma-sparing resections also serve to reduce risks.

Propensity-score adjusted comparison of pathologic nodal upstaging by robotic, video-assisted thoracoscopic, and open lobectomy for non-small cell lung cancer

OBJECTIVE

To assess the effectiveness of intraoperative lymph node (LN) staging by comparing upstaging between robotic-assisted surgery, video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach for lobectomy for non-small cell lung cancer.

METHODS

We retrospectively analyzed 1053 patients with clinical stage N0/N1 non-small cell lung cancer who underwent lobectomy at 2 centers between 2011 and 2018. Propensity score adjustment by inverse probability of treatment weighting was used to balance baseline characteristics. The primary end point was LN upstaging.

RESULTS

A total of 911 patients (254 robotic, 296 VATS, and 261 open) were included in the inverse probability of treatment weighting adjusted analysis. The overall rate of LN upstaging was highest with open lobectomy (21.8%), followed by robotic (16.2%), and VATS (12.3%) (P = .03). Mediastinal N2 upstaging was observed in similar frequencies (open 6.9% vs robotic 6.3% vs VATS 4.4%; P = .6). No differences were seen for total LN counts, but were observed in the number of stations sampled (mean, open 4.0 vs robotic 3.8 vs VATS 3.6; P = .001). On multivariate analysis, LN upstaging was lower for VATS compared with open (odds ratio, 0.50; 95% confidence interval, 0.29-0.85), but not different between robotic and open (odds ratio, 0.72; 95% confidence interval, 0.44-1.18). No significant differences were seen in mediastinal N2 upstaging between groups.

CONCLUSIONS

Pathologic LN upstaging following lobectomy for clinically N0/N1 NSCLC remains high. Compared with a traditional thoracotomy approach, robotic lobectomy was associated with similar and VATS with lower overall nodal upstaging. A thorough evaluation of hilar and mediastinal LNs remains critical to ensure accurate staging by detection of occult LN metastases.

Desaturation during Six-Minute Walk Testing Predicts Major Morbidity Following Anatomic Lung Resection among Patients with COPD

Background: Pulmonary function testing (PFT) is commonly used to risk-stratify patients prior to lung resection. Guidelines recommend that patients with reduced lung function, due to chronic lung conditions such as Chronic Obstructive Pulmonary Disease (COPD), should receive additional physiologic testing to determine fitness for resection. We reviewed our experience with six-minute walk testing (SMWT) to determine the association of test results and post-operative complications. Methods: Consecutive adult patients undergoing segmentectomy, lobectomy, bilobectomy or pneumonectomy between 1 January, 2007 and 1 January, 2017 were identified in a prospectively maintained database. Patients with poor lung function, as defined by percent predicted forced expiratory volume in 1 s (FEV1) or diffusion capacity of carbon monoxide (DLCO) ≤60%, had results of SMWT extracted from their chart. Association of test result to post-operative events was performed. Results: 581 patients had anatomic lung resections with predicted post-operative FEV1 or DLCO values ≤60%, consistent with a diagnosis of COPD. Among them, 50 (8.6%) had preoperative SMWT performed. Patients who received SMWT were more likely to have a FEV1 or DLCO less than 40 percent predicted (24/50 (48.0%) vs 166/531 (31.3%), p = 0.016). Post-operatively, patients who had SMWT performed had higher rates of pneumonia, but similar rates of major morbidity. The post-exercise oxygen saturation and the amount of desaturation correlated with the occurrence of major morbidity. In multivariable regression, oxygen desaturation was an independent risk factor for the occurrence of major morbidity, and desaturation was an excellent predictor of major morbidity by receiver operating characteristic curves analsysis. Conclusions: Among patients with elevated risk, oxygen desaturation during SMWT was independently associated with the occurence of major morbidity in multivariable analysis, while pulmonary function testing was not. SMWT is an important tool for risk-stratification, and may be underutilized.

Risk factors and short-term outcomes of postoperative pulmonary complications after VATS lobectomy

Background

Postoperative pulmonary complications (PPCs) are associated with poor outcomes following thoracotomy and lung resection. Video-assisted thoracoscopic surgery (VATS) for lobectomy is now frequently utilised as an alternative to thoracotomy, however patients remain at risk for development of PPC. There is little known of the short-term outcome associated with PPC following VATS lobectomy and if there are any potential risk factors that could be modified to prevent PPC development; our study aimed to investigate this.

Methods

A prospective observational study of consecutive patients undergoing VATS lobectomy for lung cancer over a 4-year period in a regional centre was performed (2012–2016). Exclusion criteria included re-do VATS or surgery for pulmonary infection. All patients received physiotherapy as necessary from postoperative day 1 (POD1) and PPC was determined using the Melbourne Group Scale. Outcomes included hospital LOS, intensive therapy unit (ITU) admission and hospital mortality.

Results

Of the 285 patients included in the study, 137 were male (48.1%), the median (IQR) age was 69 (13) years and the mean (±SD) FEV₁% predicted was 87% (±19). Patients that developed a PPC (n = 21; 7.4%) had a significantly longer hospital LOS (4 vs. 3 days), higher frequency of ITU admission (23.8% vs. 0.5%) and higher hospital mortality (14.3% vs. 0%) (p < 0.001). PPC patients also required more physiotherapy contacts/time, emergency call-outs and specific pulmonary therapy (p < 0.05). Current smoking and COPD diagnosis were significantly associated with development of PPC on univariate analysis (p < 0.05), however only current smoking was a significant independent risk factor on multivariate analysis (p = 0.015).

Conclusions

Patients undergoing VATS lobectomy remain at risk of developing a PPC, which is associated with an increase in physiotherapy requirements and a worse short-term morbidity and mortality. Current smoking is the only independent risk factor for PPC after VATS lobectomy, thus vigorous addressing of preoperative smoking cessation is urgently needed.

Thoracic Skeletal Muscle Is Associated With Adverse Outcomes After Lobectomy for Lung Cancer

BACKGROUND

Assessment of risk associated with lung cancer resection is primarily based on evaluation of cardiopulmonary function and remains imprecise. We investigated the relationship between thoracic muscle and early outcomes after lobectomy.

METHODS

Cross-sectional area of skeletal muscle was measured at the level of the fifth thoracic vertebra on computed tomography in 135 consecutive patients before lobectomy for lung cancer. Patients were stratified into low and high muscle groups using the sex-specific muscle median. Primary outcome was a composite of any postoperative complication as per The Society of Thoracic Surgeons General Thoracic Surgical Database. Secondary outcomes included postoperative respiratory complications, postoperative intensive care unit admission, hospital length of stay, and hospital readmission within 30 days of hospital discharge. The χ² test, adjusted multivariable regression analysis, and likelihood ratio test were performed.

RESULTS

Patients with low muscle were significantly more likely to have any postoperative complication and respiratory postoperative complications. Although postoperative intensive care unit admission was similar for low muscle and high muscle groups, low muscle patients had longer hospital length of stay and a higher rate of hospital readmission. Adjusted multivariable regression revealed the independent association of thoracic muscle with all outcomes. The likelihood ratio test suggested that thoracic muscle adds predictive capability to information captured by preoperative pulmonary function testing.

CONCLUSIONS

Low thoracic muscle is independently associated with increased postoperative complications and health care utilization among patients undergoing lobectomy for lung cancer. Evaluation of thoracic muscle may enhance risk prediction models.

Predictive value of pulmonary function measures for short-term outcomes following lung resection: analysis of a single high-volume institution

Despite the importance of preoperative risk-stratification, there is a lack of consensus on how to identify high-risk patients for pulmonary resection. Enrollment criteria for national trials propose one definition based on preoperative pulmonary function tests. We sought to examine the value of preoperative forced expiratory volume in 1 second (FEV1) and diffusion capacity for carbon monoxide (DLCO) to predict short-term outcomes following pulmonary resection. Using our institutional Society of Thoracic Surgeons (STS) database we identified 419 consecutive lung cancer patients who presented to our institution for pulmonary resection between 2012 and 2016. We identified patients as "high risk" based on the national trial criteria of FEV1 or DLCO ≤50%. Our primary outcome was any postoperative complication within 30 days of surgery. Secondary outcomes included cardiac and pulmonary complications, 30-day readmission, and discharge disposition. DLCO ≤50% was associated with any postoperative complication (P=0.03), but not predictive of cardiac events, pulmonary complications, or 30-day readmission. There were no significant differences in any of these short-term outcomes for patients with FEV1 ≤50%. On multivariable analysis, neither FEV1 nor DLCO ≤50% were significantly associated with occurrence of postoperative complication (OR =1.67, 95% CI: 0.60-4.63; OR =1.66, 95% CI: 0.96-2.86, respectively). Notably, DLCO ≤50%-but not FEV1-was associated with discharge to a skilled facility on univariate (P=0.01) and multivariable analysis (OR =2.54; 95% CI: 1.08-5.99; P=0.03). This association between DLCO and discharge to a skilled facility persisted when DLCO was used as a continuous variable. For all-comers presenting to our institution for lung cancer resection, classification based on FEV1 or DLCO ≤50% may not reliably identify those at highest risk for short-term postoperative complications. While our findings suggest caution when using pulmonary parameters in isolation, the potential value of DLCO as a proxy for underlying comorbidity warrants further investigation.

Physiopathology aspects of anatomical video-assisted thoracic surgery resections: current status and prospects of development

Pulmonary lobectomy remains the gold standard therapy for early-stage lung cancer. With the spread of video-assisted thoracic surgery (VATS), surgeons began using this approach also to perform lobectomies, becoming progressively widespread worldwide. However some early-stage lung cancer patients are of questionable eligibility for open lobectomy being considered at high-risk to develop postoperative complications due to compromised pulmonary function or cardiopulmonary reserve. Herein we evaluate pathophysiology of VATS, focusing on: the correlation between the traditional predictors of outcome and overall complications, the current status of different VATS approaches and the role of VATS segmentectomy in high-risk patients, unable to tolerate lobectomy for their compromised cardiopulmonary reserve.

Intraoperative costs of video-assisted thoracoscopic lobectomy can be dramatically reduced without compromising outcomes

OBJECTIVE

To determine whether surgeon selection of instrumentation and other supplies during video-assisted thoracoscopic lobectomy (VATSL) can safely reduce intraoperative costs.

METHODS

In this retrospective, cost-focused review of all video-assisted thoracoscopic surgery anatomic lung resections performed by 2 surgeons at a single institution between 2010 and 2014, we compared VATSL hospital costs and perioperative outcomes between the surgeons, as well as costs of VATSL compared with thoracotomy lobectomy (THORL).

RESULTS

A total of 100 VATSLs were performed by surgeon A, and 70 were performed by surgeon B. The preoperative risk factors did not differ significantly between the 2 groups of surgeries. Mean VATSL total hospital costs per case were 24% percent greater for surgeon A compared with surgeon B (P = .0026). Intraoperative supply costs accounted for most of this cost difference and were 85% greater for surgeon A compared with surgeon B (P < .0001). The use of nonstapler supplies, including energy devices, sealants, and disposables, drove intraoperative costs, accounting for 55% of the difference in intraoperative supply costs between the surgeons. Operative time was 25% longer for surgeon A compared with surgeon B (P < .0001), but this accounted for only 11% of the difference in total cost. Surgeon A's overall VATSL costs per case were similar to those of THORLs (n = 100) performed over the same time period, whereas surgeon B's VATSL costs per case were 24% less than those of THORLs. On adjusted analysis, there was no difference in VATSL perioperative outcomes between the 2 surgeons.

CONCLUSIONS

The costs of VATSL differ substantially among surgeons and are heavily influenced by the use of disposable equipment/devices. Surgeons can substantially reduce the costs of VATSL to far lower than those of THORL without compromising surgical outcomes through prudent use of costly instruments and technologies.

[Can Preoperative Peak Expiratory Flow Predict Postoperative Pulmonary Complications in Lung Cancer Patients Undergoing Lobectomy?]

BACKGROUND

Postoperative pulmonary complications (PPCs), especially postoperative pneumonia (POP), directly affect the rapid recovery of lung cancer patients after surgery. Peak expiratory flow (PEF) can reflect airway patency and cough efficiency. Moreover, cough impairment may lead to accumulation of pulmonary secretions which can increase the risk of PPCs. The aim of this study is to investigate the effect of preoperative PEF on PPCs in patients with lung cancer.

METHODS

Retrospective research was conducted on 433 lung cancer patients who underwent lobectomy at the West China Hospital of Sichuan University from January 2014 to December 2015. The associations between preoperative PEF and PPCs were analyzed based on patients' basic characteristics and clinical data in hospital.

RESULTS

Preoperative PEF value in PPCs group (280.93±88.99) L/min was significantly lower than that in non-PPCs group (358.38±93.69) L/min (P<0.001). According to the binary logistics regression analysis, PEF and operative time were independent risk factors for PPCs. Further, ROC curve showed that PEF=320 L/min was the cut-off value for predicting the occurrence of PPCs (AUC=0.706, 95%CI: 0.661-0.749). The incidence of PPCs in PEF≤320 L/min group (26.6%) was significantly higher than that in PEF>320 L/min group (9.4%)(P<0.001).

CONCLUSIONS

Preoperative PEF and PPCs are correlated, and PEF may be used as a predictor of PPCs.