Nutritional status and postoperative outcome after pneumonectomy for lung cancer

Short-term effects of preoperative nutritional intervention in lung surgery for malignant tumors: a single-center prospective study

OBJECTIVES

Preoperative malnutrition is a risk factor for postoperative morbidity and mortality in patients with lung cancer. Assessing the preoperative nutritional status should be considered essential for patients scheduled to undergo lung surgery. This prospective study aimed to investigate whether preoperative nutritional intervention improves the nutritional conditions and short-term postoperative outcomes.

METHODS

The primary endpoints included safety, feasibility and short-term therapeutic efficacy of preoperative nutritional intervention. Patients with clinical stage I-III non-small cell lung cancer (histologically proven or suspected) were screened. Patient enrollment was conducted between January 2021 and December 2022. A total of 15 patients were included in the analysis. Patients with a preoperative prognostic nutritional index of < 45 were considered eligible. All participants received preoperative nutritional intervention. The trajectories of prognostic nutritional index and the incidence of postoperative complication rates in the intervention group were investigated.

RESULTS

No adverse events were observed during the nutritional intervention. The pre-intervention and post-intervention prognostic nutritional indices were 42.2 (39.8-44.5), and 43.1 (41.4-45.9), respectively (p = 0.04). The postoperative complication rate was 26.7% (n = 15).

CONCLUSIONS

This is the first prospective study to report the preoperative trajectories of prognostic nutritional index in patients undergoing lung cancer surgery. Our results suggest the safety and feasibility of preoperative nutritional intervention. Further research, such as randomized clinical trials, is warranted to investigate clinical efficacy and optimal nutritional interventions for lung surgery for malignant tumors.

Effect of exercise on postoperative recovery of patients with non-small cell lung cancer: a systematic review and meta-analysis

Patients with non-small cell lung cancer (NSCLC) in the postoperative recovery period often experience reduced exercise capacity and impaired lung function, which affects their overall quality of life. This paper investigated the effect of exercise interventions on exercise capacity, lung function, quality of life, and symptoms in these patients.

METHODS

We performed a literature search across Cochrane, Embase, PubMed, Web of Science, and EBSCO databases were comprehensively searched for randomized controlled trials (RCTs) from inception to September 2023, all English RCTs were eligible if they assessed the effects of exercise interventions on postoperative NSCLC patients.

RESULTS

Twelve articles met our inclusion criteria, evidencing that exercise interventions could significantly improve the functional capacity of NSCLC patients in postoperative recovery. Notably, Forced Expiratory Volume in 1 s (FEV1) was improved, indicating enhanced lung function. Furthermore, exercise improved the physical and mental health scores of SF-36, along with increased quadriceps strength and relieved dyspnea. However, fatigue levels were not significantly changed.

CONCLUSIONS

Exercise interventions of NSCLC patients in the postoperative recovery are associated with improved functional capacity, lung function, quality of life, and quadriceps strength, as well as alleviated symptoms of dyspnea. These findings underscore the potential benefits of incorporating exercise into postoperative care for NSCLC patients. Nonetheless, further large-scale RCTs are required to solidify the evidence base on the clinical outcomes of exercise following pneumonectomy.

Diagnostic test accuracy of preoperative nutritional screening tools in adults for malnutrition: a systematic review and network meta-analysis

BACKGROUND

Good nutritional screening tests can triage malnourished patients for further assessment and management by dietitians before surgery to reduce the risk of postoperative complications. The authors assessed the diagnostic test accuracy of common nutritional screening tools for preoperative malnutrition in adults undergoing surgery and determined which test had the highest accuracy.

METHODS

MEDLINE, EMBASE, CINAHL, and Web of Science were searched for relevant titles with no language restriction from inception till 1 January 2023. Studies reporting on the diagnostic test accuracy of preoperative malnutrition in adults using one or more of the following index nutritional screening tools were included: Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Mini Nutritional Assessment (MNA), short-form Mini Nutritional Assessment (MNA-SF), Nutritional Risk Index (NRI), Nutrition Risk Screening Tool 2002 (NRS-2002), and Preoperative Nutrition Screening (PONS). The reference standard was the Subjective Global Assessment (SGA) before surgery. Random-effects bivariate binomial model meta-analyses, meta-regressions, and a network meta-analysis were used to estimate the pooled and relative sensitivities and specificities.

RESULTS

Of the 16 included studies (5695 participants with an 11 957 index and 11 957 SGA tests), all were conducted after hospital admission before surgery. Eleven studies ( n =3896) were at high risk of bias using the Quality Assessment of Diagnostic Accuracy Studies tool due to a lack of blinded assessments. MUST had the highest overall test accuracy performance (sensitivity 86%, 95% CI: 75-93%; specificity 89%, 95% CI: 83-93%). Network meta-analysis showed NRI had similar relative sensitivity (0.93, 95% CI: 0.77-1.13) but lower relative specificity (0.75, 95% CI: 0.61-0.92) than MUST.

CONCLUSIONS

Of all easy-to-use tests applicable at the bedside, MUST had the highest test accuracy performance for screening preoperative malnutrition. However, its predictive accuracy is likely insufficient to justify the application of nutritional optimization interventions without additional assessments.

Multidisciplinary prehabilitation to improve frailty and functional capacity in high-risk elective surgical patients: a retrospective pilot study

BACKGROUND

Frailty is associated with worse outcomes and higher healthcare costs. The long waiting time for surgery is a potential 'teachable' moment. We examined the feasibility and safety of a pilot prehabilitation programme on high-risk frail patients undergoing major elective surgery.

METHODS

A single-centre, retrospective pilot study (Dec 2020-Nov 2021) on a one-stop prehabilitation programme (structured exercise training, nutritional counselling/therapy, and psychological support) in collaboration with geriatricians and allied health professionals. At least 4 weeks before surgery, patients at high risk of frailty or malnutrition, or undergoing major hepatectomy, esophagectomy, pancreaticoduodenectomy, or radical cystectomy, were referred for prehabilitation (2-3 sessions/week). The primary outcomes were the feasibility and safety of prehabilitation. The secondary outcomes were changes in functional, emotional, and nutritional status and days alive and at home within 30 days after surgery (DAH30) associated with prehabilitation.

RESULTS

Over a 12-month period, 72 out of 111 patients (64.9%) from the Perioperative Medicine Clinic were eligible for prehabilitation, of which 54 (75%) were recruited. The mean (standard deviation) age was 71.9 (6.9) years. The adherence rate to 3 weeks of prehabilitation was high in 52 (96.3%) participants. Prehabilitation improved exercise capacity (P = 0.08), enhanced some functional mobility measures (P = 0.02), and increased nutritional energy (P = 0.04) and protein intakes (P < 0.01). However, prehabilitation-related changes in muscle strength, cognitive function, and emotional resilience were minimal. The median (interquatile range) DAH30 was 19 (14-23) days. No adverse events were reported.

CONCLUSIONS

This outpatient-based, one-stop multidisciplinary prehabilitation programme was feasible, safe, and improved several measures of patient's physiological reserve and functional capacity.

CLINICAL TRIAL REGISTRATION

NCT05668221.

Moving beyond frailty: Obesity paradox persists in lung resection

BACKGROUND

The apparent protective effect of high body mass index on postoperative outcomes, termed the "obesity paradox," has been postulated to reflect the relative frailty of patients without obesity. We wanted to examine the independent association between body mass index and outcomes after anatomic lung resection.

METHODS

All adults undergoing elective lung resection for cancer were identified in the 2012-2020 National Surgical Quality Improvement Program. The modified Frailty Index quantified degree of patient frailty. Malnutrition was defined as a preoperative serum albumin <3.5g/dL. Multivariable regressions were used to examine the independent association of body mass index and major adverse events, analyzed as a composite of 30-day mortality, postoperative complications, and unplanned reoperation.

RESULTS

Of an estimated 20,099 patients meeting study criteria, 6,424 (32.0%) had obesity. Relative to others, patients with obesity were significantly younger (49.3 vs 50.3 years), more commonly White (78.1 vs 74.9%), and more frequently frail (modified Frailty Index >1: 35.7 vs 22.5%, all P < .001). There was no significant difference in malnutrition rates (7.6 vs 8.4%, P = .05) or extent of resection between groups. After adjustment, obesity was associated with decreased odds of major adverse events (adjusted odds ratio 0.86, 95% confidence interval 0.78-0.94).

CONCLUSION

The present findings uphold the canonical obesity paradox in anatomic lung resection, despite adjustment for frailty and malnutrition. Further studies are warranted to characterize the nature of this association; however, our results may inform efforts to optimize risk stratification and patient selection for surgical intervention.

Diet as a Factor Supporting Lung Cancer Treatment-A Systematic Review

The purpose of this study was to summarize the evidence from epidemiological studies concerning associations between diet and the effectiveness of treatment for lung cancer. For this review, a literature search has been conducted in the EMBASE and PubMed databases, including papers published between 1977 and June 2022. The term "lung cancer" was used in conjunction with "diet". Footnotes from the selected papers were also analyzed. The present study is in line with the recommendations included in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The review included studies involving adults, including randomized controlled trials (RCTs) and cohort and observational studies. In total, 863 papers were found, with duplicates excluded. Ultimately, 20 papers were reviewed. The present systematic review indicates that vitamin A, ascorbic acid (vitamin C), vitamin E, selenium, and zinc-as antioxidants-can strengthen the body's antioxidant barrier. Furthermore, preoperative immunonutrition may not only improve perioperative nutritional status following induction chemoradiotherapy in lung cancer surgery patients but also reduce the severity of postoperative complications. Similarly, a protein supply may exert a beneficial effect on human health by increasing average body weight and muscle mass. Omega-3 fatty acid content in the diet and the consumption of their main source, fish, may have some regulatory effect on inflammation in patients with lung cancer treated with chemotherapy and radiotherapy. In addition, n-3 fatty acids inhibit tumor cell proliferation and may reduce the toxicity of chemotherapy. Increased energy and protein intake are strongly associated with improved quality of life, functional outcomes, hand grip strength, symptoms, and performance in patients with lung cancer. The use of a supportive diet should be the standard of care, alongside pharmaceutical therapy, in treatment for patients with lung cancer.

Protein-energy malnutrition and worse outcomes after major cancer surgery: A nationwide analysis

Background

Protein-energy malnutrition (PEM) has been recognized as a poor prognostic factor in many clinical issues. However, nationwide population studies concerning the impact of PEM on outcomes after major cancer surgery (MCS) are lacking. We aimed to evaluate the postoperative outcomes associated with PEM following MCS.

Methods

By using the Nationwide Inpatient Sample database, data of patients undergoing MCS including colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy, or prostatectomy were analyzed retrospectively from 2009 to 2015, resulting in a weighted estimate of 1,335,681 patients. The prevalence trend of PEM, as well as mortality and major complications after MCS were calculated. Multivariable regression analysis was applied to estimate the impact of PEM on postoperative outcomes after MCS.

Results

PEM showed an estimated annual percentage increase of 7.17% (95% confidence interval (CI): 4-10.44%) from 2009 to 2015, which contrasts with a 4.52% (95% CI: -6.58-2.41%) and 1.21% (95% CI: -1.85-0.56%) annual decrease in mortality and major complications in patients with PEM after MCS. PEM was associated with increased risk of mortality (odds ratio (OR)=2.26; 95% CI: 2.08-2.44; P < 0.0001), major complications (OR=2.46; 95% CI: 2.36-2.56; P < 0.0001), higher total cost ($35814 [$22292, $59579] vs. $16825 [$11393, $24164], P < 0.0001), and longer length of stay (14 [9-21] days vs. 4 [2-7] days, P < 0.0001), especially in patients underwent prostatectomy, hysterectomy and lung resection.

Conclusions

PEM was associated with increased worse outcomes after major cancer surgery. Early identification and timely medical treatment of PEM for patients with cancer are crucial for improving postoperative outcomes.

Exercise training modalities in patients with lung cancer: a protocol for systematic review and network meta-analysis

INTRODUCTION

Lung cancer is a common malignancy and a major cause of cancer-related deaths worldwide, ranking high in terms of morbidity and prevalence. Exercise is a well-established recovery aid for many chronic respiratory conditions and lung cancer. However, it is difficult to determine the superiority of different exercise training modalities using randomised controlled trials (RCTs) or pairwise meta-analyses. Our Bayesian network meta-analysis (NMA) aimed to compare the impact of different perioperative exercise training modalities on lung function, exercise capacity, adverse events, health-related quality of life and mortality in patients undergoing lung cancer surgery, including preoperative and postoperative patients.

METHODS AND ANALYSIS

We will perform a comprehensive literature search using PubMed, EMBASE, Cochrane Library and Web of Science, from inception to May 2022, to identify studies that potentially provide data regarding exercise training modalities for patients with lung cancer. We will assess the risk of bias according to the Cochrane risk-of-bias tool and certainty of evidence for the main outcomes using the Grading of Recommendations Assessment, Development and Evaluation framework. Pairwise meta-analyses will be conducted using a random effects model and Stata software, and the NMA will be analysed using R software.

ETHICS AND DISSEMINATION

Ethical approval and patient consent were not required because this study was a meta-analysis of published RCTs. The results of this study are submitted to a peer-reviewed journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42021278923.

Preoperative Omega-6/Omega-3 Fatty Acid Ratio Could Predict Postoperative Outcomes in Patients with Surgically Resected Non-Small-Cell Lung Cancer

Introduction: The aim of this study was to determine whether preoperative nutritional status and inflammatory status, specifically polyunsaturated acids and the omega 6/3 ratio, would affect postoperative outcomes and complications in patients with lung cancer undergoing lung resection. Methods: This prospective observational study included 68 patients with early-stage non-small-cell lung cancer who were candidates for radical surgery. A complete nutritional assessment was performed. The primary study variable was postoperative complications and mortality in the first 30 days. Descriptive, bivariate, and logistic regression analyses were carried out. Results: A total of 50 men (73.53%) and 18 women (26.47%) underwent surgery, with a median age of 64.2 (±9.74) years. The mean omega 6/3 ratio was 17.39 (±9.45). A complication occurred in 39.7% of the study sample (n = 27), the most common being persistent air leak in 23.53% (n = 16). After performing the bivariate analysis, the only variable that remained significant was the omega 6/3 ratio; we observed that it had a prognostic value for persistent air leak (p = 0.001) independent of age, sex, comorbidity, preoperative respiratory function, and approach or type of surgery. The remaining nutritional and inflammatory markers did not have a statistically significant association (p > 0.05) with postoperative complications. However, this significance was not maintained in the multivariate analysis by a small margin (p = 0.052; 95% CI: 0.77-1.41). Conclusions: Omega 6/3 ratio may be a prognostic factor for air leak, independent of the patient's clinical and pathological characteristics.

[Patient outcomes after lung resection. The impact of unplanned readmission]

Unplanned readmissions after lung cancer surgery impair normal postoperative recovery and are associated with increased postoperative mortality. The objective of this review was to compile a detailed and comprehensive dataset on unplanned readmissions after pulmonary resection so as to better understand the associated factors and how they may be attenuated. Based on the identified risk factors, prevention involves improved preoperative preparation of at-risk patients and preoperative discharge planning so as to help prevent unscheduled readmissions, which are predictive of a poorer prognosis.

Effect of Lowest Postoperative Pre-albumin on Outcomes after Robotic-Assisted Pulmonary Lobectomy

Objective:

Lower pre-albumin levels have been associated with increased rates of post-surgical complications, prolonged hospital length of stay (LOS), and death. This study aims to investigate the effect of postoperative pre-albumin levels on perioperative and long-term outcomes following robotic-assisted video thoracoscopic (RAVT) pulmonary lobectomy.

Methods:

We retrospectively reviewed 459 consecutive patients who underwent RAVT pulmonary lobectomy by one surgeon for known or suspected lung cancer. The lowest pre-albumin values during the postoperative hospital stay were recorded. Twenty-three patients with no pre-albumin levels available were excluded from analysis. Patients were grouped as having normal (≥ 15 mg/dL) versus low (< 15mg/dL) pre-albumin. Outcomes and demographics were compared between groups using Pearson χ², Student’s t, or Kruskal-Wallis tests. Univariate and multivariate generalized linear regression, logistic regression, or Cox proportional hazard ratio models were used to assess the association between outcomes and variables of interest. Kaplan-Meier analyses were performed to estimate and depict survival probabilities for each group.

Results:

Our study population comprised 436 patients. Lowest postoperative pre-albumin below 15 mg/dL was associated with more postoperative complications (44.2% vs 24.9%, p < 0.001), longer chest tube duration (6.9 vs 4.6 days, p = 0.001), and longer LOS (7.0 vs. 4.4 days, p < 0.001). In survival analysis, lowest perioperative pre-albumin levels were found to correlate with decreased 1 year (p = 0.012), 3-year (p = 0.001), and 5-year survival (p = 0.001).

Conclusion:

Lower pre-albumin levels postoperatively are associated with more postoperative complications, longer chest tube duration and LOS, and decreased overall survival following robotic-assisted pulmonary lobectomy.

Effects of multimodal prehabilitation on muscle size, myosteatosis, and dietary intake of surgical patients with lung cancer - a randomized feasibility study

Many patients with lung cancer undergo surgery, which can increase the risk for muscle loss, leading to worsened outcomes. A multimodal prehabilitation intervention integrating dietary and muscle assessment may help clinicians better understand changes in these outcomes. This pilot assessed feasibility of multimodal prehabilitation in early-stage surgical lung cancer patients and explored relationships between body composition, muscle characteristics and dietary intake, as well as muscle changes due to prehabilitation. Patients were randomized to one of two groups: multimodal prehabilitation including nutritional supplements (fish oil with vitamin D3 + whey protein with leucine), exercise and relaxation, or standard of care. Physical function, dietary intake and muscle were evaluated at 0 and 4 weeks pre-operatively. Of 87 patients assessed for eligibility, 34 (39%) were randomized and 3 (9%) were lost to follow-up. Median age was 69 years and baseline protein intake was 1.0 g/kg/d. Adherence to exercise (86%) and supplements was high (93%); 3 patients (16%) reported side effects. Supplements significantly increased protein, omega-3 fatty acid, leucine and vitamin D intake. There were no significant changes in muscle characteristics. Multimodal prehabilitation with dietary and muscle analyses proved to be feasible. An adequately powered randomized controlled trial is warranted. ClinicalTrials.gov registration no: NCT04610606. Novelty: • Multimodal prehabilitation incorporating dietary assessment and muscle analysis is feasible for early-stage surgical lung cancer patients. • An adequately powered randomized controlled trial is warranted to further explore functional and post-operative outcomes.

Malnourished lung cancer patients have poor baseline functional capacity but show greatest improvements with multimodal prehabilitation

OBJECTIVE

The objective is to characterize the presence of malnutrition, examine the association between malnutrition and baseline functional capacity (FC), and the extent to which patients benefit from preoperative multimodal prehabilitation in patients undergoing lung resection for cancer.

METHODS

Data from 162 participants enrolled in multimodal prehabilitation or control before lung cancer surgery were analyzed. Malnutrition was measured using the Patient-Generated Subjective Global Assessment (PG-SGA) according to triage levels: low-nutrition-risk (PG-SGA 0-3), moderate-nutrition-risk (4-8) and high-nutrition-risk (≥9). Baseline differences in FC, measured by the 6-minute walk test (6MWT), were compared. Factorial analysis of covariance (ANCOVA) was conducted to examine the effect of nutrition status and intervention on mean change in 6MWT preoperatively.

RESULTS

51.2% patients were considered low-nutrition-risk, 37.7% moderate-nutrition-risk, and 11.1% high-nutrition-risk. Low-nutrition-risk patients had significantly higher 6MWT at baseline (mean of 484 m [standard deviation (SD) = 88]) compared with moderate-nutrition-risk (432 m [SD = 107], P = .005) and high-nutrition-risk groups (416 m [SD = 90], P = .022). The adjusted mean change in 6MWT between prehabilitation vs control was 18.1 (95% confidence interval, 3.8 to 32.3) vs 5.6 m (-14.1 to 25.4) in low-nutrition-risk (P = .309), 28.5 (11 to 46) vs -4 m (-31.3 to 23.4) in moderate-nutrition-risk (P = .053), and 58.9 (16.7 to 101.2) vs -39.7 m (-80.2 to 0.826) in high-nutrition-risk group (P = .001).

CONCLUSIONS

Lung cancer patients at high-nutrition-risk awaiting surgery had significantly lower baseline FC compared with low-nutrition-risk patients but experienced significant improvements in preoperative FC upon receiving multimodal prehabilitation.

Effects of preoperative nutrition and multimodal prehabilitation on functional capacity and postoperative complications in surgical lung cancer patients: a systematic review

OBJECTIVE

To determine the effect of preoperative nutrition and multimodal prehabilitation on clinical and functional outcomes in surgical lung cancer patients.

METHODS

We searched MEDLINE, Cochrane Library and CENTRAL, EMBASE, Scopus, and clinical trial registries ( clinicaltrials.gov , International Clinical Trials Registry Platform and Google Scholar) to identify studies involving a preoperative nutrition-based intervention or multimodal prehabilitation (nutrition with exercise) of at least 7 days, in lung cancer patients awaiting surgery. Studies must have reported results on at least one of the following outcomes: functional capacity, pulmonary function, postoperative complications, and length of hospital stay. The quality of included studies was assessed using the Cochrane risk of bias assessment tool for randomized trials and the modified Newcastle-Ottawa scale for non-controlled trials.

RESULTS

Five studies were included (1 nutrition-only and 4 multimodal prehabilitation studies). Due to substantial heterogeneity in the interventions across studies, a meta-analysis was not conducted. Findings suggest that multimodal prehabilitation, compared with standard hospital care, is associated with improvements in both functional walking capacity and pulmonary function during the preoperative period; however it does not appear to have an effect on postoperative outcomes. Rather, the finding of significantly lower rates of postoperative complications in the intervention group was unique to the nutrition-only study.

CONCLUSION

Multimodal prehabilitation programs that combine nutrition and exercise may have beneficial effects on various physical function outcomes in patients with lung cancer awaiting surgery. Optimizing preoperative nutrition may have postoperative benefits which remain to be confirmed.

Nutritional status and outcome of surgery: A prospective observational cohort study of children at a tertiary surgical hospital in Harare, Zimbabwe

BACKGROUND

Undernutrition contributes to nearly 50% of all child deaths in the world, yet there is conflicting evidence regarding the association between nutritional status and postoperative complications. The aim was to describe the preoperative nutritional status among pediatric surgery patients in Zimbabwe, and to assess if nutritional status was a risk factor for adverse postoperative outcome of mortality, surgical site infection, reoperation, readmission, and longer length of stay.

METHODS

This prospective observational cohort study included 136 children undergoing surgery at a tertiary pediatric hospital in Zimbabwe. Nutritional status was standardized using Z-scores for BMI, length, weight, and middle upper arm circumference. Primary outcomes after 30 days included mortality, surgical site infection, reoperation, and readmission. Secondary outcome was length of stay. Univariate and multivariable analyses with logistic regression were performed.

RESULTS

Of the 136 patients, 31% were undernourished. Postoperative adverse outcome occurred in 20%; the mortality rate was 6%, the surgical site infection rate was 17%, the reoperation rate was 3.5%, and readmission rate was 2.5%. Nutritional status, higher ASA classification, major surgical procedures, and lower preoperative hemoglobin levels were associated with adverse outcome. Univariate logistic regression identified a seven-fold increased risk of postoperative complications among undernourished children (OR 7.3 [2.3-22.8], p = 0.001), and there was a four- to six-fold increased adjusted risk after adjustment for ASA, major surgery, and preoperative hemoglobin.

CONCLUSION

A third of all pediatric surgery patients were undernourished, and undernourished children had a considerably higher risk of adverse outcome. With a positive correlation identified between undernourishment and increased postoperative complications, future aims would include assessing if preoperative nutritional treatment could be especially beneficial for undernourished children.

LEVELS OF EVIDENCE

Level II treatment study.

Multimodal Prehabilitation for Lung Cancer Surgery: A Randomized Controlled Trial

BACKGROUND

The study was conducted to determine whether a multimodal prehabilitation program enhances postoperative functional recovery compared with multimodal rehabilitation.

METHODS

Patients scheduled for non-small cell lung cancer resection were randomized to 2 groups receiving home-based moderate-intensity exercise, nutritional counseling with whey protein supplementation, and anxiety-reducing strategies for 4 weeks before the operation (PREHAB, n = 52) or 8 weeks after (REHAB, n = 43). Functional capacity (FC) was measured by the 6-minute walk test (6MWT) at baseline, immediately before the operation, and 4 and 8 weeks after operation. All patients were treated according to enhanced recovery pathway guidelines.

RESULTS

There was no difference in FC at any point during the perioperative period between the 2 multimodal programs. By 8 weeks after operation, both groups returned to baseline FC, and a similar proportion of patients (>75%) in both groups had recovered to their baseline.

CONCLUSIONS

In patients undergoing surgical resection for lung cancer within the context of an enhanced recovery pathway, multimodal prehabilitation initiated 4 weeks before operation is as effective in recovering FC as multimodal rehabilitation.

The efficacy of enteral nutrition combined with accelerated rehabilitation in non-small cell lung cancer surgery: A randomized controlled trial protocol

OBJECTIVE

To investigate the effect of enteral nutrition combined with accelerated rehabilitation in treating the non-small cell lung cancer (NSCLC).

METHODS

It is a randomized controlled experiment to be carried out from June 2021 to December 2021. It was permitted through the Ethics Committee of Cancer Hospital Affiliated to Shandong First Medical University (00923876). 100 patients are included in the study. The inclusion criteria contain: (1) patients with NSCLCs receiving surgery as the primary treatment; (2) over 18 years of age. The exclusion criteria are as follows: (1) age ≥65 years; (2) severe metabolic and systemic diseases, such as diabetes, hypertension, or severe liver and kidney dysfunction; (3) the body mass index <18.5 kg/m; (4) patients who have received preoperational radiotherapy or chemotherapy. Patients in the control group are provided routine nutrition, including preoperative nutritional risk screening and assessment and preoperative nutrition education and dietary guidance, while patients in the nutrition group are provided additional enteral nutrition preparations combined with accelerated rehabilitation as in the control group. The primary outcomes include the perioperative change of serum albumin, serum prealbumin, hemoglobin, and total lymphocyte counts. The second outcomes include length of hospitalization, quality of life, and risk of postoperative complications.

RESULTS

shows the comparison of indicators after surgery between the 2 groups.

CONCLUSION

Enteral nutrition combined with accelerated rehabilitation appears to be beneficial in decreasing the complications and improving postoperative recovery after NSCLC surgery.

Dietetic assessment and intervention in lung cancer

PURPOSE OF REVIEW

Systemic therapy for lung cancer is increasing in intensity and duration. European nutrition guidelines suggest screening for weight loss and malnutrition, however acknowledges there is a lack of evidence. We discuss current data round this issue and identify opportunities for further research.

RECENT FINDINGS

International guidelines now exist to aid the definition of weight loss in cancer, including cachexia, sarcopenia and malnutrition. These allow consistent definition of overlapping, but distinct clinical syndromes. Nutritional status can be assessed in a range of ways including questionnaires, functional assessments, blood markers, physical activity, weight and BMI. Weight loss is commonly associated with a proinflammatory state. Future treatment is likely to be a combination of dietetic support and pharmacological treatment of cachexia.

SUMMARY

There is a paucity of data on dietetic intervention. It is potentially quick, inexpensive and patient specific, using a holistic approach to aid patients who are malnourished or at risk of malnutrition. Lung cancer-related weight loss is common, further strategies are needed to effectively assess and intervene. Dietetic intervention has the potential to improve patients' quality of life and outcomes.

Prealbumin: The clinical utility and analytical methodologies

Prealbumin is a small protein which has been widely evaluated as a nutritional and a prognostic marker. The small size and concentration of prealbumin in blood proposes challenges on measuring it with high sensitivity and specificity. Over the years, a number of analytical methodologies have been developed, which may help establish prealbumin as a useful biomarker in routine clinical practice. The aim of the short review was to explore the current literature on the clinical utility of prealbumin and the advances made in the analytical methodologies of prealbumin. We searched MEDLINE, EMBASE and the Cochrane Library for articles published between January 1980 and July 2019, with the general search terms of 'prealbumin', 'prognostic marker', 'nutritional marker', 'analytical methodologies' and 'malnutrition'. Additionally, we selected relevant articles and comprehensive overviews from reference lists of identified studies. The routine use of prealbumin in clinical practice remains debatable; however; it can complement clinical history, anthropometric assessment and physical examination to assess malnutrition with more certainty. Consensus on the clinical applications of prealbumin in the management of malnutrition is warranted.

Modifiable risk factors for patients undergoing lung cancer surgery and their optimization: a review

Enhanced recovery after surgery (ERAS) programs include a variety of pre-, intra- and post-operative interventions that seek to decrease the stress response to surgery and facilitate the recovery of surgical patients. There are a number of patient factors that may increase the risk of postoperative complications (POC) after lung cancer surgery and delay recovery. Some of these factors may be amenable to optimization preoperatively and potentially decrease the incidence of these complications. We have chosen to discuss the incidence and complications associated with factors we felt were both relatively common and significant contributors to POCs. For each of these factors we discuss potential avenues for optimization and the evidence for the resulting decrease in complications.

Impact of the Controlling Nutritional Status Score on the Prognosis After Curative Resection of Pancreatic Ductal Adenocarcinoma

OBJECTIVES

The controlling nutritional status (CONUT) score is a useful tool to evaluate immune-nutritional status. This study aimed to investigate the impact of the CONUT score on short- and long-term outcomes after curative resection of pancreatic ductal adenocarcinoma (PDAC).

METHODS

Consecutive 344 PDAC patients receiving pancreatectomy without neoadjuvant therapy were examined retrospectively. After the best predictive value of the CONUT score for survival was identified, association between the CONUT score and long-term outcomes was evaluated using log-rank tests and a Cox regression model. Then correlations between the CONUT score and postoperative complications were analyzed.

RESULTS

The optimal cutoff value of the CONUT score was 4. The high CONUT score group showed significantly lower overall survival than the low CONUT score group (P = 0.002). In contrast, no significant difference in recurrence-free survival was found (P = 0.43). A multivariate analysis demonstrated that high CONUT score had an independent association with overall survival (hazard ratio, 1.64; P = 0.003). The CONUT score showed no association with postoperative pancreatic fistula, Clavien-Dindo grade, or postoperative hospital stay.

CONCLUSION

The CONUT score had an independent association with survival in patients with PDAC after pancreatectomy and was not associated with recurrence or postoperative complications.

Establishment and validation of a predictive nomogram model for non-small cell lung cancer patients with chronic hepatitis B viral infection

Background

This study aimed to establish an effective predictive nomogram for non-small cell lung cancer (NSCLC) patients with chronic hepatitis B viral (HBV) infection.

Methods

The nomogram was based on a retrospective study of 230 NSCLC patients with chronic HBV infection. The predictive accuracy and discriminative ability of the nomogram were determined by a concordance index (C-index), calibration plot and decision curve analysis and were compared with the current tumor, node, and metastasis (TNM) staging system.

Results

Independent factors derived from Kaplan–Meier analysis of the primary cohort to predict overall survival (OS) were all assembled into a Cox proportional hazards regression model to build the nomogram model. The final model included age, tumor size, TNM stage, treatment, apolipoprotein A-I, apolipoprotein B, glutamyl transpeptidase and lactate dehydrogenase. The calibration curve for the probability of OS showed that the nomogram-based predictions were in good agreement with the actual observations. The C-index of the model for predicting OS had a superior discrimination power compared with the TNM staging system [0.780 (95% CI 0.733–0.827) vs. 0.693 (95% CI 0.640–0.746), P < 0.01], and the decision curve analyses showed that the nomogram model had a higher overall net benefit than did the TNM stage. Based on the total prognostic scores (TPS) of the nomogram, we further subdivided the study cohort into three groups: low risk (TPS ≤ 13.5), intermediate risk (13.5 < TPS ≤ 20.0) and high risk (TPS > 20.0).

Conclusion

The proposed nomogram model resulted in more accurate prognostic prediction for NSCLC patients with chronic HBV infection.

Preoperative nutritional status assessment predicts postoperative outcomes in patients with surgically resected non-small cell lung cancer

BACKGROUND

As nutritional status plays an important role in outcomes after surgery, this study evaluated the association between preoperative nutritional status (NS) and postoperative outcomes after major resection for lung cancer.

METHODS

We identified 219 patients with a diagnosis of cancer who underwent pulmonary resection from 2010 to 2012. Preoperative NS was assessed by anthropometric and biological parameters, body mass index (BMI), and the Nutritional Risk Index (NRI). We stratified this population into 4 BMI groups: underweight, normal weight, overweight and obese and 4 NRI groups: well-nourished; mildly malnourished; moderately malnourished and severely malnourished. The outcomes measured were postoperative complications; 30-day postoperative mortality; hospital length of stay (LOS), overall survival (OS) and disease-free survival (DFS). We performed both unadjusted analysis and adjusted multivariable analysis, controlling for statistically significant variables.

RESULTS

Mean BMI and NRI were, respectively, 26.5 ± 4.3 and 112.4 ± 3.3. There were no significant differences between BMI categories and resection type, pathological stage, or overall postoperative complications. By contrast, significant differences (p < 0.05) in postoperative complications were observed among the NRI groups. LOS was longer in underweight and/or malnourished patients. In terms of OS, we found no significant differences according to NRI and BMI; however, patients with underweight had significantly shorter DFS compared with patients with overweight and obesity (log-rank p-value = 0.001).

CONCLUSION

NS as measured by the NRI is an independent predictor of the risk of postsurgical complications, regardless of clinicopathologic characteristics. NRI might therefore be an useful tool for identifying early-stage lung cancer patients at risk for postoperative complications.

Is nutritional status associated with the level of anxiety, depression and pain in patients with lung cancer?

Background

Nutritional deficiencies are common in lung cancer patients, especially in those with advanced and metastatic cancers. The pathogenesis of the development of nutritional disorders in cancer patients has not been fully explained. The study was performed in order to research associations between nutritional status and mental condition and pain. The aim of the study was to assess the relationship between nutritional status and the level of anxiety, depression and perceived pain in patients with lung cancer.

Methods

A total of 257 patients with lung cancer were enrolled. The Mini-Nutritional Assessment (MNA) questionnaire was used to assess their nutritional status; the Hospital Anxiety and Depression Scale (HADS) was used to assess their levels of anxiety and depression; the Visual Analog Scale (VAS) was used to assess levels of perceived pain.

Results

The MNA showed that 23% of the study group was malnourished, 33% at risk of malnutrition and 44% displayed a normal nutritional status. The HADS questionnaire showed that 65% of the study group had depressive symptoms and 65% had anxiety. The mean score of the VAS was 4.35. A significant negative correlation between nutritional status and pain was observed (r=-0.65; P<0.001) as well as between nutritional status and anxiety and depression (r=-0.68; P<0.001 and r=-0.60; P<0.001, respectively).

Conclusions

The prevalence of nutritional disorders and the intensity of somatic symptoms and psychological distress are high among lung cancer patients. The significant levels of depression, anxiety and pain in patients at risk of malnutrition which were highlighted in comparison to patients with a normal nutritional status indicate the need for early supportive psychotherapy or pharmacological interventions.

Impact of distance from surgery department on the outcome of patients followed for non-small-cell lung cancer in the respiratory department of nonacademic hospitals: Results of the KBP-2010-study

OBJECTIVE

Increased postoperative mortality in low volume centers has contributed to merge and space thoracic surgical centers. Some studies have showed that the likelihood of receiving surgery was lower in lung cancer patients living far from a thoracic surgery center. Our objective was thus to determine whether surgery and survival rates in patients with non-small-cell lung cancer (NSCLC) were influenced by the distance between the respiratory and thoracic surgery departments.

METHODS

KBP-2010-CPHG is a prospective multicenter epidemiological study including 6083 patients followed in 104 nonacademic hospitals for primary NSCLC diagnosed in 2010. Distance between respiratory and thoracic surgery departments were obtained retrospectively. Predictive factors for surgery and mortality were identified by logistic regression and Cox hazard model.

RESULTS

Twenty-three percent of hospitals had a thoracic surgery department; otherwise, mean distance between the hospital and the surgery center was 65km. Nineteen percent of patients underwent surgery. Distance was neither an independent factor for surgery (odds-ratios [95% CI]: 0.971 [0.74-1.274], 0.883 [0.662-1.178], and 1.015 [0.783-1.317] for 1-34, 35-79, and ≥80km vs. 0km) nor for mortality (hazard-ratios [95% CI]: 1.020 [0.935-1.111], 1.003 [0.915-1.099], and 1.006 [0.927-1.091]) (P>0.05).

DISCUSSION

This result supports the French national strategy which merges surgery departments and should reassure patients (and physicians) who could be afraid to be lately addressed to surgery or loose chance when being followed far from the thoracic surgical center.

An inflammation-based prognostic score, the C-reactive protein/albumin ratio predicts the morbidity and mortality of patients on parenteral nutrition

BACKGROUND

There is no "gold standard" score for predicting poor-nutrition-related outcomes. The objective of this study was to identify the optimal predictive score, based on inflammatory parameters, for the clinical outcomes of parenteral nutrition (PN).

MATERIAL AND METHODS

This was a 4-year retrospective observational study of 460 patients treated with PN. C-reactive protein (CRP), prealbumin, albumin, CRP/prealbumin and CRP/albumin were studied as potential prognostic scores at the beginning of PN for clinical outcomes during PN. Three different statistical approaches were developed: 1) A univariate analysis of each of the 5 prognostic scores and 5 multivariate models for CRP/albumin and CRP/prealbumin to study their association with exitus, infection, sepsis, liver failure, renal impairment, cancer, intensive care unit stay, mechanical ventilation; 2) Univariate and multivariate survival analysis of PN length, intensive care unit (ICU) length of saty and days of mechanical ventilation vs CRP/albumin and CRP/prealbumin; 3) A ROC analysis of the prognostic accuracy of CRP/albumin and CRP/prealbumin over morbidity/mortality.

RESULTS

1) CRP, albumin and CRP/albumin gave more information about morbidity/mortality than prealbumin and CRP/prealbumin. CRP/albumin was statistically significant for exitus (OR 1.85; CI 95%: 1.00-3.45), infection (OR 2.15; CI 95%: 1.22-3.80), sepsis (OR 2.82; CI 95%: 1.69-4.70) and liver failure (OR 2.66; CI 95%: 1.55-4.58). CRP/prealbumin for sepsis was (OR 2.21; CI 95%: 1.34-3.64) and for liver failure (OR 2.04; CI 95%: 1.17-3.53); 2) CRP/albumin and CRP/prealbumin significantly predict PN duration, days in ICU and days on mechanical ventilation; 3) and are related to exitus, infection, sepsis and liver failure.

CONCLUSION

The CRP/albumin score at the beginning of PN treatment has more prognostic capability than CRP/prealbumin, albumin or prealbumin. The systematic use of this score could help to identify those patients with higher risk.

Stratification of Fat-Free Mass Index Percentiles for Body Composition Based on National Health and Nutrition Examination Survey III Bioelectric Impedance Data

BACKGROUND

Loss of protein mass and lower fat-free mass index (FFMI) are associated with longer length of stay, postsurgical complications, and other poor outcomes in hospitalized patients. Normative data for FFMI of U.S. populations do not exist. This work aims to create a stratified FFMI percentile table for the U.S. population using the large bioelectric impedance analysis data obtained from National Health and Nutrition Examination Surveys (NHANES).

METHODS

Fat-free mass (FFM) was calculated from the NHANES III bioelectric impedance analysis and anthropometric data for males and females ages 12 to >90 years for 3 race/ethnicities (non-Hispanic white, non-Hispanic black, and Mexican American). FFM was normalized by subject height to create an FFMI distribution table for the U.S.

POPULATION

Selected percentiles were obtained by age, sex, and race/ethnicity. Data were collapsed by race/ethnicity before and after removing obese and underweight participants to create an FFMI decile table for males and females 12 years and older for the healthy-weight U.S.

POPULATION

RESULTS

FFMI increased during adolescent growth but stabilized in the early 20s. The FFMI deciles were similar by race/ethnicity, with age group remaining relatively stable between ages 25 and 80 years. The FFMI deciles for males and females were significantly different.

CONCLUSIONS

After eliminating the obese and extremely thin, FFMI percentiles remain stable during adult years allowing creation of age- and race/ethnicity-independent decile tables for males and females. These tables allow stratification of individuals for nutrition intervention trials to depict changing nutrition status during medical, surgical, and nutrition interventions.

Bronchial colonization and complications after lung cancer surgery

PURPOSE

Infectious complications occur following pulmonary resections preceded or not by induction chemoradiotherapy. We aimed to investigate whether bacterial colonization of the bronchial tree at the time of surgery was associated with postoperative complications.

PATIENTS AND METHODS

A retrospective analysis of all patients who underwent open anatomical pulmonary resections for malignancies at a single center was performed. Demographical data of the included patients, intraoperative data, and data on the postoperative course of patients were collected. Outcome of patients with a positive intraoperative bronchial culture was compared to patients with a negative bronchial culture. Relations between the presence of potential bacterial pathogens in the bronchial tree and other possible risk factors for the development of postoperative infectious and non-infectious complications, were analyzed using uni- and multivariate analysis.

RESULTS

Between January 2010 and January 2012, a total of 121 consecutive patients underwent open anatomical pulmonary resections for malignancy, of whom 45 were preceded by induction chemoradiotherapy and 5 by induction chemotherapy. Intraoperative bronchial cultures were taken from 58 patients (48 %). Patients with a positive bronchial culture developed significantly more infectious (88 % vs. 20 %, p < 0.001) and non-infectious complications (63 % vs. 12 %, p = 0.001). Positive intraoperative bronchial cultures showed the strongest association with the development of infectious and non-infectious postoperative complications (OR 24.8 and 12.2, respectively). After multivariate analysis, only BMI less than 20 kg/m(2) and the presence of a positive intraoperative bronchial culture were found to be independent risk factors for the development of infectious complications. Chemoradiotherapy was not associated with postoperative complications in the present study.

CONCLUSIONS

Bacterial colonization of the bronchial tree assessed intraoperatively, appears to be associated with higher rates of infectious and non-infectious complications after pulmonary resection. Whether early starting of appropriate antibiotics based on intraoperative-taken culture findings will reduce the infectious complication rate in a subcategory of patients needs to be investigated.

A Twelve-Year Consecutive Case Experience in Thoracic Reconstruction

Background:

We describe the second largest contemporary series of flaps used in thoracic reconstruction.

Methods:

A retrospective review of patients undergoing thoracomyoplasty from 2001 to 2013 was conducted. Ninety-one consecutive patients were identified.

Results:

Thoracomyoplasty was performed for 67 patients with intrathoracic indications and 24 patients with chest wall defects. Malignancy and infection were the most common indications for reconstruction (P < 0.01). The latissimus dorsi (LD), pectoralis major, and serratus anterior muscle flaps remained the workhorses of reconstruction (LD and pectoralis major: 64% flaps in chest wall reconstruction; LD and serratus anterior: 85% of flaps in intrathoracic indication). Only 12% of patients required mesh. Only 6% of patients with <2 ribs resected required mesh when compared with 24% with 3–4 ribs, and 100% with 5 or more ribs resected (P < 0.01). Increased rib resections required in chest wall reconstruction resulted in a longer hospital stay (P < 0.01). Total comorbidities and complications were related to length of stay only in intrathoracic indication (P < 0.01). Average intubation time was significantly higher in patients undergoing intrathoracic indication (5.51 days) than chest wall reconstruction (0.04 days), P < 0.05. Average hospital stay was significantly higher in patients undergoing intrathoracic indication (23 days) than chest wall reconstruction (12 days), P < 0.05. One-year survival was most poor for intrathoracic indication (59%) versus chest wall reconstruction (83%), P = 0.0048.

Conclusion:

Thoracic reconstruction remains a safe and successful intervention that reliably treats complex and challenging problems, allowing more complex thoracic surgery problems to be salvaged.

Is preoperative protein-rich nutrition effective on postoperative outcome in non-small cell lung cancer surgery? A prospective randomized study

Objective

Protein-rich nutrition is necessary for wound healing after surgery. In this study, the benefit of preoperative nutritional support was investigated for non-small cell lung cancer patients who underwent anatomic resection.

Methods

A prospective study was planned with the approval of our institutional review board. Fifty-eight patients who underwent anatomic resection in our department between January 2014 and December 2014 were randomized. Thirty-one patients were applied a preoperative nutrition program with immune modulating formulae (enriched with arginine, omega-3 fatty acids and nucleotides) for ten days. There were 27 patients in the control group who were fed with only normal diet. Patients who were malnourished, diabetic or who had undergone bronchoplastic procedures or neoadjuvant therapy were excluded from the study. Patients’ baseline serum albumin levels, defined as the serum albumin level before any nutrition program, and the serum albumin levels on the postoperative third day were calculated and recorded with the other data.

Results

Anatomic resection was performed by thoracotomy in 20 patients, and 11 patients were operated by videothoracoscopy in the nutrition program group. On the other hand 16 patients were operated by thoracotomy and 11 patients were operated by videothoracoscopy in the control group. In the control group, the patients’ albumin levels decreased to 25.71 % of the baseline on the postoperative third day, but this reduction was only 14.69 % for nutrition program group patients and the difference was statistically significant (p < 0.001). Complications developed in 12 patients (44.4 %) in the control group compared to 6 patients in the nutrition group (p = 0.049). The mean chest tube drainage time was 6 (1–42) days in the control group against 4 (2–15) days for the nutrition program group (p = 0.019).

Conclusions

Our study showed that preoperative nutrition is beneficial in decreasing the complications and chest tube removal time in non-small cell lung cancer patients that were applied anatomic resection with a reduction of 25 % in the postoperative albumin levels of non-malnourished patients who underwent resection.

Multidisciplinary Care

Optimal multidisciplinary care of the lung cancer patient at all stages should encompass integration of the key relevant medical specialties, including not only medical, surgical, and radiation oncology, but also pulmonology, interventional and diagnostic radiology, pathology, palliative care, and supportive services such as physical therapy, case management, smoking cessation, and nutrition. Multidisciplinary management starts at staging and tissue diagnosis with pathologic and molecular phenotyping, extends through selection of a treatment modality or modalities, management of treatment and cancer-related symptoms, and to survivorship and end-of-life care. Well-integrated multidisciplinary care may reduce treatment delays, improve cancer-specific outcomes, and enhance quality of life. We address key topics and areas of ongoing investigation in multidisciplinary decision making at each stage of the lung cancer treatment course for early-stage, locally advanced, and metastatic lung cancer patients.

Systematic Review of Tobacco Use after Lung or Head/Neck Cancer Diagnosis: Results and Recommendations for Future Research

Tobacco use after cancer diagnosis is associated with adverse cancer outcomes, yet reliable prevalence estimates for this behavior are lacking. We conducted a systematic literature review of the prevalence of current tobacco use among individuals with a history of lung or head/neck cancer (CRD #42012002625). An extensive search of electronic databases (MEDLINE, EMBASE, Cochrane Library, CINAHL, PsycINFO, and Web of Science) identified 7,777 potentially relevant articles published between 1980 and 2014 and 131 of these yielded pertinent information. Aggregating results across heterogeneous study designs and diverse patient samples, the overall mean prevalence rate of current tobacco use (mostly cigarette smoking) was 33.0% (median, 31.0%). Among current tobacco users at cancer diagnosis, the mean prevalence rate of current tobacco use (mostly cigarette smoking) was 53.8% (median, 50.3%). In many cases, an operational definition of "current" tobacco use was absent, and biochemical verification of self-reported smoking status was infrequent. These and other observed methodologic limitations in the assessment and reporting of cancer patients' tobacco use underscore the necessity of uniform tobacco use assessment in future clinical research and cancer care.

Development and validation of a risk score for predicting death after pneumonectomy

Pneumonectomy is associated with significant postoperative mortality. This study was undertaken to develop and validate a risk model of mortality following pneumonectomy. We reviewed our prospective database and identified 774 pneumonectomies from a total of 7792 consecutive anatomical lung resections in the years 2003 to 2010 (rate of pneumonectomy: 9.9%). Based on data from 542 pneumonectomies between 2003 and 2007 (i.e., the "discovery set"), a penalized multivariable logistic regression analysis was performed to identify preoperative risk factors. A risk model was developed and validated in an independent data set of 232 pneumonectomies that were performed between 2008 and 2010 (i.e., the "validation set"). Of the 542 patients in the discovery set (DS), 35 patients (6.5%) died after pneumonectomy during the same admission. We developed a risk prediction model for in-hospital mortality following pneumonectomy; that model included age, current alcohol use, coronary artery disease, preoperative leukocyte count and palliative indication as possible risk factors. The risk model was subsequently successfully validated in an independent data set (n = 232) in which 18 patients (7.8%) died following pneumonectomy. For the validation set, the sensitivity of the model was 53.3% (DS: 54.3%), the specificity was 88.0% (DS: 87.4%), the positive predictive value was 26.7% (DS: 22.9%) and the negative predictive value was 95.8% (DS: 96.5%). The Brier score was 0.062 (DS: 0.054). The prediction model is statistically valid and clinically relevant.

[Lung cancer surgery and cirrhosis]

INTRODUCTION

Lung cancer is the leading cause of death by cancer and cirrhosis is the fourteenth, all causes included. Surgery increases postoperative risks in cirrhotic patients. Our purpose was to analyze this point in lung cancer surgery.

METHODS

We collected, among 7162 patients, the data concerning those operated for lung cancer (n=6105) and compared patients with hepatic disease (n=448) to those presenting other medical disorder (n=2587). We analyzed cirrhotic patients' characteristics (n=49).

RESULTS

Five-year survival of patients with hepatic disease was lower (n=5657/6105): 35.3% versus 43.8% for patients with no hepatic disease, P=0.0021. Survival of cirrhotic patients was not statistically different from the one of patients with other hepatic disorder, but none survived beyond 10 years (0% versus 26.4%). Surgery in cirrhotic patients consisted in one explorative thoracotomy, three wedges resections, two segmentectomies, 33 lobectomies and 10 pneumonectomies. Postoperative mortality (8.2%; 4/49) was not different for patients without hepatic disease (4.2%; 239/5657) (P=0.32), as well as the rate of complications (40.8%; 20/49 and 24.8%; 1404/5657, P=0.11). Only one postoperative death was associated to a hepatic failure. Multivariate analysis pointed age, histological subtype of the tumour and stage of disease as independent prognosis factors.

CONCLUSION

When cirrhosis is well compensated, surgical resection of lung cancer can be performed with acceptable postoperative morbidity and satisfactory rates of survival. Progressive potential of this disease is worse after five years.

Assessment of preoperative and postoperative prealbumin in thoracic surgery – a two months experience in a Romanian university hospital / Evaluarea preoperatorie şi postoperatorie a prealbuminei în chirurgia toracică - experiența de 2 luni a unui spital universitar din România

Malnutrition is a frequent and serious finding in surgical departments. Although its consequences include postoperative complications and higher costs, nutritional assessment is not part of the routine preoperative protocols. Nutritional assessment involves clinical and biological parameters and is vital in order to start treatment and improve outcome. Prealbumin is currently recognized as a faithful marker of malnutrition being introduced in practice guidelines. One of the most important aspects about prealbumin is the fact that its variations in time are more valuable than the absolute values. The aim of this study was to assess and compare the perioperative nutritional evolution of patients requiring thoracic surgery, with and without cancer, using prealbumin - preoperative and postoperative - as main marker. Thirty six patients from the Thoracic Surgery Department were assessed prior to surgery by body mass index, Subjective Global Assessment nutrition risk score and routine biochemical parameters. Prealbumin was assessed prior to surgery and 3 days after surgery. The age, length of postoperative stay and the presence was complications was noted. Patients with cancer (n=19) were significantly older than patients without cancer (p=0.007) and were more frequently, but not significantly, evaluated as malnourished through SGA (42.1% compared to 11.6%). Preoperative prealbumin and other parameters did not differ significantly between groups. However, there was a significant postoperative decrease in prealbumin only in patients with cancer. Therefore, prealbumin has been found to be valuable in assessing acute malnutrition in cancer patients, especially if variations are monitored in time, which could be useful in planning nutritional treatment

Pneumonectomy for lung cancer: contemporary national early morbidity and mortality outcomes

OBJECTIVE

The study objective was to determine contemporary early outcomes associated with pneumonectomy for lung cancer and to identify their predictors using a nationally representative general thoracic surgery database (EPITHOR).

METHODS

After discarding inconsistent files, a group of 4498 patients who underwent elective pneumonectomy for primary lung cancer between 2003 and 2013 was selected. Logistic regression analysis was performed on variables for mortality and major adverse events. Then, a propensity score analysis was adjusted for imbalances in baseline characteristics between patients with or without neoadjuvant treatment.

RESULTS

Operative mortality was 7.8%. Surgical, cardiovascular, pulmonary, and infectious complications rates were 14.9%, 14.1%, 11.5%, and 2.7%, respectively. None of these complications were predicted by the performance of a neoadjuvant therapy. Operative mortality analysis, adjusted for the propensity scores, identified age greater than 65 years (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.5-2.9; P < .001), underweight body mass index category (OR, 2.2; 95% CI, 1.2-4.0; P = .009), American Society of Anesthesiologists score of 3 or greater (OR, 2.310; 95% CI, 1.615-3.304; P < .001), right laterality of the procedure (OR, 1.8; 95% CI, 1.1-2.4; P = .011), performance of an extended pneumonectomy (OR, 1.5; 95% CI, 1.1-2.1; P = .018), and absence of systematic lymphadenectomy (OR, 2.9; 95% CI, 1.1-7.8; P = .027) as risk predictors. Induction therapy (OR, 0.63; 95% CI, 0.5-0.9; P = .005) and overweight body mass index category (OR, 0.60; 95% CI, 0.4-0.9; P = .033) were protective factors.

CONCLUSIONS

Several risk factors for major adverse early outcomes after pneumonectomy for cancer were identified. Overweight patients and those who received induction therapy had paradoxically lower adjusted risks of mortality.

Prognostic significance of basic laboratory methods in non- small-cell-lung cancer

BACKGROUND

In our study, the LDH, albumin, hemoglobin, neutrophile, thrombocyte, lymphocyte counts and prognostic significance of neutrophile-lymphocyte and thrombocyte-lymphocyte ratios in NSCLC derived from these counts obtained during regular examinations of patients were examined.

MATERIALS AND METHODS

Histopathologically diagnosed non-small-cell-lung cancer patients between 2008 and 2010 were included in the study. Before the treatment, full blood count including routine lymphocyte count, blood biochemistry examinations including liver (AST, ALT, total protein, Albumin), LDH and kidney (BUN, Cre) function tests were performed.

RESULTS

A total of 156 patients, 76 of whom (48.7%) were female and 80 of whom (51.3%) were male were included. Mean hemoglobin level was determined as 12. Overall survival was found to be significantly dependent on whether patients were anemic or not (p: 0.005). Mean LDH level was determined as 233.4. There was nosurvival difference between patients with and without high LDH (p: 0.532). In patients where NLR showed systemic inflammatory response, overall survival was 10.8 months whereas this duration was 19.6 months in patients where the systemic inflammatory response was negative (p: 0.012). In patients where TLR showed systemic inflammatory response, overall survival was 13.6 months whereas this duration was 21.9 months in patients where the systemic inflammatory response was negative (p: 0.04).

CONCLUSIONS

Molecular methods have been changing rapidly in today's world and they manage the treatment besides defining the prognosis of patients. However, easily accessible and cheap laboratory parameters should be considered in the prognosis of patients besides these new methods.

Association of body mass index and outcomes after major lung resection

OBJECTIVES

Obesity has been thought to predispose patients to excess morbidity after lung resection because of decreased diaphragm excursion, reduced lung volumes and relative immobility. We assessed the relationship of body mass index (BMI) to acute outcomes after major lung resection.

METHODS

Information from our database of lung resections was evaluated for the period 1980-2011. Univariate analysis for adverse events (pulmonary, cardiovascular, other and overall) was used to select variables for inclusion in multivariate logistic regression analyses. Missing values were imputed. BMI was categorized as underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), obese (30-34.9) and very obese (≥ 35).

RESULTS

Among 1369 patients, there were 703 males (51%) and the mean age was 62 ± 11 years. Complications included the following: pulmonary 12%, cardiovascular 15%, other 16%, mortality 5% and any 29%. The incidence of complications decreased during each decade of study (40, 30, 26, 20%; P < 0.0001) and the incidence of obese/very obese increased during the same intervals (11, 22, 30, 25%; P = 0.0007). Adjusting for age, performance status, coronary artery disease, smoking status, diffusing capacity of the lung for carbon monoxide, forced expiratory volume in 1 s and operation year, being overweight/obese/very obese did not increase the risk of postoperative complications in any category. In fact, patients in this group showed a lower rate of cardiovascular complications than those with BMI ≤ 25 (odds ratio (OR): 0.72; 95% confidence interval (CI): 0.51-1.00; P = 0.048). However, being underweight was importantly associated with an increased risk of pulmonary complications (OR: 2.5; 95% CI: 1.3-4.9; P = 0.0087) and of operative mortality (OR: 2.96; 95% CI: 1.28-6.86; P = 0.011).

CONCLUSION

Being overweight or obese does not increase the risk of complications after major lung resection. In contrast, patients who are underweight are at significantly increased risk of pulmonary complications and mortality. Knowledge of the relationship of BMI to perioperative risk for major lung resection is essential in proper risk stratification.