Prediction of Major Cardiovascular Events After Lung Resection Using a Modified Scoring System

Preoperative frailty screening in elderly patients with non-small cell lung cancer surgery: an essential step for a good surgical outcome

INTRODUCTION

Non-small cell lung cancer (NSCLC) is a disease commonly diagnosed in the elderly, often in advanced stages. However, elderly patients with lung cancer can benefit from surgery, provided that postoperative risks are assessed appropriately before surgery. Frailty is a measure of age-related impaired functional status and a predictor of mortality and morbidity. However, its importance as a preoperative marker is not well defined.

AREAS COVERED

This systematic review discusses the importance of preoperative frailty screening in elderly patients with NSCLC. A literature search was performed on the MEDLINE database in June 2023, and relevant studies on frailty or preoperative assessment of NSCLC which were published between 2000 and 2023 were retained and discussed in this review.

EXPERT OPINION

Among the types of existing methods used to assess frailty those on the geriatric assessment seem to be the most appropriate; however, they are unable to fully capture the 'surgical' frailty; thus, other instruments should be developed and validated in NSCLC.

Impact of diabetes on stage I lung cancer treatment patterns and prognosis in older adults: A population-based cohort study

Background

Diabetes is a common comorbidity in patients with early-stage non-small cell lung cancer (NSCLC), a growing population due to increased LC screening. However, it is unknown if diabetes is associated with less aggressive NSCLC treatment and worse NSCLC outcomes. This study aimed to investigate treatment patterns and outcomes of older patients with Stage I NSCLC and diabetes.

Methods

Using national cancer registry data linked to Medicare, we identified patients ≥65 years old with Stage I NSCLC. Patients were categorized as having no diabetes, diabetes without severe complications (DM-c), or diabetes with ≥1 severe complication (DM + c). We used multinomial logistic regression to assess the association of diabetes and NSCLC treatment. The association of diabetes category with NSCLC and non-NSCLC survival was analyzed with Fine-Grey competing-risks regression.

Results

In 25,358 patients (75% no diabetes, 12% DM-c and 13% had DM + c), adjusted analyses showed that DM-c and DM + c were associated with increased odds of receiving limited resection rather than lobectomy (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.07-1.37 and OR 1.42, 95% CI 1.26-1.59, respectively). Competing risk regression showed diabetes was associated with increased risk of non-NSCLC death (DM-c hazard ratio [HR] 1.16, 95% CI: 1.08-1.25, DM + c HR 1.49, 95% CI: 1.40-1.59), but not NSCLC-specific death.

Conclusion

This study uncovers critical information on how diabetes is associated with less aggressive early-stage NSCLC care in older patients. This study also confirms that diabetes increases death from non-lung cancer causes and managing comorbidities is crucial to improving outcomes in older early-stage NSCLC survivors.

Hyperoxemia post thoracic surgery - Does it matter?

Introduction

Post-operative oxygen therapy is used to prevent hypoxemia and surgical site infection. However, with improvements of anesthesia techniques, post-operative hypoxemia incidence is declining and the benefits of oxygen on surgical site infection have been questioned. Moreover, hyperoxemia might have adverse effects on the pulmonary and cardiovascular systems. We hypothesized hyperoxemia post thoracic surgery is associated with post-operative pulmonary and cardiovascular complications.

Methods

Consecutive lung resection patients were included in this post-hoc analysis. Post-operative pulmonary and cardiovascular complications were prospectively assessed during the first 30 post-operative days, or hospital stay. Arterial blood gases were analyzed at 1, 6 and 12 h after surgery. Hyperoxemia was defined as arterial partial pressure of oxygen (PaO₂)>100 mmHg. Patients with hyperoxemia duration in at least two adjacent time points were considered as hyperoxemic. Student t-test, Mann-Whitney U test and two-tailed Fisher exact test were used for group comparison. P values < 0.05 were considered statistically significant.

Results

Three hundred sixty-three consecutive patients were included in this post-hoc analysis. Two hundred five patients (57%), were considered hyperoxemic and included in the hyperoxemia group. Patients in the hyperoxemia group had significantly higher PaO₂ at 1, 6 and 12 h after surgery (p < 0.05). Otherwise, there was no significant difference in age, sex, comorbidities, pulmonary function tests parameters, lung surgery procedure, incidence of post-operative pulmonary and cardiovascular complications, intensive care unit and hospital length of stay and 30-day mortality.

Conclusion

Hyperoxemia after lung resection surgery is common and not associated with post-operative complications or 30-day mortality.

Cardiovascular Toxicity and Risk Mitigation with Lung Cancer Treatment

PURPOSE OF REVIEW

Patients with lung cancer often have concomitant cardiovascular comorbidities and receive potentially cardiotoxic therapies. As oncologic outcomes improve, the relative impact of cardiovascular disease on lung cancer survivors is expected to increase. This review summarizes cardiovascular toxicities observed after treatment for lung cancer, as well as recommended risk mitigation strategies.

RECENT FINDINGS

A variety of cardiovascular events may be observed after surgery, radiation therapy (RT), and systemic therapy. The risk of cardiovascular events after radiation therapy (RT) is higher than previously appreciated (23-32%), and RT dose to the heart is a modifiable risk factor. Targeted agents and immune checkpoint inhibitors have been associated with cardiovascular toxicities distinct from those of cytotoxic agents; these are rare but can be severe and require prompt intervention. Optimization of cardiovascular risk factors is important at all phases of cancer therapy and survivorship. Recommended practices for baseline risk assessment, preventive measures, and appropriate monitoring are discussed herein.

Ventilatory efficiency is superior to peak oxygen uptake for prediction of lung resection cardiovascular complications

Introduction

Ventilatory efficiency (V_E/VCO₂ slope) has been shown superior to peak oxygen consumption (VO₂) for prediction of post-operative pulmonary complications in patients undergoing thoracotomy. V_E/VCO₂ slope is determined by ventilatory drive and ventilation/perfusion mismatch whereas VO₂ is related to cardiac output and arteriovenous oxygen difference. We hypothesized pre-operative VO₂ predicts post-operative cardiovascular complications in patients undergoing lung resection.

Methods

Lung resection candidates from a published study were evaluated by post-hoc analysis. All of the patients underwent preoperative cardiopulmonary exercise testing. Post-operative cardiovascular complications were assessed during the first 30 post-operative days or hospital stay. One-way analysis of variance or the Kruskal–Wallis test, and multivariate logistic regression were used for statistical analysis and data summarized as median (IQR).

Results

Of 353 subjects, 30 (9%) developed pulmonary complications only (excluded from further analysis), while 78 subjects (22%) developed cardiovascular complications and were divided into two groups for analysis: cardiovascular only (n = 49) and cardiovascular with pulmonary complications (n = 29). Compared to patients without complications (n = 245), peak VO₂ was significantly lower in the cardiovascular with pulmonary complications group [19.9 ml/kg/min (16.5–25) vs. 16.3 ml/kg/min (15–20.3); P<0.01] but not in the cardiovascular only complications group [19.9 ml/kg/min (16.5–25) vs 19.0 ml/kg/min (16–23.1); P = 0.18]. In contrast, V_E/VCO₂ slope was significantly higher in both cardiovascular only [29 (25–33) vs. 31 (27–37); P = 0.05] and cardiovascular with pulmonary complication groups [29 (25–33) vs. 37 (34–42); P<0.01)]. Logistic regression analysis showed V_E/VCO₂ slope [OR = 1.06; 95%CI (1.01–1.11); P = 0.01; AUC = 0.74], but not peak VO₂ to be independently associated with post-operative cardiovascular complications.

Conclusion

V_E/VCO₂ slope is superior to peak VO₂ for prediction of post-operative cardiovascular complications in lung resection candidates.

Nongated computed tomography predicts perioperative cardiovascular risk in lung cancer surgery

BACKGROUND

The coronary artery calcification score (CACS) is a strong predictor of cardiovascular events and mortality, which can be assessed by nongated chest computed tomography (CT). The study aimed to determine whether CACS based on nongated CT is predictive of perioperative cardiovascular events during intermediate-risk lung cancer surgery.

METHODS

In this retrospective, single-center study, we used nongated CT images to evaluate CACS in 4,491 lung cancer patients who underwent intermediate-risk surgeries. Perioperative cardiovascular events were defined as in-hospital cardiac death, nonfatal myocardial infarction (MI), heart failure, atrial and ventricular arrhythmia with hemodynamic compromise, and complete heart block. Risk factors of perioperative cardiovascular were identified using multivariate logistic regression analysis.

RESULTS

In total, 110 inpatients (2.5%) experienced perioperative cardiac events. Coronary calcification was observed on nongated CT in 1,070 (23.8%) patients. CACS was significantly associated with the incidence of cardiovascular events and longer hospital stays. According to receiver operating characteristic curve analysis, the CACS cutoff value was set to 1. In the multivariate analysis, CACS ≥1 (odds ratio (OR) = 1.75, 95% confidence interval (CI): 1.14-2.68, p = 0.011) or the number of calcified vessels (OR = 1.23, 95%CI: 1.01-1.50, p = 0.043), age, forced expiratory volume in one second/predicted, operation time, and thoracotomy were predictive of cardiovascular complications.

CONCLUSIONS

CACS is an independent predictor of severe perioperative cardiovascular risk in patients undergoing intermediate-risk lung cancer surgery. CACS may represent a valuable tool for preoperative risk assessments among these patients.

Definition and assessment of high risk in patients considered for lobectomy for stage I non-small cell lung cancer: The American Association for Thoracic Surgery expert panel consensus document

OBJECTIVE

Lobectomy is a standard treatment for stage I non-small cell lung cancer, but a significant proportion of patients are considered at high risk for complications, including mortality, after lobectomy and might not be candidates. Identifying who is at risk is important and in evolution. The objective of The American Association for Thoracic Surgery Clinical Practice Standards Committee expert panel was to review important considerations and factors in assessing who is at high risk among patients considered for lobectomy.

METHODS

The American Association for Thoracic Surgery Clinical Practice Standards Committee assembled an expert panel that developed an expert consensus document after systematic review of the literature. The expert panel generated a priori a list of important risk factors in the determination of high risk for lobectomy. A survey was administered, and the expert panel was asked to grade the relative importance of each risk factor. Recommendations were developed using discussion and a modified Delphi method.

RESULTS

The expert panel survey identified the most important factors in the determination of high risk, which included the need for supplemental oxygen because of severe underlying lung disease, low diffusion capacity, the presence of frailty, and the overall assessment of daily activity and functional status. The panel determined that factors, such as age (as a sole factor), were less important in risk assessment.

CONCLUSIONS

Defining who is at high risk for lobectomy for stage I non-small cell lung cancer is challenging, but remains critical. There was impressive strong consensus on identification of important factors and their hierarchical ranking of perceived risk. The panel identified several key factors that can be incorporated in risk assessment. The factors are evolving and as the population ages, factors such as neurocognitive function and frailty become more important. A minimally invasive approach becomes even more critical in this older population to mitigate risk. The determination of risk is a clinical decision and judgement, which should also take into consideration patient perspectives, values, preferences, and quality of life.

Clinical Outcome in Patients with Nosocomial COVID-19 Infection After Thoracic Surgery

In the present study, we retrospectively evaluated outcomes in 8 patients (mean age 67 ± 7, range 55-77 years; male/female 7/1) who acquired nosocomial COVID-19 infection postoperatively out of the 39 adults who underwent elective thoracic surgery in November 2020. All patients were tested negative for COVID-19 on admission. The mortality rate in the eight patients was 25%. The surviving six patients were discharged in a good clinical condition. Fatal outcomes were due to the development of severe and unrelenting acute respiratory distress syndrome (ARDS) and were associated with preoperatively reduced serum albumin (<3 g/dL), an open surgical approach, oxygen saturation <90% at the time of COVID-19 diagnosis, and the real-time PCR cycle threshold (Ct) value <20. A high mortality rate indicates a need for systematic and frequent COVID-19 screening in patients scheduled for elective thoracic surgery and the use of minimally invasive procedures whenever feasible.

Tailored anaesthesia for thoracoscopic surgery promoting enhanced recovery: The state of the art

PURPOSE OF THE REVIEW

The current review focuses on precise anaesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery. The main aim of an enhanced recovery program after thoracic surgery is to reduce postoperative stress response, protect from postoperative pulmonary complications, give hospitals a better financial option and improve overall patient outcome. This can ultimately reduce hospital stay and increase patient satisfaction. With advances in endoscopic, robotic and endovascular techniques, video-assisted thoracoscopic surgery (VATS) can be performed in a minimally invasive way in managing most pulmonary, pleural and mediastinal diseases. As a minimally invasive technique, video-assisted thoracoscopic surgery (VATS) represents an important element of enhanced recovery program in thoracic surgery as it can achieve most of its goals. Anaesthetic management during preoperative, intraoperative and postoperative period is essential for the establishment of a successful enhanced recovery program. In the era of enhanced recovery protocols, non-intubated thoracoscopic procedures present a step forward. This article focuses on the key anaesthetic elements of the enhanced recovery program during all phases of thoracoscopic surgery. Having reviewed recent literature, a systematic review of literature will highlight successful ERAS protocols published for thoracoscopic surgery.

Preoperative coronary artery calcifications in veterans predict higher all-cause mortality in early-stage lung cancer: a cohort study

Background

Lung cancer patients often have comorbidities that may impact survival. This observational cohort study examines whether coronary artery calcifications (CAC) impact all-cause mortality in patients with resected stage I non-small cell lung cancer (NSCLC).

Methods

Veterans with stage I NSCLC who underwent resection at a single institution between 2005 and 2018 were selected from a prospectively collected database. Radiologists blinded to patient outcomes graded CAC severity (mild, moderate, or severe) in preoperative CT scans using a visual estimation scoring system. Inter-rater reliability was calculated using the kappa statistic. All-cause mortality was the primary outcome. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to compare time-to-death by varying CAC.

Results

The Veteran patients (n=195) were predominantly older (median age of 67) male (98%) smokers (96%). The majority (68%) were pathologic stage IA. Overall, 12% of patients had no CAC, 27% mild, 26% moderate, and 36% severe CAC. Median unadjusted survival was 8.8 years for patients with absent or mild CAC versus 6.3 years for moderate and 5.9 years for severe CAC (P=0.01). The adjusted hazard ratio for moderate CAC was 1.44 (95% CI, 0.85–2.46) and for severe CAC was 1.73 (95% CI, 1.03–2.88; P for trend <0.05).

Conclusions

The presence of severe CAC on preoperative imaging significantly impacted the all-cause survival of patients undergoing resection for stage I NSCLC. This impact on mortality should be taken into consideration by multidisciplinary teams when making treatment plans for patients with early-stage disease.

Postoperative Cardiac Ischemic Complications in Lung Cancer Patients

Background. Perioperative myocardial ischemia often complicates extracardiac surgery. The problems of its prediction, diagnostics, treatment and prevention are not solved. Frequency, structure and clinical features of cardiac ischemic complications of surgical treatment of lung cancer are not well understood.The aim of the study was to investigate the frequency of postoperative myocardial infarction and myocardial ischemia in the surgical treatment of patients with non-small cell lung cancer.Methods. The frequency (%) of myocardial infarction (MI) with and without ST segment elevation of electrocardiogram, acute myocardial ischemia in a complete sample of cancer patients (n = 2051) who underwent treatment for non-small cell lung cancer for the last 10 years was calculated. By comparing the relative indicators and calculating the Odds Ratio (OR), we studied the relationship between the cardiac ischemic events with age, type of surgery, prevalence and localization of the tumour. The clinical manifestations and pathomorphology of postoperative myocardial infarction were analysed.Results. Cardiac ischemic complications of thoracotomy for lung cancer occurred in 2.73 % (95% CI 1.98–3.48) cases. Myocardial infarction with ST segment elevation was recorded in 1.07 % (95% CI 0.58–1.57) patients, MI without ST segment elevation – in 0.54 % (95% CI 0.17–0.9), myocardial ischemia – in 1.12 % (95% CI 0.62–1.63). An increase in the frequency of ischemic events after pneumonectomy was observed compared with lobectomy (OR 6.5, 95% CI 3.5–12.2) and after right-sided pneumonectomy compared with left-sided one (OR 3.2, 95% CI 1.6–6.3), and also the age over 70. Hospital mortality from MI was 39.3 %. According to autopsies of patients who died of МI, coronary atherothrombosis was detected in 2 of 22 cases.Conclusion. In the surgical treatment of non-small cell lung cancer, cardiac ischemic events develop in 2.73 % of patients. The greatest risk is associated with right-sided pneumonectomy.

Anesthetic considerations for lung resection: preoperative assessment, intraoperative challenges and postoperative analgesia

This article is intended to provide a general overview of the anesthetic management for lung resection surgery including the preoperative evaluation of the patient, factors influencing the intraoperative anesthetic management and options for postoperative analgesia. Lung cancer is the leading cause of death among cancer patients in the United States. In patients undergoing lung resection, perioperative pulmonary complications are the major etiology of morbidity and mortality. Risk stratification of patients should be part of the preoperative assessment to predict their risk of short-term vs. long-term pulmonary complications. Improvements in surgical technique and equipment have made video assisted thoracoscopy and robotically assisted thoracoscopy the procedures of choice for thoracic surgeries. General anesthesia including lung isolation has become essential for optimizing visualization of the operative lung but may itself contribute to pulmonary complications. Protective lung ventilation strategies may not prevent acute lung injury from one-lung ventilation, but it may decrease the amount of overall lung injury by using small tidal volumes, positive end expiratory pressure, low peak and plateau airway pressures and low inspired oxygen fraction, as well as by keeping surgical time as short as possible. Because of the high incidence of chronic post-thoracotomy pain syndrome following thoracic surgery, which can impact a patient's normal daily activities for months to years after surgery, postoperative analgesia is a necessary part of the anesthetic plan. Multiple options such as thoracic epidural analgesia, intravenous narcotics and several nerve blocks can be considered in order to prevent or attenuate chronic pain syndromes. Enhanced recovery after thoracic surgery is a relatively new topic with many elements taken from the experience with colorectal surgery. The goal of enhanced recovery is to improve patient outcome by improving organ function and decreasing postoperative complications, and therefore decreasing length of hospital stay.

Simultaneous resection of thymic and bronchial carcinoid tumors in a patient diagnosed with multiple endocrine neoplasia type 1

Thymic carcinoid tumors are rare tumors which may be associated with multiple endocrine neoplasia type 1. Bronchial carcinoids are also rare tumors and associated with multiple endocrine neoplasia type 1. Coexisting of thymic and bronchial carcinoid tumors in this case is extremely rare. Herein, we report a unique case of coexistence of thymic and bronchial carcinoid tumors which were simultaneously resected via thoracotomy.

Preoperative Computed Tomography–Determined Sarcopenia and Postoperative Outcome After Surgery for Non-Small Cell Lung Cancer

Background:

Sarcopenia, reduced skeletal muscle mass, is associated with frailty, injuries, and mortality. The purpose of this study was to evaluate the impact of computed tomography–determined sarcopenia on surgical complications and outcomes after resection of non-small cell lung cancer.

Methods:

For a total 272 non-small cell lung cancer patients that underwent surgery between 2011 and 2016, cross-sectional area of muscle at the third lumbar vertebra (L3) was retrospectively measured using preoperative chest computed tomography images. Sarcopenia was defined as an L3 muscle index of <55 cm2/m2 for men and of <39 cm2/m2 for women. Clinical characteristics, postoperative complications, disease-free survival, and overall survival of patients with or without sarcopenia were compared.

Results:

A total of 60.3% ( n = 164) were male, and mean patient age was 62.9 ± 9.6 years. The prevalence of sarcopenia was 22.4% for all study subjects, 32.9% for men, and 6.5% for women. No significant difference was observed between patients with or without sarcopenia in terms of intensive care unit or hospital stay ( p = 0.502 and p = 0.378, respectively), and the presence of sarcopenia was not associated with postoperative complications. Furthermore, no significant difference was observed between the 3-year disease-free survival rate (74.3% vs 66.7%, p = 0.639) or 3-year overall survival rate (83.9% vs 87.7%, p = 0.563) of patients with or without sarcopenia.

Conclusion:

Sarcopenia as determined by preoperative computed tomography does not appear to have a negative impact on surgical outcome or overall survival for resected non-small cell lung cancer patients.

Intensive care in thoracic oncology

The admission of lung cancer patients to intensive care is related to postprocedural/postoperative care and medical complications due to cancer or its treatment, but is also related to acute organ failure not directly related to cancer.

Despite careful preoperative risk management and the use of modern surgical and anaesthetic techniques, thoracic surgery remains associated with high morbidity, related to the extent of resection and specific comorbidities. Fast-tracking processes with timely recognition and treatment of complications favourably influence patient outcome. Postoperative preventive and therapeutic management has to be carefully planned in order to reduce postoperative morbidity and mortality.

For patients with severe complications, intensive care unit (ICU) mortality rate ranges from 13% to 47%, and hospital mortality ranges from 24% to 65%. Common predictors of in-hospital mortality are severity scores, number of failing organs, general condition, respiratory distress and the need for mechanical ventilation or vasopressors. When considering long-term survival after discharge, cancer-related parameters retain their prognostic value.

Thoracic surgeons, anesthesiologists, pneumologists, intensivists and oncologists need to develop close and confident partnerships aimed at implementing evidence-based patient care, securing clinical pathways for patient management while promoting education, research and innovation. The final decision on admitting a patient with lung to the ICU should be taken in close partnership between this medical team and the patient and his or her relatives.

Coronary artery disease is associated with an increased mortality rate following video-assisted thoracoscopic lobectomy

OBJECTIVE

To compare the incidence of major adverse cardiac events (MACE) and mortality following video-assisted thoracoscopic surgery (VATS) lobectomy in patients with and without coronary artery disease (CAD).

METHODS

Multicentre retrospective analysis of 1699 patients undergoing VATS lobectomy (January 2012-March 2015). CAD definition: previous acute myocardial infarct (AMI), angina, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). MACE definition: postoperative acute myocardial ischemia, cardiac arrest or any cardiac death. Propensity score analysis was performed to match patients with and without CAD. Outcomes of the 2 matched groups were compared.

RESULTS

The incidence of MACE and mortality for the entire population was 0.4% (7 patients) and 1.7% (29 patients); 218 patients (13%) had a history of CAD: 106 previous AMI, 55 angina, 32 CABG, and 81 PCI. The propensity score yielded 2 well-balanced groups of 218 pairs with and without CAD. MACE (CAD 2 [0.9%] vs no-CAD 1 [0.5%]; P = 1), cardiovascular and pulmonary complications (CAD 61 [28%] vs no-CAD 51 [23%]; P = .3) and postoperative stay (CAD 7.3 days vs no-CAD 6.2 days; P = .3) were not different between the groups. The incidence of atrial fibrillation (CAD 31 [14%] vs no-CAD 18 [8.2%]; P = .07), 30-day mortality (CAD: 11 [5%] vs no-CAD 2 [0.9%]; P = .02) and death among complicated patients (CAD 18% vs no-CAD 3.9%; P = .009) were higher in the CAD group.

CONCLUSIONS

The incidence of MACE following VATS lobectomy in patients with CAD is low and similar to patients without CAD. However, their risk of postoperative mortality is fivefold higher compared with non-CAD patients, warranting refined preoperative functional evaluation and more intense postoperative monitoring.

Impact of Increasing Age on Cause-Specific Mortality and Morbidity in Patients With Stage I Non-Small-Cell Lung Cancer: A Competing Risks Analysis

Purpose To perform competing risks analysis and determine short- and long-term cancer- and noncancer-specific mortality and morbidity in patients who had undergone resection for stage I non-small-cell lung cancer (NSCLC). Patients and Methods Of 5,371 consecutive patients who had undergone curative-intent resection of primary lung cancer at our institution (2000 to 2011), 2,186 with pathologic stage I NSCLC were included in the analysis. All preoperative clinical variables known to affect outcomes were included in the analysis, specifically, Charlson comorbidity index, predicted postoperative (ppo) diffusing capacity of the lung for carbon monoxide, and ppo forced expiratory volume in 1 second. Cause-specific mortality analysis was performed with competing risks analysis. Results Of 2,186 patients, 1,532 (70.1%) were ≥ 65 years of age, including 638 (29.2%) ≥ 75 years of age. In patients < 65, 65 to 74, and ≥ 75 years of age, 5-year lung cancer-specific cumulative incidence of death (CID) was 7.5%, 10.7%, and 13.2%, respectively (overall, 10.4%); noncancer-specific CID was 1.8%, 4.9%, and 9.0%, respectively (overall, 5.3%). In patients ≥ 65 years of age, for up to 2.5 years after resection, noncancer-specific CID was higher than lung cancer-specific CID; the higher noncancer-specific, early-phase mortality was enhanced in patients ≥ 75 years of age than in those 65 to 74 years of age. Multivariable analysis showed that low ppo diffusing capacity of lung for carbon monoxide was an independent predictor of severe morbidity ( P < .001), 1-year mortality ( P < .001), and noncancer-specific mortality ( P < .001), whereas low ppo forced expiratory volume in 1 second was an independent predictor of lung cancer-specific mortality ( P = .002). Conclusion In patients who undergo curative-intent resection of stage I NSCLC, noncancer-specific mortality is a significant competing event, with an increasing impact as patient age increases.

Preoperative functional workup for patients with advanced lung cancer

Locally advanced lung cancer remains a surgical indication in selected patients. This condition often demands larger resections. As a consequence preoperative functional workup is of paramount importance to stratify the risk and choose the most appropriate treatment. We reviewed the current evidence on functional evaluation with a special focus on specific aspects related to locally advanced lung cancer stages (i.e., risk after neoadjuvant treatment, pneumonectomy). Evidence is discussed to provide information that could assist clinicians in their preoperative workup of these challenging patients.

Surgery for non-small cell lung cancer in patients with a history of cardiovascular surgery

Purpose

To clarify if previous cardiovascular surgery (CVS) affects the postoperative outcome of surgery for non-small cell lung cancer (NSCLC).

Methods

We reviewed, retrospectively, the medical records of 36 patients with a history of CVS, who underwent lung cancer surgery at a single institution (study group; SG) and compared their characteristics and postoperative outcomes with those of patients without a history of CVS history (control group; CG), and also with those of patients with coexisting cardiovascular diseases in the CG (specified control group; SCG). Finally, we used a thoracic revised cardiac risk index (ThRCRI) to evaluate the risk of perioperative cardiovascular events.

Results

There was a significant difference in the ThRCRI classifications between the SG and the SCG (p < 0.0001). There were no significant differences in the incidence of intraoperative and postoperative complications between the SG and CG, or between the SG and SCG. The 5-year survival rates of the SG, CG, and SCG were 69.3, 73.9, and 65.4 % in all stages, and 83.5, 82.2, and 70.4 % in stage I, respectively.

Conclusions

Previous CVS did not increase the number of perioperative cardiovascular events in this study and had no significant influence on the prognosis of patients undergoing resection of NSCLC.

Prediction of Surgical Outcome by Modeling Based on Risk Factors of Morbidity After Pulmonary Resection for Lung Cancer in Older Adults

BACKGROUND

Surgical treatment for older patients with lung cancer presents more challenges compared with general population. The aim of the study was to predict surgical outcome after pulmonary resection in older patients with lung cancer by developing a clinical model.

METHODS

Clinical records of 525 patients who were older than 70 years of age and who underwent pulmonary resection for lung cancer in a single center were reviewed. Patients were divided into three ordered categories of surgical outcome according to the Clavien-Dindo classification. By using a development cohort of 401 patients, an ordinal logistic regression was performed to develop a prediction model for surgical outcome. The model was internally validated by the bootstrap method and was externally validated by another cohort of 124 patients. Two previous models were tested as benchmarks of our model.

RESULTS

The model was developed based on five risk factors of morbidity: American Society of Anesthesiologists classification (p < 0.001), pulmonary disease (p = 0.001), tumor size (p = 0.011), tumor location (p = 0.015), and surgical approach (p = 0.036). The c-statistic of the model was 0.75 (95% confidence interval: 0.69 to 0.80), which was similar to the bootstrapping one (0.75; 95% confidence interval: 0.68 to 0.80). The Hosmer-Lemeshow test showed a strong goodness of fit of the model (p = 0.674). In external validation, the performance of our model was superior to that of the two previous models.

CONCLUSIONS

Our model displayed an acceptable ability to predict surgical outcome in older patients undergoing pulmonary resection for lung cancer. Use of the model can be helpful in decision making about surgical treatment in this special population.

Thoracoscopic Mesh Repair of Diaphragmatic Defects in Hepatic Hydrothorax: A 10-Year Experience

BACKGROUND

The objective was to analyze the outcomes of thoracoscopic mesh repair for hepatic hydrothorax (HH) at our institution during the past 10 years.

METHODS

A total of 63 patients with refractory HH who underwent thoracoscopic mesh onlay reinforcement to repair diaphragmatic defects from January 2005 to December 2014 were included in the study. Mesh covering alone was used in 47 patients and mesh with suturing was used in 16 patients. Patient demographics, Child-Pugh class, and model for end-stage liver disease (MELD) score were evaluated to predict morbidity and mortality.

RESULTS

Of the patients (mean age, 60.4 ± 15 years; 31 men and 32 women), 14.3% had concomitant underlying diseases of renal insufficiency, 34.9% had diabetes mellitus, and 4.8% had pneumonia. Diaphragmatic blebs were the most common diaphragmatic defects (29 of 63 [46%]). After a median 20.5 months of follow-up examinations, 4 patients experienced recurrence. The 1-month mortality rate was 9.5% (6 of 63 patients). On multivariable analysis, underlying impaired renal function (p = 0.039) and MELD scores (p = 0.048) were associated with increased 3-month mortality in 16 patients. Contrary to the rising Child-Pugh score (p = 0.058), rising MELD scores represented an increase in kidney or liver failure and mortality. The main causes of 3-month mortality were septic shock (n = 6), acute renal insufficiency (n = 4), gastrointestinal bleeding (n = 4), hepatic encephalopathy (n = 1), and ischemic bowel (n = 1).

CONCLUSIONS

Thoracoscopic mesh repair for refractory HH improves symptoms and lowers the recurrence rate.