Ninety-Day Mortality: Redefining the Perioperative Period After Lung Resection

Predictive value of gradient boosting decision trees for postoperative atelectasis complications in patients with pulmonary destruction

OBJECTIVE

To explore the application value of a gradient boosting decision tree (GBDT) in predicting postoperative atelectasis in patients with destroyed lungs.

METHODS

A total of 170 patients with damaged lungs who underwent surgical treatment in Chest Hospital of Guangxi Zhuang Autonomous Region from January 2021 to May 2023 were retrospectively selected. The patients were divided into a training set (n = 119) and a validation set (n = 51). Both GBDT algorithm model and Logistic regression model for predicting postoperative atelectasis in patients were constructed. The receiver operating characteristic (ROC) curve, calibration curve and decision curve were used to evaluate the prediction efficiency of the model.

RESULTS

The GBDT model indicated that the relative importance scores of the four influencing factors were operation time (51.037), intraoperative blood loss (38.657), presence of lung function (9.126) and sputum obstruction (1.180). Multivariate Logistic regression analysis revealed that operation duration and sputum obstruction were significant predictors of postoperative atelectasis among patients with destroyed lungs within the training set (P = 0.048, P = 0.002). The ROC curve analysis showed that the area under the curve (AUC) for GBDT and Logistic model in the training set was 0.795 and 0.763, and their AUCs in the validation set were 0.776 and 0.811. The GBDT model's predictions closely matched the ideal curve, showing a higher net benefit than the reference line.

CONCLUSIONS

GBDT model is suitable for predicting the incidence of complications in small samples.

The impact of preoperative coronavirus disease 19 infection on early postoperative mortality during the vaccination era: a nationwide retrospective cohort study

BACKGROUND

We aimed to investigate the optimal surgical timing in patients with preoperative coronavirus disease 2019 (COVID-19) infection to minimize postoperative morbidity and mortality during the COVID-19 vaccination era.

METHODS

The Korean nationwide data on patients who underwent standard surgery under general anesthesia in 2021 were analyzed. Patients were categorized based on the time from COVID-19 diagnosis to surgery: 0-4, 5-8, > 8 weeks, and those without preoperative COVID-19 infection. Multivariable logistic regression analysis, considering preoperative COVID-19 vaccination status (fully vaccinated vs. unvaccinated or partially vaccinated), was performed to associate the preoperative COVID-19 infection timing with 30- and 90-day postoperative mortality and 30-day respiratory complications.

RESULTS

Among the 750,175 included patients, 28.2% were preoperatively fully vaccinated. Compared with patients without prior COVID-19 infection, those who had surgery 0-4 weeks (adjusted odds ratio [OR]: 4.28, 95% CI [1.81, 10.13], P = 0.001) and 5-8 weeks (adjusted OR: 3.38, 95% CI [1.54, 7.44], P = 0.002) after COVID-19 infection had a significantly increased risk of 30-day mortality. Preoperative full vaccination was significantly associated with a decrease in 90-day mortality (adjusted OR: 0.93, 95% CI [0.89, 0.98], P = 0.007) and 30-day respiratory complications (adjusted OR: 0.85, 95% CI [0.82, 0.87], P < 0.001), but not with 30-day mortality (P = 0.916).

CONCLUSIONS

COVID-19 infection eight weeks preoperatively was associated with an increased 30-day postoperative mortality. Preoperative full vaccination was not associated with 30-day mortality but was related to lower risk of 90-day mortality and 30-day respiratory complications.

Efficacy and safety comparison of neoadjuvant chemotherapy followed by surgery and upfront surgery for treating intrahepatic cholangiocarcinoma: a systematic review and meta-analysis

BACKGROUND AND AIMS

Currently, surgical resection is the most commonly performed and effective treatment for intrahepatic cholangiocarcinoma (ICC) worldwide. However, the prognosis of ICC is unsatisfactory. This study aimed to compare the efficacy and safety of neoadjuvant chemotherapy followed by surgery and upfront surgery in treating intrahepatic cholangiocarcinoma (ICC). The study also intends to explore whether chemotherapy should be introduced before surgery and which populations should be considered for neoadjuvant chemotherapy.

METHOD

Four databases, including PubMed, EMBASE, Cochrane Library, and Web of Science, were searched from their inception dates to January 2022 for relevant articles. The statistical analysis was performed using the Review Manager Software (version5.3). The non-randomized interventions (ROBINS-I) was used to assess the methodological quality of included studies and the overall quality of evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. Moreover, the primary outcomes included 1-year, 3-year and 5-year overall survival (OS), while the secondary outcomes were R0 resection, 1-year, 3-year and 5-year recurrence-free survival (RFS), postoperative complications and ninety-day postoperative mortality.

RESULTS

Five studies involving 2412 patients were included in this meta-analysis. There was no significant difference in 1-year OS, 3-year OS, 1-year, 3-year and 5-year RFS, postoperative complications and ninety-day postoperative mortality between the two groups. However, the meta-analysis showed that the neoadjuvant chemotherapy group had a better 5-year OS benefit in ICC patients than the upfront surgery group (OR = 1.27, 95% CI: 1.02-1.58), while the R0 resection rate was lower in neoadjuvant chemotherapy group than that in the upfront surgery group (OR = 0.49, 95% CI: 0.26-0.91).

CONCLUSION

Compared with the upfront surgery, neoadjuvant chemotherapy followed by surgery could prolong the 5-year OS without increasing the risk of postoperative complications in ICC patients. Considering that the patients in the neoadjuvant chemotherapy followed by surgery group had more advanced ICC cases, the benefits of neoadjuvant chemotherapy may be more significant in patients with more advanced ICC.

Neoadjuvant Chemotherapy vs Chemoradiation Therapy Followed by Sleeve Resection for Resectable Lung Cancer

BACKGROUND

Traditionally, neoadjuvant chemoradiation therapy is followed by resection in patients with locally advanced non-small cell lung cancer (NSCLC). The risks and benefits of this approach are not well defined in patients requiring a sleeve lung resection. In this context, we compare the short- and long-term outcomes of neoadjuvant chemotherapy alone vs chemoradiation therapy followed by sleeve lung resection.

METHODS

We used the National Cancer Database to identify locally advanced NSCLC patients who received chemotherapy-alone or chemoradiation therapy in the neoadjuvant setting, followed by a sleeve lung resection, between 2006 and 2017. Our outcomes of interest were 30-day mortality, 90-day mortality, and overall survival. To minimize confounding by indication, we used propensity score adjustment, logistic regression, Kaplan-Meier survival analysis, and Cox proportional hazards models to identify associations.

RESULTS

Of 176 patients undergoing sleeve lung resection, 92 (52.3%) received neoadjuvant chemotherapy-alone, and 84 (47.7%) received neoadjuvant chemoradiation therapy. Patients in both groups were well balanced in age, sex, race, Charlson-Deyo comorbidity index, insurance status, median income, and education (all P > .05). Similarly, the groups were well balanced in histology, tumor location, and stage (all P > .05). Patients receiving neoadjuvant chemoradiation therapy had higher 90-day mortality (11.96% vs 2.38%, P = .015), and there was no difference in overall survival between the neoadjuvant chemotherapy-alone vs chemoradiation therapy cohorts (P = .621).

CONCLUSIONS

In this national study of patients with locally advanced resectable NSCLC requiring a sleeve lung resection, neoadjuvant chemoradiation therapy was associated with a 5-fold increase in 90-day mortality without an overall survival benefit over neoadjuvant chemotherapy-alone.

Pneumonectomy for primary lung cancer: contemporary outcomes, risk factors and model validation

OBJECTIVES

Despite the increased rate of adverse outcomes compared to lobectomy, for selected patients with lung cancer, pneumonectomy is considered the optimal treatment option. The objective of this study was to identify risk factors for mortality in patients undergoing pneumonectomy for primary lung cancer.

METHODS

Data from all patients undergoing pneumonectomy for primary lung cancer at 2 large thoracic surgical centres between 2012 and 2018 were analysed. Multivariable logistic and Cox regression analyses were used to identify risk factors associated with 90-day and 1-year mortality and reduced long-term survival, respectively.

RESULTS

The study included 256 patients. The mean age was 65.2 (standard deviation 9.4) years. In-hospital, 90-day and 1-year mortality were 6.3% (n = 16), 9.8% (n = 25) and 28.1% (n = 72), respectively. The median follow-up time was 31.5 months (interquartile range 9-58 months). Patients who underwent neoadjuvant therapy had a significantly increased risk of 90-day [odds ratio 6.451, 95% confidence interval (CI) 1.867-22.291, P = 0.003] and 1-year mortality (odds ratio 2.454, 95% CI 1.079-7.185, P = 0.044). Higher Performance Status score was associated with higher 1-year mortality (odds ratio 2.055, 95% CI 1.248-3.386, P = 0.005) and reduced overall survival (hazard ratio 1.449, 95% CI 1.086-1.934, P = 0.012). Advanced (stage III/IV) disease was associated with reduced overall survival (hazard ratio 1.433, 95% CI 1.019-2.016, P = 0.039). Validation of a pneumonectomy-specific risk model demonstrated inadequate model performance (area under the curve 0.54).

CONCLUSIONS

Pneumonectomy remains associated with a high rate of perioperative mortality. Neoadjuvant chemoradiotherapy, Performance Status score and advanced disease emerged as the key variables associated with adverse outcomes after pneumonectomy in our cohort.