Factors affecting major morbidity after video-assisted thoracic surgery for lung cancer

Small airway dysfunction associated with poor short-term outcomes in patients undergoing thoracoscopic surgery for lung cancer

BACKGROUND

Although small airway dysfunction is a common respiratory dysfunction, its prognosis after lung cancer surgery is often neglected. This study investigated the relationship between small airway dysfunction and outcomes in patients who underwent thoracoscopic surgery for lung cancer.

METHODS

A retrospective cohort study of patients who underwent thoracoscopic surgery was conducted between December 2019 and March 2021 at Ningbo First Hospital. We used univariate and multivariate analyses to assess the possible associations between postoperative outcomes and clinical variables, including small airway dysfunction. To balance the potential confounding factors, propensity score matching was performed to establish 1:1 small airway dysfunction and small airway normal function group matching.

RESULTS

In this study, 1,012 patients undergoing thoracoscopic surgery for lung cancer were enrolled. Small airway dysfunction was present in 18.7% of patients (189/1,012). The incidence of postoperative pulmonary complications in the small airway dysfunction group was higher than that of the small airway normal function group (16.4% vs 6.2%, P < .001). The most significant postoperative pulmonary complications were pneumonia (7.4% vs 2.4%, P < .001) in the small airway dysfunction and normal function groups, respectively. In addition, a significantly prolonged median hospital length of stay was observed in the small airway dysfunction group compared to the small airway normal function group (median [interquartile range], 9 [7-12] vs 8 [7-9], P < .001). After 1:1 propensity score matching, 298 patients (149 pairs) were included in the comparison between small airway dysfunction and small airway normal function, and this association remained. Postoperative pulmonary complications (13.4% vs 6.0%, P = .032) were still higher, and length of stay (median [interquartile range] 9 [7-11] vs 8 [6-10] days, P = .001) was still longer in the small airway dysfunction group. Multivariate analysis indicated that small airway dysfunction was the independent risk factor associated with both postoperative pulmonary complications (odds ratio = 2.694, 95% confidence interval: 1.640-4.426, P < .001) and prolonged length of stay (beta = 1.045, standard error = 0.159, 95% confidence interval: 0.733-1.357, P < .001).

CONCLUSION

Our study showed that small airway dysfunction increased the incidence of postoperative pulmonary complications and prolonged length of stay in patients undergoing thoracoscopic surgery for lung cancer.

[Perioperative pain therapy in minimally invasive thoracic surgery]

Thoracic surgery is often associated with severe postoperative pain levels. Even though these are less pronounced in thoracoscopic approaches, mechanical irritation, compression or injury of intercostal nerves and placement of chest tubes can cause pain levels, which must be treated. An adequate pain therapy in thoracic surgery is essential as insufficient inspiration due to inadequate analgesia may result in postoperative complications. Epidural anesthesia was considered the gold standard in thoracotomy for a long time. For video-assisted thoracoscopy, however, it is sometimes no longer recommended due to its benefit-risk ratio. Alternative thoracic blocks are the paravertebral block, the erector spinae plane block and the serratus anterior block, for which research has found heterogeneous results.This article summarizes the current recommendations for perioperative management of thoracoscopic surgery and gives an overview of the PROSPECT recommendations as well as the current Association of the Scientific Medical Societies in Germany (AWMF) guidelines for perioperative and postoperative pain therapy. In particular, individual regional anesthesia techniques and their current evidence are reviewed.

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

Background

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

Methods

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

Results

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

Conclusion

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

Application Value of PET/CT and MRI in the Diagnosis and Treatment of Patients With Synchronous Multiple Pulmonary Ground-Glass Nodules

Background

Synchronous multiple ground-glass nodules (SMGGNs) in synchronous multiple lung cancers are associated with specific imaging findings. It is difficult to distinguish whether multiple nodules are primary tumors or metastatic lesions in the lungs. The need for PET/CT and contrast-enhanced brain MRI for these patients remains unclear. This study investigated the necessity of these two imaging examinations for SMGGN patients by means of retrospective analysis.

Methods

SMGGN patients who were diagnosed and treated in our hospital from October 2017 to May 2020 and underwent whole-body PET/CT(Cranial excepted) and/or contrast-enhanced brain MRI+DWI were enrolled in this study. We analyzed the imaging and clinical characteristics of these patients to evaluate SMGGN patients’ need to undergo whole-body PET/CT and brain MRI examination.

Results

A total of 87 SMGGN patients were enrolled. 51 patients underwent whole-body PET/CT examinations and did not show signs of primary tumors in other organs, metastatic foci in other organs, or metastasis to surrounding lymph nodes. 87 patients underwent whole-brain MRI, which did not reveal brain metastases but did detect an old cerebral infarction in 23 patients and a new cerebral infarction in one patient. 87 patients underwent surgical treatment in which 219 nodules were removed. All nodules were diagnosed as adenocarcinoma or atypical adenomatous hyperplasia. No lymph node metastasis was noted.

Conclusion

For SMGGN patients, PET/CT and enhanced cranial MRI are unnecessary for SMGGNs patients, but from the perspective of perioperative patient safety, preoperative MRI+DWI examination is recommended for SMGGNs patients.

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

Background

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

Methods

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

Results

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

Conclusions

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

To tube or not to tube: a skeptic's guide to nonintubated thoracic surgery

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the rationale and evidence for nonintubated thoracic surgery and guide clinicians, considering the implementation of nonintubated thoracic surgery, to find an anesthetic approach suitable for their department.

RECENT FINDINGS

Based on physiologic considerations alone, nonintubated thoracic surgery would be expected to be an advantageous concept in thoracic anesthesia, especially in patients at high risk for pulmonary complications. Currently existing evidence, however, does not support these claims. Although the feasibility and safety have been repeatedly demonstrated, high-quality evidence showing a significant benefit regarding clinically relevant patient-centered outcomes is not available.Anesthetic approaches to nonintubated thoracic surgery differ significantly; however, they usually concentrate on six main aspects: maintenance of airway patency, respiratory support, analgesia, patient comfort, cough suppression, and conversion techniques. Given the lack of high-quality studies comparing different techniques, evidence-based guidance of clinical decision-making is currently not possible. Until further evidence is available, anesthetic management will depend mostly on local availability and expertise.

SUMMARY

In select patients and with experienced teams, nonintubated thoracic surgery can be a suitable alternative to intubated thoracic surgery. Until more evidence is available, however, a general change in anesthetic management in thoracic surgery is not justified.

Changes in the Risk of Mortality and Morbidity After Lung Resection in the Last 20 Years

INTRODUCTION

The aim of this study is to evaluate changes in the risk of cardiorespiratory mortality and morbidity calculated by Eurolung risk models 1 and 2 in the last 20 years, and to identify variations in patient selection or surgical practice that might have altered the risk of death and complications after anatomical lung resections.

METHOD

This was a retrospective analysis of a series of 2,435 consecutive patients who underwent anatomical lung resection. The population was divided into three time periods: 1994-2006 (976 cases), 2007-2015 (945 cases), and 2016-2017 (420 cases). Eurolung models 1 and 2 were applied to the series, and the individual probability of adverse effects was calculated. We compared this mean probability, and the prevalence or means of each of the variables included in the models in each period and plotted the evolution of the risk.

RESULTS

A progressive decrease was observed in both adverse effects over time. The prevalence of the binary variables, except for coronary heart disease, was higher in the last period. The percentage of pneumonectomies and extended resections fell in the last two periods and the number of cases treated with VATS increased substantially in 2016-2017.

CONCLUSIONS

The decline in the number of pneumonectomies and the increase in the rate of minimally invasive procedures appear to be the variables most closely associated with decreased risk. Other changes in the clinical characteristics of the patients do not seem to have influenced the outcomes.

Video-assisted thoracoscopic lobectomy: which patients require postoperative physiotherapy?

OBJECTIVES

Following major thoracic surgery physiotherapy is recommended to improve reduced lung volume, aid secretion clearance, and improve mobility, however, in many centres physiotherapy provision is variable following minimally invasive video-assisted thoracoscopic surgery (VATS). The objective of this study was to observe frequency of problems potentially amenable to physiotherapy following VATS lobectomy, and to identify associated baseline factors of patients in whom physiotherapy may be beneficial.

METHODS

A prospective observational study was performed including all consecutive cancer patients undergoing VATS lobectomy in a regional centre over 4years (2012-2016). Standard postoperative care included early mobilisation by nursing staff from postoperative day one (POD1). Physiotherapy assessment of all patients on POD1 determined presence of issues potentially amenable to physiotherapy intervention, and treatment was commenced. Outcome measures included postoperative pulmonary complication (PPC) development, hospital and high dependency unit (HDU) length of stay (LOS).

RESULTS

Of 285 patients, 209 (73%) received physiotherapy to assist/improve reduced mobility, of these 23 (8%) also received sputum clearance therapies and 65 (23%) specific therapy for lung volume loss. The remaining 76 (27%) patients had significantly lower hospital/HDU LOS (P<0.001) reflecting uncomplicated recovery. Chronic obstructive pulmonary disease (COPD), body mass index (BMI), preoperative mobility and age were independently associated with issues potentially amenable to physiotherapy (P=0.013).

CONCLUSION

Following VATS lobectomy a large proportion of patients demonstrated issues potentially amenable to physiotherapy. The authors recommend that patients receive routine physiotherapy assessment following this type of surgery to ensure that all issues are identified early. Screening of COPD, BMI, preoperative mobility and age will allow early identification of patients who may benefit most from postoperative physiotherapy and preoperative optimisation, however, these factors cannot predict the need for physiotherapy.

Lung Cancer and Pulmonary Embolism: What Is the Relationship? A Review

Pulmonary embolism (PE) is gradually considered to be the third most common disease in the vascular disease category. Lung cancer is the most frequently diagnosed cancer and the leading cause of cancer death among males worldwide. Although initially appearing as distinct entities, lung cancer is a great risk factor for the development of PE. Pulmonary embolism is common in lung cancer patients, with a pooled incidence of 3.7%, and unsuspected pulmonary embolism (UPE) is also non-negligible with a rough rate ranging from 29.4% to 63%. Many risk factors of PE have been detected and could be classified into three categories: lung cancer-related, patient-related, and treatment-related factors. Decreased mean survival time could be significantly observed in lung cancer patients with PE or UPE compared to those only, but suspected PE has higher mortality than UPE. Prophylactic anticoagulant therapy benefit might be highest in patients with stage IV non-small cell lung cancer (NSCLC) or limited small cell lung cancer (SCLC), and heparin seems superior to warfarin for thrombotic prophylaxis. Periodically reassessing the risk-benefit ratio of anticoagulant treatment will be an efficient treatment strategy in lung cancer patients with PE.

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

Background

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

Methods

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

Results

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

Conclusions

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

Surgery for lung tumors in the elderly: A retrospective cohort study on the influence of advanced age (over 80 years) on the development of complications by using a multivariate risk model

BACKGROUND

The prevalence of lung cancer and other tumors is increasing among the elderly people. The purpose of this study was to examine the influence of advanced age (80 + years) on the immediate perioperative outcome as well as to define potential risk factors that may lead to increasing morbidity and mortality after lung resections.

METHODS

A retrospective cohort analysis of the data from an electronic database of 208 elderly patients (165 patients ≥70 years, 45 patients ≥80 years) undergoing pulmonary anatomical resection for lung tumors during January 2013-December 2016 was conducted. The patients were initially observed and then divided into two groups: septuagenarians and octogenarians. The risk of developing postoperative complications in association with the numerous observed factors, which appeared significant in univariate tests, was assessed using univariate and multivariate logistic regression analyses to construct a risk model that assesses the highest chance of developing complications. Readmission rate and mortality within 90 days were recorded.

RESULTS

There were 140 men and 68 women with the mean age of 76 ± 4 years. A total of 15 pneumonectomies (7.2%), 11 bilobectomies (5.3%), 27 segmentectomies (13%), and 155 lobectomies (74.5%) were performed through 84 thoracotomies (40.4%) and 124 video-assisted thoracoscopic surgery (VATS) procedures (59.6%). Ninety-one patients (44%) exhibited at least one of 113 postoperative complications. There were four deaths (1.9%). Readmission rate was 12%, and 90-day mortality was 5.3%. There was no difference in postoperative morbidity among the groups according to their age (RR = 0.95; p = 78). According to multivariate logistic regression, adjusted Charlson Comorbidity Index≥11, FEV₁≤0.72, DLCO≤0.57, male gender, and nonsegmentectomies appeared to be strong predictors for the development of complications.

CONCLUSIONS

In this cohort, age more than 80 years was not found to be significant for the development of complications, when compared to the septuagenarians. Female gender, better lung function (FEV1>72%, DLCO>57%), less comorbidities (ACCI<11), and segmentectomy type of lung resection were associated with improved outcomes.

Comorbidities with non-small cell lung cancer: Is there an interdisciplinary consensus needed to qualify patients for surgical treatment?

INTRODUCTION:

Radical surgical treatment is the preferred action for patients with early-stage non-small cell lung cancer (NSCLC). Qualification for surgical treatment should consider a risk associated with the effect of comorbidities on the general condition of the patient. The aim of this article was an attempt to identify the risk factors for postoperative complications in patients treated for NSCLC, with a special focus on the coexisting diseases.

METHODS:

A total of 400 patients with NSCLC were included in this retrospective study. The incidence of postoperative complications (including major complications according to the European Society of Thoracic Surgeons [ESTS]) was analyzed. Factors associated with high risk of postoperative complications were identified.

RESULTS:

Postoperative complications occurred in 151 patients (39% operated patients), including severe complications according to ESTS in 75 patients (19%). From univariate analysis, risk factors for postoperative complications were arrhythmias, pneumonectomy, and open thoracotomy. According to ESTS, for major complications, the risk factors included age ≥65 years, the presence of comorbidities, hypertension, and arrhythmias. From multivariate analysis, the risk of complications was higher in patients undergoing pneumonectomy and with cardiac arrhythmias, whereas the risk of serious complications according to ESTS was found in people ≥65 years of age and suffering from comorbidities.

CONCLUSIONS:

The risk of postoperative complications is affected by both surgical factors and the general health of the patient. Elderly patients with chronic disease history, hypertension, and arrhythmias have an increased risk of postoperative complications. Knowledge of these factors will identify a group of patients requiring internal consultation and optimization of preoperative treatment and postoperative follow-up.

[Analysis of Postoperative Complications and Risk Factors of Patients with Lung Cancer through Clavien-Dindo Classification]

背景与目的

术后并发症是肺切除术后患者死亡的重要原因。在本研究中，我们应用Clavien-Dindo并发症分级系统对肺癌术后并发症按照严重程度进行分级，并分析术后并发症的发生率，探讨不同分级术后并发症的危险因素。

方法

回顾性分析2013年6月-2014年12月四川大学华西医院胸外科966例行肺叶切除术的肺癌患者，依据术后30 d内是否发生并发症将此966例患者分为并发症组与无并发症组；同时根据Clavien-Dindo分级系统将并发症分为4级，并针对不同分级的并发症进行危险因素分析。

结果

966例患者中，并发症组占15.0%（145/966），发生总数380次；依据Clavien-Dindo分级系统将此380次并发症进行分级，其中Ⅰ级、Ⅱ级、Ⅲ级、Ⅳ级及以上分别占6.8%、75.3%、15.0%和2.9%。Logistic回归分析结果显示术前第1秒用力呼气容积（forded expiratory volume in one second, FEV₁）、肺一氧化碳弥散量（diffusion capacity for carbon monoxide of the lung single breath, DLco SB）及术前合并慢性阻塞性肺疾病（chronic obstructive pulmonary disease, COPD）是术后并发症的独立危险因素；其中术前FEV₁是Ⅰ级、Ⅱ级、Ⅲ级及以上并发症的独立危险因素。

结论

在Clavien-Dindo分级系统下，Ⅱ级并发症在术后30天内最常见；FEV₁与术后并发症的发生密切相关，可作为评估术后并发症发生风险的可靠指标之一。

Trends in use and safety of image-guided transthoracic needle biopsies in patients with cancer

PURPOSE

Image-guided transthoracic needle biopsy (IGTTNB) is an important tool in the diagnosis of patients with cancer. Common complications include pneumothorax and chest tube placement, with rates ranging from 6% to 57%. We performed a population-based study to determine patterns of use, complications, and costs associated with IGTTNB.

METHODS

The Premier Perspective database was used to identify patients with cancer with ≥ one claim for IGTTNB from 2006 to 2012. Patients were stratified on the basis of inpatient versus outpatient setting. Pneumothorax was defined by a new claim within 1 month of IGTTNB; hospitalization and chest tube placement rates were analyzed. Multivariable analysis was used to identify factors associated with pneumothorax.

RESULTS

We Identified 79,518 patients with cancer who underwent IGTTNB: 42,955 (54.0%) outpatients and 36,563 (46.0%) inpatients. Of patients who underwent outpatient IGTTNB, 5,261 (12.2%) developed a pneumothorax. Of those, 1,006 (19.1%, 2.3% of total) were hospitalized, and 180 (3.4%, 0.42% of total) required chest tubes. Pneumothorax after outpatient IGTTNB was associated with number of comorbidities, rural site, hospital bed size of more than 600, and biopsy of parenchymal as opposed to pleural lesions. Of patients who underwent inpatient IGTTNB, 7,830 (21.4%) developed a pneumothorax, and 2,894 (36.0%, 7.9% of total) required chest tube. Over time, total IGTTNB volume increased by 40.6%, and mean outpatient cost per procedure increased by 24.4%.

CONCLUSION

While pneumothorax was frequent in outpatients, rates of hospitalization and chest tube placement were low. As screening for lung cancer increases, we anticipate an increased need for IGTNBB. Patients can be reassured by the low rate of serious complications.