Time in the stair-climbing test as a predictor of thoracotomy postoperative complications

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Stair-Climbing Tests or Self-Reported Functional Capacity for Preoperative Pulmonary Risk Assessment in Patients with Known or Suspected COPD-A Prospective Observational Study

BACKGROUND

This prospective study aims to determine whether preoperative stair-climbing tests (SCT) predict postoperative pulmonary complications (PPC) better than self-reported poor functional capacity (SR_PFC) in patients with known or suspected COPD.

METHODS

A total of 320 patients undergoing scheduled for major non-cardiac surgery, 240 with verified COPD and 80 with GOLD key indicators but disproved COPD, underwent preoperative SR_PFC and SCT and were analyzed. Least absolute shrinkage and selection operator (LASSO) regression was used for variable selection. Two multivariable regression models were fitted, the SR_PFC model (baseline variables such as sociodemographic, surgical and procedural characteristics, medical preconditions, and GOLD key indicators plus SR_PFC) and the SCT model (baseline variables plus SCT_PFC).

RESULTS

Within all stair-climbing variables, LASSO exclusively selected self-reported poor functional capacity. The cross-validated area under the receiver operating characteristic curve with bias-corrected bootstrapping 95% confidence interval (95% CI) did not differ between the SR_PFC and SCT models (0.71; 0.65-0.77 for both models). SR_PFC was an independent risk factor (adjusted odds ratio (OR) 5.45; 95% CI 1.04-28.60; p = 0.045 in the SR_PFC model) but SCT_PFC was not (adjusted OR 3.78; 95% CI 0.87-16.34; p = 0.075 in the SCT model).

CONCLUSIONS

Our findings indicate that preoperative SR_PFC adequately predicts PPC while additional preoperative SCTs are dispensable in patients with known or suspected COPD.

Chest three-dimensional-computed tomography imaging data analysis for the variation of exercise capacity after lung lobectomy

BACKGROUND

Postoperative loss of exercise capacity and pulmonary function is a major concern among lung cancer patients. In this study, the time for a stair-climbing to 12-m height was used to investigate whether preoperative chest 3D-computed tomography (CT) could be a useful tool for predicting postoperative variations in exercise capacity and pulmonary function.

METHODS

Seventy-eight patients undergoing lobectomy for suspected stage I lung cancer were prospectively enrolled. Preoperatively, lobe volume and low attenuation volume (LAV) were evaluated using the SYNAPSE VINCENT system. Preoperative data on stair-climbing time, spirometry, and diffusing capacity of the lung for carbon monoxide (DL_CO ) at baseline and 6-month postoperative data were used to evaluate variations in exercise capacity and pulmonary function. Maximal oxygen uptake (VO₂ t) was evaluated based on the stair-climbing time.

RESULTS

Significant differences in the variation of exercise capacity at 6 months postoperatively were found between the groups categorized by target lobe volume and LAV status: The large volume/LAV (+) group had a greater decline in VO₂ t. Mean loss of VO₂ t was -6.2%, -1.4%, -1.6%, and -0.1% in the large volume/LAV (+), large volume/LAV (-), small volume/LAV (+), and small volume/LAV (-) groups, respectively. The large volume/LAV (-) group had a greater decline in forced expiratory volume in 1 s. The small volume/LAV (+) group showed a reduced decline in the DL_CO .

CONCLUSIONS

Analysis of chest 3D-CT scans is a potential tool for predicting the loss of exercise capacity and pulmonary function after lung lobectomy. This article is protected by copyright. All rights reserved.

Integrating supportive care into the multidisciplinary management of lung cancer: we can't wait any longer

INTRODUCTION

Due to important achievements in terms of diagnostic and therapeutic tools and the complexity of the disease itself, lung cancer management needs a multidisciplinary approach. To date, the classical multidisciplinary team involves different healthcare providers mainly dedicated to lung cancer diagnosis and treatments. Nevertheless, the underlying disease and related treatments significantly impact on patient function and psychological well-being. In this sense, supportive care may offer the best approach to relieve and manage patient symptoms and treatment-related adverse events.

AREAS COVERED

Evidence report that exercise, nutrition, smoking cessation and psychological well-being bring many benefits in patients with lung cancer, from both a physical and socio-psychological points of view, and potentially improving their survival. Nevertheless, supportive care is rarely offered to patients, and even less frequently these needs are discussed within the multidisciplinary meeting.

EXPERT OPINION

Integrating supportive care as part of the standard multidisciplinary approach for lung cancer involves a series of challenges, the first one represented by the daily necessity of specialists, such as kinesiologists, dietitians, psycho-oncologists, able to deliver a personalized approach. In the era of precision medicine this is an essential step forward to guarantee comprehensive and patient-centered care for all patients with lung cancer.

Exercise prehabilitation in lung cancer: Getting stronger to recover faster

Despite several recent advances, lung cancer surgery is still associated with potentially severe postoperative complications. It has been suggested that preoperative exercise training could render patients with borderline functional parameters eligible for surgery, improve perioperative outcomes and that these benefits might reduce healthcare costs. Nevertheless, given the substantial heterogeneity of the available studies, no specific guidelines for preoperative exercise training have been released so far. This narrative review aims to provide an overview of the potential benefits of exercise training in the preoperative period as a central intervention for lung cancer patients. In detail, the effects of exercise (with different regimens) were evaluated in terms of physical functions, patients' eligibility for curative surgery, postoperative complications and length of stay, with an exploratory focus on healthcare costs and long-term outcomes. Furthermore, a feasible approach for every-day clinical practice is proposed in order to increase the expected benefit deriving from a more extensive and methodical application of prehabilitation exercise, ideally in the context of a comprehensive approach to lung cancer patients, including nutritional and psychological support.

Factors associated with changes in the 12-m stair-climbing time after lung lobectomy

OBJECTIVE

Postoperative loss-of-exercise capacity is one of the main concerns for patients undergoing lung cancer surgery. This study was designed to identify the factors associated with loss-of-exercise capacity after lobectomy, using an easy surrogate measure: the 12-m stair-climbing time (SCt).

METHODS

Ninety-eight patients undergoing lobectomy for suspected stage I lung cancer were prospectively enrolled. SCt and pulmonary function test were evaluated preoperatively as baseline and at 6 months postoperatively. At 6 months postoperatively, 20 patients dropped out. Loss-of-exercise capacity was defined as at least a 3.3% decline (lower quartile) in the estimated maximal oxygen uptake (VO₂t: 43.06 - 0.4 × SCt). Factors associated with loss-of-exercise capacity were analyzed.

RESULTS

Median (interquartile range) baseline SCt was 31.5 (28.2-36.7) s. Baseline SCt was not significantly associated with complications. At 6 months postoperatively, SCt increased by + 4.4 (+ 3.2, + 6.8) s in patients with loss-of-exercise capacity. Sex, smoking status, lobe, procedure, and forced expiratory volume in 1 s showed no significant association with loss-of-exercise capacity. In the multivariable logistic regression, older age (≥ 73 years) (odds ratio: 5.25, 95% confidence interval: 1.50-18.43, p = 0.010) and lower baseline diffusing capacity of the lung for carbon monoxide (< 75%) (odds ratio: 9.23, 95% confidence interval: 1.94-43.93, p = 0.005) were significantly associated with loss-of-exercise capacity.

CONCLUSION

Age and the baseline diffusing capacity of the lung for carbon monoxide were identified as significant variables associated with variation of exercise capacity after lung cancer surgery, using pre- and postoperative SCt.

Performance at stair-climbing test is associated with postoperative complications after lung resection: a systematic review and meta-analysis

Background

Thoracic surgery is the optimal treatment for early-stage lung cancer, but there is a high risk of postoperative morbidity. Therefore, it is necessary to evaluate patients’ preoperative general condition and cardiorespiratory capacity to determine the risk of postoperative complications. The objective of this study was to assess whether the stair-climbing test could be used in the preoperative evaluation of lung resection patients to predict postoperative morbidity following thoracic surgery.

Methods

We performed a systematic review and a meta-analysis on the association between stair-climbing test result and morbidity/mortality after thoracic surgery. We analysed all articles published until May 2020 in the following databases: Pubmed/Medline, Pedro, The Cochrane library, Embase and CINAHL. The risk of bias was assessed using the Quality in Prognosis Studies tool. This meta-analysis is registered as PROSPERO CRD42019121348.

Results

13 articles were included in the systematic review for a total of 2038 patients and 6 in the meta-analysis. There were multiple test evaluation criteria: rise time, height, desaturation and heart rate change. For the meta-analysis, we were able to pool data on the height of rise at a variable threshold: risk ratio 2.34 (95% CI 1.59 to 3.43) with I²=53% (p=0.06). The threshold for occurrence of complications was estimated at a 10 m climb.

Conclusions

Our results indicate that the stair-climbing test could be used as a first-line functional screening test to predict postoperative morbidity following thoracic surgery and that patients with a poor test result (<10 m) should be referred to formal cardiopulmonary exercise testing.

Pulmonary arterial enlargement predicts cardiopulmonary complications after pulmonary resection for lung cancer: a retrospective cohort study

BACKGROUND

The finding of pulmonary arterial enlargement on computed tomography has been reported to be associated with pulmonary hypertension. On the other hand, pulmonary hypertension is a known risk factor for thoracic surgery. We investigated whether pulmonary arterial enlargement predicts cardiopulmonary complications following pulmonary resection for lung cancer.

METHODS

We reviewed 237 consecutive patients who underwent pulmonary resection for lung cancer. Preoperative patient characteristics (sex, age, Brinkman index, cardiopulmonary comorbidities, cardiothoracic ratio, pulmonary function, and pulmonary arterial enlargement) and surgical data (surgical procedure, pathological stage, postoperative complications, mortality, and length of postoperative hospital stay) were analyzed. In order to evaluate preoperative pulmonary arterial enlargement, we measured the diameter of the main pulmonary artery at its bifurcation and that of the ascending aorta at its widest point using chest computed tomography and calculated the ratio of the former diameter to the latter.

RESULTS

In all, 16 patients developed postoperative cardiopulmonary complications and 221 did not. One patient died from postoperative pneumonia. The mean age of patients who developed postoperative cardiopulmonary complications was significantly higher than that of those who did not (78 ± 5 years vs 69 ± 9 years, P=0.0001). The pulmonary artery-to-ascending-aorta ratio was significantly higher in patients who developed postoperative complications than in those who did not (0.94 ± 0.15 vs. 0.81 ± 0.11, P=0.03). Other preoperative patient characteristics and surgical data did not differ significantly between the groups. On multivariate analysis, pulmonary artery-to-ascending-aorta ratio (0.1-point increase; odds ratio 2.3, 95 % confidence interval 1.5-3.5; P=0.0002) and age (1-year increase; odds ratio 1.2, 95 % confidence interval 1.1-1.3; P=0.03) were found to be independent predictors of postoperative cardiopulmonary complications.

CONCLUSIONS

A finding of pulmonary arterial enlargement on computed tomography is a potential predictor of postoperative cardiopulmonary complications after lung cancer surgery.

Pulmonary function tests in the preoperative evaluation of lung cancer surgery candidates. A review of guidelines

Before planned surgical treatment of lung cancer, the patient's respiratory system function should be evaluated. According to the current guidelines, the assessment should start with measurements of FEV₁ (forced expiratory volume in 1 second) and DLco (carbon monoxide lung diffusion capacity). Pneumonectomy is possible when FEV₁ and DLco are > 80% of the predicted value (p.v.). If either of these parameters is < 80%, an exercise test with VO₂ max (oxygen consumption during maximal exercise) measurement should be performed. When VO₂ max is < 35 % p.v. or < 10 ml/kg/min, resection is associated with high risk. If VO₂ max is in the range of 35-75% p.v. or 10-20 ml/kg/min, the postoperative values of FEV₁ and DLco (ppoFEV₁, ppoDLco) should be determined. The exercise test with VO₂ max measurement may be replaced with other tests such as the shuttle walk test and the stair climbing test. The distance covered during the shuttle walk test should be > 400 m. Patients considered for lobectomy should be able to climb 3 flights of stairs (12 m) and for pneumonectomy 5 flights of stairs (22 m).

Fixed-altitude stair-climbing test replacing the conventional symptom-limited test. A pilot study

INTRODUCTION

The objective of this study was to investigate whether a patient's maximum capacity is comparable in 2 different stair-climbing tests, allowing the simplest to be used in clinical practice.

METHOD

Prospective, observational study of repeated measures on 33 consecutive patients scheduled for lung resection. Stair-climbing tests were: the standard test (climb to 27 m) and the alternative fixed-altitude test (climb to 12 m). In both cases, heart rate and oxygen saturation were monitored before and after the test. The power output of stair-climbing for each test (Watt1 for the standard and Watt2 for the fixed-altitude test) was calculated using the following equation: Power (watt)=weight (kg)*9.8*height (m)/time (sec). Concordance between tests was evaluated using a regression model and the residuals were plotted against Watt1. Finally, power output values were analyzed using a Bland-Altman plot.

RESULTS

Twenty-one male and 12 female patients (mean age 63.2±11.2) completed both tests. Only 12 patients finished the standard test, while all finished the fixed-altitude test. Mean power output values were Watt1: 184.1±65 and Watt2: 214.5±75.1. The coefficient of determination (R(2)) in the linear regression was 0.67. No fixed bias was detected after plotting the residuals. The Bland-Altman plot showed that 32 out of 33 values were within 2 standard deviations of the differences between methods.

CONCLUSIONS

The results of this study show a reasonable level of concordance between both stair-climbing tests. The standard test can be replaced by the fixed-altitude test up to 12 m.

Cardiorespiratory evaluation in pre and post operative moments of laparoscopic cholecystectomy

PURPOSE

To analyze the changes in both respiratory function and cardiopulmonary exercise tests results in patients subjected to laparoscopic cholecystectomy.

METHODS

Fifty patients were evaluated (76% women) and the average age was 47.8 ± 14.2 years. All individuals underwent the measurement of spirometry, manovacuometry, 6-minute walk test (6MWT) and stair-climbing test (SCT). All tests were performed at the first (PO1), fifth (PO5) and thirtieth (PO30) postoperative days.

RESULTS

BMI average was 28.8 ± 4.8 kg/m(2). Sample comprised 68% non-smokers, 20% current smokers, and 12% former smokers. There was no incidence of postoperative complication whatsoever. There was a significant decrease in spirometric values at PO1, but values were similar to the ones of PRE at PO30. Manovacuometry showed alterations at PO1 displaying values that were similar to the ones of PRE at PO30. 6MWT was significantly shorter at until PO5, but at PO30 values were similar to ones of PRE. As for SCT, values were significantly compromised at PO5 and PO30 since they were similar to the ones of PRE.

CONCLUSION

Patients submitted to laparoscopic cholecystectomy present a decrease in cardiorespiratory function on the first postoperative moments but there is a rapid return to preoperative conditions.