Financial validation of the European Society of Thoracic Surgeons risk score predicting prolonged air leak after video-assisted thoracic surgery lobectomy

Index hospital cost of adverse events following thoracic surgery: a systematic review of economic literature

OBJECTIVES

Adverse events (AEs) following thoracic surgery place considerable strain on healthcare systems. A rigorous evaluation of the economic impact of thoracic surgical AEs remains lacking and is required to understand the value of money of formal quality improvement initiatives. Our objective was to conduct a systematic review of all available literature focused on specific cost of postoperative AEs following thoracic surgery.

DESIGN

Systematic review of the economic literature was performed, following recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

An economic search filter developed by the Canadian Agency for Drugs and Technologies in Health was applied, and MEDLINE, Embase and The Cochrane Library were searched from inception to January 2022.

ELIGIBILITY CRITERIA

We included English articles involving adult patients who underwent a thoracic surgical procedure with estimated costs of postoperative complications. Eligible study designs included comparative observational studies, randomised control trials, decision analytic or cost-prediction models, cost analyses, cost or burden of illness studies, economic evaluation studies and systematic reviews and/or meta-analyses of cost analyses and cost of illness studies.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened titles and abstracts in the first stage and full-text articles of included studies in the second stage. Disagreements during abstract and full-text screening stages were resolved via discussion until a consensus was reached. Studies were appraised for methodological quality using the Critical Appraisal Skills Program checklist.

RESULTS

3349 studies were identified: 20 met inclusion criteria. Most were conducted in the USA (12/20), evaluating AE impact on hospital expenditures (18/20). 68 procedure-specific AE mean costs were characterised (USD$). The most commonly described were anastomotic leak (mean:range) (USD$49 278:$6 176-$133 002) and pneumonia ($12 258:$2608-$34 591) following esophagectomy, and prolonged air leak ($2556:$571-$3573), respiratory failure ($19 062:$11 841-$37 812), empyema ($30 189:$23 784-$36 595), pneumonia ($15 362:$2542-$28 183), recurrent laryngeal nerve injury ($16 420:$4224-$28 616) and arrhythmia ($6835:$5833-$8659) following lobectomy.

CONCLUSIONS

Hospital costs associated with AEs following thoracic surgery are substantial and varied. Quantifying costs of AEs enable future economic evaluation studies, which could help prioritising value-directed quality improvement to optimally improve outcomes and reduce costs.

Intraoperative ventilatory leak: Real-time guidance for management of air leak in lung cancer patients undergoing VATS lobectomy

BACKGROUND

Persistent air leak (PAL) is a common complication after video-assisted thoracoscopic surgery (VATS) lobectomy. We aimed to evaluate whether the intraoperative quantitative measurement of air leaks using a mechanical ventilation test could predict PAL and identify those patients needing additional treatment for the prevention of PAL.

METHODS

This was an observational, retrospective, single-center study that included 82 patients who underwent VATS lobectomy with a mechanical ventilation test for VL. Only 2% of patients who underwent lobectomy surgery had persistent air leaks.

RESULTS

At the end of lobectomy performed in patients with non-small cell lung cancer, the lung was reinflated at a 25-30 mmH2O pressure and ventilatory leaks (VL) were calculated and in relation to the entity of the air leaks, we evaluated the most suitable intraoperative treatment to prevent persistent air leaks.

CONCLUSION

VL is an independent predictor of PAL after VATS lobectomy; it provides a real-time intraoperative guidance to identify those patients who can benefit from additional intraoperative preventive interventions to reduce PAL.

Facing the challenges of perioperative air leaks using water seal in Colombia

Air leaks following thoracic surgery continue to be a significant cause of morbidity and mortality. In contemporary thoracic surgery, many aspects of post-surgical air leaks are still controversial. In developing countries like Colombia, state-of-the-art technology such as newer digital drainage systems are not always available, and surgeons rely primarily on water seal systems for air leak management. Although efforts are being made to increase the use of newer digital systems, being a third-world country has its challenges, and we emphasize the importance of following international guidelines as much as possible, especially when facing complex situations such as perioperative air leaks with limited resources.

Novel air leak test using surfactant for lung surgery

Background

Prolonged air leak is the most common complication after pulmonary resection surgery. Water submersion test (WST) has been used to check for air leak. However, it is cumbersome under the circumstances of video-assisted thoracic surgery (VATS). This study aimed to devise a new air leak detection method that is suitable for the VATS.

Methods

We decided to utilize the properties of the surfactants to overcome the disadvantages of WST. To find the optimal surfactant, ex-vivo porcine lung experiments were prepared with a custom-made large glass vessel mimicking a human thoracic cavity. A fresh lung was put inside the glass vessel and connected with the ventilator. We made a needle injury on the lung surface and dropped various kinds of liquid surfactants to create air bubbles during the lung ventilation. The appearances of bubbles were recorded through 5mm thoracoscope.

Results

Considering the bubble forming ability, Pluronic F-127 solution (PF127), a well-known non-toxic and non-ionic colorless surfactant, was chosen as candidate substance. To find the optimal condition, various concentrations of PF127 (30%, 25%, 20%, 15%, 10%) were tested. Greater than 20% concentration of PF127 were not feasible due to its high viscosity; the bubbles kept increasing in size without popping and blocked the thoracoscopic vision. The 10% PF127 did not form any bubbles. On the contrary, the 15% PF127 formed bubbles that are 1-2 cm in size with dynamic movement allowing for clear visibility of the air leak point. We finally made a green colored 15% PF127 by mixing an indocyanine green to increase its visibility. All of the components in the solution are FDA approved and permissible to be used in the human body.

Conclusions

Our bubble solution can easily detect the air leak even in small quantities and is expected to be useful in VATS with limited vision. However, in order for its full-scale clinical use, its safety in the human body must be verified.

The everlasting issue of prolonged air leaks after lobectomy for non-small cell lung cancer: A data-driven prevention planning model in the era of minimally invasive approaches

BACKGROUND AND OBJECTIVES

Prolonged air leaks (PAL) are the most frequent complication after lobectomy for non-small cell lung cancer, even in case of minimally invasive approaches. We developed a novel score to identify high-risk patients for PAL during minimally invasive lobectomy.

METHODS

A dedicated database was created. We investigated preoperative candidate features and specific intraoperative variables. Univariate and subsequent logistic regression analysis with bootstrap resampling have been used. Model performance has been assessed by reckoning the area under the receiver operating characteristics curve and the Hosmer-Lemeshow goodness of fit.

RESULTS

PAL (>5 days) occurred in 72 (15.69%) patients. Five variables emerged from the model. Each one was assigned a score to provide a cumulative scoring system: forced expiratory volume in 1 second below 86% (P = 0.004, 1.5 points), body mass index <24 ( P = 0.002, 1 point), active smoking ( P = 0.001, 1.5 points), incomplete fissures ( P = 0.004, 1.5 points), and adhesions ( P = 0.0001, 1 point). The new score provided a stratification into four risk classes.

CONCLUSIONS

The risk score incorporates either general or more specific variables, providing a risk stratification that could be readily applied intra- and postoperatively. Henceforth, specific technical and management measures could be properly allocated to curb PAL.