High-risk patients and postoperative complications following video-assisted thoracic surgery lobectomy: a case-matched comparison with lower-risk counterparts†

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 3: systematic review of evidence regarding surgery in compromised patients or specific tumors

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in older patients, patients with limited pulmonary reserve and favorable tumors is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons (NRCs) with adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In older patients, perioperative mortality is minimally altered by resection extent and only slightly affected by increasing age; sublobar resection may slightly decrease morbidity. Long-term outcomes are worse after lesser resection; the difference is slightly attenuated with increasing age. Reported short-term outcomes are quite acceptable in (selected) patients with severely limited pulmonary reserve, not clearly altered by resection extent but substantially improved by a minimally invasive approach. Quality-of-life (QOL) and impact on pulmonary function hasn't been well studied, but there appears to be little difference by resection extent in older or compromised patients. Patient selection is paramount but not well defined. Ground-glass and screen-detected tumors exhibit favorable long-term outcomes regardless of resection extent; however solid tumors <1 cm are not a reliably favorable group.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in compromised patients and favorable tumors with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.

A Prediction Model for Postoperative Pulmonary Complication in Pulmonary Function-Impaired Patients Following Lung Resection

Purpose

Most patients with lung cancer have impaired pulmonary function. Single pulmonary function parameters have been suggested as good indices for predicting postoperative pulmonary complications (PPC). The purpose of this retrospective study was to construct a prediction model, including more than one pulmonary function parameter, for better prediction of PPC in patients with lung cancer and impaired pulmonary function.

Patients and Methods

Our database of patients who underwent lung resection for non-small cell lung cancer was reviewed and those with impaired pulmonary function were enrolled. Clinical data, including PPC, were recorded. Univariate and logistic regression analyses were applied to explore potential predictors and a prediction model constructed based on the results of logistic regression.

Results

Patients with impaired pulmonary function (n = 124) were enrolled. Most patients were male, current smokers, >60 years old, and had adenocarcinoma and mild ventilatory dysfunction or diffusion dysfunction. In univariate analysis, we identified six pulmonary function parameters that differed significantly between the PPC and non-PPC groups. Receiver operating characteristic curves were used to determine the best cutoff values. In logistic regression, only forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC%), peak expiratory flow (PEF%), and post predictive operation (ppo)-FEV1% remained significant. Based on these results, we constructed a prediction model for PPC including FEV1/FVC%, PEF%, and ppo-FEV1%, which had an good diagnostic performance of, with 76.7% sensitivity and 67.6% specificity.

Conclusion

Our prediction model, including the pulmonary function parameters, FEV1/FVC%, PEF%, and ppo-FEV1%, shows excellent performance for predicting PPC in patients with lung cancer and impaired pulmonary function following resection, and has potential for wide application in clinical practice.

Effects of intraoperative goal-directed fluid therapy and restrictive fluid therapy combined with enhanced recovery after surgery protocol on complications after thoracoscopic lobectomy in high-risk patients: study protocol for a prospective randomized controlled trial

BACKGROUND

Acute kidney injury (AKI) is a common complication after thoracoscopic lobectomy in high-risk patients due to insufficient intraoperative infusion. Goal-directed fluid therapy (GDFT) is an individualized fluid infusion strategy; the fluid infusion strategy is adjusted according to the patient's fluid response. GDFT during operation can reduce the incidence of AKI after major surgery. Enhanced recovery after surgery (ERAS) protocol optimizes perioperative interventions to decrease the postoperative complications after surgery. In ERAS protocol of lobectomy, intraoperative restrictive fluid therapy is recommended. In this study, we will compare the effects of intraoperative GDFT with restrictive fluid therapy combined with an ERAS protocol on the incidence of AKI after thoracoscopic lobectomy in high-risk patients.

METHODS/DESIGN

This is a prospective single-center single-blind randomized controlled trial. Two hundred seventy-six patients scheduled for thoracoscopic lobectomy are randomly allocated to receive either GDFT or restrictive fluid therapy combined with an ERAS protocol at a 1:1 ratio. The primary outcome is the incidence of AKI after operation. The secondary outcomes include (1) the incidence of renal replacement therapy, (2) the length of intensive care unit stay after operation, (3) the length of hospital stay after operation, and (4) the incidence of other complications including infection, acute lung injury, pneumonia, arrhythmia, heart failure, myocardial injury after noncardiac surgery, and cardiac infarction.

DISCUSSION

This is the first study to compare intraoperative GDFT with restrictive fluid therapy combined with an ERAS protocol on the incidence of AKI after thoracoscopic lobectomy in high-risk patients. The hypothesis is that the restrictive fluid therapy is noninferior to GDFT in reducing the incidence of AKI, but restrictive fluid therapy is simpler to apply than GDFT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04302467 . Registered on 26 February 2020.

Impact of paravertebral blockade use in geriatric patients undergoing thoracic surgery on postoperative adverse outcomes

Background

While it is known that thoracic paravertebral blockade (TPVB) could reduce pain undergoing thoracic surgery, it has not been confirmed whether this reduction in pain reduces pulmonary complications in an elderly population.

Methods

We performed a monocentric retrospective analysis for a prospectively collected patients receiving thoracic surgery with or without intraoperative TPVB between November 7, 2018 and April 1, 2019, at Shanghai Chest Hospital. Whether or not to use TPVB depending on anesthesiologists' preference, the chances of harm and benefit of each patients after discussed with their anesthetist. Chest wall resection, bilateral lung resection, conversion to thoracotomy and ipsilateral reoperation were excluded. A total of 154 patients with lung operations were included in the final analysis, 34 of whom received general anesthesia combined with TPVB (GA-TPVB). The primary outcome was the incidence of postoperative pulmonary complications (PPCs). The secondary outcomes were the incidence of cardiovascular and other complications, required analgesia in post anesthesia care unit (PACU), patient controlled analgesia (PCA) pressing frequency in 24h, chest tube duration, ICU stay and the hospital length of stay (LOS).

Results

The incidence of PPCs undergoing thoracic surgery was about 21.4% (33/154). Compared with GA, GA-TPVB could reduce the incidence of PPCs (25% vs. 9%, P=0.042), mostly reduce postoperative atelectasis (19% vs. 3%, P=0.021). TPVB could reduce the rate of required analgesia in PACU, PCA pressing frequency in 24 h and chest tube duration. However, there were no significant differences on the rate of cardiovascular and other complications, ICU stay and LOS between the two groups (P>0.05). Multivariable logistic regression analysis identified preoperative DLCO% ≥92% (OR =0.293, P=0.006), duration of surgery <75 min (OR =0.278, P=0.008) and GA-TPVB (OR =0.270, P=0.048) was associated with fewer PPCs.

Conclusions

Our study shows that general anesthesia combined with TPVB may reduce PPCs by reducing postoperative pain in geriatric patients undergoing thoracic surgery compared with general anesthesia alone.

Trial registration

Chinese Clinical Trial Registry number, ChiCTR1800019526. Registered on Nov 7, 2018.

VATS lobectomy program: the trainee perspective

Due to its intrinsic characteristics, video assisted thoracic surgery (VATS) lobectomy is currently the recommended surgical approach for early stage lung cancer treatment. The importance of increasing the number of surgeons capable of performing VATS lobectomies is implicit and of utmost importance. In fact, the need of performing independently and routinely VATS lobectomies for early stage lung cancer will soon be a prerequisite to the new generation of thoracic surgeons. The feeling that VATS lobectomy teaching should be part of their training is strongly felt among trainees but, at the moment, a formal, uniform and certified process of learning VATS lobectomy is not available in all training centres. Perhaps, through the supervision, support and aid from national and European Thoracic Surgery Societies, programs of integration of recognized, standardized and certified teaching of VATS lobectomy could be planned and undertaken by the training centres, both at national as well as European level.