Thirty-day mortality and five-year survival in thoracic surgery: "real-world" assessment of outcomes from a single-institution audit

BACKGROUND

Accurate measurement of outcomes is essential to monitor the effectiveness of public health policies. In Italy, the Ministry of Health has chosen 30-day mortality after major surgical or medical procedures as the main outcome measure, pooling all pulmonary resections for malignancy in a single category. The present audit evaluated all pulmonary resections performed over a 13-year period in a single institution to assess the immediate (30-day mortality) and long-term (5-year survival) outcomes according to type and stage of disease and extent of surgery.

METHODS

We analyzed the results of 4,234 first pulmonary resections performed from 2003 to 2015 for lung cancer (2,636), lung metastases (1,080), other primary cancers (259) and benign diseases (259). The median follow-up of cancer patients was 4.1 years.

RESULTS

Overall 30-day mortality was 1.1%, being 1.2% for lung cancer, 0.3% for lung metastases, 3.5% for pneumonectomies, 1% for lobectomies, and 0.5% for sublobar resections. Among lung cancer patients, 30-day mortality was 0.7% for simple anatomical resections, 2.8% for complex resections, 0.7% for stage I, and 1.6% for higher stages. Overall 5-year survival was 56% for lung cancer, 49% for lung metastases, and 53% for other primary cancers (p = 0.03). According to the surgical procedure for lung cancer, 5-year survival was 60%, 55% and 36% for lobectomies, segmentectomies and pneumonectomies, respectively (p<0.0001).

CONCLUSIONS

For better monitoring of thoracic surgery outcomes in a real-world setting, we suggest evaluating lung cancer separately from other thoracic malignancies, and including 5-year survival rates stratified by resection volume and surgical procedure complexity.

Sex differences in early outcomes after lung cancer resection: analysis of the Society of Thoracic Surgeons General Thoracic Database

OBJECTIVES

Women with lung cancer have superior long-term survival outcomes compared with men, independent of stage. The cause of this disparity is unknown. For patients undergoing lung cancer resection, these survival differences could be due, in part, to relatively better perioperative outcomes for women. This study was undertaken to determine differences in perioperative outcomes after lung cancer surgery on the basis of sex.

METHODS

The Society of Thoracic Surgeons' General Thoracic Database was queried for all patients undergoing resection of lung cancer between 2002 and 2010. Postoperative complications were analyzed with respect to sex. Univariable analysis was performed, followed by multivariable modeling to determine significant risk factors for postoperative morbidity and mortality.

RESULTS

A total of 34,188 patients (16,643 men and 17,545 women) were considered. Univariable analysis demonstrated statistically significant differences in postoperative complications favoring women in all categories of postoperative complications. Women also had lower in-hospital and 30-day mortality (odds ratio, 0.56; 95% confidence interval, 0.44-0.71; P < .001). Multivariable analysis demonstrated that several preoperative conditions independently predicted 30-day mortality: male sex, increasing age, lower diffusion capacity, renal insufficiency, preoperative radiation therapy, cancer stage, extent of resection, and thoracotomy as surgical approach. Coronary artery disease was an independent predictor of mortality in women but not in men. Thoracotomy as the surgical approach and preoperative radiation therapy were predictive of mortality for men but not for women. Postoperative prolonged air leak and empyema predicted mortality in men but not in women.

CONCLUSIONS

Women have lower postoperative morbidity and mortality after lung cancer surgery. Some risk factors are sex-specific with regard to mortality. Further study is warranted to determine the cause of these differences and to determine their effect on survival.

Predicting risk of intensive care unit admission after resection for non-small cell lung cancer: a validation study

A model for predicting the risk of emergency, unplanned intensive care unit (ICU) admission after lung resection for lung cancer has been reported. However, it has not been validated outside of the derivation cohort, and the aim of our study was to undertake external validation at our institution. We reviewed a series of consecutive patients who underwent major lung resection for non-small cell lung cancer over a 6-year period. Test performance was evaluated by area under the receiver operator characteristic (ROC) curve. Between 2003 and 2008, 425 patients underwent major lung resections for lung cancer. The mean age (SD) was 65 (10) years and 241 (57%) were men. A total of 77 (18%) patients were admitted to ICU, 47 for elective admission and 30 (7%) for treatment of post-procedure complications. Of the 30 patients admitted for complications, the median length of ICU (interquartile range) stay was 3 days (1-15 days). The mortality rate among these patients was 17%. The area under the ROC curve was 0.66 (95% CI 0.53-0.79). The Brunelli scoring system had moderate discriminating ability to predict the risk of ICU admission after lung resection in our institution.