Thoracic surgery: risk factors for postoperative complications of lung resection

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

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.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Assessment of lung ultrasound for early detection of respiratory complications in thoracic surgery

BACKGROUND AND OBJECTIVES

To assess lung ultrasound for the diagnosis and monitoring of respiratory complications in thoracic surgery.

METHODS

Prospective observational study in a University hospital, single institution. Adult patients scheduled for pulmonary resection surgery excluding pneumonectomy. An ultrasound follow-up was performed from the day before the surgery to the third day after surgery with calculation of B-line and lung score (reaeration and loss of aeration scores). Respiratory complications were collected throughout the hospitalization period.

RESULTS

Fifty-six patients were included. Eighteen patients presented a respiratory complication (32%), and they presented significantly higher BMI and ASA scores. Patients operated by videothoracoscopy were less at risk of complications. At day 3, a reaeration score ≤ 2 on the ventilated side or ≤ -2 on the operated side, and a B-line score>6 on the operated side were in favor of a complication.

CONCLUSION

Lung ultrasound can help in the diagnosis of respiratory complications following pulmonary resection surgery.

Efficacy of preoperative white blood cell count and lymphocyte/monocyte ratio in predicting post-lobectomy pneumonia

Background

This study aims to examine preoperative white blood cell count and lymphocyte/monocyte ratio and to investigate foreknown risk factors for pneumonia following lobectomy.

Methods

Between January 2005 and May 2018, a total of 152 patients (135 males, 17 females; mean age: 61.9±7.5 years; range, 45 to 73 years) who underwent right lower lobectomy for non-small cell lung cancer were retrospectively analyzed. Data including age, sex, preoperative white blood cell count and lymphocyte/monocyte ratio, smoking, preexisting chronic diseases, body mass index, stage of lung cancer, the use of neoadjuvant chemotherapy, type of surgery, operation duration, blood transfusion, and postoperative intensive care unit admission were recorded.

Results

Twenty-five (16.4%) patients developed postoperative pneumonia. Older patients presenting with elevated levels of preoperative white blood cell count and lymphocyte/monocyte ratio, excessive tobacco consumption, prolonged operation duration, history of a chronic disease, a body mass index over 30 kg/m2, advanced lung cancer, neoadjuvant chemotherapy, and intensive care unit admission after surgery were at high risk for postoperative pneumonia. There was no significant difference in sex, type of surgery (thoracotomy versus thoracoscopy), and the use of blood products. In predicting the development of postoperative pneumonia, lymphocyte/monocyte ratio had 85.% sensitivity and 87.5% specificity, while white blood cell count had 72.5% sensitivity and 77.5% specificity.

Conclusion

Preoperative white blood cell count and lymphocyte/ monocyte ratio provide supporting evidence in predicting pneumonia following lobectomy contributing to the existing risk identification criteria.

Modifiable risk factors for patients undergoing lung cancer surgery and their optimization: a review

Enhanced recovery after surgery (ERAS) programs include a variety of pre-, intra- and post-operative interventions that seek to decrease the stress response to surgery and facilitate the recovery of surgical patients. There are a number of patient factors that may increase the risk of postoperative complications (POC) after lung cancer surgery and delay recovery. Some of these factors may be amenable to optimization preoperatively and potentially decrease the incidence of these complications. We have chosen to discuss the incidence and complications associated with factors we felt were both relatively common and significant contributors to POCs. For each of these factors we discuss potential avenues for optimization and the evidence for the resulting decrease in complications.

Burden of air leak complications in thoracic surgery estimated using a national hospital billing database

Background

One of the most common outcomes of lung resections are parenchymal air leaks. These air leaks are most often self-limited and spontaneously resolve several days after surgery. Historically, only prolonged air leaks have been considered to have a significant effect on patient outcomes. This study aims to evaluate the impact of any air leak complications (aALCs) on resource utilization and mortality.

Methods

The Premier Perspective^® database was used to identify all elective primary lobectomy, segmentectomy, and wedge resections performed from 2012 to 2014; aALC was defined as a composite of air leak and pneumothorax. Generalized estimating equation models were used to estimate the impact of aALCs on length of stay (LOS), operating room time (ORT), hospital costs, and mortality during index hospitalization.

Results

A total of 21,150 patients undergoing lung resection surgery were included in the analysis: lobectomy (n=10,946), segmentectomy (n=1,788), and wedge resection (n=8,416). The overall incidence of aALCs was 24.26% (95% CI [23.68, 24.83]). Identified risk factors included resection type, surgical approach, male gender, and presence of COPD. Patients with aALCs had a significantly higher economic burden (adjusted mean [standard error of mean, SE]: LOS=7.24 [SE=0.12] days; ORT=214.9 [SE=6.4] min; and hospital costs=$26,070 [SE=$1404]) compared to those without aALCs (adjusted mean [SE]: LOS=4.75 [SE=0.07] days; ORT=201.7 [SE=3.9] min; and hospital costs=$19,558 [SE=$399]). aALC was also associated with increased overall index hospitalization mortality (odds ratio=1.90, 95% CI [1.42, 2.55]).

Conclusion

This analysis showed that aALCs are not only frequent but also associated with significantly higher resource utilization and mortality.

Intensive care unit and lung cancer: when should we intubate?

Lung cancer still remains the leading cause of cancer death among males. Several new methodologies are being used in the everyday practise for diagnosis and staging. Novel targeted therapies are being used and others are being investigated. However; early diagnosis still remains the cornerstone for efficient treatment and disease management. Lung cancer patients requires in many situations intensive care unit (ICU) admission, either due to the necessity for supportive care until efficient disease symptom control (respiratory distress due to malignant pleural effusion) or disease adverse effect management (massive pulmonary embolism). In any case guidelines indicating the patient that has to be intubated have not yet been issued. In the current review we will present current data and finally present an algorithm based on the current published information for lung cancer patients that will probably benefit from admission to the ICU.

Incidência de infecção do sítio cirúrgico com o preparo pré-operatório utilizando iodopolividona 10% hidroalcoólica e clorexidina alcoólica 0,5%

OBJETIVO: analisar a incidência de infecção do sítio cirúrgico, quando o preparo pré-operatório da pele foi realizado com iodopolividona 10% em solução hidroalcoólica e clorexidina 0,5% alcoólica, MÉTODOS: estudo longitudinal randomizado, a partir de variáveis obtidas de pacientes submetidos à operações limpas e potencialmente contaminadas. Os envolvidos foram alocados em dois grupos. No grupo 1 (G1) participaram 102 pacientes com pele preparada com iodopolividona e do grupo 2 (G2) 103 que utilizaram clorexidina. No terceiro, sétimo e 30º dia de pós-operatório avaliou-se o sítio cirúrgico, buscando-se sinais de infecção. RESULTADOS: os dados relacionados ao perfil clínico como: diabete melito, tabagismo, alcoolismo, dados hematológicos (Hb, VG e leucócitos), idade e sexo, e as variáveis relativas como: número de dias de internamento pré-operatório, tricotomia, topografia da incisão, antibioticoprofilaxia e a participação de residentes na operação, não foram evidenciadas como fatores predisponentes a infecção do sítio cirúrgico. Dois pacientes do G1 e oito do G2 submetidos à operações limpas apresentaram algum tipo de infecção (p=0,1789), cinco do G1 e três do G2 submetidos à operações potencialmente contaminadas apresentaram algum tipo de infecção (p=0,7205). CONCLUSÃO: a incidência de infecção do sítio cirúrgico em operações classificadas como limpas e potencialmente contaminadas, cujo preparo da pele foi feito com iodopolividona 10% em solução hidroalcoólica e clorexidina alcoólica 0,5%, foi semelhante.

Using synchrotron radiation angiography with a highly sensitive detector to identify impaired peripheral perfusion in rat pulmonary emphysema

Owing to limitations in spatial resolution and sensitivity, it is difficult for conventional angiography to detect minute changes of perfusion in diffuse lung diseases, including pulmonary emphysema (PE). However, a high-gain avalanche rushing amorphous photoconductor (HARP) detector can give high sensitivity to synchrotron radiation (SR) angiography. SR angiography with a HARP detector provides high spatial resolution and sensitivity in addition to time resolution owing to its angiographic nature. The purpose of this study was to investigate whether this SR angiography with a HARP detector could evaluate altered microcirculation in PE. Two groups of rats were used: group PE and group C (control). Transvenous SR angiography with a HARP detector was performed and histopathological findings were compared. Peak density of contrast material in peripheral lung was lower in group PE than group C (p < 0.01). The slope of the linear regression line in scattering diagrams was also lower in group PE than C (p < 0.05). The correlation between the slope and extent of PE in histopathology showed significant negative correlation (p < 0.05, r = 0.61). SR angiography with a HARP detector made it possible to identify impaired microcirculation in PE by means of its high spatial resolution and sensitivity.

Respiratory pressures and expiratory peak flow rate of patients undergoing coronary artery bypass graft surgery

Background

To evaluate clinical and laboratorial parameters that predict decreased respiratory function in patients subjected to coronary artery bypass graft surgery (CABG).

Material/Methods

This was a prospective study evaluating 61 patients subjected to CABG with cardiopulmonary bypass, median sternotomy, and under mechanical ventilation for up to 24 h. One day before surgery, clinical information was recorded. Maximal inspiratory (MIP) and expiratory (MEP) pressures, and expiratory peak flow rate (EPFR) values were assessed 1 day before surgery and on the fifth postoperative day. Student’s t test, 2-way ANOVA, Pearson’s linear correlation, and logistic regression were used for statistical analysis.

Results

Patients were 63±10 years old, 67% males. Arterial hypertension was found in 75.4% of the patients, diabetes in 31.2%, dyslipidemia in 63.9%, tabagism in 25%, and chronic obstructive pulmonary disease (COPD) in 16.4%. Previous myocardial infarction was found in 67%. Preoperative hemoglobin levels were 12.8±1.71 g/dL. Older individuals had lower preoperative MEP and EPFR values. Preoperatively, positive association was found between hemoglobin levels and maximal respiratory pressures and EPFR values. Patients with both class III angina and COPD presented higher reductions in pulmonary pressures between the preoperative period and the 5^th postoperative day.

Conclusions

Older age and low hemoglobin levels are associated with preoperative low maximal respiratory pressures and EPFR. The combination of severe angina and COPD results in higher postoperative reduction of maximal respiratory pressures for patients who underwent CABG.

Significant correlation between endothelial nitric oxide synthase (eNOS) expression and alveolar repair in elastase-induced rat pulmonary emphysema

BACKGROUND AND PURPOSE

Angiogenic factors, such as endothelial nitric oxide synthase (eNOS), are thought to play an important role in the repair of pulmonary emphysema (PE); yet, the correlation of the factors involved has not been investigated. We conducted this study to clarify the positive correlation between eNOS expression and alveolar repair in PE recovery.

METHODS

We used elastase to induce PE in rats, which were divided into Groups A (Control), B (G-CSF), C (PE) and D (PE + G-CSF). G-CSF was injected for 12 days, 4 weeks after which the alveolar walls, arterioles, and angiogenic factors including eNOS were examined histopathologically and by western blotting.

RESULTS

In comparing Groups A, B, C, and D, the alveolar density was 2.4 ± 0.2, 2.4 ± 0.1, 1.8 ± 0.1, 2.5 ± 0.1 per 100 μm(2), respectively (C vs. others; p < 0.00001) and the number of arterioles was 4.5 ± 1.0, 5.6 ± 0.6, 3.2 ± 0.5, 5.5 ± 0.7/mm(2), respectively (C vs. others; p < 0.05). Immunohistochemical staining (IHC) revealed different eNOS expression in Group D versus Group C (p < 0.0001) and western blotting revealed different eNOS, VEGF, and FLT-1 expression in Group D versus Group C (p < 0.01, p < 0.05, p < 0.001), reflecting the contribution of angiogenesis to PE repair. eNOS showed a significantly positive correlation to alveolar density and arteriole repair.

CONCLUSION

Alveolar repair was correlated positively with eNOS expression by vascular regeneration in elastase-induced rat PE.