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Dimberg A, Dalén M, Sartipy U. Bleeding and long-term survival after lung resections: nationwide observational cohort study. J Thorac Dis 2024; 16:4409-4416. [PMID: 39144293 PMCID: PMC11320260 DOI: 10.21037/jtd-24-502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/07/2024] [Indexed: 08/16/2024]
Abstract
Background Bleeding following lung surgery can lead to reoperation and blood transfusions, potentially impairing outcomes. This study aimed to assess how bleeding complications affect long-term survival and postoperative complications in a nationwide contemporary group of patients undergoing lung resections. Methods Adult patients who underwent lung resections, for both malignant and nonmalignant diagnoses, between 2013-2021, were included from the Swedish national registry for thoracic surgery. Patients with bleeding complications, defined as requiring reexploration and/or transfusions, were compared to patients without bleeding complications regarding long-term survival and postoperative complications. We used propensity scores and optimal full matching to account for differences in baseline characteristics between the groups. Results The cohort comprised 15,617 adult patients, of which 646 patients (4.1%) had bleeding complications. The unadjusted 90-day mortality was 9.4% vs. 1.0% in the bleeding group vs. no bleeding group, respectively. After matching, the odds ratio (OR) for 90-day mortality in the bleeding group compared with the no bleeding group was 3.66 [95% confidence interval (CI): 2.17-6.17]. Long term overall survival was lower among patients in the bleeding group, adjusted hazard ratio (95% CI) for all-cause mortality was 1.47 (1.29-1.69). Postoperative complications were more common in the bleeding group (OR: 3.00, 95% CI: 2.38-3.79), including infections (OR: 2.80, 95% CI: 1.86-4.20). Bleeding complications were more frequent during the first third of the study time period as compared to the last third (P<0.001). Conclusions Patients with bleeding complications had reduced long-term survival and higher incidence of postoperative complications. A declining trend in bleeding rates over time was noted.
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Affiliation(s)
- Axel Dimberg
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Dalén
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Xu K, Xie E, Lv Y, Gu W, Shi M, Yao J, Wu J, Ye B. Unplanned reoperation after pulmonary surgery: Rate, risk factors and early outcomes at a single center. Heliyon 2023; 9:e20538. [PMID: 37818013 PMCID: PMC10560774 DOI: 10.1016/j.heliyon.2023.e20538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/18/2023] [Accepted: 09/28/2023] [Indexed: 10/12/2023] Open
Abstract
Background Unplanned reoperation is a potential risk factor for worse prognoses and reflects the quality of surgical treatment. This study compared the short-term outcomes between patients with and without reoperation and identified clinical factors predicting reoperation within 90 days following pulmonary surgery. Methods Consecutive patients undergoing pulmonary resection from January 2012 to August 2021 at our institution were retrospectively reviewed. Clinical and operation-related data were collected and analyzed. Kaplan‒Meier, Cox hazard proportional regression, and propensity score matching were adopted for prognostic evaluation. Results A total of 90263 patients were included: 247 (0.27%) patients required reoperation within 90 days. Patients undergoing unplanned reoperation had higher mortality and more postoperative complications than the nonreoperation group. Reoperation within 24 h was associated with reduced odds of mortality relative to reoperation beyond 24 h. Independent risk factors for unplanned reoperation were male sex, benign lung disease, specific surgical locations, lobectomy, and pneumonectomy. A history of smoking, pulmonary tuberculosis, intraoperative pleural adhesion, and postoperative complications were also identified as predisposing factors. The most common complication was hemorrhage in 75.7% (187 of 247). Conclusion Our study found that unplanned reoperation was a rare but serious event that increased the risk of postoperative complications and mortality. We identified several risk factors that could be used to stratify patients according to their reoperation risk and suggest that high-risk patients should receive more intensive monitoring and preventive measures. Moreover, our study indicated that reoperating within 24 h could improve the outcomes for patients who needed reoperation.
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Affiliation(s)
- Kuan Xu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Ermei Xie
- Key Laboratory of Synthetic Biology Regulatory Element, Institute of Systems Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Suzhou Institute of Systems Medicine, Suzhou, China
| | - Yilv Lv
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Wei Gu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Minjun Shi
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Jueya Yao
- Department of General Surgery Department, Shanghai Construction Group Hospital, Shanghai, 200030, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Bo Ye
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
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Hong Y, Zhang Y, Xiang Y, Ye Z, Lu X. Incidence of venous thromboembolism and hemorrhage in Chinese patients after pulmonary lobectomy: mechanical prophylaxis or mechanical prophylaxis combined with pharmacological prophylaxis: a randomized controlled trial. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1478. [PMID: 34734030 PMCID: PMC8506730 DOI: 10.21037/atm-21-4231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/18/2021] [Indexed: 11/06/2022]
Abstract
Background Venous thromboembolism (VTE) and postoperative bleeding are important complications of lung resection surgery. We investigated the preventive effect of mechanical prophylaxis versus pharmacological prophylaxis after lobectomy, and evaluated the effect of both on the incidence of hemorrhagic events. Methods A prospective study of 424 lobectomies with moderate to high risk of VTE (Caprini risk score <5) in a single center was performed from April 2020 to March 2021. Patients were 1:1 randomly allocated to mechanical prophylaxis or to the low-molecular-weight heparin (LMWH)-combination-prophylaxis. The incidence of postoperative thrombotic and bleeding events and relevant factors of the two groups were analyzed. Results A total of 410 participants, with 202 and 208 in the mechanical prophylaxis and LMWH-combination-prophylaxis groups respectively, were selected for analysis. Both groups had similar baseline and clinical characteristics. There were no cases of VTE or major bleeding during the study, but the incidence rate of minor bleeding in the LMWH-combination-prophylaxis group was significantly higher than mechanical prophylaxis group [odds ratio (OR) 0.035, 95% confidence interval (CI): 0.011–0.113]. Conclusions A case-by-case risk assessment of VTE and hemorrhage remains necessary to determine the most appropriate method of thrombosis prophylaxis for patients undergoing pulmonary surgery. Mechanical prophylaxis may be preferable for lung cancer patients with moderate to high risk of VTE (Caprini risk score <5) undergoing lobectomy. Trial Registration Chinese Clinical Trial Registry ChiCTR2100051073.
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Affiliation(s)
- Yun Hong
- Department of Clinical Pharmacy, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yanfang Zhang
- Department of Clinical Pharmacy, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yangwei Xiang
- Department of Lung Transplantation and Thoracic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ziqi Ye
- Department of Clinical Pharmacy, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoyang Lu
- Department of Clinical Pharmacy, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Management of Complications Following Lung Resection. Surg Clin North Am 2021; 101:911-923. [PMID: 34537151 DOI: 10.1016/j.suc.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Lung resections are associated with a variety of potential postoperative complications. Not surprisingly, pulmonary complications are most frequent after lung surgery. Cardiac and thromboembolic complications are also important. It is essential that surgeons anticipate the possibility of these complications and take preventative measures whenever possible. When complications do occur, prompt recognition and treatment is required to assure optimal patient outcomes.
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Smith D, Raices M, Diego C, Julián D, Montagne J, Dietrich A. Incidence of venous thromboembolism and bleeding after pulmonary lobectomy: evaluating the timing for thromboprophylaxis. J Thromb Thrombolysis 2020; 51:997-1004. [PMID: 32929687 DOI: 10.1007/s11239-020-02277-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/24/2022]
Abstract
Venous thromboembolism (VTE) is an important postoperative complication after major lung cancer resective surgery, such as lobectomy. It is recommended to start chemical thromboprophylaxis within the first 12 h following the procedure. Postoperative bleeding is also a relevant complication in patients with predisposing conditions. However, the criterion for classifying a patient as "high risk of bleeding" is not standardized and is left to the expertise of the attending physician or surgeon. We aim to describe the incidence and risk factors for postoperative VTE and hemorrhage after pulmonary lobectomy; and to assess the impact of the timing of thromboprophylaxis on the incidence of postoperative thrombotic or hemorrhagic events. A retrospective observational study of 358 lobectomies performed in a single center was performed, analyzing the rates of postoperative thrombotic and hemorrhagic events and predisposing factors, including postoperative thromboprophylaxis management. Cumulative incidence of VTE was 3.07% (95% CI 1.54-5.43), and early postoperative bleeding was 10.05% (95% CI 7.14-13.64). Underlying pulmonary disease was associated with VTE (p = 0.001) and open approach was associated with hemorrhagic events (p = 0.01). The use of thromboprophylaxis and timing of its initiation were not associated with a higher incidence of events. VTE and postoperative hemorrhage are relevant complications following pulmonary lobectomy. Compliance with VTE prophylaxis guidelines is essential. Even so, a case-by-case risk evaluation of VTE and bleeding remains preferable and safe in order to decide on the most suitable timing of thromboprophylaxis.
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Affiliation(s)
- David Smith
- Department of Thoracic Surgery. Hospital Italiano de Buenos Aires. Juan D. Perón, 4190. C1199ABD, Buenos Aires, Argentina
| | - Micaela Raices
- Department of General Surgery. Hospital Italiano de Buenos Aires. Juan D. Perón, 4190. C1199ABD, Buenos Aires, Argentina.
| | - Carolina Diego
- Department of General Surgery. Hospital Italiano de Buenos Aires. Juan D. Perón, 4190. C1199ABD, Buenos Aires, Argentina
| | - Drago Julián
- Department of General Surgery. Hospital Italiano de Buenos Aires. Juan D. Perón, 4190. C1199ABD, Buenos Aires, Argentina
| | - Juan Montagne
- Department of Thoracic Surgery. Hospital Italiano de Buenos Aires. Juan D. Perón, 4190. C1199ABD, Buenos Aires, Argentina
| | - Agustín Dietrich
- Department of Thoracic Surgery. Hospital Italiano de Buenos Aires. Juan D. Perón, 4190. C1199ABD, Buenos Aires, Argentina
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Van Haren RM, Rajaram R, Correa AM, Mehran RJ, Antonoff MB, Hofstetter WL, Sepesi B, Swisher SG, Vaporciyan AA, Walsh GL, Rice DC, Roth JA. Preoperative Heparin for Lung Cancer Resection Increases Risk of Reoperation for Bleeding. Semin Thorac Cardiovasc Surg 2019; 32:337-343. [PMID: 31857153 DOI: 10.1053/j.semtcvs.2019.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/10/2019] [Indexed: 12/13/2022]
Abstract
Lung cancer patients are at risk for venous thromboembolism (VTE). Preoperative heparin administration may increase the risk of bleeding requiring reoperation. The purpose of this study was to evaluate preoperative heparin's effect on reoperation for bleeding. A retrospective review compared outcomes for patients undergoing pulmonary resection for primary lung cancer from January 2006 to April 2018. Preoperative heparin was administered at the discretion of the attending surgeon. Comparisons were performed between preoperative subcutaneous heparin (5000 U) and no heparin groups. A total of 3325 lung resections were reviewed, 1.4% (n = 48) required reoperation for bleeding. VTE occurred in 1.1% (n = 38). Four hundred sixty-four patients (14.0%) did not receive preoperative heparin. The preoperative heparin group had increased rates of prior thoracic surgery (5.1% [n = 146] vs 1.7% [n = 8], P < 0.001), minimally invasive approach (40.2% [n = 1150] vs 10.6% [n = 49], P < 0.001), and sublobar resections (17.7% [n = 506] vs 10.6% [n = 49], P < 0.001). There were no differences in blood loss/transfusions. Reoperation for bleeding was significantly increased in the preoperative heparin group (1.6% [n = 47] vs 0.2% [n = 1], P = 0.017). There were no differences in VTE (1.5% [n = 7] vs 1.1% [n = 31], P = 0.424). On logistic regression, preoperative heparin was independently associated with increased reoperation for bleeding (odds ratio 8.13, P = 0.039); however, preoperative heparin was not independently associated with VTE. Preoperative heparin was associated with increased reoperation for bleeding. VTE rates are low after pulmonary resection for lung cancer and are not decreased by preoperative heparin. Preoperative heparin use should be determined by risk factor stratification for VTE and reoperation for bleeding in patients undergoing lung cancer resection.
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Affiliation(s)
- Robert M Van Haren
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas; Division of Thoracic Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
| | - Ravi Rajaram
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Arlene M Correa
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Ara A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Garrett L Walsh
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Jack A Roth
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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