Major Lung Surgery Research Articles

Interest of the Leicester Cough Questionnaire in predicting postoperatives complications after lung resection: LCQ-SURGE.

Postoperative complications may occur after major lung surgery for non-small cell lung cancer (NSCLC), with a high rate of morbidity and mortality. The main objective of this study was to assess the relevance of preoperative Leicester Cough Questionnaire (LCQ) to predict postoperative complications after major lung resection for any indication. This was a retrospective cohort study conducted in the Thoracic Surgery Department of Rouen University Hospital from November 21st, 2022, to June 2nd, 2023. Patients aged ≥18 years who underwent major lung resection for any indications and filled an LCQ self-questionnaire were included. Seventy-one patients were eligible for our study. One patient was lost to follow-up upon hospital discharge. Nineteen (27.1%) postoperative complications of grade ≥2 according to the Clavien-Dindo classification were observed. The mean LCQ total score was 18.11±2.56. The area under the receiver operating characteristic (ROC) curve for the LCQ result to predict postoperative complications of grade ≥2 within 30 days following the surgical intervention was 0.60 [95% confidence interval (CI): 0.45, 0.75]. This study failed to demonstrate the relevance of a preoperative LCQ to predict postoperative complications after major lung surgery. However, the statistical precision of this study was insufficient to show a moderate predictive performance. Further studies conducted in larger populations are needed.

Hybrid GA-SVM Approach for Postoperative Life Expectancy Prediction in Lung Cancer Patients

Medical outcomes must be tracked in order to enhance quality initiatives, healthcare management, and mass education. Thoracic surgery data have been acquired for those who underwent major lung surgery for primary lung cancer, a field in which there has been little research and few reliable recommendations have been made for lung cancer patients. Early detection of lung cancer benefits therapy choices and increases the odds of a patient surviving a lung cancer infection. Using a Hybrid Genetic and Support Vector Machine (GA-SVM) methodology, this study proposes a method for identifying lung cancer patients. To estimate postoperative life expectancy, ensemble machine-learning techniques were applied. The article also presents a strategy for estimating a patient’s life expectancy following thoracic surgery after the detection of cancer. To perform the prediction, hybrid machine-learning methods were applied. In ensemble machine-learning algorithms, attribute ranking and selection are critical components of robust health outcome prediction. To enhance the efficacy of algorithms in health data analysis, we propose three attribute ranking and selection procedures. Compared to other machine-learning techniques, GA-SVM achieves an accuracy of 85% and a higher F1 score of 0.92. The proposed algorithm was compared with two recent state-of-the-art techniques and its performance level was ranked superior to those of its counterparts.

Feasibility of repeated ipsilateral anatomical pulmonary resection.

This study aimed to elucidate the feasibility of repeated ipsilateral anatomical pulmonary resection. The subjects of this retrospective analysis were 50 patients who underwent ipsilateral anatomical pulmonary resection after major lung surgery. The patients were divided into two groups according to the type of primary operation performed: a repeated anatomical pulmonary resection group (RA group; n = 24) and an anatomical pulmonary resection after wedge resection group (AW group; n = 26). We compared the perioperative outcomes of the two groups. Completion lobectomy was performed in 9 of the 24 patients (38%) from the RA group and adhesion of the pulmonary hilum was more severe in this group (P = 0.004). Although the operative time was significantly longer in the RA group (P = 0.030), there was no significant difference in the amount of blood loss (P = 0.217) between the groups. A significantly higher rate of severe postoperative complications was observed in the RA group (42%) than in the AW group (12%) (P = 0.024). None of the patients who underwent repeated surgery died within 90days postoperatively. Although repeated anatomical pulmonary resection is a more challenging procedure than anatomical resection after wedge resection, it does not increase short-term mortality; therefore, it is a feasible treatment option.

Feasibility study of a randomised controlled trial of preoperative and postoperative nutritional supplementation in major lung surgery

ObjectivesMalnutrition and weight loss are important risk factors for complications after lung surgery. However, it is uncertain whether modifying or optimising perioperative nutritional state with oral supplements results in a...

Use of extracorporeal membrane oxygenation in non-elective major thoracic surgery for infectious lung abscess.

Extracorporeal membrane oxygenation (ECMO) support for elective cardiothoracic surgery is well established. In contrast, there are not much data regarding the usefulness and outcome of ECMO in non-elective major lung resections for infectious lung abscess. All patients undergoing non-elective major lung surgery for infectious lung abscess at 5 centres in Germany, UK and Spain were enrolled in a prospective database. Malignant disorders and intrathoracic complications of other procedures were excluded. There were 127 patients. The median age was 59 years (interquartile range 18.75). The mean Charlson index of comorbidity was 2.83 (standard deviation 2.57). Surgical procedures were lobectomy (89), pneumectomy (20) and segmentectomy (18). ECMO was used for 10 patients (pneumectomy 2, lobectomy 8) and several more received pre-ECMO treatment. Mortality was 17/127. Intraoperatively no ECMO-associated complications were encountered. EMCO [1/10 vs 16/117; odds ratio (OR): 0.70, 95% confidence interval (CI) 0.08-5.91, P = 0.74] and the extent of pulmonary resection were not associated with higher mortality. Preoperative sepsis (OR: 17.84, 95% CI 2.29-139.28, P < 0.01), preoperative air leak (OR: 13.12, 95% CI 4.10-42.07, P < 0.001), acute renal failure (OR: 7.00, 95% CI 2.19-22.43, P < 0.01) and Charlson index of comorbidity ≥3 (OR: 10.83, 95% CI 2.36-49.71, P < 0.01) were associated with significantly higher mortality. The application of ECMO is widening the possibilities for successful surgical management of infectious, non-malignant lung abscesses. Particularly, patients with marginal functional operability benefit from the availability and readiness to use ECMO. Mortality is determined by the burden of pre-existent comorbidity, severe sepsis and septic shock.

Shared Decision Making and Human Bias

Surrogate decision makers play an important role in the shared decision making process. Attending the surgical consultation with a family member or a close friend is frequent and also recommendable as often patients struggle to retain all the information conveyed by the surgeon and would benefit from a person to assist them. In particular, elderly and high-risk patients commonly defer the treatment decision until after further reflection and discussion with family members. In this context, the importance of nonclinical surrogate decision makers appear crucial in influencing the treatment choice. In this issue of The Annals of Thoracic Surgery, Lee and colleagues 1 Lee A.C.H. Madariaga M.L.L. Liao C. Ferguson M.K. Gender bias in judging frailty and fitness for lung surgery. Ann Thorac Surg. 2023; 115: 356-362 Abstract Full Text Full Text PDF Scopus (2) Google Scholar have shown that the general population display sex and race biases in judging frailty and fitness for major surgery. This is a timely study complementing the recent evidence confirming how possible sex-related factors influence patient-physician communication, relationship, and ultimately, postoperative clinical outcomes. 2 Wallis C.J.D. Jerath A. Coburn N. et al. Association of surgeon-patient sex concordance with postoperative outcomes. JAMA Surg. 2022; 157: 146-156 Crossref PubMed Scopus (53) Google Scholar Gender Bias in Judging Frailty and Fitness for Lung SurgeryThe Annals of Thoracic SurgeryVol. 115Issue 2PreviewDisparities in surgical care for lung cancer have been well documented, and unconscious bias may be a source of inequity. We assessed whether gender biases exist when nonclinical decision makers render decisions about major lung surgery. Full-Text PDF

A Nomogram for Prediction of Complications Based on TM&M System of VATS Major Lung Surgery for Lung Cancer

背景与目的并发症是肺切除术后患者死亡的重要原因，目前我国肺癌胸腔镜手术普及率逐年增高，但肺癌胸腔镜手术术后并发症的预测模型尚缺乏基于大样本数据库的支持。本研究采用TM&M（Thoracic Mortality and Morbidity）分级系统全面描绘我中心胸腔镜肺癌手术术后并发症，并建立和验证并发症的预测模型。该模型可为此类患者术后并发症的预防和干预提供依据，从而加速患者康复。方法回顾性收集我中心2007年1月-2018年12月胸腔镜肺癌手术患者临床资料，仅纳入Ⅰ期-Ⅲ期肺癌行胸腔镜肺主要手术的肺癌患者，术后并发症登记严格采用TM&M分级系统。将患者按照手术时期分为两组：前期组（2007年-2012年）和后期组（2013年-2018年），以倾向评分匹配法对两组基线数据进行匹配；匹配后数据采用二元Logistic回归分析建立并发症的预测模型，Bootstrap法内抽样进行内部验证。结果研究共纳入2, 881例肺癌患者，平均年龄（61.0±10.1）岁，其中发生主要并发症180例（6.2%）。匹配后的1, 268例患者进行二元Logistic回归分析显示：年龄（OR=1.04, 95%CI: 1.02-1.06, P < 0.001）、手术时期（OR=0.62, 95%CI: 0.49-0.79, P < 0.001）、病理类型（OR=1.73, 95%CI: 1.24-2.41, P=0.001）、术中出血量（OR=1.001, 95%CI: 1.000-1.003, P=0.03）、清扫淋巴结数目（OR=1.022, 95%CI: 1.00-1.04, P=0.005）为术后并发症发生的独立危险因素；将其纳入列线图模型，受试者工作特征曲线（receiver operating characteristic curve, ROC）提示该模型区分度较好（C-指数为0.699），1, 000次重复Bootstrap内部抽样验证C-指数为0.680。校准曲线显示预测模型的校准度良好。结论TM&M并发症分级系统可全面准确地报告胸腔镜肺癌外科的术后并发症。年龄、手术时期、病理类型、术中出血量、清扫淋巴结数目是胸腔镜肺癌手术后主要并发症的独立危险因素，以此建立的并发症预测模型具有较好的区分度和校准度。

Gender Bias in Judging Frailty and Fitness for Lung Surgery

BackgroundDisparities in surgical care for lung cancer have been well documented, and unconscious bias may be a source of inequity. We assessed whether gender biases exist when nonclinical decision makers render decisions about major lung surgery. MethodsAmazon Mechanical Turk workers, remotely located "crowdworkers" readily available for hire to perform discrete on-demand tasks on the Amazon Mechanical Turk platform, were each shown 4 videos of different standardized patients (SPs) in a clinic setting, 1 video in each energy level (vigorous or frail) and race category (White or Black), randomized to male or female. Workers scored video characteristics and whether they would support the SP’s decision to undergo a major lung operation. ResultsA total of 855 workers were recruited. The frail White male SP was more likely to have support to undergo lung surgery than the frail White female SP, while the frail Black male SP was much less likely to have support to undergo lung surgery than the frail Black female SP. There were no significant differences in support for surgery between the vigorous male and female SPs and ratings by male and female workers in their recommendations. ConclusionsBiases related to patient gender exist in the general population and affect views on surgery, particularly in the setting of frailty. Understanding such differences may aid in educational efforts directed at reducing gender-based biases in treatment recommendations.

MAJOR PULMONARY SURGERY IN PATIENTS WITH COMPROMISED LUNG FUNCTION.

The risk stratification of lung resection is fundamentally based on the results of pulmonary function tests. In patients considered to be at risk, major surgery is generally denied, opting for potentially less curative therapies. To evaluate the postoperative outcomes of major lung surgery in a group of patients deemed high risk. We performed a retrospective review of clinical records of all patients submitted to lobectomy, bilobectomy or pneumonectomy in a 3-year period in a reference Thoracic Surgery Unit. The patients were then divided in two groups: group A composed of patients with normal preoperative pulmonary function and group B which included patients with impaired lung function, defined as FEV1 and/or DLCO ≤60%. A total of 234 patients were included, 181 (77.4%) in group A and 53 (22.6%) in group B. In group B, patients had more smoking habits, were more often associated with chronic obstructive pulmonary disease and were also more frequently submitted to thoracotomy. When surgery was motivated by primary lung cancer this group had a more advanced clinical stage of the disease. In the postoperative period, these patients had longer hospital stay, longer chest drainage time and greater need for oxygen therapy at home, however, no statistically significant difference was noted in morbidity or mortality. Major thoracic surgery can be safely performed in selected patients considered to be high risk for resection by pulmonary function tests. A potentially curative surgery should not be denied based on respiratory function tests alone.

Protocol for a feasibility study of smoking cessation in the surgical pathway before major lung surgery: Project MURRAY

IntroductionSmoking prior to major thoracic surgery is the biggest risk factor for development of postoperative pulmonary complications, with one in five patients continuing to smoke before surgery. Current guidance is...

Smoking Cessation in the Surgical Pathway Before Major Lung Surgery

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Perioperative Factors for Predicting the Need for Postoperative Intensive Care after Major Lung Resection.

Postoperative management after major lung surgery is critical. This study evaluates risk factors for predicting mandatory intensive care unit (ICU) admission immediately after major lung resection. We retrospectively reviewed patients for whom the surgeon requested an ICU bed before major lung resection surgery. Patients were classified into three groups. Univariable and multivariable logistic regression analyses were performed, and a clinical nomogram was constructed. Among 340 patients, 269, 50, and 21 were classified into the no need for ICU, mandatory ICU admission, and late-onset complication groups, respectively. Predictive postoperative diffusion capacity of the lung for carbon monoxide (47.2 (interquartile range (IQR) 43.3–65.7)% versus vs. 67.8 (57.1–79.7)%; p = 0.003, odds ratio (OR) 0.969, 95% confidence interval (CI) 0.95–0.99), intraoperative blood loss (400.00 (250.00–775.00) mL vs. 100.00 (50.00–250.00) mL; p = 0.040, OR 1.001, 95% CI 1.000–1.002), and open thoracotomy (p = 0.030, OR 2.794, 95% CI 1.11–7.07) were significant predictors for mandatory ICU admission. The risk estimation nomogram demonstrated good accuracy in estimating the risk of mandatory ICU admission (concordance index 83.53%). In order to predict the need for intensive care after major lung resection, preoperative and intraoperative factors need to be considered.

Epidemiology and Appropriateness of Antibiotic Prescribing in Severe Pneumonia After Lung Resection

Postoperative pneumonia (POP) is a severe complication of major lung resection. The objective of this study was to describe the current epidemiology and appropriateness of antibiotic prescriptions in severe POP, 4 years after implementation of an antimicrobial stewardship program that was based on weekly multidisciplinary review of all antibiotic therapies. This study was a retrospective analysis of a prospectively collected database. It included all cases of severe POP occurring within 30 days after major lung resection of in a 1,500-bed hospital between 2013 and 2015. Criteria for severe POP were acute respiratory failure, severe sepsis, or a rapidly extensive pulmonary infiltrate. The study collected data on incidence, clinical outcomes, and microbiological analyses. Appropriateness of antibiotic prescribing was assessed by quality indicators previously validated in the literature. Over the study period, 1,555 patients underwent major lung surgery. Severe POP occurred in 91 patients (5.8%; confidence interval, 4.7%; 7.0%), with a mortality rate of 9.0% (8 of 91; confidence interval, 3.0%; 14.6%). In POP with positive microbiological results, the proportion of gram-negative bacteria other than Haemophilus was 76% (50 of 66 cases). All patients (91 of 91) had respiratory samples taken within 24 hours after the start of antibiotics; empiric therapy was concordant with the guideline in 80% (69 of 86), and it was switched topathogen-directed therapy in 74% (46 of 62). In 71 of 91patients (78%), the antibiotic duration was up to 7days. This study reported a high proportion of gram-negative bacteria in severe POP. Four years after implementation of the program, quality indicators of antibiotic prescribing were all >70%. The rate of de-escalation to pathogen-directed therapy could be improved, however.

178 - A randomised controlled trial to investigate the feasibly of a nutritional intervention of carbohydrate and post-operative nutritional drinks after elective major lung surgery

178 - A randomised controlled trial to investigate the feasibly of a nutritional intervention of carbohydrate and post-operative nutritional drinks after elective major lung surgery

Low-dose buprenorphine infusion to prevent postoperative hyperalgesia in patients undergoing major lung surgery and remifentanil infusion: a double-blind, randomized, active-controlled trial

BackgroundPostoperative secondary hyperalgesia arises from central sensitization due to pain pathways facilitation and/or acute opioid exposure. The latter is also known as opioid-induced hyperalgesia (OIH). Remifentanil, a potent μ-opioid agonist, reportedly induces postoperative hyperalgesia and increases postoperative pain scores and opioid consumption. The pathophysiology underlying secondary hyperalgesia involves N-methyl-D-aspartate (NMDA)-mediated pain pathways. In this study, we investigated whether perioperatively infusing low-dose buprenorphine, an opioid with anti-NMDA activity, in patients receiving remifentanil infusion prevents postoperative secondary hyperalgesia. MethodsSixty-four patients, undergoing remifentanil infusion during general anaesthesia and major lung surgery, were randomly assigned to receive either buprenorphine i.v. infusion (25 μg h−1 for 24 h) or morphine (equianalgesic dose) perioperatively. The presence and extent of punctuate hyperalgesia were assessed one day postoperatively. Secondary outcome variables included postoperative pain scores, opioid consumption and postoperative neuropathic pain assessed one and three months postoperatively. ResultsA distinct area of hyperalgesia or allodynia around the surgical incision was found in more patients in the control group than in the treated group. Mean time from extubation to first morphine rescue dose was twice as long in the buprenorphine-treated group than in the morphine-treated group: 18 vs 9 min (P=0.002). At 30 min postoperatively, patients receiving morphine had a higher hazard ratio for the first analgesic rescue dose than those treated with buprenorphine (P=0.009). At three months, no differences between groups were noted. ConclusionsLow-dose buprenorphine infusion prevents the development of secondary hyperalgesia around the surgical incision but shows no long-term efficacy at three months follow-up.

Best Evidence Topic: Avoidance and Treatment of a Bronchial Stump Insufficiency following Major Lung Surgery

Objectives: Almost a century after the first successful pneumonectomy postoperative insufficiency of the bronchus stump remains one of the most feared complications in thoracic surgery. This complication is not only associated with high mortality and morbidity, but also the treatment itself is challenging for the surgeon.

Association of Preoperative Right and Left Ventricular Diastolic Dysfunction With Postoperative Atrial Fibrillation in Patients Undergoing Lung Surgery: A Prospective Observational Study

To clarify the relationship between right and left ventricular (RV and LV) diastolic function and postoperative atrial fibrillation (POAF). The early effects of major lung surgery on cardiac function in the intraoperative period during lung surgery were evaluated, using transesophageal echocardiography. Single-center prospective observational study. A public hospital. Patients undergoing elective lobectomy with lymph node dissection for lung cancer (n = 116). Transesophageal echocardiography examination was performed under general anesthesia before skin incision (preoperative) and after chest closure (postoperative). According to measured echocardiographic variables, ventricular systolic and diastolic functions were classified at each time point. Of the 116 patients, 24 (20.7%) experienced POAF. Preoperative RV and LV diastolic dysfunction were more common in patients with POAF than in those without POAF (58.3 v 28.3%, p = 0.008; 54.2 v 19.6%, p = 0.001, respectively). Among patients without preoperative diastolic dysfunction, a small number developed RV and LV diastolic dysfunction immediately after surgery (9.2% and 16.5%, respectively) and these distributions were comparable between patients with POAF and those without POAF. RV systolic dysfunction was observed in 6.5% of patients immediately after surgery and was not related to the occurrence of POAF. Multivariate analysis revealed older age, chronic obstructive pulmonary disease (COPD), and preoperative biventricular diastolic dysfunction as risk factors for POAF. Preoperative biventricular diastolic dysfunction, as well as older age and COPD, are associated with POAF in patients undergoing lobectomy. Major lung surgery has minimal early effects on postoperative systolic and diastolic functions.

Pharmacokinetics and pharmacodynamics of propofol in cancer patients undergoing major lung surgery.

Despite the growing number of cancer cases and cancer surgeries around the world, the pharmacokinetics (PK) and pharmacodynamics (PD) of anesthetics used in this population are poorly understood. Patients operated due to cancer are usually in severe state and often require chemotherapy. It might affect the PK/PD of drugs used in this population. Therefore, in this study we explored the PK/PD of propofol in cancer patients having a major lung surgery. 23 patients that underwent a propofol–fentanyl total intravenous anesthesia were included in the analysis. A large set of demographic, biochemical and hemodynamic parameters was collected for the purpose of covariate analysis. Nonlinear mixed effect modeling in NONMEM was used to analyze the collected data. A three-compartment model was sufficient to describe PK of propofol. The anesthetic effect (AAI index) was linked to the propofol effect site concentrations through a sigmoidal E max model. A slightly higher value of clearance, a lower value of distribution clearance, and a decreased volume of peripheral compartment were observed in our patients, as compared with the literature values reported for healthy volunteers by Schnider et al. and by Eleveld et al. Despite these differences, both models led to a clinically insignificant bias of −8 and −1 % in concentration predictions, as reflected by the median performance error. The C e50 and propofol biophase concentration at the time of postoperative orientation were low and equaled 1.40 and 1.13 mg/L. The population PK/PD model was proposed for cancer patients undergoing a major lung surgery. The large body of studied covariates did not affect PK/PD of propofol significantly. The modification of propofol dosage in the group of patients under study is not necessary when TCI-guided administration of propofol by means of the Schnider model is used.Electronic supplementary materialThe online version of this article (doi:10.1007/s10928-015-9404-6) contains supplementary material, which is available to authorized users.

Evaluation of the efficacy of a haemostatic matrix for control of intraoperative and postoperative bleeding in major lung surgery: a prospective randomized study.

This prospective randomized study was designed to assess the safety and efficacy of a haemostatic matrix in intraoperative bleeding control and prevention of postoperative bleeding after major lung surgery. One hundred and twenty patients undergoing major lung resection and presenting with intraoperative persistent active bleeding have been prospectively enrolled and randomly assigned to receive [Floseal® group (FG)] or not (control group) the application of Floseal® to the bleeding site and to the site of the hilar dissection. To evaluate the efficacy of the product, several intraoperative and postoperative data were compared between the two groups. No adverse event related to the haemostatic matrix application occurred. The intraoperative haemostasis rate at 3 (primary end-point), 6 and 10 min was significantly higher and the mean time to haemostasis was significantly shorter in the FG. The quantity of chest drain fluids did not show significant differences at 24, 48 and 72 h between the two groups. Postoperative haemoglobin-level variation was significantly lower in patients of the FG (-0.7 ± 0.66 vs -2.3 ± 5.87 g/dl; P = 0.04). Similarly, haematocrit variation was lower in the haemostatic group (-2.6 ± 2.19 vs -4.2 ± 3.71; P = 0.006). The chest drain duration resulted significantly shorter in the FG (10.3 ± 5.05 vs 13.3 ± 6.28 days; P = 0.005). In-hospital stay was shorter in the FG (6.4 ± 2.9 vs 8.1 ± 5.42 days; P = 0.044). In conclusion, the application of Floseal® in major lung resections proved safe and effective in increasing the intraoperative successful haemostasis rate and in reducing postoperative variation in haemoglobin and haematocrit levels. The sealant use was also related with a significantly shorter chest drain duration and hospitalization.

Anterior Muscle and Neurovascular-Sparing Thoracotomy and Posterolateral Thoracotomy: Postoperative Pain and Morbidity Assessment

We conducted this study to evaluate the thoracotomy approaches commonly used nowadays for treating thoracic pathologies and to decide whether it was necessary to make a choice between them for different situations. We used prospective analysis to compare hospital stay, analgesic usage, morbidity and postoperative chest pain between anterior muscle and neurovascular-sparing thoracotomy (AST) with disconnection of anterior rib cartilage, and serratus-sparing posterolateral thoracotomy (PLT). We also looked for a correlation between localization of the lesion and thoracotomy type for this factors. A total of 152 patients who had undergone a thoracotomy for major lung surgery from January through November 2011 were recruited in this study. Of these, 52 patients received AST and 100 underwent PLT. Location of the lesions in the thoracic cavity and all detected postoperative complications were documented. Postoperative chest pain was evaluated using a PIQ-6 pain questionnaire. Analgesic usage and duration of hospitalization were also noted. Pain questionnaire scores were equivalent for both groups in all of the evaluations. Postoperative total median narcotic analgesic usage was lower in AST group than in PLT group. Complication rates were close in both groups. Median hospital stay was also shorter in patients who received AST. We conclude that AST is a reasonable thoracotomy alternative to standard PLT for major lung surgery. But our study fails to demonstrate a clear advantage regarding postoperative pain and complications.