Patients Undergoing Lung Resection Surgery Research Articles

Recurrence-free survival after curative resection of non-small cell lung cancer between inhalational gas anesthesia and propofol-based total intravenous anesthesia: a multicenter, randomized, clinical trial (GAS TIVA trial): protocol description

BackgroundSurgery is the primary treatment for non-small cell lung cancer (NSCLC), but microscopic residual disease may be unavoidable. Preclinical studies have shown that volatile anesthetics might suppress host immunity and promote a pro-malignant environment that supports cancer cell proliferation, migration, and angiogenesis, whereas propofol may preserve cell-mediated immunity and inhibit tumor angiogenesis. However, clinical evidence that propofol-based total intravenous anesthesia (TIVA) can reduce tumor recurrence after curative resection remains inconsistent due to the retrospective observational nature of previous studies. Therefore, we will test the hypothesis that the recurrence-free survival (RFS) after curative resection of NSCLC is higher in patients who received TIVA than volatile anesthetics (GAS) in this multicenter randomized trial.MethodsThis double-blind, randomized trial will enroll patients at 22 international sites, subject to study registration, institutional review board approval, and patient written informed consent. Eligible patients are adult patients undergoing lung resection surgery with curative intent for NSCLC. Exclusion criteria will be contraindications to study drugs, American Society of Anesthesiologists physical status IV or higher, or preexisting distant metastasis or malignant tumor in other organs. At each study site, enrolled subjects will be randomly allocated into the TIVA and GAS groups with a 1:1 ratio. This pragmatic trial does not standardize any aspect of patient care. However, potential confounders will be balanced between the study arms. The primary outcome will be RFS. Secondary outcomes will be overall survival and complications within postoperative 7 days. Enrollment of 5384 patients will provide 80% power to detect a 3% treatment effect (hazard ratio of 0.83) at alpha 0.05 for RFS at 3 years.DiscussionConfirmation of the study hypothesis would demonstrate that a relatively minor and low-cost alteration in anesthetic management has the potential to reduce cancer recurrence risk in NSCLC, an ultimately fatal complication. Rejection of the hypothesis would end the ongoing debate about the relationship between cancer recurrence and anesthetic management.Trial registrationThe study protocol was prospectively registered at the Clinical trials (https://clinicaltrials.gov, NCT06330038, principal investigator: Hyun Joo Ahn; date of first public release: March 25, 2024) before the recruitment of the first participant.

Introduction: Video-assisted thoracic surgery is a well-known and established technique for the treatment of lung diseases. It is considered less invasive than conventional open thoracotomy and, as a result, provides less pain and less impairment of lung

Introduction: Video-assisted thoracic surgery is a well-known and established technique for the treatment of lung diseases. It is considered less invasive than conventional open thoracotomy and, as a result, provides less pain and less impairment of lung function and the shoulder girdle. Objective: To evaluate the quality of post-anesthetic recovery of patients undergoing video-assisted thoracic lung resection surgery, who received analgesia through erector spinae block or intercostal nerve block, through the application of the Qor-15 questionnaire, 24 hours after anesthesia. Method: This is a pilot project of a randomized clinical trial developed with patients undergoing lung resection surgery at the Hospital Universitário Onofre Lopes (HUOL). In it, 18 patients were randomized into two groups: one (10 patients) received analgesia through intercostal block (INT) and the other (08 patients) underwent erector spinae plane block ESP block). As a primary outcome, we assessed the quality of post-anesthesia recovery between different blocks using the QoR-15 questionnaire, applied 24 hours after the end of anesthesia. As secondary outcomes, the consumption of morphine equivalents in mg/kg in the first 24 hours and the intensity of pain through EVN (0 for absence of pain and 10, worst pain imaginable) at times 1, 3, 6, were recorded. 12 and 24 hours after the end of anesthesia, at rest and after deep inspiration. Results: There was no difference in the anesthetic quality assessed through the application of the QoR-15 questionnaire between the ESP and INT groups. Furthermore, there was no significant discrepancy in the intraoperative dose of fentanyl, numerical visual scale (VNS) at rest and movement and consumption of morphine equivalent in the 24 hours after the surgical procedure. Discussion: The results of our study suggest similar results in relation to analgesia and post-anesthesia recovery in patients undergoing video-assisted thoracic lung resection surgery, showing that the erector spinae block can provide analgesia similar to the intercostal block. The choice of anesthetic method varies according to the anesthetist's personal preference. It should also be emphasized that this is a pilot study and was not designed or developed to provide clinical inference, serving as a guide and foundation for the basis of therapeutic plans and more assertive clinical practices during future research. Conclusion: It's evident the importance of nerve blocks for pain management in video-assisted thoracoscopic surgery (VATS) patients. However, the study's findings must be viewed considering its limitations, which prevents definitive conclusions about the superiority or inferiority of the techniques. There is a necessity for larger, multicenter studies to accurately assess the clinical and statistical significance of these findings.

The association between cardiopulmonary exercise testing and postoperative outcomes in patients with lung cancer undergoing lung resection surgery: A systematic review and meta-analysis

Background Exercise capacity should be determined in all patients undergoing lung resection for lung cancer surgery and cardiopulmonary exercise testing (CPET) remains the gold standard. The purpose of this study was to investigate associations between preoperative CPET and postoperative outcomes in patients undergoing lung resection surgery for lung cancer through a review of the existing literature. Methods A search was conducted on PubMed, Scopus, Cochrane Library and CINAHL from inception until December 2022. Studies investigating associations between preoperative CPET and postoperative outcomes were included. Risk of bias was assessed using the QUIPS tool. A random effect model meta-analysis was performed. I2 > 40% indicated a high level of heterogeneity. Results Thirty-seven studies were included with 6450 patients. Twenty-eight studies had low risk of bias. V˙O2 peak is the oxygen consumption at peak exercise and serves as a marker of cardiopulmonary fitness. Higher estimates of V˙O2 peak, measured and as a percentagege of predicted, showed significant associations with a lower risk of mortality [MD: 3.66, 95% CI: 0.88; 6.43 and MD: 16.49, 95% CI: 6.92; 26.07] and fewer complications [MD: 2.06, 95% CI: 1.12; 3.00 and MD: 9.82, 95% CI: 5.88; 13.76]. Using a previously defined cutoff value of > 15mL/kg/min for V˙O2 peak, showed evidence of decreased odds of mortality [OR: 0.55, 95% CI: 0.28–0.81] and but not decreased odds of postoperative morbidity [OR: 0.82, 95% CI: 0.64–1.00]. There was no relationship between V˙E/V˙CO2 slope, which depicts ventilatory efficiency, with mortality [MD: -9.60, 95% CI: -27.74; 8.54] however, patients without postoperative complications had a lower preoperative V˙E/V˙CO2 [MD: -2.36, 95% CI: -3.01; -1.71]. Exercise load and anaerobic threshold did not correlate with morbidity or mortality. There was significant heterogeneity between studies. Conclusions Estimates of cardiopulmonary fitness as evidenced by higher V˙O2 peak, measured and as a percentage of predicted, were associated with decreased morbidity and mortality. A cutoff value of V˙O2 peak > 15mL/kg/min was consistent with improved survival but not with fewer complications. Ventilatory efficiency was associated with decreased postoperative morbidity but not with improved survival. The heterogeneity in literature could be remedied with large scale, prospective, blinded, standardised research to improve preoperative risk stratification in patients with lung cancer scheduled for lung resection surgery.

Performance Comparison of Pulmonary Risk Scoring Systems in Lung Resection

To validate and compare the performance of different pulmonary risk scoring systems to predict postoperative pulmonary complications (PPCs) in lung resection surgery. Retrospective cohort study SETTING: A historic single-center cohort of lung resection surgeries PARTICIPANTS: Adult patients undergoing lung resection surgery under 1-lung ventilation. None. The accuracy of the following pulmonary risk scoring systems were used to predict pulmonary complications: the ARISCAT (Assess respiratory RIsk in Surgical patients in CATalonia), the LAS VEGAS (Local Assessment of VEntilatory management during General Anesthesia for Surgery), the SPORC (Score for Prediction of Postoperative Respiratory Complications), and a recent thoracic-specific risk score, named CARDOT. Discrimination and calibration were assessed using the concordance (c) index and the intercept of LOESS (locally estimated scatterplot)-smoothed curves, respectively. Additional models were constructed that incorporated predicted postoperative forced expiratory volume (ppoFEV1) into each scoring system. Of the 2,104 patients undergoing lung surgery, 123 developed postoperative pulmonary complications (PPCs; 5.9%). All scoring systems had poor discriminatory power to predict PPCs (ARISCAT c-index 0.60, 95% confidence interval [CI] 0.55-0.65; LAS VEGAS c-index 0.68, 95% CI 0.63-0.73; SPORC c-index 0.63, 95% CI 0.59-0.68; CARDOT c-index 0.64, 95% CI 0.58-0.70), but the inclusion of ppoFEV1 slightly improved the performance of LAS VEGAS (c-index 0.70, 95% CI 0.66-0.75) and CARDOT (c-index 0.68, 95% CI 0.62-0.73). Analysis of calibration showed a slight overestimation when using ARISCAT (intercept -0.28) and LAS VEGAS (intercept -0.27). None of the scoring systems appeared to have adequate discriminatory power to predict PPCs among patients undergoing lung resection. An alternative risk score is necessary to better predict patients at risk of PPCs after thoracic surgery.

Comparison between functional lung volume measurement and segment counting for predicting postoperative pulmonary function after pulmonary resection in lung cancer patients

BackgroundFunctional lung volume (FLV) obtained from computed tomography images was a breakthrough for lung imaging and functional assessment. We compared the accuracy of the FLV measurement method and the segment-counting (SC) method in predicting postoperative pulmonary function.MethodsA total of 113 patients who underwent two thoracoscopic surgeries were enrolled in our study. We predicted postoperative pulmonary function by the FLV measurement method and the SC method. Novel formulas based on the FLV measurement method were established using linear regression equations between the factors affecting pulmonary function and the measured values.ResultsThe predicted postoperative forced vital capacity (ppoFVC) and forced expiratory volume in 1 s (ppoFEV1) measured by the 2 methods showed high concordance between the actual postoperative forced vital capacity (postFVC) and the forced expiratory volume in 1 s (postFEV1) [r = 0.762, P < 0.001 (FLV method) and r = 0.759, P < 0.001 (SC method) for FVC; r = 0.790, P < 0.001 (FLV method) and r = 0.795, P < 0.001 (SC method) for FEV1]. Regression analysis showed that the measured preoperative pulmonary function parameters (FVC, FEV1) and the ratio of reduced FLV to preoperative FLV were significantly associated with the actual postoperative values and could predict these parameters (all P < 0.001). The feasibility of using these equations [postFVC = 0.8 × FVC − 0.784 × ΔFLV/FLV + 0.283 (R2 = 0.677, RSD = 0.338), postFEV1 = 0.766 × FEV1 − 0.694 × ΔFLV/FLV + 0.22 (R2 = 0.743, RSD = 0.265)] to predict the pulmonary function parameters after wedge resection was also verified.ConclusionsThe new FLV measurement method is valuable for predicting postoperative pulmonary function in patients undergoing lung resection surgery, with accuracy and consistency similar to those of the conventional SC method.

Postoperative Hypoxemia After Dual-Controlled vs Volume-Controlled Ventilation in Lung Surgery

BackgroundOne-lung ventilation for thoracic surgery represents a challenge due to the risk for hypoxemia and barotrauma. Dual-controlled ventilation (ie, pressure-regulated volume control [PRVC]) may confer improved lung mechanics compared with conventional ventilation (volume-controlled ventilation [VCV]). Our objective was to determine the association between ventilatory mode and pulmonary outcomes after lung resection surgery. MethodsA historical cohort (2016-2021) of patients undergoing lung resection surgery was used to identify cases performed with PRVC ventilation (intervention) vs VCV (conventional). Both groups were matched in a 1:1 fashion using propensity scoring based on preoperative oxygen saturation, chronic obstructive pulmonary disease, intraoperative ventilator settings, and surgical approach. Our primary outcome was postoperative hypoxemia (oxygen saturation <92% requiring supplemental oxygen longer than 2 hours). Secondary outcomes included respiratory failure, pneumonia, atelectasis, acute respiratory distress syndrome, pleural effusion, and reintubation. Associations were reported using adjusted odds ratios (aOR). ResultsOf 2107 eligible patients (PRVC = 1587 vs VCV = 520), a total of 774 matched pairs were analyzed (PRVC = 387 vs VCV = 387). The overall incidence of postoperative hypoxemia was 35.5% (95% CI 32.2%-39.0%). Hypoxemia was less likely among patients managed with low tidal volumes (≤6 mL/kg per ideal body weight, aOR 0.73, 95% CI 0.57-0.92, P = .008). No significant association was observed between ventilator mode and postoperative hypoxemia (33.3% in PRVC vs 37.7% in VCV; aOR 0.93, 95% CI 0.71-1.23, P = .627) or secondary pulmonary complications (3.9% in PRVC vs 3.4% in VCV; aOR 0.96, 95% CI 0.47-1.97, P = .909). ConclusionsDual-controlled ventilation was not associated with improved pulmonary outcomes compared with conventional ventilation in lung resection surgery.

Association between driving pressure and postoperative pulmonary complications in patients undergoing lung resection surgery: A randomised clinical trial

BackgroundIt is uncertain whether an association exists for decreases in driving pressure and the occurrence of postoperative pulmonary complications (PPCs) in patients undergoing selective lung resection surgery. Thus, we designed this study to determine whether the positive end-expiratory pressure (PEEP) titration to the lowest driving pressure compared with conventional low PEEP level during one-lung ventilation (OLV) in patients undergoing selective lung resection surgery decreases PPCs. MethodsThis single-centre, randomised trial approved by the Ethical Committee of the Sun Yat-Sen University Cancer Center involved patients who signed written consent. Patients were randomised to the PEEP titration to the lowest driving pressure group (n = 104), or to the conventional low level of PEEP group (n = 103), consisting a PEEP level of 4 cm H2O during OLV. All patients received volume-controlled ventilation with a tidal volume of 6 mL/kg of predicted body weight. The primary outcome was defined as positive if 4 or more of eight Melbourne Group Scale (MGS) variables developed within the first 3 days after surgery. The incidence of major PPCs occurring during postoperative 7 days was also recorded. ResultsAmong 222 patients who were randomised, 207 (93%) completed the trial (109 men [53%]; mean age, 56.9 years). The primary outcome occurred in 4 of 104 patients (4%) in the PEEP titration to the lowest driving pressure group compared with 13 of 103 patients (13%) in the conventional low level of PEEP group (risk ratio, 0.32 [95% CI, 0.10−0.90]; P = 0.021). ConclusionsAmong patients undergoing selective lung surgery, intraoperative OLV with PEEP titration to the lowest driving pressure compared with conventional low PEEP level (4 cm H2O) significantly reduced PPCs within the first 3 postoperative days, however, did not significantly reduce PPCs within the first 7 postoperative days.

Effect of ventilation mode on postoperative pulmonary complications following lung resection surgery: a randomised controlled trial.

The effect of intra-operative mechanical ventilation modes on pulmonary outcomes after thoracic surgery with one-lung ventilation has not been well established. We evaluated the impact of three common ventilation modes on postoperative pulmonary complications in patients undergoing lung resection surgery. In this two-centre randomised controlled trial, 1224 adults scheduled for lung resection surgery with one-lung ventilation were randomised to one of three groups: volume-controlled ventilation; pressure-controlled ventilation; and pressure-control with volume guaranteed ventilation. Enhanced recovery after surgery pathways and lung-protective ventilation protocols were implemented in all groups. The primary outcome was a composite of postoperative pulmonary complications within the first seven postoperative days. The outcome occurred in 270 (22%), with 87 (21%) in the volume control group, 89 (22%) in the pressure control group and 94 (23%) in the pressure-control with volume guaranteed group (p = 0.831). The secondary outcomes also did not differ across study groups. In patients undergoing lung resection surgery with one-lung ventilation, the choice of ventilation mode did not influence the risk of developing postoperative pulmonary complications. This is the first randomised controlled trial examining the effect of three ventilation modes on pulmonary outcomes in patients undergoing lung resection surgery.

Driving pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: a multicentre randomised clinical trial

BackgroundAirway driving pressure, easily measured as plateau pressure minus PEEP, is a surrogate for alveolar stress and strain. However, the effect of its targeted reduction remains unclear. MethodsIn this multicentre trial, patients undergoing lung resection surgery were randomised to either a driving pressure group (n=650) receiving an alveolar recruitment/individualised PEEP to deliver the lowest driving pressure or to a conventional protective ventilation group (n=650) with fixed PEEP of 5 cm H2O. The primary outcome was a composite of pulmonary complications within 7 days postoperatively. ResultsThe modified intention-to-treat analysis included 1170 patients (mean [standard deviation, sd]; age, 63 [10] yr; 47% female). The mean driving pressure was 7.1 cm H2O in the driving pressure group vs 9.2 cm H2O in the protective ventilation group (mean difference [95% confidence interval, CI]; −2.1 [−2.4 to −1.9] cm H2O; P<0.001). The incidence of pulmonary complications was not different between the two groups: driving pressure group (233/576, 40.5%) vs protective ventilation group (254/594, 42.8%) (risk difference −2.3%; 95% CI, −8.0% to 3.3%; P=0.42). Intraoperatively, lung compliance (mean [sd], 42.7 [12.4] vs 33.5 [11.1] ml cm H2O−1; P<0.001) and Pao2 (median [inter-quartile range], 21.5 [14.5 to 30.4] vs 19.5 [13.5 to 29.1] kPa; P=0.03) were higher and the need for rescue ventilation was less frequent (6.8% vs 10.8%; P=0.02) in the driving pressure group. ConclusionsIn lung resection surgery, a driving pressure-guided ventilation improved pulmonary mechanics intraoperatively, but did not reduce the incidence of postoperative pulmonary complications compared with a conventional protective ventilation. Clinical trial registrationNCT04260451.

BRONCHO-PLEURAL FISTULA AS A COMPLICATION OF A PNEUMONECTOMY AND ITS MANAGEMENT WITH A PECTORAL FLAP: A CASE REPORT

INTRODUCTION: Broncho-pleural stula (BPF) is one of the most serious complications that can occur in patients undergoing lung resection surgery. Its incidence is estimated at 1.5-11.1%. A 55-CASE REPORT: year-old male patient was admitted to the internal medicine area of the hospital for presenting a chronic injury to the right chest, through which he expels air and mucous secretions. He does not report pain, difculty breathing, or fever; during examination, his vital signs are normal. He presents discrete right mid-basal hypoventilation, without dullness in the area; there is evidence of a wound dehiscence area from a probable mini-thoracotomy in the anterior region of the right chest, where it presents sero- purulent material at the site of insertion of the thoracic catheter 17 months ago, not fetid. ItDISCUSSION AND CONCLUSIONS: is common practice in thoracic surgery to cover the bronchial stump in high-risk patients with viable tissue in an attempt to minimize the incidence of BPF. Some authors found that the pectoral ap is a viable option due to the scarcity of viable intrathoracic aps. The patient reported in this case had a bronchopleural stula, a complication of a pneumonectomy, for more than a year; in this particular case, surgery was considered necessary.

The effect of thoracic epidural nerve block with dezocine and ropivacaine on arterial oxygen saturation and IDO gene expression during pulmonary ventilation in lung resection surgery.

During lung resection surgery, the blood supply to the lungs increases the intrapulmonary shunt and reduces arterial oxygenation in patients. Ventilation anesthesia of a lung may affect oxygenation. The present study aimed to compare intravenous anesthesia with and without thoracic epidural block (dezocine and ropivacaine) on oxygen saturation during lung ventilation in patients undergoing lung resection surgery. For this purpose, this study was performed as a double-blind, randomized clinical trial. Sixty patients who were candidates for lung resection were divided into two intervention groups (thoracic epidural block with dezocine and ropivacaine and intravenous anesthesia) and a control group (placebo thoracic epidural block and intravenous anesthesia). Hemodynamic variables, Aldert score, and possible complications were compared between the two groups before surgery and after recovery. Also, the expression level of the IDO gene was evaluated using the real-time PCR technique. SPSS, t-test, Mann-Whitney U, Chi-square, and Fisher performed data analysis and comparison. The results showed that the changes in hemodynamic variables and PaO2, SaO2, and ETCO2 were not statistically significant between the two groups. Aldrete's score at entry and exit of recovery was similar between the two groups. During the recovery period, the percentage of pain or chills in the group under complete intravenous anesthesia was significantly higher. There was no significant difference between the two groups regarding the frequency of nausea and hypotension. Also, the results of IDO gene expression showed that general anesthesia with the thoracic epidural block (dezocine and ropivacaine), which is involved in inducing immunological tolerance and suppressing immune responses, has no significant effect. The stress of performing surgery before surgery can play a role in suppressing the patient's immunity, and anesthesia of the thoracic epidural block (dezocine and ropivacaine) has no significant effect on IDO expression. In general, thoracic epidural block with complete intravenous anesthesia has no significant effect on oxygen saturation in ventilated lungs compared with intravenous anesthesia alone. Nevertheless, this combination significantly reduces postoperative pain and chills.

Gut microbiome functionality might be associated with exercise tolerance and recurrence of resected early-stage lung cancer patients

Impaired exercise tolerance and lung function is a marker for increased mortality in lung cancer patients undergoing lung resection surgery. Recent data suggest that the gut-lung axis regulates systemic metabolic and immune functions, and microbiota might alter exercise tolerance. Here, we aimed to evaluate the associations between gut microbiota and outcomes in lung cancer patients who underwent lung resection surgery. We analysed stool samples, from 15 early-stage lung cancer patients, collected before and after surgical resection using shotgun metagenomic and Internal Transcribed Spacer (ITS) sequencing. We analysed microbiome and mycobiome associations with post-surgery lung function and cardiopulmonary exercise testing (CPET) to assess the maximum level of work achieved. There was a significant difference, between pre- and post-surgical resection samples, in microbial community functional profiles and several species from Alistipes and Bacteroides genus, associated with the production of SCFAs, increased significantly in abundance. Interestingly, an increase in VO2 coincides with an increase in certain species and the "GABA shunt" pathway, suggesting that treatment outcome might improve by enriching butyrate-producing species. Here, we revealed associations between specific gut bacteria, fungi, and their metabolic pathways with the recovery of lung function and exercise capacity.

BNP for prediction of outcome following lung resection surgery (Profiles); an interim analysis

Introduction Lung cancer is the leading cause of cancer death in the UK with the highest incidence in Scotland. In suitable cases surgical resection is the first-choice treatment; resection rates have risen markedly particularly in elderly patients. Lung cancer surgery is associated with significant co-morbidity resulting in high cardio-respiratory complication rates. B-type natriuretic peptide (BNP) is a quantitative biomarker of myocardial dysfunction, identifying patients at risk of cardiopulmonary complications in a variety of surgeries. Little work has focused on its use for prediction of cardiopulmonary complications following lung resection. The British Thoracic Society (BTS) and The National Institute of Clinical Excellence (NICE) highlight the need for studies concerning patient fitness and operative risk when deciding to undergo lung resection. This analysis explores the predictive role of BNP as a peri-operative biomarker of cardiopulmonary complications following lung resection. Methods With informed consent and ethics approval we prospectively recruited 107 patients undergoing lung resection in a single centre. BNP was measured pre-op (BNPpre-op) and on post-op days 2&3 (BNPpost-op). Association was sought between peri-operative BNP levels and cardiopulmonary complications (according to the European Society of Thoracic Surgeons definitions) and hospital length of stay. Friedman's test, Mann-Whitney U-test and Spearman's rank test were used as appropriate. Results BNP increased post-operatively, peaking on POD2, (p Discussion This study demonstrates association between peri-operative BNP levels and post-operative, in-hospital, cardio-pulmonary complications highlighting the potential for BNP as a predictive marker in patients undergoing lung resection. Further work is required to identify association between peri-operative BNP and longer-term complications and to explore the integration of BNP into risk prediction models for patients undergoing lung resection surgery. In previous pilot work, Pre-op BNP was associated with breathlessness 3-months postoperatively1. PROFILES is a multicentre prospective observational cohort study of 250 patients (across four sites in Scotland and Northern Ireland) undergoing lung resection and seeks to validate this finding (NCT03888937). Upon completion of recruitment we hope to create a novel scoring tool incorporating BNP, to identify those at risk of disabling dyspnoea.

Troponin I as a mortality marker after lung resection surgery \u2013 a prospective cohort study

BackgroundCardiovascular complications associated with thoracic surgery increase morbidity, mortality, and treatment costs. Elevated cardiac troponin level represents a predictor of complications after non-cardiac surgeries, but its role after thoracic surgeries remains undetermined. The objective of this study was to analyze the relationship between troponin I elevation and morbidity and mortality after one year in patients undergoing lung resection surgery.MethodsThis prospective cohort study evaluated 151 consecutive patients subjected to elective lung resection procedures using conventional and video-assisted thoracoscopic techniques at a University Hospital in Brazil, from July 2012 to November 2015. Preoperative risk stratification was performed using the scores obtained by the American College of Physicians (ACP) and the Society of Cardiology of the state of São Paulo (EMAPO) scoring systems. Troponin I levels were measured in the immediate postoperative period (POi) and on the first and second postoperative days.ResultsMost patients had a low risk for complications according to the ACP (96.7%) and EMAPO (82.8%) scores. Approximately 49% of the patients exhibited increased troponin I (≥0.16 ng/ml), at least once, and 22 (14.6%) died in one year. Multivariate analysis showed that the elevation of troponin I, on the first postoperative day, correlated with a 12-fold increase in mortality risk within one year (HR 12.02, 95% CI: 1.82–79.5; p = 0.01).ConclusionsIn patients undergoing lung resection surgery, with a low risk of complications according to the preoperative evaluation scores, an increase in troponin I levels above 0.16 ng/ml in the first postoperative period correlated with an increase in mortality within one year.

Preoperative Evaluation for Lung Resection Surgery

The purpose of this article is to review the literature surrounding preoperative assessment and management of patients undergoing lung resection surgery. The traditional preoperative cardiovascular risk assessment can be further refined in patients undergoing lung resection surgery with the Thoracic Revised Cardiac Risk Index and cardiac biomarkers such as B-type natriuretic peptide. Cardiorespiratory exercise testing parameters such as the maximal achieved oxygen consumption (VO2 peak) and the minute ventilation to carbon dioxide output (VE/VCO2) slope are strong preoperative prognosticators in patients with borderline lung function. Preoperative pulmonary rehabilitation holds promising benefits in improving surgical candidacy and postoperative outcomes. The preoperative assessment of lung resection candidates must evaluate perioperative cardiorespiratory risk. The patient’s comorbidities should be optimized as time permits. A clear perioperative plan should be established and may include cardiology consultation, prevention strategies for arrhythmias, preoperative pulmonary rehabilitation, smoking cessation, intensive perioperative monitoring, and enhanced recovery protocols.

Airway narrowing and response to simulated deep inspiration in bronchial segments from subjects with fixed airflow obstruction.

The volume fraction of extracellular matrix (ECM) within the layer of airway smooth muscle (ASM) is increased in subjects with fixed airflow obstruction. We postulated that changes in ECM within the ASM layer will impact force transmission during induced contraction and/or in response to externally applied stresses like a deep inspiration (DI). Subjects were patients undergoing lung resection surgery who were categorized as unobstructed (n = 12) or "fixed" obstructed (n = 6) on the basis of preoperative spirometry. The response to a DI, assessed by the ratio of isovolumic flows from maximal and partial inspirations (M/P), was also measured preoperatively. M/P was reduced in the obstructed group (P = 0.02). Postoperatively, bronchial segments were obtained from resected tissue, and luminal narrowing to acetylcholine and bronchodilation to simulated DI were assessed in vitro. Airway wall dimensions and the volume fraction of ECM within the ASM were quantified. Maximal airway narrowing to acetylcholine (P = 0.01) and the volume fraction of ECM within the ASM layer (P = 0.02) were increased in the obstructed group, without a change in ASM thickness. Whereas bronchodilation to simulated DI in vitro was not different between obstructed and unobstructed groups, it was correlated with increased M/P (bronchodilation/less bronchoconstriction) in vivo (P = 0.03). The volume fraction of ECM was inversely related to forced expiratory volume in 1 s FEV1 %predicted (P = 0.04) and M/P (P = 0.01). Results show that in subjects with fixed airflow obstruction the mechanical behavior of the airway wall is altered and there is a contemporaneous shift in the structural composition of the ASM layer.NEW & NOTEWORTHY Cartilaginous airways from subjects with fixed airflow obstruction have an increase in the volume fraction of extracellular matrix within the airway smooth muscle layer. These airways are also intrinsically more reactive to a contractile stimulus, which is expected to contribute to airway hyperresponsiveness in this population, often attributed to geometric mechanisms. In view of these results, we speculate on how changes in extracellular matrix may impact airway mechanics.

Short-Physical Performance Battery (SPPB) score is associated with postoperative pulmonary complications in elderly patients undergoing lung resection surgery: A prospective multicenter cohort study.

Elderly patients awaiting lung resection surgery often have poor physical function, which puts them at a high risk of postoperative pulmonary complications. The aim of this study was to investigate the impact of preoperative physical performance on postoperative pulmonary complications in patients awaiting lung resection surgery. In this prospective multicenter cohort study, the characteristics of patients and postoperative pulmonary complications were compared between subjects with low (<10) and high (≥10) Short Physical Performance Battery (SPPB) scores. Postoperative pulmonary complications were defined as over grade II in Clavien-Dindo classification system. We estimated the effects of physical performance on postoperative pulmonary complications using multivariable hierarchical logistic regression. The postoperative pulmonary complications were compared between 331 patients in the high and 33 patients in the low SPPB group. Patients in the low SPPB score group had a significantly higher rate of postoperative pulmonary complications (p < 0.001). Low SPPB score was associated with a higher risk of postoperative pulmonary complications (odds ratio, 8.80; p < 0.001). The SPPB is a clinically useful evaluation tool to assess surgical patients’ physical performance. The low physical performance indicated by the SPPB may be predictive of postoperative pulmonary complications after lung resection surgery.Trial registration: Clinical Trials. University hospital Medical Information Network Center (UMIN-CTR) UMIN000021875.

Association between anaesthetic technique and unplanned admission to intensive care after thoracic lung resection surgery: the second Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) National Audit.

Unplanned intensive care admission is a devastating complication of lung resection and is associated with significantly increased mortality. We carried out a two-year retrospective national multicentre cohort study to investigate the influence of anaesthetic and analgesic technique on the need for unplanned postoperative intensive care admission. All patients undergoing lung resection surgery in 16 thoracic surgical centres in the UK in the calendar years 2013 and 2014 were included. We defined critical care admission as the unplanned need for either tracheal intubation and mechanical ventilation or renal replacement therapy, and sought an association between mode of anaesthesia (total intravenous anaesthesia vs. volatile) and analgesic technique (epidural vs. paravertebral) and need for intensive care admission. A total of 253 out of 11,208 patients undergoing lung resection in the study period had an unplanned admission to intensive care in the postoperative period, giving an incidence of intensive care unit admission of 2.3% (95%CI 2.0-2.6%). Patients who had an unplanned admission to intensive care unit had a higher mortality (29.00% vs. 0.03%, p<0.001), and hospital length of stay was increased (26 vs. 6days, p<0.001). Across univariate, complete case and multiple imputation (multivariate) models, there was a strong and significant effect of both anaesthetic and analgesic technique on the need for intensive care admission. Patients receiving total intravenous anaesthesia (OR 0.50 (95%CI 0.34-0.70)), and patients receiving epidural analgesia (OR 0.56 (95%CI 0.41-0.78)) were less likely to have an unplanned admission to intensive care after thoracic surgery. This large retrospective study suggests a significant effect of both anaesthetic and analgesic technique on outcome in patients undergoing lung resection. We must emphasise that the observed association does not directly imply causation, and suggest that well-conducted, large-scale randomised controlled trials are required to address these fundamental questions.

High frequency of infection of lung cancerpatients with the parasite Toxoplasma gondii.

BackgroundToxoplasma gondii is an intracellular protozoan parasite that can cause a wide range of clinical conditions, including miscarriage and pneumonia. The global prevalence is 30% in humans, but varies by locality (e.g. in the UK it is typically 10%). The association between lung cancer and T. gondii infection was investigated by direct detection in lung tissue samples.MethodsLung tissue samples were taken from patients undergoing lung resection surgery (n=72) for suspected lung cancer (infection prevalence 100% (95% CI: 93.9–100%)). All 72 participants were confirmed as having lung cancer following subsequent diagnostic tests. In addition, bronchial biopsy samples were collected from non-lung cancer healthy control subjects (n=10). Samples were tested for T. gondii using PCR amplification of T. gondii specific gene markers and T. gondii specific immunohistochemistry.ResultsAll 72 lung cancer patients were infected with T. gondii (prevalence 100% (95% CI: 93.9–100%)). Of which, 95.8% (n=69) of patients showed evidence of active parasite stages. Infection prevalence in the controls (10%) was significantly lower (p<0.0001).ConclusionsClinicians treating lung cancer patients should be aware of the potential presence of the parasite, the potential for induction of symptomatic complications and interference with treatment success.

Changes in Blood Gases and Hemodynamic Parameters in Patients Undergoing Lung Resection Surgery and Its Clinical Implications

Introduction: Lung resection surgery is a challenge to thoracic surgeons. Outcome of surgery depends on patients’ tolerance to reduced lung volume and hemodynamic alterations. The present study aimed to investigate the changes in blood gases and hemodynamic parameters in patients undergoing lung resection surgery and the associated clinical implications. Materials and methods: This study included 25 candidates for lung resection surgery. After thoracotomy, isolation of pulmonary artery (PA) and veins were performed as usual. Blood samples were taken from the PA and radial artery simultaneously before clamping, as well as 5 and 20 min after clamping the PA. The systemic as well as PA pressure was also measured. All patients were followed up, arterial blood gas and pulmonary function tests were performed 3-6 months after the surgery. Results: Cough (56%) and hemoptysis (56%) were the commonest symptom. Most prevalent pathology was squamous cell carcinoma (56%). Lobectomy was the most common procedure performed on the patients. No change was observed in blood gases before and after the clamping of the PA. There was a significant increase in the mean PA pressure (P 45 mmHg had more postoperative complications than those with a PCO2 of ≤45 mmHg (P=0.047). Conclusion: Given the lack of any significant changes in the PCO2 and oxygen saturation following the lung resection surgery, it seems that this parameter is not a limiting factor for deciding on operability in patients with lung lesions having an acceptable preoperative PO2 level. However, the patients with a PCO2 of >45 mmHg should be categorized as high-risk group since they have significantly higher postoperative complications/morbidity.