Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence

BACKGROUND: Factors affecting the incidence of empyema and bronchopleural fistula (BPF) after pneumonectomy were analyzed. METHODS: All patients who underwent pneumonectomy at the Mayo Clinic in Rochester, Minnesota, from January 1985 to September 1998 were reviewed. There were 713 patients (514 males and 199 females). Ages ranged from 12 to 86 years (median 64 years). Indication for resection was primary malignancy in 607 patients (85.1%), metastatic disease in 32 (4.5%), and benign disease in 74 (10.4%). One hundred fifteen patients (16.1%) underwent completion pneumonectomy. Factors affecting the incidence of postoperative empyema and BPF were analyzed using univariate and multivariate analysis. RESULTS: Empyema was documented in 53 patients (7.5%; 95% confidence interval [CI], 5.7% to 9.7%) and a BPF in 32 (4.5%; 95% CI, 3.1% to 6.3%). Univariate analysis demonstrated that the development of empyema was adversely affected by benign disease (p = 0.0001), lower preoperative forced expiratory volume in 1 second (FEV1; p < 0.01) and diffusion capacity of lung to carbon monoxide (DLCO; p = 0.0001), lower preoperative serum hemoglobin (p = 0.05), right pneumonectomy (p = 0.0109), bronchial stump reinforcement (p = 0.007), completion pneumonectomy (p < 0.01), timing of chest tube removal (p = 0.01), and the amount of blood transfusions (p < 0.01). Similarly, the development of BPF was significantly associated with benign disease (p = 0.03), lower preoperative FEV1 (p = 0.03) and DLCO (p = 0.01), right pneumonectomy (p < 0.0001), bronchial stump reinforcement (p = 0.03), timing of chest tube removal (p = 0.004), increased intravenous fluid in the first 12 hours (p = 0.04), and blood transfusions (p = 0.04). Bronchial stump closure with staples had a protective effect against BPF compared with suture closure (p = 0.009). No risk factors were identified as being jointly significant in multivariate analysis. CONCLUSIONS: Multiple perioperative factors were associated with an increased incidence of empyema and BPF after pneumonectomy. Prophylactic reinforcement of the bronchial stump with viable tissue may be indicated in those patients suspected at higher risk for either empyema or BPF.     

全肺切除术后支气管残端瘘的原因与治疗

目的 探讨肺癌全肺切除术后支气管残端瘘的因素,并寻找其预防与治疗方法.方法 回顾性分析1987年5月至2007年5月965例因肺癌行全肺切除术患者中32例术后发生支气管残端瘘患者的临床资料.对全肺切除术后支气管残端瘘的风险因素进行分析.结果 全肺切除术后支气管残端瘘的发生率为3.3%(32/965),左侧12.5%(4/32),右侧87.5%(28/32).单因素分析显示,全肺切除术后支气管残端瘘的风险因素包括右全肺切除、术前接受放疗、延长机械通气、支气管残端长度>2 cm和血清白蛋白<30 g/L.Logistic回归证实右全肺切除、术前接受放疗和血清白蛋白<30 g/L是全肺切除术后支气管残端瘘的危险因素.对直径≤3 mm的瘘口行生物胶粘堵,治愈率为83.3%(5/6).对直径＞3 mm的瘘口行大网膜加固残端,治愈率为83.3%(5/6).结论 右全肺切除、术前接受放疗和血清白蛋白水平低于3 g/L是全肺切除术后支气管残端瘘的危险因素.对直径≤3 mm的瘘口,可应用生物胶粘堵;对直径>3 mm的瘘口,可利用转移大网膜加固残端.     

Morbidity, mortality, and long-term survival after sleeve lobectomy for non-small cell lung cancer.

OBJECTIVE: Sleeve lobectomy is a widely accepted procedure for central tumors for which the alternative is pneumonectomy. The purpose of this study is to assess operative mortality, morbidity, and long-term results of sleeve lobectomies performed for non-small cell lung carcinoma (NSCLC). METHODS: A retrospective review of 218 patients who underwent sleeve lobectomy for NSCLC between 1981 and 2005 was undertaken. There were 186 (85%) men and 32 women with a mean age of 61.9 years (range, 19-82 years). Eighty patients (36.6%) had a preoperative contraindication to pneumonectomy. Right upper lobectomy was the most common operation (45.4%). Vascular sleeve resection was performed in 28 patients (12.8%) and was commonly associated with left upper lobectomy (n=20; 9.1%; p=0.0001). The histologic type was predominantly squamous cell carcinoma (n=164; 75%), followed by adenocarcinoma (n=46; 21%). Resection was incomplete in nine (4.1%) patients. RESULTS: There were nine operative deaths; the operative mortality and the morbidity rates were 4.1% and 22.9%, respectively. A total of 14 (6.4%) patients presented with bronchial anastomotic complications: two were fatal postoperatively, seven patients required reoperation, three required a stent insertion, and two were managed conservatively. Multivariate analysis showed that compromised patients (p=0.001), current smoking (p=0.01), right sided resections (p=0.003), bilobectomy (p=0.03), squamous cell carcinoma (p=0.03), and presence of N1 or N2 disease (p=0.01) were risk factors for mortality and morbidity. Follow-up was complete in 208 patients (95.4%). Overall 5-year and 10-year survival rates were 53% and 28.6%, respectively. After complete resection, recurrence was local in 10 patients, mediastinal in 20, and distant in 25. By multivariate analysis, two factors significantly and independently influenced survival: nodal status (N0-N1 vs N2; p=0.01) and the stage of the lung cancer (stage I-II vs III, p=0.02). CONCLUSIONS: For patients with NSCLC, sleeve lobectomy achieves local tumor control, even in patients with preoperative contraindication to pneumonectomy and is associated with low mortality and bronchial anastomotic complication rates. Postoperative complications are higher in compromised patients, smokers, N disease, right sided resections, bilobectomies, and squamous cell cancers. The presence of N2 disease and stage III significantly worsen the prognosis.     

Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management.

BACKGROUND: The incidence of a bronchopleural fistula (BPF) as a major complication after non-small cell lung carcinoma (NSCLC) surgery has decreased in recent years, due to new surgical refinements and a better understanding of the bronchial healing process. We reviewed our most recent experience with BPFs and tried to determine methods which may effectively reduce its occurrence. METHODS: Data on 490 patients with lung resections for NSCLC over a period from 1990 to 1999 were retrospectively reviewed. Details regarding surgery and the subsequent treatment were carefully reviewed. Particular attention was paid to factors possibly affecting the occurrence of BPFs: the technique of the initial bronchial closure, previous radiation and/or chemotherapy, need for postoperative ventilation and presence of residual carcinomatous tissue at the bronchial suture line. Information about age, sex, clinical diagnosis, associated conditions, TNM stage, period between primary operation and rethoracotomy and postoperative outcome was also recorded. RESULTS: The overall BPF incidence was 4.4% (22/490). There were 21 (95.5%) males and 1 (4.5%) female, mean age was 57.8 years. BPFs occurred after pneumonectomy in 12 (54.6%), after lobectomy in 9 (40.9%) patients and after sleeve resections in 1 (4.5%) patient. Mortality rate was 27.2% (6/22). Right-sided pneumonectomy and postoperative mechanical ventilation were identified as risk factors for BPFs (p<0.05). Initial chest re-exploration was performed in 20 (90.9%) patients. After debridement, the bronchial stump was reclosed by hand suture in 10 (45.4%) patients. All 10 (45.4%) patients with a post-lobectomy- and sleeve resection BPF necessitated completion surgery. The BPF was additionally covered with a vascularized flap in 20 (90.9%) patients. In 2 (9%) patients with small BPFs and poor overall condition the initial treatment was endoscopic. In both the fistula persisted and the stump had to be surgically resutured. CONCLUSIONS: A BPF remains a major complication in the surgery of NSCLC because of its high mortality and morbidity rate. A BPF is more common after right-sided pneumonectomy and is frequently associated with postoperative mechanical ventilation. The management varies according to the initial type of surgery, the size of the BPF, the overall patient condition and that of the remaining lung. Endoscopic treatment is reserved only for small fistulas associated with poor general condition.     

Sleeve lobectomy for primary lung cancer

We reviewed Fukuoka University Hospital thoracic surgery data base of 60 sleeve lobectomy (SL) and 40 pneumonectomy (PN) [for T1-3 disease] for primary lung cancer during 1993-2006. Morbidity rates were 20.0% and 37.5% in SL and PN group, respectively (p = 0.054). Three and 1 patient from PN and SL group, respectively, presented with bronchial anastomotic complications. Multivariate analysis showed that adjuvant chemotherapy and preoperative concomitant respiratory disease, but not the surgical procedures SL or PN, were risk factors for surgical morbidity. SL requires special consideration on its surgical technique either bronchial anastomosis or associated angioplastic procedure, however, it is safe and valuable less invasive surgical option especially for elderly patients.     

Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis.

BACKGROUND: The aim of this study was to determine independent risk factors for early bronchopleural fistula (BPF) after pneumonectomy and to assess the efficacy of bronchial coverage in preventing this complication. METHODS: We reviewed 242 consecutive patients undergoing pneumonectomy for lung cancer. The bronchial stump was covered with autologous tissue in 178 patients (74%). Perioperative data were recorded to identify risk factors of BPF by univariate and multivariate analyses. RESULTS: Overall morbidity and mortality rates were 59% and 5.4%, respectively. The incidence of BPF was 5.4%. By univariate analysis, patients with chronic obstructive pulmonary disease (COPD; p = 0.017), hyperglycemia (p = 0.003), hypoalbuminemia (p = 0.017), previous steroid therapy (p < 0.001), poor predicted postpneumonectomy forced expiratory volume in 1 second (FEV1; p = 0.012), long bronchial stumps (p < 0.001), and mechanical ventilation (p = 0.015), were related with higher risk of BPF. In the multiple logistic regression model, the independent risk factors of BPF were the bronchial stump coverage and length, side of pneumonectomy, predicted postpneumonectomy FEV1, COPD, and mechanical ventilation. CONCLUSIONS: Bronchial stump coverage is highly recommended in all cases to minimize the risks of BPF. A shorter length of the bronchial stump and early extubation may prevent the development of BPF. Careful attention must be paid to those patients with COPD and poor predicted postpneumonectomy FEV1.     

T1期非小细胞肺癌肺叶切除和亚肺叶切除的临床疗效比较

目的探讨肺叶切除和亚肺叶切除在T1期非小细胞肺癌(NSCLC)(肿瘤直径≤3 cm)外科治疗中的应用价值。 方法收集2007年1月至2014年12月在北京中日友好医院胸外科接受手术治疗的278例T1期NSCLC患者的临床资料。患者平均年龄(60.7 ± 10.4)岁。其中亚肺叶切除61例(楔形切除35例,肺段切除26例),肺叶切除217例。腺癌占81.7%,鳞癌占12.9%,其他占5.4%;高分化癌占8.6%,中分化癌占27.0%,低分化癌占20.5%,不能确定占43.9%。在腺癌中,浸润前病变占4.0%,微浸润腺癌占7.5%,浸润性腺癌占88.5%。T1N0M0占86.7%,T1N1M0占1.1%,T1N2M0占12.2%。 结果与肺叶切除组比较,亚肺叶切除组患者年龄较大、手术时间较短、病变≤2 cm的比例较高,两组间比较差异均有统计学意义(t＝0.496,P＝0.009;t＝8.082,P＝0.029;χ²＝2.105,P＝0.002)。但两组间在1秒钟用力呼气容积(FEV₁)、FEV₁%,以及手术方式和术后并发症发生率方面,差异均无统计学意义(t＝0.065,P＝0.713;t＝2.12,P＝0.085;χ²＝0.399,P＝0.274;χ²＝0.438,P＝0.490)。对于T1N0M0的NSCLC患者,亚肺叶和肺叶切除组患者的5年生存率分别为73.9%和83.5%,差异无统计学意义(P＝0.883)。亚肺叶切除组内分析显示：楔形切除组和肺段切除组患者的5年生存率分别为79.4%和70.6%,差异无统计学意义(P＝0.979)。多因素分析显示：仅有年龄和纵隔淋巴结转移N2为预后不良的危险因素(HR＝1.07,P＝0.048;HR＝5.56,P＝0.011)。亚肺叶切除组患者的5年生存率与肺叶切除组比较差异无统计学意义(HR＝1.38,P＝0.552)。 结论对于T1N0M0的NSCLC患者,亚肺叶切除虽然不可能完全替代肺叶切除手术,但是对于肺功能储备较差的老年患者可能逐渐成为主流术式。     

Stage I non-small cell lung cancer: a pragmatic approach to prognosis after complete resection

BACKGROUND: Long-term results of the surgical treatment of stage I non-small cell lung cancer (NSCLC) are disappointing. METHODS: Univariate and multivariate analyses were conducted on 515 consecutive lung resections for stage I NSCLC performed from 1990 to 1999 and identified by reviewing a database into which data were entered prospectively. Tumors were staged as stages IA (n = 147) and IB (n = 348) according to the 1997 UICC (Union Internationale Contre le Cancer) pTNM classification. RESULTS: Operative mortality rates were 6.2%, 5.3%, 2.3%, and 0% for pneumonectomy, bilobectomy, lobectomy, and lesser resections, respectively. Overall survival rate was 61.1% (55.8% to 66.5%) at 5 years. Univariate analysis identified three significant adverse prognosticators: arteriosclerosis as comorbidity, pathologic T2 status, and blood vessel invasion. Male sex (p = 0.056) and performance of pneumonectomy (p = 0.057) were at the threshold of statistical significance. At multivariate analysis, three independent prognosticators entered the model: arteriosclerosis, blood vessels invasion, and performance of pneumonectomy. CONCLUSIONS: Long-term survival of patients with completely resected stage I NSCLC was adversely influenced in a relatively balanced way by factors related to the clinical status of the patient, to the tumor, and to the treatment.     

Elective Pneumonectomy for Non-Small Cell Lung Cancer: Factors Affecting Early Operative Mortality and Morbidity

Background: The aim of this study was to investigate the factors influencing the morbidity and mortality of the non-small cell lung cancer (NSCLC) cases where pneumonectomy was performed.

Material & methods: All 101 patients who had underwent a pneumonectomy for NSCLC between 1994–2001 in our hospital were included in the retrospective study. There were 97 males and 4 females with a mean age of 56 ± 9.6. Factors affecting morbidity and mortality were analysed by univariate and multivariate analysis. Results: The morbidity rate was 53% and the mortality rate was 9%. Morbidity was related to cardiopulmonary complications in 40% of the cases. The risk factors for cardiopulmonary morbidity with univariate analysis were age

> 60 years (p = 0.004), FEV1 < 2 lt (p = 0.016), early bronchopleural fistula (p = 0.0001), tumour size > 4 cm (p = 0.033), vital capacity < 3.7 lt (p = 0.016), forced vital capacity < 3.5 lt (p = 0.033). With multivariate analysis the risk factors cardiopulmonary morbidity were age (60 >) (p = 0.012) and tumour size > 4 cm (p = 0.043). The risk factors mortality with univariate analysis were right pneumonectomy (p = 0.025), respiratory morbidity (p = 0.0001), cardiac morbidity (p = 0.002), cell type (Epidermoid CA) (0.047), tumour size > 6 cm (p = 0.036), fluid infusion (p = 0.009), forced vital capacity < 78% (p = 0.039), forced expiratory volume in 1 second < 75% (p = 0.039), PO2 (p = 0.037), PCO2

> 42 mmHg (p = 0.023).

Conclusion: Among the pneumonectomies performed for NSCLC, the causes of postoperative morbidity were multi-factorial, however, multivariate analysis did not show any significant factor affecting the mortality, related to this procedure.     

Successful lung autotransplantation for central non-small-cell lung cancer: report of a case

Non-small-cell lung cancer (NSCLC) confined to the lung is generally treated by surgical resection. The extent of resection is determined by the location of the tumor and the patient’s pulmonary function. This report presents a successful lung autotransplantation in a man with NSCLC that could not tolerate pneumonectomy or sleeve lobectomy. Right upper and middle bilobectomies were performed, the right lower lobe was resected and retrograde perfusion of Raffinose low-potassium dextran solution (4 °C) was administered. The isolated lower lobe was reimplanted by anastomosis of the bronchus, pulmonary artery, and vein. The patient was cancer-free 1 year after the surgery. Lung autotransplantation can therefore be successfully performed for selected patients with central NSCLC.     

Comparison in prognosis after VATS lobectomy and open lobectomy for stage I lung cancer

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has become an attractive surgical procedure, but several issues remain to be resolved. Prognosis after VATS lobectomy is important to evaluate the adequacy of VATS lobectomy as a cancer operation. Interestingly, several investigators, including us, have reported that prognosis after VATS lobectomy was superior to that after open lobectomy in early non-small-cell lung cancer (NSCLC). One of the possible reasons is the low invasiveness of VATS lobectomy. But we considered that patient bias might have some influence favoring VATS lobectomy. To evaluate our hypothesis, we reviewed medical records of stage I NSCLC patients undergoing operation between 1993 and 2002. We compared and evaluated the relationship between patient characteristics and prognosis after VATS and open lobectomy. We focused particularly on histological type, classifying it into four subgroups; (1) bronchioloalveolar carcinoma (BAC), (2) mixed BAC + papillary adenocarcinoma (BAC + Pap), (3) other adenocarcinoma (Other adeno), (4) squamous cell carcinoma + others (Sq + others). RESULTS: A total of 165 patients underwent VATS lobectomy, and 123 patients underwent open lobectomy. The 5-year survival rate of the VATS lobectomy group was 94.5% and that of the open lobectomy group was 81.5%. Univariate Cox regression of survival revealed that male, CEA > 5, Other adeno, Sq + others, open lobectomy, and tumor size > 3 cm were significant negative prognostic variables. Multivariate Cox regression of survival revealed that histological subtype and tumor size were independent prognostic factors, but surgical procedure was not an independent prognostic factor. COMMENTS: Prognosis after VATS lobectomy was superior to that after open lobectomy, but patient bias influenced the prognosis in favor of VATS lobectomy, and the surgical procedure itself was not a prognostic factor.     

Surgical strategy for clinical stage I non-small cell lung cancer in octogenarians.

OBJECTIVE: The purpose of this study was to determine whether lobectomy without radical systematic mediastinal lymphadenectomy (LA) is a satisfactory alternative surgical treatment for octogenarians with clinical stage I non-small cell lung cancer (NSCLC). METHODS: From April 1985 through December 2001, 49 patients aged 80 years and older who underwent surgical treatment for clinical stage I NSCLC were reviewed. Lobectomy without radical systematic mediastinal LA was performed for 27 patients (LA0 group) and lobectomy with radical systematic mediastinal LA was performed for 22 patients (LA group). RESULTS: The mortality rate was 0% in the LA0 group and 4.5% in the LA group. Five-year survival rate according to the type of surgery was 44.8% in the LA0 group and 55.5% in the LA group, a difference that was not significant (P=0.88). Although there was no significant statistical difference, postoperative pulmonary complication was more frequent in the LA group than in the LA0 group (32% in the LA group versus 11% in the LA0 group P=0.07). Five-year survival rates according to serum carcinoembryonic antigen (CEA) levels were 0% for patients with elevated CEA levels (n=9) and 56.5% for patients with normal CEA levels (n=40) (P<0.01). CONCLUSION: Lobectomy without radical systematic mediastinal LA appears to be a satisfactory surgical procedure for octogenarians with clinical stage I NSCLC. However, mediastinoscopy is necessary in such octogenarians if their serum CEA level is elevated so that the precise clinical stage can be determined and an accurate prognosis can be given.     

The incidence, etiology, and prevention of postresectional bronchopleural fistula

Bronchopleural fistula (BPF) is a life-threatening complication after pulmonary resection. The incidence varies from 4.5% to 20% after pneumonectomy and is only 0.5% after lobectomy. Certain patient characteristics increase this incidence. These include preoperative radiation to the chest, destroyed or infected lung from inflammatory disease, immunocompromised host, and insulin-dependent diabetes. Certain surgical techniques also increase the incidence. These include pneumonectomy, right-sided pneumonectomy, a long bronchial stump, residual cancer at the bronchial margin, devascularization of the bronchial stump, prolonged ventilation, or reintubation after resection and surgical inexperience. The best treatment of a BPF is prevention. Prevention centers around meticulous surgical technique and the liberal use of prophylactic, pedicled muscle flaps for the patient at increased risk. Survival of BPF depends on a high index of suspicion, early diagnosis, and aggressive surgical intervention.     

Prognostic Factors for Surgically Resected N2 Non-small Cell Lung Cancer

Purpose: Non-small cell lung cancers (NSCLCs) with pathologically documented ipsilateral mediastinal lymph node (LN) metastases (pN2) are a broad spectrum of diseases. We retrospectively analyzed prognostic factors for cases of pN2 NSCLC treated by surgical resection.Methods: Clinicopathological data were reviewed for consecutive 121 patients who underwent anatomical pulmonary resection with mediastinal LN sampling or dissection for pN2 NSCLC over a 15-year period.Results: The 5-year survival rate for all patients was 29.9%. Clinical N status, curability, surgical procedure and adjuvant chemotherapy were favorable prognostic factors in univariate analysis, with 5-year survival rates of 35.0% for cN0/1 vs. 17.7% for cN2/3 cases; 33.1% for R0 vs. 14.7% for R1/2 resection; 31.5% for lobectomy vs. 25.0% for bilobectomy and 15.6% for pneumonectomy; and 72.7% with adjuvant chemotherapy vs. 23.8% without adjuvant chemotherapy. Survival did not differ significantly based on gender, age, smoking status, clinical T status, tumor location, histology, skip metastasis, subcarinal LN metastasis, or number of involved N2 levels. In multivariate analysis, adjuvant chemotherapy, R0 resection, and lobectomy emerged as independent favorable prognostic factors.Conclusion: Complete resection using lobectomy and adjuvant chemotherapy are favorable prognostic factors in cases of pN2 NSCLC.     

Significant Prognostic Factors for Completely Resected pN2 Non-small Cell Lung Cancer without Neoadjuvant Therapy

Purpose: To identify prognostic factors for pathologic N2 (pN2) non-small cell lung cancer (NSCLC) treated by surgical resection.Methods: Between 1990 and 2009, 287 patients with pN2 NSCLC underwent curative resection at the Cancer Institute Hospital without preoperative treatment.Results: The 5-year overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) rates were 46%, 55% and 24%, respectively. The median follow-up time was 80 months. Multivariate analysis identified four independent predictors for poor OS: multiple-zone mediastinal lymph node metastasis (hazard ratio [HR], 1.616; p = 0.003); ipsilateral intrapulmonary metastasis (HR, 1.042; p = 0.002); tumor size >30 mm (HR, 1.013; p = 0.002); and clinical stage N1 or N2 (HR, 1.051; p = 0.030). Multivariate analysis identified three independent predictors for poor RFS: multiple-zone mediastinal lymph node metastasis (HR, 1.457; p = 0.011); ipsilateral intrapulmonary metastasis (HR, 1.040; p = 0.002); and tumor size >30 mm (HR, 1.008; p = 0.032).Conclusion: Multiple-zone mediastinal lymph node metastasis, ipsilateral intrapulmonary metastasis, and tumor size >30 mm were common independent prognostic factors of OS, CSS, and RFS in pN2 NSCLC.     

Bronchial fistula postpneumonectomy: predictive factors

OBJECTIVE: To determine predictive factors of bronchial fistula following pneumonectomy. PATIENTS AND METHODS: In 14 years (1989-2003), we collect 58 cases of bronchial fistula following 725 consecutive pneumonectomy in the service of thoracic surgery of the Sainte Marguerite Hospital in Marseilles. There were 53 cases (91.4%) of cancers and 5 cases (8.6%) of various pathology. The average age of the patients was of 61 +/- 10 years (range 24 to 80 years). The sex ratio M/F was 8.7. The software of regression SPSS (version11.5) was used to identify the factors risk of a bronchial fistula after a univariate and multivariate analysis. RESULTS: The prevalence of the bronchial fistula after a pneumonectomy was 8%.The preoperative factors which increased to a significant degree the incidence of the bronchial dent to the univariate analysis were the chronic smoking (P < 0.001), the existence of COPD (P = 0.001) and of a previous thoracic surgery (P = 0.01). Operational data like a right- side pulmonary resection (P < 0.001), the type of bronchial stup carried out (P = 0.03) as and an extended pneumonectomy to the auricule (P = 0.03) were significant risk factors. With the logistic regression the significant risk factors were the chronic smoking (P = 0.002), the existence of COPD (P = 0.003), a previous pulmonary surgery (P = 0.03) and the right - side of the pneumonectomy (P < 0.001). The indication of the pneumonectomy was retained neither by the univariate analysis, nor by the logistic regression significant risk factors. CONCLUSION: The predictive factors of a bronchial fistula after a pneumonectomy are dominated by respiratory co-morbidities. To prevent this complication, we insist on the stop of the tobacco, a better respiratory preparation and the acquisition of a protocol adapted of the bronchial stub after a pneumonectomy particularly on the right side.     

Identification of risk factors for allogenic transfusion in cardiac surgery from an observational study

OBJECTIVE: To determine perioperative variables for predicting allogenic transfusion in adult cardiac surgery. STUDY DESIGN: Prospective study. PATIENTS: We included 335 consecutive patients undergoing cardiac surgery between February and April 2001. METHODS: Perioperative variables were prospectively collected in a database. For each patient who received transfusion, hemoglobin threshold for transfusion and total number of units of red cell concentrates were collected. Univariate and multivariate analysis were performed. RESULTS: The two strategies for blood conservation which were predominantly used were aprotinin therapy (78%) and blood salvage from the extracorporeal circuit (68%). During perioperative period, 42% of patients [95% CI: 37-47%] received allogenic transfusion. The haemoglobin threshold for transfusion was 7.4 +/- 1.1 and 8.0 +/- 0.7 g x dl(-1) in operating room and in intensive care unit, respectively. On average, 3.4 +/- 2.7 units of red cell concentrates were transfused perioperatively per patient. Using multivariate analysis, perioperative allogenic transfusion was significantly associated with the following variables: preoperative haemoglobin level < 12 g x dl(-1) (odds ratio 8.9; p = 0.001), emergency procedure (odds = 3.7, p = 0.01), reoperation (odds ratio = 3.3; p = 0.002), chronic obstructive pulmonary disease (odds ratio = 2.5; p = 0.03) and complex surgery (odds ratio = 2.4; p = 0.01). The age, the gender, and body mass index were only independent risk factors by univariate analysis. CONCLUSION: In despite of techniques to limit requirement of allogenic transfusion, a large proportion of cardiac surgical patients remains transfused. Independent risk factors of perioperative transfusion are haemoglobin level < 12 g x dl(-1), emergency procedure, reoperation, chronic obstructive pulmonary disease and complex surgery.     

Operative risk factors of type A aortic dissection: analysis of 252 consecutive patients

OBJECTIVE: We examined operative risk factors for postoperative death after surgery for acute type A aortic dissection. METHODS: Between 1974 and 1999, 252 patients, 163 men and 89 women (mean+/-SD age, 58+/-12 years) underwent surgery for acute type A aortic dissection. Fifty-eight (23.0%) were in cardiogenic shock at time of surgery. Most patients underwent ascending aorta replacement which was combined with aortic valve replacement by means of a composite graft in 30 (11.9%) patients and an isolated aortic valve replacement in 16 (6.3%) patients. RESULTS: The overall operative mortality rate was 25.0% (n=63); 27.0% for patients operated upon with aortic cross-clamping, 23.7% after deep hypotherm circulatory arrest and 23.3% after antegrade selective cerebral perfusion (ASCP) (p=0.73). Multivariate analysis revealed iatrogenic dissection (p=0.0096, odds ratio=5.7), preoperative cardiopulmonary resuscitation (p=0.0095, odds ratio=5.5) and every quarter of an hour longer extracorporeal circulation (p=0.049, odds ratio=1.1) as independent risk factors for operative mortality. Aortic valve replacement or Bentall procedure (p=0.0185, odds ratio=0.3) were protective factors. There were 44 new postoperative strokes: 4.7% in the group operated upon with and 20.1% in the group without ASCP (p=0.01). CONCLUSION: In order to avoid cardiogenic shock and preoperative cardiopulmonary resuscitation, patients with acute type A aortic dissection should be treated promptly. The choice to use an aortic valve prosthesis or Bentall procedure when applicable seems to benefit the postoperative early survival. The risk of new postoperative neurological events might be reduced by avoiding the appliance of an aortic cross-clamp and by using ASCP.     

肺切除术影响围手术期右心功能

目的 检测肺切除术后围手术期右心功能指标的变化,以指导临床治疗.方法 将肺切除病人45例分为肺楔形切除组(Ⅰ组,10例)、单肺叶切除组(Ⅱ组,19例)、双肺叶切除组(Ⅲ组,7例)及全肺切除组(Ⅳ组,9例).通过中心静脉压(CVP)测定、脉冲多普勒血流频谱及组织多普勒技术了解术前、术后5-7d、术后1个月的右心室前、后负荷及泵功能变化.结果 与术前相比,各种术式术后5～7d中心静脉压均无明显变化;Ⅰ组术后右心后负荷、泵功能较术前无明显改变;Ⅱ组、Ⅲ组及Ⅳ组术后5～7d右心后负荷增加,右心泵功能下降,Ⅳ组更为明显;术后1个月,Ⅱ组右心后负荷、泵功能恢复到术前水平,但Ⅲ组及Ⅳ组与术前相比仍有异常.结论 肺切除术后存在不同程度的右心功能下降.     

Effect of postoperative epidural analgesia on morbidity and mortality following surgery in medicare patients

BACKGROUND: Because of the uncertainty and limitations in available randomized controlled trials, we performed an analysis of the Medicare claims database to determine whether an association exists between postoperative epidural analgesia and mortality. METHODS: A 5% nationally random sample of Medicare beneficiaries from 1997 to 2001 was analyzed to identify patients undergoing segmental excision of the lung (International Statistical Classification of Diseases, Ninth Revision, Clinical Modification codes 32.3 and 32.4), complete pneumonectomy (code 32.5), partial excision of large intestine (codes 45.73 and 45.76), anastomosis of the esophagus (codes 42.5 and 42.6), total knee replacement/revision (codes 81.54 and 81.55), total/radical abdominal hysterectomy (codes 68.4 and 68.6), partial/radical pancreaticoduodenectomy (codes 52.5 and 52.7), partial/complete nephrectomy (codes 55.4 and 55.5), partial/complete cystectomy (codes 57.6 and 57.7), hepatotomy/lobectomy of the liver (codes 50.0 and 50.3), partial/total gastrectomy (codes 43.5 to 43.9), and radical retropubic prostatectomy (codes 60.4 and 60.5). Patients were divided into 2 groups, depending on the presence or absence of postoperative epidural analgesia. The rate of major morbidity and death at 7 and 30 days after surgery were compared. Multivariate regression analyses incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status were performed. RESULTS: The presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.38 to 0.73; P = .0001) and 30 days (OR, 0.74; 95% CI, 0.63 to 0.89; P = .0005) after surgery; however, no difference was seen between the groups with regard to overall major morbidity, with the exception of an increase in pneumonia at 30 days for the epidural group (OR, 1.91;[95% CI, 1.09 to 3.34; P = .02). CONCLUSIONS: Postoperative epidural analgesia may contribute to lower odds of death after surgery.