Early discharge after thoracoscopic anatomical pulmonary resection for non-small-cell lung cancer

 Open in a separate windowOBJECTIVESAlthough video-assisted thoracic surgery (VATS) has shortened hospitalization duration for non-small-cell lung cancer (NSCLC) patients, the factors associated with early discharge remain unclear. This study aimed to identify patients eligible for a 72-h stay after VATS anatomical resection.METHODSMonocentric retrospective study including all consecutive patients undergoing VATS anatomical resection for NSCLC between February 2010 and December 2019. Two groups were defined according to the discharge: ‘early discharge’ (within 72 postoperative hours) and ‘routine discharge’ (at >72 postoperative hours).RESULTSA total of 660 patients with a median age of 66.5 years (interquartile range 60–73 years) (female/male: 321/339) underwent VATS anatomical pulmonary resection for NSCLC [segmentectomy in 169 (25.6%), lobectomy in 481 (72.9%), bilobectomy in 8 (1.2%) and pneumonectomy in 2 (0.3%) patients]. The cardiopulmonary and Clavien–Dindo III–IV postoperative complication rates were 32.6% and 7.7%, respectively. The median postoperative length of stay was 6 days (interquartile range 4–10 days). In total, 119 patients (18%) could be discharged within 72 h of surgery. On multivariable analysis, the factors significantly associated with an increased likelihood of early discharge were: body mass index >20 kg/m² [odds ratio (OR) 2.37], absence of prior cardiopathy (OR 2), diffusing capacity of the lung for carbon monoxide >60% (OR 1.82), inclusion in an enhanced recovery after surgery protocol (OR 2.23), use of a single chest tube (OR 5.73) and postoperative transfer to the ward (OR 4.84). Factors significantly associated with a decreased likelihood of early discharge were: age >60 years (OR 0.53), American Society of Anaesthesiologists score >2 (OR 0.46) and use of an epidural catheter (OR 0.41). Readmission rates were not statistically different between both groups (5.9% vs 3.1%; P = 0.17).CONCLUSIONSAge, pulmonary functions and comorbidities may influence discharge after VATS anatomical resection. The early discharge does not increase readmission rates.     

Investigation of postoperative death after lung resection for lung cancer caused by interstitial pneumonia]

We investigated interstitial pneumonia, one of the most severe postoperative acute complications of respiratory surgery. In sixteen years, from 1982 through 1997, 2,453 cases underwent thoracotomies caused by lung cancers, in our institute. There were 20 cases (0.79%) who died within 30 days after surgery (operative death). Six out of 20 cases died of interstitial pneumonia, one of the most frequent postoperative complications. We examined these six patients and 2 patients with postoperative interstitial pneumonia who died within 32 days. Preoperative lung function tests, laboratory data, chest CT and/or chest X-ray films cannot predict development of postoperative interstitial pneumonia. Those who acquired postoperative interstitial pneumonia had continuous high fever after surgery following reticular shadows on their chest X-ray and increase in LDH levels. We could not detect any characteristic viral infections. Although, they were treated by steroid, elastase inhibitor and/or immune suppressant, they died within 32 days. In conclusion, development of postoperative of interstitial pneumonia cannot be predicted from preoperative laboratory data and/or lung function tests.     

Causes of mortality beyond 1 year after primary pediatric liver transplant under tacrolimus

BACKGROUND: Success of pediatric liver transplantation has improved significantly. Most posttransplant deaths occur early and are related to surgical complications or recipient status at the time of transplantation. The causes of mortality beyond the first year have not been well described. METHODS: Three hundred twenty-six pediatric liver transplants were performed between November 1989 and April 1998 using tacrolimus-based immunosuppression. Patients were followed until March 2002. Mean follow-up was 9.2+/-2.4 years. RESULTS: At 1 year, 279 patients (85.5%) were alive. In the subsequent 12.5 years, 10 of the remaining children died (3.58%) at a mean interval of 3.68+/-1.69 years after transplant. The mean age at transplant was 5.62+/-6.3 years. Six patients had infections as a major contributor to mortality, including two patients with posttransplant lymphoproliferative disorder (PTLD) and one patient that died after retransplantation for hepatitis. Two patients had recurrent malignancy. Other deaths were attributable to chronic rejection, liver failure after being lost to follow-up, and complications of cystic fibrosis. CONCLUSIONS: Pediatric liver transplantation using tacrolimus-based immunosuppression has demonstrated excellent success, with 1- and 10-year survival rates of 85.5% and 82.9%, respectively. Late mortality after pediatric liver transplantation overall remains low, with a rate of 0.32% per year. The most common cause of death was infection (60%), including PTLD-related disease (20%). However, in the recent cohort of patients who underwent transplantation after September 1995, there were no fatal cases of Epstein-Barr virus or PTLD or late mortality thus far, suggesting a benefit from improved infectious disease surveillance using currently available modalities. Mortality from chronic rejection and noncompliance under tacrolimus has been exceedingly rare.     

Detected troponin elevation is associated with high early mortality after lung resection for cancer

Background  

Myocardial infarction can be difficult to diagnose after lung surgery. As recent diagnostic criteria emphasize serum cardiac markers (in particular serum troponin) we set out to evaluate its clinical utility and to establish the long term prognostic impact of detected abnormal postoperative troponin levels after lung resection.     

Vocal cord dysfunction after left lung resection for cancer.

OBJECTIVES: To evaluate the prevalence, the impact-related postoperative complications and the risk factors of vocal cord dysfunction (VCD) after left lung resection for cancer. METHODS: From February 1996 to April 1999, a review of prospectively gathered data was performed on 99 consecutive patients who underwent a pneumonectomy (n=50) or a lobectomy (n=49) with a mediastinal lymph node dissection. A fiber optic laryngeal examination was performed preoperatively for all patients and within the first week postoperatively in patients with symptom(s) or sign(s) of VCD or respiratory complications. RESULTS: Thirty-one patients (31%) had a postoperative VCD (group VCD) and 68 (68%) did not (group non-VCD). Mortality rate was 19% in group VCD and 9% in group non-VCD (P=0.13). Group VCD patients developed more pulmonary complications (P=0.014) and cardiac complications (P<0.001) compared to group non-VCD patients. A higher rate of reintubation (P=0.005), pneumonia (P=0.06), arrhythmia (P=0.002), cardiac failure (P<0.001) was noticeable in group VCD and may account for the higher rate of complications in this group. Using multivariate analysis, preoperative radiotherapy (P=0.001) and pneumonectomy (P=0.008) were predictive of postoperative VCD. Hospital stay was 22+/-16 days in group VCD and 13+/-9 days in group non-VCD (P<0.002). CONCLUSION: VCD is a frequent event that can lead to dramatic pulmonary complications. We would recommend to track it and to treat it as early as possible.     

肝癌切除术后近期死亡的原因

肝癌是我国最常见的恶性肿瘤之一 ,手术切除占有首选的重要地位。但国人肝癌的特点是与肝炎病毒感染及肝硬化关系密切 ,合并率 80 %以上 ,它严重制约着肝癌切除的治疗效果 ,包括 :切除指征的掌握 ,肝切除量的限制 ,对出血的耐受力 ,余肝的代偿及贮备功能情况 ,术后并发症与死亡率及切除后复发等等。随着影像诊断、切除技术及围手术期监护治疗的飞跃发展 ,肝癌切除死亡率已由 2 0世纪90年代初的 2 0 %～ 37%降至 4 %～ 10 %,但减少术后近期死亡仍然占有重要的地位 ,它决定于肿瘤的部位、肝硬化合并的有无与严重程度 ,肝功能分级 ,围手术期出…     

Risk factors for airway complications within the first year after lung transplantation.

OBJECTIVE: Lung transplantation (LTx) has enjoyed increasing success with better survival in recent years. Nevertheless, airway anastomotic complications (AC) are still a potential cause of early morbidity and mortality. In this retrospective cohort study we looked at possible predictors of AC within the first year after LTx. METHODS: Between July 1991 and December 2004, 232 consecutive single (n=102) and bilateral (n=130) LTx were performed (142 males and 90 females; mean age: 48 years [range 15-66 years]). Indications for LTx were emphysema (n=113), pulmonary fibrosis (n=45), cystic fibrosis (n=35), pulmonary hypertension (n=10), sarcoidosis (n=7) and miscellaneous (n=22). Donor variables (age, gender, PaO(2)/FiO(2), mechanical ventilation, ischemic time and preservation solution) and recipient variables (age, diagnosis, length, gender, pre-operative steroids, smoking, cytomegalovirus matching, LTx type, anastomotic type, wrapping and bypass) were evaluated in an univariate and multivariate model. RESULTS: Fifty-seven complications occurred in 362 airway anastomoses (15.7%) of which 55 (15.2%) within the first year after transplantation. Six patients died as a result of AC (mortality 2.6%) during the first year after LTx. In a univariate analysis (321 airway anastomoses at risk), anastomotic type (7/17 [Telescoping] vs 48/304 [End-to-end]; p=0.011), recipient length (p=0.0012), donor ventilation (>50-70h<; p=0.0015) and recipient male gender (43/191 [M] vs 12/130 [F]; p=0.0092) were significant predictors of AC. Three factors remained significant predictors in the multivariate analysis: telescoping technique (p=0.0495), recipient length (p=0.0029) and donor ventilation (p=0.003). CONCLUSIONS: Tall recipients and those receiving lungs from donors with prolonged ventilation have an increased risk to develop bronchial anastomotic problems. An end-to-end anastomosis should be preferred. Airway complications remain a matter of concern after lung transplantation.     

Risk factors for 30-day mortality after resection of lung cancer and prediction of their magnitude

BACKGROUND: There is considerable variability in reported postoperative mortality and risk factors for mortality after surgery for lung cancer. Population-based data provide unbiased estimates and may aid in treatment selection. METHODS: All patients diagnosed with lung cancer in Norway from 1993 to the end of 2005 were reported to the Cancer Registry of Norway (n = 26 665). A total of 4395 patients underwent surgical resection and were included in the analysis. Data on demographics, tumour characteristics and treatment were registered. A subset of 1844 patients was scored according to the Charlson co-morbidity index. Potential factors influencing 30-day mortality were analysed by logistic regression. RESULTS: The overall postoperative mortality rate was 4.4% within 30 days with a declining trend in the period. Male sex (OR 1.76), older age (OR 3.38 for age band 70-79 years), right-sided tumours (OR 1.73) and extensive procedures (OR 4.54 for pneumonectomy) were identified as risk factors for postoperative mortality in multivariate analysis. Postoperative mortality at high-volume hospitals (> or = 20 procedures/year) was lower (OR 0.76, p = 0.076). Adjusted ORs for postoperative mortality at individual hospitals ranged from 0.32 to 2.28. The Charlson co-morbidity index was identified as an independent risk factor for postoperative mortality (p = 0.017). A prediction model for postoperative mortality is presented. CONCLUSIONS: Even though improvements in postoperative mortality have been observed in recent years, these findings indicate a further potential to optimise the surgical treatment of lung cancer. Hospital treatment results varied but a significant volume effect was not observed. Prognostic models may identify patients requiring intensive postoperative care.     

Lobar torsion after pulmonary resection for lung cancer

We reviewed our experience on postoperative lobar torsion. From January 1994 to December 2003, 1002 patients underwent lobectomy for lung cancer. Two (0.2%) patients with postoperative lobar torsion required surgical reintervention. The first case was that of a 79-year-old man who underwent left lower lobectomy for pulmonary adenocarcinoma. Based on the postoperative course, lobar torsion was highly suspected with progressive respiratory dysfunction and the chest X-ray showed complete opacification of the residual lobe. Rethoracotomy was performed on postoperative day 4. The left upper lobe was rotated clockwise, and completion pneumonectomy was carried out. The patient died 16 days after the second surgery because of respiratory failure due to severe pneumonia. The second case was that of a 24-year-old man with a diagnosis of metastatic lung cancer in the right upper lobe arising from pharyngeal cancer. The patient underwent right upper lobectomy and developed hemoptysis and persistent high fever. A chest computed tomography (CT) and bronchoscopy findings revealed lobar torsion of the middle lobe, and a reoperation was performed. The middle lobe was resected and the patient was discharged 8 days after the rethoracotomy. Pulmonary lobar torsion poses a difficult diagnostic dilemma in the early postoperative period after the pulmonary resection. Since late reoperation for postoperative lobar torsion sometimes results in poor prognosis, careful observation with bronchial fiberscopy as well as chest radiography is necessary for accurate diagnosis. Rethoracotomy should be carried out without any delay in cases of lobar torsion following pulmonary resection.     

Late-onset chylothorax after pulmonary resection for lung cancer

Chylothorax is a relatively rare complication of thoracic surgery. Most instances of chylothorax after pulmonary resection are diagnosed within 3 days after surgery. Hence, late-onset chylothorax is rare. A 68-year-old woman underwent right lower lobectomy and mediastinal dissection for lung cancer. After discharge, the patient developed a dry cough, and chest radiography more than 3 months after surgery revealed a right-sided pleural effusion occupying more than half of the right hemithorax, which we diagnosed as late-onset chylothorax. Treatment comprised chest drainage, subcutaneous octreotide, and pleurodesis by injecting a preparation of OK-432. Follow-up chest radiography confirmed no reaccumulation of fluid. Three months later no recurrence of pleural effusion was detected. We report a rare case of postoperative late-onset chylothorax that proved difficult to treat.