Amy Kerr

Long-term impact of developing a postoperative pulmonary complication after lung surgery

Introduction Postoperative pulmonary complications (PPC) such as atelectasis and pneumonia are common following lung resection. PPCs have a significant clinical impact on postoperative morbidity and mortality. We studied the long-term effects of PPCs and sought to identify independent risk factors. Methods A prospective observational study involved all patients following lung resection in a regional thoracic centre over 4 years. PPCs were assessed daily in hospital using the Melbourne group scale based on chest X-ray, white cell count, fever, purulent sputum, microbiology, oxygen saturations, physician diagnosis and intensive therapy unit (ITU)/high-dependency unit readmission. Follow-up included hospital length of stay (LOS), 30-day readmissions, and mortality. Results 86 of 670 patients (13%) who had undergone a lung resection developed a PPC. Those patients had a significantly longer hospital LOS in days (13, 95% CI 10.5–14.9 vs 6.3, 95% CI 5.9 to 6.7; p<0.001) and higher rates of ITU admissions (28% vs 1.9%; p<0.001) and 30-day hospital readmissions (20.7% vs 11.9%; p<0.05). Significant independent risk factors for development of PPCs were COPD and smoking (p<0.05), not age. Excluding early postoperative deaths, developing a PPC resulted in a significantly reduced overall survival in months (40, 95% CI 34 to 44 vs 46, 95% CI 44 to 47; p=0.006). Those who developed a PPC had a higher rate of non-cancer-related deaths (11% vs 5%; p=0.020). PPC is a significant independent risk factor for late deaths in non-small cell lung cancer patients (HR 2.0, 95% CI 1.9 to 3.2; p=0.006). Conclusions Developing a PPC after thoracic surgery is common and is associated with a poorer long-term outcome.

Surgical lung cancer patients' views about smoking and support to quit after diagnosis: a qualitative study.

PurposeEvidence suggests that quitting smoking improves symptoms as well as disease-related mortality for cancer patients. However, smoking cessation support is typically not well integrated into routine cancer care even in the case of lung cancer.. We explored surgical lung cancer patients’ views about smoking and about their preferences for support to help them to quit.MethodsWe conducted semi-structured, qualitative interviews with 22 surgical lung cancer patients with a smoking history, after treatment with surgery. Data were analysed using the framework approach.ResultsAlthough diagnosis promoted a successful quit attempt in some, others continued smoking or relapsed after a quit attempt. Most participants wished they were a non-smoker but, in conflict with this, also felt that smoking was enjoyable, helped with psychological coping or had some health benefits. Some also demonstrated a fatalist attitude towards the potential detrimental health effects. However, all participants felt that it was important for health professionals to address smoking and some wanted cessation support although it was often not provided. Participants wanted support to start as early as possible and to continue for the first weeks after discharge.ConclusionsSurgical lung cancer patients often stop smoking during hospitalisation, and many want to remain quit but relapse shortly after discharge. Although it is often not provided, many patients want to be offered support to help them quit.Implications for Cancer SurvivorsSurveys suggest that clinicians believe that addressing smoking will be difficult and/or unwanted. However, these findings suggest that surgical lung cancer patients would tolerate, and most would prefer, integration of smoking cessation support into routine cancer care.

Does the revised cardiac risk index predict cardiac complications following elective lung resection

No abstract

Randomised controlled pilot study to investigate the effectiveness of thoracic epidural and paravertebral blockade in reducing chronic post-thoracotomy pain: TOPIC feasibility study protocol

Introduction Open chest surgery (thoracotomy) is considered the most painful of surgical procedures. Forceful wound retraction, costochondral dislocation, posterior costovertebral ligament disruption, intercostal nerve trauma and wound movement during respiration combine to produce an acute, severe postoperative pain insult and persistent chronic pain many months after surgery is common. Three recent systematic reviews conclude that unilateral continuous paravertebral blockade (PVB) provides analgesia at least equivalent to thoracic epidural blockade (TEB) in the postoperative period, has a lower failure rate, and symptom relief that lasted months. Crucially, PVB may reduce the development of subsequent chronic pain by intercostal nerve protection or decreased nociceptive input. The overall aim is to determine in patients who undergo thoracotomy whether perioperative PVB results in reducing chronic post-thoracotomy pain (CPTP) compared with TEB. This pilot study will evaluate feasibility of a substantive trial. Methods and analysis TOPIC is a randomised controlled trial comparing the effectiveness of TEB and PVB in reducing CPTP. This is a pilot study to evaluate feasibility of a substantive trial and study processes in 2 adult thoracic centres, Heart of England NHS Foundation Trust (HEFT) and University Hospital of South Manchester NHS Foundation Trust (UHSM). The primary objective is to establish the number of patients randomised as a proportion of those eligible. Secondary objectives include evaluation of study processes. Analyses of feasibility and patient-reported outcomes will primarily take the form of simple descriptive statistics and where appropriate, point estimates of effects sizes and associated 95% CIs. Ethics and dissemination The study has obtained ethical approval from NHS Research Ethics Committee (REC number 14/EM/1280). Dissemination plan includes: informing patients and health professionals; engaging multidisciplinary professionals to support a proposal of a definitive trial and submission for a full HTA application dependent on the success of the study. Trial registration number ISRCTN45041624; Pre-results.

Patients want more information after surgery: a prospective audit of satisfaction with perioperative information in lung cancer surgery

BackgroundReceiving information about their disease and treatment is very important to patients with cancer. There is an association between feeling appropriately informed and better quality of life. This audit aimed to estimate patient satisfaction with perioperative information in those undergoing surgery for lung cancer and any change in satisfaction over time.MethodsA questionnaire (EORTC-Info-25) was administered prospectively to patients preoperatively and up to six months postoperatively. The preoperative questionnaire was completed by 292 patients and 88 free text comments were completed. Intrapersonal responses were compared over time.ResultsPatients were highly satisfied with information prior to surgery. The overall helpfulness of information did not change over time but satisfaction with the amount of information decreased. Patients who received more information about ‘the disease’ and ‘things you can do to help yourself get well’ were less likely to report a drop in satisfaction (Odds Ratio 0.858, 95% Confidence interval 0.765 to 0.961, p = 0.008 and OR 0.102, 95% CI 0.018 to 0.590, p = 0.011 respectively). Free text responses revealed patients most frequently wanted more information on the disease, aftercare and self-care. Suffering complications from surgery was not associated with a change in satisfaction with information postoperatively.ConclusionsPatients want to know more about their diagnosis, but also how to recover and cope with issues once they have gone home after surgery. Postoperative satisfaction with information may improve if patients are given more information on these topics.

S65 Developing a multi-disciplinary thoracic surgery research team improves the recruitment into and quality of clinical trials

Objectives Recruitment into surgical trials historically has been fraught with difficulty. We examine whether developing a multi-disciplinary research team has aided recruitment, data collection, patient retention and so success of clinical trials. In addition we look at effects on the patient experience of the surgical pathway. Methods We evaluated the development and impact of a specialist thoracic trained research team of nurses and allied health care professionals in a regional thoracic unit from 2009–2015. We assessed the impact on the recruitment into National Institute for Health Research Clinical Research Network (NIHR CRN) thoracic surgery portfolio trials. Patient experience was captured through a survey (n = 30) and research team feedback through interviews (n = 5). During the development, clear leadership and support networks were created, new members were trained by specialist thoracic research nurses to obtain competences in both research and thoracic surgery to enable confident valid informed consent and the collection of robust quality data. Results Since the development of a specialised thoracic surgery research team in 2010 the number trials have steadily increased and along with number of team members whilst clinical activity remained constant. The number of patient consented into clinical trials increased 7 fold (Table 1). From staff interviews a recurring theme was that a clear team structure and a specialist training aided them to be better patient advocate not only in research but in the clinical pathway. Patients universally agreed that involvement of the research team helped reduce their anxiety about their surgery and so enhanced patients experience. Conclusion The impact of a dedicated research team goes well beyond research but improves clinical care. Having a clear support system and a specialist trained team has increased recruitment and retention into thoracic surgical trials and enhanced the patient’s experience of research and the surgical pathway. Abstract S65 Table 1

P164 Smoking at the time of curative-intent lung cancer surgery increases perioperative complications: is there a role for electronic cigarettes?

Introduction Smoking is a risk factor for postoperative pulmonary complications (PPCs) following curative-intent surgery for lung cancer. Risk modification is via smoking cessation; the role that electronic cigarettes (e-cigarettes) have in preoperative tobacco replacement is a debated topic. Aims Investigate the impact of smoking on postoperative outcome including long-term survival. Assess current smoking habits and attitudes towards preoperative smoking cessation, with emphasis on e-cigarette use. Methods A prospective observational study was carried out on all patients following curative-intent lung cancer resection in a regional thoracic centre over 4 years. Preoperative smoking status was self-reported by all patients. PPCs were assessed daily in hospital using the Melbourne group scale.1 Other data included patient demographics, hospital length of stay (LOS), intensive treatment unit (ITU) admission and mortality data. To assess smoking habits, a questionnaire was given to 105 patients attending the preoperative assessment unit. Results Of 460 patients, 24% were current smokers, 12% ex-smokers 6 weeks duration, and 11% never smoked Compared to never smokers, current smokers had significantly longer hospital LOS in days (9, CI 7–11 vs. 6, CI 4–8; p < 0.001), higher frequency of PPCs (22% vs 2%, p = 0.001) and ITU admissions (14% vs. 0%; p < 0.005). Compared to never smokers, the trend was for reduced survival in current smokers from 1–3 years, but the survival lines converged after this (median follow-up 30 vs. 31 months; p = 0.31). The questionnaire found 24/105 patients were smokers, of these 80% patients had previously tried to quit but only 38% had been specifically approached by health-care professionals about smoking cessation. When asked if they would consider stopping smoking immediately if supplied an e-cigarette, 54% said yes. Conclusions Preoperatively, 1 in 4 patients continue to smoke; the majority have attempted to quit and failed. Current smokers have higher postoperative morbidity with no significant survival difference within our follow-up period. Current methods of preoperative smoking cessation in this population are ineffective; patients appear willing to use e-cigarettes. Further research in this field is urgently needed. Reference 1 Agostini P, et al. Thorax 2010;65:815–18