M. Kalkat

Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors?

Background Postoperative pulmonary complications (PPC) are the most frequently observed complications following lung resection, of which pneumonia and atelectasis are the most common. PPCs have a significant clinical and economic impact associated with increased observed number of deaths, morbidity, length of stay and associated cost. The aim of this study was to assess the incidence and impact of PPCs and to identify potentially modifiable independent risk factors. Methods A prospective observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 13 months. PPC was assessed using a scoring system based on chest x-ray, raised white cell count, fever, microbiology, purulent sputum and oxygen saturations. Results Thirty-four of 234 subjects (14.5%) had clinical evidence of PPC. The PPC patient group had a significantly longer length of stay (LOS) in hospital, high dependency unit (HDU) LOS, higher frequency of intensive care unit (ITU) admission and a higher number of hospital deaths. Older patients, body mass index (BMI) ≥30 kg/m2, preoperative activity <400 m, American Society of Anesthesiologists (ASA) score ≥3, smoking history, chronic obstructive pulmonary disease (COPD), lower preoperative forced expiratory volume in 1 s (FEV1) and predicted postoperative (PPO) FEV1 were all significantly (p<0.05) associated with PPC on univariate analysis. Multivariate analysis confirmed that age >75 years, BMI ≥30 kg/m2, ASA ≥3, smoking history and COPD were significant independent risk factors in the development of PPC (p<0.05). Conclusion The clinical impact of PPCs is marked. Significant independent preoperative risk factors have been identified in current clinical practice. Potentially modifiable risk factors include BMI, smoking status and COPD. The impact of targeted therapy requires further evaluation.

One-stage surgical procedure for bilateral lung and liver hydatid cysts

BACKGROUND Echinococcus disease is endemic in areas where livestock are raised in association with dogs. The majority of patients reporting in the Department of Cardiovascular and Thoracic Surgery at Postgraduate Institute of Medical Education and Research have unilateral pulmonary hydatid disease. METHODS From March 1988 to May 1996 we came across 58 patients with pulmonary hydatidosis, of which 5 patients presented with combined bilateral pulmonary and hepatic hydatid cysts. In these patients, to avoid three-stage operation of two thoracotomies and a laparotomy, we proceeded with simultaneous combined resection of hydatid cysts in one stage through midsternotomy along with laparotomy or transdiaphragmatic removal of liver cysts. RESULTS Results indicate that combined resection of pulmonary and hepatic hydatid cysts is feasible with minimum morbidity and no recurrence. CONCLUSIONS We conclude that a one-stage surgical procedure for bilateral lung and liver hydatid cysts is superior to the classic three-stage approach as it decreases morbidity, hospital stay, and cost.

Global myocardial revascularization without cardiopulmonary bypass using innovative techniques for myocardial stabilization and perfusion

BACKGROUND In off-pump coronary bypass grafting (CABG), invasiveness is reduced but technically perfect anastomosis is jeopardized by cardiac motion and the need to hurry to reduce the time of ischemia. Also, a major cause of postoperative morbidity and mortality is ungrafted circumflex coronary artery disease. We have devised a means of overcoming these shortcomings and performing multivessel CABG. The objective of this study was to assess the safety and efficacy of our technique. METHODS One hundred patients with severe triple-vessel disease underwent multivessel off-pump CABG. For cardiac stabilization, a combination of local pericardial stabilization sutures and lifting and rotating the heart by means of posterior pericardial sutures were used. For myocardial perfusion, a technique of retrograde coronary sinus perfusion by arterial blood from the ascending aorta was used. RESULTS Each patient received an average of 3.8 grafts (range 3 to 5). Complications included conversion to cardiopulmonary bypass (CPB) in 1 patient and a perioperative myocardial infarction in the same patient. In all other patients we were able to perform a satisfactory grafting in all territories with no operative mortality. Rapid recovery allowed 95% of our patients to resume normal activity within 1 month. A predischarge graft angiogram in 35 patients showed 97.8% patency. CONCLUSIONS These results suggest that off-pump CABG with our techniques is effective and safe. Early clinical outcome and excellent patency rates suggest its more widespread use in selected cases.

Effectiveness of incentive spirometry in patients following thoracotomy and lung resection including those at high risk for developing pulmonary complications

Background Following thoracotomy, patients frequently receive routine respiratory physiotherapy which may include incentive spirometry, a breathing technique characterised by deep breathing performed through a device offering visual feedback. This type of physiotherapy is recommended and considered important in the care of thoracic surgery patients, but high quality evidence for specific interventions such as incentive spirometry remains lacking. Methods 180 patients undergoing thoracotomy and lung resection participated in a prospective single-blind randomised controlled trial. All patients received postoperative breathing exercises, airway clearance and early mobilisation; the control group performed thoracic expansion exercises and the intervention group performed incentive spirometry. Results No difference was observed between the intervention and control groups in the mean drop in forced expiratory volume in 1 s on postoperative day 4 (40% vs 41%, 95% CI −5.3% to 4.2%, p=0.817), the frequency of postoperative pulmonary complications (PPC) (12.5% vs 15%, 95% CI −7.9% to 12.9%, p=0.803) or in any other secondary outcome measure. A high-risk subgroup (defined by ≥2 independent risk factors; age ≥75 years, American Society of Anaesthesiologists score ≥3, chronic obstructive pulmonary disease (COPD), smoking status, body mass index ≥30) also demonstrated no difference in outcomes, although a larger difference in the frequency of PPC was observed (14% vs 23%) with 95% CIs indicating possible benefit of intervention (−7.4% to 2.6%). Conclusions Incentive spirometry did not improve overall recovery of lung function, frequency of PPC or length of stay. For patients at higher risk for the development of PPC, in particular those with COPD or current/recent ex-smokers, there were larger observed actual differences in the frequency of PPC in favour of the intervention, indicating that investigations regarding the physiotherapy management of these patients need to be developed further.

Pulmonary rehabilitation programme for patients undergoing curative lung cancer surgery.

OBJECTIVES The aim of the study was to develop a multistranded pragmatic rehabilitation programme for operable lung cancer patients, that looks into feasibility, process indicators, outcome measures, local adaptability, compliance and potential cost benefit. METHODS An outpatient-based complex intervention, rehabilitation for operated lung cancer (ROC) programme, was developed to optimize physical status, prepare for the inpatient journey and support through recovery after surgery. It includes exercise classes, smoking cessation, dietary advice and patient education and was tested in an enriched cohort study within a regional thoracic unit over 18 months. RESULTS A multistranded pragmatic rehabilitation programme pre- and post-surgery is feasible. Fifty-eight patients received the intervention and 305 received standard care. Both groups were matched for age, lung function comorbidity and type of surgery. Patients in the intervention group attended exercise classes twice a week until surgery, which was not delayed. Patients attended four sessions presurgery (range 1-15), resulting in an improvement of 20 m (range -73-195, P = 0.001) in a 6-min walk test and 0.66 l in forced expiratory volume in 1 s (range -1.85 from 1.11, P = 0.009) from baseline to presurgery. Fifty-four percentage of smokers in the intervention group stopped smoking. Sixteen percentage of patients were identified as being at risk of malnourishment and received nutritional intervention. There was a trend in patients in the intervention group towards experiencing fewer postoperative pulmonary complications than those in the non-intervention group (9 vs 16%, respectively, P = 0.21) and fewer readmissions to hospital because of complications (5 vs 14% respectively, P = 0.12). CONCLUSION Chronic obstructive pulmonary disease-type pulmonary rehabilitation before and after lung cancer surgery is viable, and preliminary results suggest improvement in physical measures. A multicentre, randomized controlled trial is warranted to confirm clinical efficacy. ISRCTN REGISTRATION NUMBER ISRCTN00061628.

Comparison of recognition tools for postoperative pulmonary complications following thoracotomy

OBJECTIVES To evaluate the recognition of postoperative pulmonary complications (PPC) following thoracotomy and lung resection using three PPC scoring tools. DESIGN Prospective observational study. SETTING Regional thoracic centre. PARTICIPANTS One hundred and twenty-nine consecutive thoracotomy and lung resection patients (October 2007 and April 2008). MAIN OUTCOME MEASURES PPC assessment was performed on a daily basis using three sets of criteria described by Brooks-Brunn, Gosselink et al. and Reeve et al.: the Brooks-Brunn Score (BBS), Gosselink Score (GS) and Melbourne Group Scale (MGS), respectively. The results were compared with treatment for PPC and clinical outcomes including mortality, postoperative length of stay and high dependency unit length of stay. RESULTS PPC frequency was 13% (17/129) with the MGS, 6% (8/129) with the GS and 40% (51/129) with the BBS. The clinically observed incidence of treated (requiring antibiotic therapy or bronchoscopy) PPC was 12% (16/129). CONCLUSION PPC treatment following thoracotomy is common. Of the three scoring tools, the MGS outperforms the BBS and the GS in terms of PPC recognition following thoracotomy and lung resection. Patients with a PPC-positive MGS score have a worse outcome as defined by mortality, high dependency unit length of stay and postoperative length of stay. The MGS is an easy-to-use multidisciplinary scoring tool, but further work is required into its use in minimally invasive surgery and in targeting high-risk groups for therapy.

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.

Thoracoscore fails to predict complications following elective lung resection

The Thoracoscore mortality risk model has been incorporated into the British Thoracic Society guidelines on the radical management of patients with lung cancer. The discriminative and predictive ability to predict mortality and post-operative pulmonary complications (PPCs) in this group of patients is uncertain. A prospective observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 42 months. 128 out of 703 subjects developed a PPC. 16 (2%) patients died in hospital. In a logistic regression analysis the Thoracoscore was not a significant predictor of mortality (OR 1.07, 95% CI 0.99–1.17; p=0.11) but was a significant predictor of PPCs (OR 1.08, 95% CI 1.03–1.13; p=0.002). However, the area under the receiver operator characteristic curve for the Thoracoscore was 0.68 (95% CI 0.56–0.80) for predicting mortality and 0.64 (95% CI 0.59–0.69) for PPCs, indicating limited discriminative ability. In a logistic regression analysis, another risk model, the European Society Objective Score, was predictive of mortality (OR 1.43, 95% CI 1.11–1.83; p=0.006) and PPCs (OR 1.48, 95% CI 1.30–1.68; p<0.0001). Therefore, Thoracoscore may have poor discriminative and predictive ability for mortality and PPCs following elective lung resection.

Composite Aortic Valve Graft Replacement Mortality Outcomes in a National Registry

Background— Composite aortic valve and root replacement (CVG) is a complex surgical procedure, but excellent center-specific outcomes are reported. We sought to report outcomes in a national cohort. Methods and Results— The United Kingdom Heart Valve Registry was interrogated for 1962 first-time CVG (and 37 102 aortic valve replacements [AVR] as a reference group) procedures from 1986 to 2004. We analyzed 30-day mortality, long-term survival (97.2% complete follow-up), and examined available risk factors for mortality using univariate and multivariate logistic regression analysis and causes of death. CVG patients were younger, received larger valve sizes and were more likely to be emergent than AVR patients. Overall 30-day mortality was 10.7% (CVG) and 3.6% (AVR). For CVG, multivariate analysis identified advanced age (>70 years), concomitant coronary artery surgery, impaired left ventricular function, urgent or emergency status, prosthetic valve size ≤23 mm and hospital activity volume ≤8 procedures per annum as significant factors for 30-day mortality. Kaplan-Meier, 1-year, 5-year, 10-year and 20-year survival were 85.2%, 77.1%, 70% and 59.3%, respectively. The conditional (post–30-day) survival was similar to the AVR cohort. Conclusions— These Registry data provide a unique national insight into CVG outcomes. After a higher initial mortality risk, CVG has equivalent conditional longer-term survival to AVR.

Postoperative pulmonary complications and rehabilitation requirements following lobectomy: a propensity score matched study of patients undergoing video-assisted thoracoscopic surgery versus thoracotomy

OBJECTIVES : Video-assisted thoracoscopic surgical (VATS) lobectomy is increasingly used for curative intent lung cancer surgery compared to open thoracotomy due to its minimally invasive approach and associated benefits. However, the effects of the VATS approach on postoperative pulmonary complications (PPC), rehabilitation and physiotherapy requirements are unclear; our study aimed to use propensity score matching to investigate this. METHODS Between January 2012 and January 2016 all consecutive patients undergoing lobectomy via thoracotomy or VATS were prospectively observed. Exclusion criteria included VATS converted to thoracotomy, re-do thoracotomy, sleeve/bilobectomy and tumour size >7 cm diameter (T3/T4). All patients received physiotherapy assessment on postoperative day 1 (POD1), and subsequent treatment as deemed appropriate. PPC frequency was measured daily using the Melbourne Group Scale. Postoperative length of stay (LOS), high dependency unit (HDU) LOS, intensive therapy unit (ITU) admission and in-hospital mortality were observed. Propensity score matching (PSM) was performed using previous PPC risk factors (age, ASA score, body mass index, chronic obstructive pulmonary disease, current smoking) and lung cancer staging. RESULTS Over 4 years 736 patients underwent lobectomy with 524 remaining after exclusions; 252 (48%) thoracotomy and 272 (52%) VATS cases. PSM produced 215 matched pairs. VATS approach was associated with less PPC (7.4% vs 18.6%; P  < 0.001), shorter median LOS (4 days vs 6; P  < 0.001), and a shorter median HDU LOS (1 day vs 2; P  = 0.002). Patients undergoing VATS required less physiotherapy contacts (3 vs 6; P  < 0.001) and reduced therapy time (80 min vs 140; P  < 0.001). More patients mobilized on POD1 (84% vs 81%; P  = 0.018), and significantly less physiotherapy to treat sputum retention and lung expansion was required ( P  < 0.05). CONCLUSIONS This study demonstrates that patients undergoing VATS lobectomy developed less PPC and had improved associated outcomes compared to thoracotomy. Patients were more mobile earlier, and required half the physiotherapy resources having fewer pulmonary and mobility issues.