Shuangjiang Li

Neoadjuvant therapy and risk of bronchopleural fistula after lung cancer surgery: a systematic meta-analysis of 14 912 patients

OBJECTIVE Neoadjuvant therapy has been extensively analyzed in studies addressing the risk factors of bronchopleural fistula, but their results vary hugely. Therefore, we conducted this meta-analysis to determine the association between neoadjuvant therapy and risk of bronchopleural fistula in patients undergoing lung cancer surgery. METHODS We searched PubMed and EMBASE to identify the full-text literatures that met our eligibility criteria. Odds ratio with 95% confidence interval served as the summarized statistics. Heterogeneity within this meta-analysis was evaluated by Q-test and I (2) statistic. Sensitivity analysis was performed for further assessments of robustness. Publication bias was detected by Beggs test and Eggers test. RESULTS Thirty studies enrolling 14 912 lung cancer cases were included into this meta-analysis. The incidence of bronchopleural fistula was 2.4% (354/14 912) in the large scale. Overall, neoadjuvant therapy significantly increased the risk of bronchopleural fistula after pulmonary resections (odds ratio: 2.166; 95% confidence interval: 1.398-3.357; P = 0.001). In subgroup analysis, neoadjuvant radiotherapy (odds ratio: 3.914; 95% confidence interval: 1.401-10.935; P = 0.009) and chemo-radiation (odds ratio: 2.533; 95% confidence interval: 1.353-4.741; P = 0.004) were significantly associated with the bronchopleural fistula risk but neoadjuvant chemotherapy was not (odds ratio: 1.857; 95% confidence interval: 0.881-3.911; P = 0.104). The impact of neoadjuvant therapy on bronchopleural fistula occurrence remains statistically prominent in the other subgroups. CONCLUSIONS Neoadjuvant therapy is significantly associated with the occurrence of bronchopleural fistula after lung cancer surgery. Both neoadjuvant radiotherapy and chemo-radiation significantly increase the bronchopleural fistula risk but neoadjuvant chemotherapy does not. Some limitations still exist in this meta-analysis. The updated high-quality studies can help to further confirm and enrich our discoveries in the future.

A systematic review and meta-analysis—does chronic obstructive pulmonary disease predispose to bronchopleural fistula formation in patients undergoing lung cancer surgery?

BACKGROUND we conducted this systematic meta-analysis to determine the association between chronic obstructive pulmonary disease (COPD) and risk of bronchopleural fistula (BPF) in patients undergoing lung cancer surgery. METHODS Literature retrieval was performed in PubMed, Embase and the Web of Science to identify the full-text articles that met our eligibility criteria. Odds ratio (OR) with 95% confidence interval (CI) served as the summarized statistics. Q-test and I(2)-statistic were used to evaluate the level of heterogeneity. Sensitivity analysis was performed to further examine the stability of pooled OR. Publication bias was detected by both Beggs test and Eggers test. RESULTS Eight retrospective observational studies were included into this meta-analysis. The overall summarized OR was 2.03 (95% CI: 1.44-2.86; P<0.001), revealing that COPD was significantly associated with the risk of BPF after lung cancer surgery. In subgroup analysis, the relationship between COPD and BPF occurrence remained statistically prominent in the subgroups stratified by statistical analysis (univariate analysis, OR: 1.91; 95% CI: 1.35-2.69; P<0.001; multivariate analysis, OR: 3.18; 95% CI: 1.95-5.19; P<0.001), operative modes (pneumonectomy, OR: 2.11; 95% CI: 1.15-3.87; P=0.016) and in non-Asian populations (OR: 2.36; 95% CI: 1.18-4.73; P=0.016). No significant impact of COPD on BPF risk was observed in Asian patients (OR: 1.48; 95% CI: 0.85-2.57; P=0.16). No significant heterogeneity or publication bias was discovered across the included studies. CONCLUSIONS Our meta-analysis indicates that COPD can significantly predispose to BPF formation in patients undergoing lung cancer surgery. Because some limitations still exist in this meta-analysis, our findings should be further verified and modified in the future.

Incidence, risk factors and prognosis of postoperative atrial arrhythmias after lung transplantation: a systematic review and meta-analysis

Postoperative atrial arrhythmia is the most common dysrhythmia seen after lung transplantation. However, risk factors for postoperative atrial arrhythmias and their impact on outcomes were inconsistent. The aim of our study was to conduct a meta-analysis to analyse risk factors of postoperative atrial arrhythmias and the impact of postoperative atrial arrhythmias on outcomes after lung transplantation. All eligible articles from MEDLINE, EMBASE, CENTRAL and the Chinese BioMedical Literature Database (until November 2015) were incorporated into this study. We extracted the data from the included studies and performed a meta-analysis to evaluate predictors for postoperative atrial arrhythmias and their impact on outcomes. R software and STATA 13.0 software were used for the meta-analysis. A total of 2094 patients from 11 studies were included in this meta-analysis. The pooled incidence of postoperative atrial arrhythmias after lung transplantation was 31% [95% confidence interval (CI), 25-37%]. We found that gender (female versus male) with an odds ratio (OR) of 0.44 (95% CI 0.35-0.56, P < 0.001), age (>50 vs ≤50 or atrial arrhythmias versus non-atrial arrhythmias) with OR of 2.73 (95% CI 1.86-4.00, P < 0.001) and weighted mean difference (WMD) of 5.88 years (95% CI 3.69-8.07, P < 0.001), history of atrial arrhythmias with OR of 1.76 (95% CI 1.34-2.32, P = 0.002), vasopressor use with OR of 1.76 (95% CI 1.34-2.32, P < 0.001), cystic fibrosis with OR of 0.32 (95% CI 0.18-0.59, P < 0.001), interstitial lung disease with OR of 1.85 (95% CI 1.27-2.71, P = 0.001), hypertension with OR of 1.49 (95% CI 1.12-1.97, P = 0.006), coronary artery disease with OR of 1.58 (95% CI 1.20-2.08, P = 0.001), hyperlipidaemia with OR of 1.52 (95% CI 1.06-2.20, P = 0.025) and left atrial enlargement with OR of 2.99 (95% CI 1.91-4.67, P < 0.001) were significantly associated with postoperative atrial arrhythmias after lung transplantation. Postoperative atrial arrhythmias had a significant influence on length of stay (WMD 9.72, 95% CI 5.07-14.38, P < 0.001) and overall survival (OS) (hazard ratio 1.72, 95% CI 1.39-2.12, P < 0.001) after lung transplantation. In conclusion, the significant risk factors for postoperative atrial arrhythmias were gender, age, history of atrial arrhythmias, vasopressor use, cystic fibrosis, interstitial lung disease, hypertension, coronary artery disease, hyperlipidaemia, cardiac index and left atrial size. Development of postoperative atrial arrhythmias has prognostic implications for length of stay and overall survival after lung transplantation. Prospective and randomized trials are needed to address these issues in the future.

Residual disease at the bronchial stump is positively associated with the risk of bronchoplerual fistula in patients undergoing lung cancer surgery: a meta-analysis

OBJECTIVES Residual disease at the bronchial stump (RDBS) is regarded as an important factor possibly resulting in bronchopleural fistula (BPF) after lung cancer surgery, but this has not been confirmed. We conducted this meta-analysis to evaluate the effects of RDBS on BPF formation in patients undergoing lung cancer surgery. METHODS PubMed and EMBASE databases were searched for full-text articles that met our eligibility criteria. Odds ratios (ORs) with 95% confidence interval (95% CI) served as the summarized outcomes. Q-test and I(2) statistic were used to evaluate the level of heterogeneity, determining the fixed-effect model or random-effect model for quantitative synthesis. Sensitivity analysis was conducted to identify the possible origins of heterogeneity. The publication bias was assessed by Beggs test. RESULTS A total of eight retrospective observational studies were included in our meta-analysis. In overall analysis, the pooled outcomes indicated that RDBS was significantly associated with BPF formation after lung cancer surgery (OR: 3.12; 95% CI: 1.72-5.64; P < 0.001). In subgroup analysis, the pooled outcomes revealed a significantly increased risk of post-pneumonectomy BPF in patients with RDBS (OR: 2.78; 95% CI: 1.06-7.28; P = 0.037). The subgroup analysis assessing the effects of RDBS on post-lobectomy BPF was given up due to the scarcity of available data. No heterogeneity was revealed within this meta-analysis. No evidence for publication bias was detected by Beggs test. CONCLUSIONS Our meta-analysis indicates that RDBS is positively associated with the increased risk of BPF in patients undergoing lung cancer surgery. The further analysis also reveals an increased risk of post-pneumonectomy BPF in patients with RDBS. More accurate and comprehensive evidence should be collected and summarized in updated meta-analyses.

Degree of pulmonary fissure completeness can predict postoperative cardiopulmonary complications and length of hospital stay in patients undergoing video-assisted thoracoscopic lobectomy for early-stage lung cancer

OBJECTIVES To estimate the effects of pulmonary fissure completeness on postoperative cardiopulmonary complications (PCCs) and hospital stay in patients undergoing video-assisted thoracoscopic surgery lobectomy for early-stage non-small-cell lung cancer. METHODS We performed a single-centre retrospective analysis based on the prospectively maintained data of our institution during the study period. Demographic differences between the PCC group and the non-PCC group were initially examined. Then, the patients were classified into 3 groups according to their fissure sum averages (FSAs: 0 ≤ FSA ≤ 1, 1 < FSA ≤ 2, 2 < FSA ≤ 3) calculated by fissure development scores. The differences in PCC incidences and hospital stay between these 3 groups were further evaluated. Finally, FSA > 1 was determined as the cut-off to indicate the degree of pulmonary fissure completeness and involved into a multivariate logistic regression model to identify the predictors for PCCs. RESULTS In total, 528 patients with Stage I to Stage II non-small-cell lung cancer were enrolled. There were 343 patients with 0 ≤ FSA ≤ 1, 105 patients with 1 < FSA ≤ 2 and 80 patients with 2 < FSA ≤ 3. Pulmonary complication rate in patients with 1 < FSA ≤ 2 (25.7% vs 14.3%; P = 0.006) and with 2 < FSA ≤ 3 (33.8% vs 14.3%; P < 0.001) was significantly higher than that in patients with 0 ≤ FSA ≤ 1. No difference was found in cardiovascular complication rate between these groups (P = 0.22). The Kaplan-Meier analysis showed that the length of hospital stay and the length of chest tube drainage in patients with 1 < FSA ≤ 2 and with 2 < FSA ≤ 3 were significantly longer than those in patients with 0 ≤ FSA ≤ 1. Incomplete pulmonary fissure (FSA > 1) was a strong independent predictor for PCCs (odds ratio = 2.12; P = 0.002) in the multivariate analysis. CONCLUSIONS The degree of pulmonary fissure completeness can predict the PCCs and the length of hospital stay following video-assisted thoracoscopic surgery lobectomy for early-stage non-small-cell lung cancer.

Prognostic value of stromal decorin expression in patients with breast cancer: a meta-analysis

BACKGROUND Numbers of studies have investigated the biological functions of decorin (DCN) in oncogenesis, tumor progression, angiogenesis and metastasis. Although many of them aim to highlight the prognostic value of stromal DCN expression in breast cancer, some controversial results still exist and a consensus has not been reached until now. Therefore, our meta-analysis aims to determine the prognostic significance of stromal DCN expression in breast cancer patients. METHODS PubMed, EMBASE, the Web of Science and China National Knowledge Infrastructure (CNKI) databases were searched for full-text literatures met out inclusion criteria. We applied the hazard ratio (HR) with 95% confidence interval (CI) as the appropriate summarized statistics. Q-test and I(2) statistic were employed to estimate the level of heterogeneity across the included studies. Sensitivity analysis was conducted to further identify the possible origins of heterogeneity. The publication bias was detected by Beggs test and Eggers test. RESULTS There were three English literatures (involving 6 studies) included into our meta-analysis. On the one hand, both the summarized outcomes based on univariate analysis (HR: 0.513; 95% CI: 0.406-0.648; P<0.001) and multivariate analysis (HR: 0.544; 95% CI: 0.388-0.763; P<0.001) indicated that stromal DCN expression could promise the high cancer-specific survival (CSS) of breast cancer patients. On the other hand, both the summarized outcomes based on univariate analysis (HR: 0.504; 95% CI: 0.389-0.651; P<0.001) and multivariate analysis (HR: 0.568; 95% CI: 0.400-0.806; P=0.002) also indicated that stromal DCN expression was positively associated with high disease-free survival (DFS) of breast cancer patients. No significant heterogeneity or publication bias was observed within this meta-analysis. CONCLUSIONS The present evidences indicate that high stromal DCN expression can significantly predict the good prognosis in patients with breast cancer. The discoveries from our meta-analysis have better be confirmed in the updated review pooling more relevant investigations in the future.

Effects of degree of pulmonary fissure completeness on major in-hospital outcomes after video-assisted thoracoscopic lung cancer lobectomy: a retrospective-cohort study

Background To evaluate the clinical significance of degree of pulmonary fissure completeness (PFC) on major in-hospital outcomes following video-assisted thoracoscopic (VATS) lobectomy for non-small-cell lung cancer (NSCLC). Materials and methods We carried out a single-center retrospective analysis on the prospectively maintained database at our unit between August 2014 and October 2015. Patients were divided into two groups based on their fissure sum average (FSA). Patients with FSA >1 (1< FSA ≤3) were considered to have incomplete pulmonary fissures (group A), while patients with FSA of 0–1 were considered to have complete pulmonary fissures (group B). Demographic differences in perioperative characteristics and surgical outcomes between these two groups were initially assessed. Then, a multivariate logistic-regression analysis was further conducted to identify the independent predictors for major in-hospital outcomes. Results A total of 563 patients undergoing VATS lobectomy for NSCLC were enrolled. There were 190 patients in group A and 373 patients in group B. The overall morbidity and mortality rates of our cohort were 30.6% and 0.5%, respectively. Group A patients had a significantly higher overall morbidity rate than group B patients (42.1% vs 24.7%, P<0.001). Both minor morbidity (40.5% vs 22%, P<0.001) and major morbidity (11.1% vs 5.6%, P=0.021) rates in group A patients were also significantly higher than group B patients. No significant difference was observed in mortality rate between these two groups (1.1% vs 0.3%, P=0.26). The incomplete degree of PFC was significantly correlated with length of stay and chest-tube duration (log-rank P<0.001) after surgery. Finally, the incomplete degree of PFC was found to be predictive of overall morbidity (OR 2.08, P<0.001), minor morbidity (OR 2.39, P<0.001), and major morbidity (OR 2.06, P=0.031) by multivariate logistic-regression analyses. Conclusion Degree of PFC is an excellent categorical predictor for both major and minor morbidity after VATS lobectomy for NSCLC.

Presence of pleural adhesions can predict conversion to thoracotomy and postoperative surgical complications in patients undergoing video-assisted thoracoscopic lung cancer lobectomy

Background The purpose of our cohort study was to investigate the effects of pleural adhesions on perioperative outcomes in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for non-small-cell lung cancer (NSCLC). Methods We performed a single-center retrospective analysis on the prospectively-maintained dataset at our unit from February 2014 to November 2015. Patients were divided into two groups (Group A: presence of pleural adhesions; Group B: absence of pleural adhesions) according to our grading system of pleural adhesions when entering the chest cavity. Demographic differences in perioperative outcomes between these two groups were initially estimated. A multivariate logistic-regression analysis was then performed to confirm the predictive value of the presence of pleural adhesions. Results A total of 593 NSCLC patients undergoing VATS lobectomy were enrolled. The conversion and postoperative morbidity rates were 3.2% and 29.2%, respectively. There were 154 patients with pleural adhesions (Group A) and 439 patients without pleural adhesions (Group B). Group A patients had significantly higher rates of conversion to thoracotomy (9.1% vs. 1.1%; P<0.001) and surgical complications (24.0% vs. 14.4%; P=0.006) than those of Group B patients. No significant difference was found in the overall morbidity and cardiopulmonary complication rates between these two groups. The presence of pleural adhesions was also significantly associated with the prolonged length of chest tube drainage (log-rank P<0.001) and length of stay (log-rank P=0.032). Finally, the presence of pleural adhesions was identified as an independent risk factor for conversion to thoracotomy [odds ratio (OR) =5.49; P=0.003] and surgical complications (OR =1.94; P=0.033) by multivariate logistic-regression analyses. Conclusions Presence of pleural adhesions can predict conversion to thoracotomy and postoperative surgical complications in patients undergoing VATS lobectomy for NSCLC. Our study calls for an internationally accepted grading system for the presence of pleural adhesions to stratify the surgical risk.

Short-term inpatient-based high-intensive pulmonary rehabilitation for lung cancer patients: is it feasible and effective?

Background This study was conducted to develop a preoperative in-hospital short-term rehabilitation program for surgical lung cancer patients, and investigate its feasibility, potential cost benefit and effectiveness on outcome measures including reduction of postoperative pulmonary complications (PPCs) and postoperative length of stay. Methods A 7-day inpatient-based high-intensive rehabilitation regimen was performed between March 01, 2014 and June 30, 2015. It was combined with inspiratory muscles training (IMT) and aerobic endurance training and was tested in an enriched cohort study with 939 lung cancer patients undergoing lobectomy in a regional thoracic unit. Results Finally, 939 patients were divided into pulmonary rehabilitation (PR) group (n=197) and non-PR (NPR) group (n=742), according to whether they received the 7-day preoperative in-hospital systematic rehabilitation. The PR group had a shorter total length of stay (14.7±4.0 vs. 16.7±6.2 days, P<0.001) as well as postoperative length of stay (6.2±3.3 vs. 8.3±5.6 days, P<0.001) than the NPR group. Lower incidences of total PPCs (18.3%, 36/197 vs. 26.1%, 194/742, P=0.022), pneumonia (11.2%, 22/197 vs. 17.3%, 128/742, P=0.024) and atelectasis (6.6%, 13/197 vs. 12.3%, 91/742, P=0.038) were found in the PR group compared with NPR group. Meanwhile, a multivariable analysis of risk to PPCs, atelectasis and pneumonia, revealed that the PR intervention was the independent risk factor of the occurrence of the PPCs (OR =0.57, 95% CI: 0.47 to 0.93, P=0.033) and atelectasis (OR =0.49, 95% CI: 0.26 to 0.91, P=0.024). Conclusions The study showed the effectiveness of this systematic and high-intensive PR combining IMT and aerobic exercise in reductions of the length of stay and occurrence of PPCs without increase in in-hospital cost, suggesting the potential of this rehabilitation pattern as a practicable strategy performed preoperatively in surgical lung cancer patients.

Short-term high-intensity rehabilitation in radically treated lung cancer: a three-armed randomized controlled trial

BACKGROUND The feasibility and practicality of preoperative rehabilitation (PR) programs remains quite controversial in the treatment of lung cancer (LC). This study explored whether a short-term high-intensity rehabilitation program could improve postoperative outcomes compared to those achieved with conventional inspiratory muscle training (IMT). METHODS A three-armed randomized controlled trial comparing the two training modalities and routine care was conducted in surgical LC patients. Patient groups received one of three treatment regimens: (I) high-intensity pulmonary rehabilitation (PR) that combined IMT with conventional resistance training (CRT) (combined PR group); (II) conventional PR (single IMT group); or (III) routine preoperative preparation (control group). The primary endpoint was a change in the occurrence of post-operative pulmonary complications (PPCs) that occurred within 30 days after surgery, while secondary endpoints included changes in length of hospital stay, quality of life (QoL) scores, 6-min walk distance (6-MWD) and peak expiratory flow (PEF). RESULTS A total of 90 enrolled patients were randomized into three groups with a computer-based 1:1:1 ratio. The intention-to-treat analysis of the study revealed that, compared with the Control Group, the Combined PR Group had a significant increase in ∆6-MWD (by 32.67 m, P=0.002), ∆PEF (by 14.3 L/min, P=0.001), ∆global scores (by 3.7, P=0.035); and a reduced ∆average total hospital stay (by 3.2 d, P=0.001) and ∆postoperative stay (by 3.6 d, P=0.001). With regard to PPC rate, the Combined PR Group had a somewhat lower PPC severity (grade II-V) compared to the Control Group. CONCLUSIONS This hospital-based short-term program of PR combining high-intensity IMT with CRT was significantly superior to the conventional IMT program, indicating that this approach would be a feasible strategy for treating LC patients, especially those waiting operations with surgery-related risk factors.