Incidence of Early Acute Kidney Injury in Lung Transplant Patients: A Single-Center Experience.

BACKGROUND: Acute kidney injury (AKI) is a common complication in the early period of lung transplantation (LTx). We aimed to describe the incidence and perioperative risk factors associated with AKI following LTx. METHODS: Clinical data of 30 patients who underwent LTx were retrospectively reviewed. Primary outcomes were development of AKI and patient mortality within 30 postoperative days. Postoperative AKI is determined based on creatinine criteria from Acute Kidney Injury Network (AKIN) classification. Secondary outcomes included the association between AKI and demographic and clinical parameters of patients and treatment modalities in the pre- and postoperative periods. RESULTS: Of the 30 LTx recipients included, AKI occurred in 16 patients (53.4%) within the first 30 days. Length of intensive care unit (P = .06) and hospital stay (P = .008) and mechanical ventilation duration (P = .03) were significantly higher in patients with AKI compared with patients without AKI. Factors independently associated with AKI were intraoperative hypotension (odds ratio [OR] 0.500; 95% confidence interval [CI], 1.145 to 26.412, P = .02), longer duration of mechanical ventilation (OR 1.204; 95% CI 0.870 to 1.665, P = .03), and systemic infection (OR 8.067; 95% CI 1.538 to 42.318, P = .014) in the postoperative period. Short-term mortality was similar in patients with and patients without AKI. CONCLUSION: By the AKIN definition, AKI occurred in half of the patients following LTx. Several variables including intraoperative hypotension, longer duration of mechanical ventilation, and systemic infection in the postoperative period independently predict AKI in LTx recipients.

Assessment of Pulmonary Hypertension in Lung Transplantation Candidates: Correlation of Doppler Echocardiography With Right Heart Catheterization.

BACKGROUND: Right heart catheterization (RHC) remains the gold standard to diagnosis of pulmonary hypertension among lung transplantation candidates. Doppler echocardiography (DE) may be as accurate as RHC, without risks of an invasive test. The aim of the study was to assess the feasibility of DE for the measurement of pulmonary artery pressure in lung transplantation candidates and the correlation between pulmonary artery pressures estimated by DE versus measured by RHC. METHODS: A total of 103 lung transplantation candidates undergoing DE who were scheduled to undergo RHC within 72 hours were analyzed. The performance characteristics of DE were compared with RHC, and correlation analysis was performed to determine the correlation of pulmonary pressures obtained by DE versus measured by RHC. RESULTS: The prevalence of pulmonary hypertension was 57% in lung transplantation candidates. Of the 103 candidates, evaluation of pulmonary artery systolic pressure (PASP) by DE was possible in 92 (89%). Median PASP by RHC was 45 (12-145) mm Hg and by DE 45 (20-144) mm Hg. There was a positive correlation between PASP estimated by DE and measured by RHC (r = 0.585, P < .0001). Sensitivity, specificity, and positive and negative predictive values of PASP estimation for diagnosis of pulmonary hypertension were 85%, 67%, 87%, and 61%, respectively. CONCLUSIONS: There is a strong positive correlation between PASP estimated by DE compared with measured by RHC with an acceptable sensitivity and specificity in detecting pulmonary hypertension. Echocardiography can be recommended for measuring pulmonary pressures in lung transplantation candidates.

Osteoporosis in Lung Transplantation Candidates: Association With 6-minute Walking Test and Body Mass Index.

BACKGROUND: Osteoporosis is a well-recognized complication in lung transplantation because of steroid use and immobilization. The aim of the study was to assess the prevalence of osteoporosis and risk factors associated with osteoporosis in lung transplantation candidates. METHODS: The bone mineral density of 174 patients with various end-stage lung diseases was assessed at the pretransplantation period. Osteoporosis risk factors were analyzed with the consideration to principal diagnosis, demographic, and clinical parameters of lung disease, lung function tests and mobility test (6-minute walking test). A multivariate analysis was conducted to determine various demographic and clinical risk factors associated with bone mass loss in the pretransplant period. RESULTS: The prevalence of osteoporosis and osteopenia was 46% and 35%, respectively, in the study population. Osteoporotic patients have lower body mass index and lower 6-minute walking distance than patients without osteoporosis. In addition, they have higher pulmonary artery pressure and history of noninvasive mechanical ventilation than in patients without osteoporosis. There was a significant negative correlation between the 6-minute walking test, body mass index, and the presence of osteoporosis in the study population. Multivariate logistic regression analysis confirmed that 6-minute walking test (odds ratio, 0.996) and body mass index (odds ratio, 0.847) were significantly and negatively correlated with the presence of osteoporosis. CONCLUSIONS: A significant proportion of patients with end-stage lung diseases have osteopenia or osteoporosis pretransplantation. This is the first study to demonstrate that 6-minute walking distance and bone mineral density independently predict osteoporosis in lung transplant candidates.

"Stripping" to prevent prolonged air leak; is there a future in the past?

BACKGROUND: A number of technical precautions and many synthetic or biological materials have been suggested to reduce the frequency of prolonged air leak (PAL) following lung resection. Preserving the three-dimensional properties of the remaining lung parenchyma may prevent this complication to some extent. This study presents our experience with an old technique called "stripping" for the division of incomplete fissures to preserve the original shape of the remaining lung with the hope that this will minimize PAL-related problems. METHODS: 262 consecutive patients with incomplete fissures underwent lobectomy or bilobectomy. Stripping was employed for the division of incomplete fissures in Group S (Study arm; n = 148) and a cut-and-sew technique or staplers were used in Group C (Control arm; n = 114). To evaluate a possible learning curve effect with this technique, Group S was further divided into two subgroups, designated the initial experience (Group S (IE)) and the late experience group (Group S (LE)) and consisting of the first 1/3 (n = 50) and remaining 2/3 (n = 98) of patients, respectively. The frequency of PAL and other related morbidities were investigated. RESULTS: Morbidity and mortality rates were comparable between Group S and C (10 % vs. 8.7 % and 2 % vs. 2.6 %; P = 0.83 and P = 0.96), as was the frequency of PAL, which occurred in 12 (8.1 %) and 13 (11.4 %) patients ( P = 0.40), respectively. When each of the subgroups was compared with Group C, PAL occurred in 9 (18 %) patients in Group S(IE) ( P = n. s.) but only in 3 (3 %) patients in Group S(LE) ( P = 0.03). There was also more postoperative persistent air space in Group C, without this difference reaching statistical significance. CONCLUSION: This study suggests that preservation of the original shape of the remaining lung might decrease the incidence of PAL in patients with relatively healthy lung tissue. An actual favorable effect of stripping over other techniques emerges only when the technique is precisely applied, which is only possible with experience.

The role of positron emission tomography/computed tomography in the diagnosis of pleural diseases.

BACKGROUND: The aim of the study was to assess the role of F-18 fluoro-2-D-deoxyglucose positron emission tomography ( (18)FDG-PET)/computed tomography (CT) in patients with undiagnosed pleural diseases and to compare the findings with those of invasive diagnostic procedures. METHODS: The study included 83 patients with pleural lesions (63 with pleural effusion; 20 with pleural thickening) on CT scan performed between November 2005 and December 2007. The study group consisted of 63 males and 20 females; their median age was 47 years. PET-CT scan was performed for all patients before surgery. A maximum standard uptake value greater than 3.0 was accepted as positive for malignancy. For histopathological diagnosis, video-assisted thoracoscopic surgery was performed in 76 patients and a mini-thoracotomy was performed for the remaining 7 patients. RESULTS: Postoperative histopathological examination revealed malignancy in 44 cases, 25 of which were malignant mesothelioma; the remaining 39 cases were benign. There were no false negative results, but two false positive results (tuberculosis). PET-CT scanning had 100 % sensitivity, 94.8 % specificity and 97.5 % accuracy. CONCLUSION: Our study suggests that PET-CT may be an effective tool for the differentiation of benign and malignant pleural diseases. We believe that PET/CT may prevent redundant surgical procedures in young patients who are SUVmax negative.

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 multifactorial, however, multivariate analysis did not show any significant factor affecting the mortality, related to this procedure.

VATS decortication in patients with stage 3 empyema.

We present here a technique for VATS decortication in patients with stage 3 empyema. It was undertaken with satisfactory outcomes in a limited number of patients. In our technique, the fibrous peel at the surface of the lung is completely removed via two or three incisions without parietal decortication. We believe that our technique will be improved with increased experience and may be an alternative to open thoracotomy and decortication in a selected group of stage 3 empyema patients.

A quick technique for division of the first rib using a posterior approach.

Here we describe a simple and quick technique for anterior division of the first rib using a posterior approach. In this technique, the tip of a right angled clamp is introduced through the fibers of the anterior scalene muscle and the rib is turned completely. Then, the clamp is opened wide enough to obtain a space for division of the rib using a bone cutter.

Chylothorax: a complication following lung resection in patients with NSCLC - chylothorax following lung resection.

BACKGROUND: Chylothorax following lung resection is not as rare as a postoperative complication as previously reported due to systematic lymph node dissection in patients undergoing lung resection for NSCLC. METHODS: We retrospectively reviewed our cases that had undergone lung resection for NSCLC and investigated the frequency and outcome of chylothorax in these patients. The factors investigated were the site and type resection, technique of systematic lymph node dissection, tumour histology and disease stage. RESULTS: Seven of 673 patients that had undergone lung resection were complicated by chylothorax (1.04 %), following lobectomy in 5 (1.28 %) and pneumonectomy in 2 (0.7 %) (p = 0.36). The fistula closed spontaneously in 5 patients between 4 - 17 days postoperatively (71 %). One of the patients in the conservative management group died on the 28th day postoperatively due to pneumonia (14 %). The remaining 2 patients underwent rethoracotomy on the 5th and 6th days. CONCLUSIONS: These results suggest that the site of operation, type resection, and technique of systematic nodal dissection, tumour histology and disease stage do not influence the development of chylothorax in patients with NSCLC. The chylous fistula following lung resection for NSCLC tends to close spontaneously.

Antibiotic prophylaxis in elective thoracic surgery: cefuroxime versus cefepime.

BACKGROUND: Infection is one of the major morbidity factors after thoracic surgery. Although different prophylactic regimens have been used to prevent this complication, the ideal prophylactic agent, dose and duration of administration remain unknown. METHODS: All patients included underwent elective lung resection. 102 selected patients consecutively scheduled for major thoracic surgery were enrolled in this study and randomized into either the cefuroxime group (n = 50) or the cefepime group (n = 52). RESULTS: Twelve pathologic bacterium strains were isolated in the cefepime group, whereas only 5 pathogenic strains were isolated in the cefuroxime group; the difference was statistically significant (p = 0.04). Two empyemas (3.8 %) in the cefepime group were noted, while the cefuroxime group showed no cases of empyema (p = 0.16). Overall infection rate (pneumonia + bronchopneumonia + empyema) were 14.0 % and 26.7 % in the cefuroxime and the cefepime groups, respectively (p = 0.12). Using chest radiography, pulmonary infiltration was found to be more frequent in the cefuroxime group (p=0.002). CONCLUSION: Cefuroxime as a prophylactic agent in major thoracic surgical operations was marginally more effective than cefepime, and presented an additional cost advantage.

Early experience with PET scanning in thoracic tumours.

BACKGROUND: Positron emission tomography (PET) scan is an imaging technique which relies on metabolic properties of the lesions. In this study, we evaluated the potential contribution of PET for thoracic malignancy in a consecutive series of patients presenting with multiple lesions or equivocal diagnosis. METHODS: PET with 2-18 F fluorodeoxyglucose (FDG) was carried out in 41 patients. The diagnosis was primary intrathoracic malignancy in 22 (Group 1). On routine staging using CT scan we found 29 additional lesions and assessed these using PET scan. PET was performed to evaluate the number of metastatic lesions in the lung in 11 (Group 2), to characterise undiagnosed pathology in the chest in 4 (Group 3), to search clinically suspicious extrathoracic spread in 4 patients with known intrathoracic malignancy. RESULTS: In Group 1, the sensitivity and specificity of PET was 81.2% and 92.3%. The accuracy of PET in the confirmation of metastatic disease to the chest was 73%. PET was falsely positive in a patient with chronic inflammatory disease in Group 3 and highly accurate to characterise unknown pathology in Group 4. CONCLUSIONS: Even though infection may cause false positive results, PET is a useful imaging technique for the evaluation of patients with thoracic tumours.

Shoulder-girdle strength after standard and lateral muscle-sparing thoracotomy.

BACKGROUND: There is no objective data in the literature to support the statement that shoulder-girdle strength can be preserved better after muscle-sparing thoracotomy compared with standard thoracotomy. The aim of this study is to determine the decrease on muscle strength with objective criteria by measuring the peak torque value produced by the shoulder girdle. METHOD: Peak torque values on abduction and adduction of entire shoulder range at the velocity of 60 and 120 degree per second were measured with an isokinetik dynomometer which was attached to a computer. The measurements were performed in 20 cases, all candidates for thoracotomy. Patients were randomised into 2 groups; muscle sparing thoracotomy was undertaken in group A, and standard thoracotomy in group B. The same measurements were repeated 3 months after the surgery. RESULTS: The decrease in postoperative PT values between group A and B was statistically significant (p<0.003). The decrease on shoulder abduction and adduction was insignificant in group A (p = 0.33 and p=0.13) and statistically significant in group B (p<0.0001 and p<0.001). CONCLUSION: These results confirm the statement that shoulder girdle strength is better preserved with muscle-sparing thoracotomy.

Acute lung injury and acute respiratory distress syndrome after pulmonary resection.

BACKGROUND: In this study we investigate the frequency and mortality of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) after pulmonary resection. METHODS: Patients that underwent pulmonary resection at the Royal Brompton Hospital between 1991 and 1997 were included. The case notes of all patients developing postoperative complications were retrospectively reviewed. RESULTS: The overall combined frequency of ALI and ARDS was 3.9%. The frequency was higher in patients over 60 years of age, males and those undergoing resection for lung cancer. ALI/ARDS caused 72.5% of the total mortality after resection in this series. CONCLUSIONS: In our experience ALI and ARDS are major causes of mortality after lung resection.

Tracheobronchial sleeve resection with the use of a continuous anastomosis: results of one hundred consecutive cases.

OBJECTIVE: We have used a continuous suture technique for all tracheal and bronchial anastomoses with satisfactory results in our institution. The objective of this article is to review our experience with sleeve resections using this technique and report the associated morbidity and mortality in 100 consecutive cases. METHODS: Our experience with sleeve resection using a continuous suture (3-0 polypropylene) technique was reviewed in 100 consecutive cases. The median age of the patients was 53.3 years with a range of 21 to 81 years. There were 54 male patients and 46 female patients. Resection was undertaken for malignant disease in 81 patients, acquired stricture in 14 patients, benign tumor in 4 patients, and trauma in 1 patient. Among 28 patients in whom lung parenchyma was not resected, 16 patients had tracheal resection and 12 had bronchial sleeve resection. Sleeve pneumonectomy was undertaken in 2, sleeve lobectomy in 66, and sleeve segmentectomy in 4. RESULTS: There were 12 postoperative complications (12%) and 2 postoperative deaths resulting from bronchoatrial fistula and pneumonia (2%). Stricture as a late complication occurred in 5 patients, 2 of whom required a bronchial stent. Other late complications were bougienage, reanastomosis, and completion pneumonectomy (1 each). CONCLUSION: Our experience suggests that the results of continuous suture technique are comparable with those from reported series using interrupted suture technique for tracheal and bronchial anastomosis.

Selective use of PET scan in the preoperative staging of NSCLC.

Positron emission tomography (PET) is a imaging technique which identifies abnormalities by utilising their metabolic properties rather than their anatomical density. In this study, we evaluated the place of PET scanning for the characterisation of additional abnormalities discovered on routine, preoperative CT evaluation of patients with proven NSCLC. A total of 21 patients underwent PET scanning using fluorodeoxyglucose (FDG). In these patients, routine CT scans had found 26 concomitant lesions which were in lung, adrenal gland, liver, kidney, spleen and pleura. FDG uptake was positive at the primary site in all patients. FDG uptake in 13 of the concomitant lesions suggested malignancy. Malignancy was confirmed at all of these foci by histology in eight (six at thoracotomy, fine needle aspiration biopsy (FNAB) and open biopsy) and by clinical and radiological follow-up for 1-15 months in five. In 13 lesions, PET suggested benign disease. Histology reported no evidence of malignancy in five and the six foci followed on clinical and radiographic follow-up for 2-16 months had no evidence of malignancy. PET was falsely negative in only one site where malignancy was proven by thoracotomy. PET failed to detect the remaining lesion which was an unassociated primary kidney tumour in a patient with Li-Fraumeni syndrome. The accuracy of PET scanning in the assessment of those additional lesions found on CT evaluation of otherwise operable NSCLC was found to be 96% with a sensitivity of 93% and specificity of 100%. These results indicate that PET is useful to characterise additional lesions found on CT scan of patients with NSCLC.