Predictors of reoperation after lung volume reduction surgery.

OBJECTIVES: Lung volume reduction surgery (LVRS) has proven an effective treatment for emphysema, by decreasing hyperinflation and improving lung function, activity level and reducing dyspnoea. However, postoperative air leak is an important complication, often leading to reoperation. Our aim was to analyse reoperations after LVRS and identify potential predictors. METHODS: Consecutive single-centre unilateral VATS LVRS performed from 2017 to 2022 were included. Typically, 3-5 minor resections were made using vascular magazines without buttressing. Data were obtained from an institutional database and analysed. Multivariable logistic regression was used to identify predictors of reoperation. Number and location of injuries were registered. RESULTS: In total, 191 patients were included, 25 were reoperated (13%). In 21 patients, the indication for reoperation was substantial air leak, 3 patients bleeding and 1 patient empyema. Length of stay (LOS) was 21 (11-33) vs. 5 days (3-11), respectively. Only 3 injuries were in the stapler line, 13 within < 2cm and 15 injuries were in another site. Multivariable logistic regression analysis showed that decreasing DLCO increased risk of reoperation, OR 1.1 (1.03, 1.18, P = 0.005). Resections in only one lobe, compared to resections in multiple lobes, were also a risk factor OR 3.10 (1.17, 9.32, P = 0.03). Patients undergoing reoperation had significantly increased 30-day mortality, OR 5.52 (1.03, 26.69, P = 0.02). CONCLUSIONS: Our incidence of reoperation after LVRS was 13% leading to prolonged LOS and increased 30-day mortality. Low DLCO and resections in a single lobe were significant predictors of reoperation. The air leak was usually not localized in the stapler line.

Platelet function in lung cancer patients undergoing lobectomy.

A growing interest concerns arterial thromboembolic disease in cancer patients. As platelets may be key players in this process, investigation of platelet aggregation in cancer patients is of importance. We aimed to investigate platelet aggregation in patients with lung cancer prior to surgery and during video-assisted thoracoscopic surgery (VATS) lobectomy compared with lobectomy performed through a thoracotomy. We included 93 patients (VATS + low molecular weight heparin (LMWH), n = 32; VATS no LMWH, n = 31; thoracotomy + LMWH, n = 30). Data obtained from 121 healthy individuals were used for comparison prior to surgery. Platelet aggregation was analysed by impedance aggregometry using adenosine diphosphate 6.5 µM (ADPtest) and collagen 3.2 µg/mL (COLtest) as agonists. Prior to surgery, platelet aggregation was significantly increased in both VATS-patients (ADPtest, p < .0001; COLtest, p = .0002) and patients undergoing thoracotomy (ADPtest, p < .0001; COLtest, p < .0001) compared with healthy individuals. Platelet aggregation did not differ between VATS-patients and thoracotomy patients prior to surgery (p-values >.11). At the first postoperative day, VATS-patients demonstrated significantly higher collagen-induced platelet aggregation than preoperatively (p = .001), but the increase in platelet aggregation did not differ significantly between VATS and thoracotomy patients (p-values ≥.24). At the second postoperative day, platelet aggregation was significantly reduced in thoracotomy patients compared with the preoperative level (ADPtest, p = .002; COLtest, p = .05). In conclusion, platelet aggregation was significantly increased in patients with primary lung cancer prior to surgery compared with healthy individuals. At the first postoperative day, platelet aggregation was significantly higher than the preoperative level in VATS-patients; however, this increase did not differ between patient groups.

Coagulation profile in open and video-assisted thoracoscopic lobectomies: a cohort study.

OBJECTIVES: Lung cancer patients are perceived to have a relatively high risk of venous thromboembolic events due to an activation of the coagulation system. In terms of activation of the coagulation system, the difference between video-assisted thoracoscopic surgery (VATS) and open lobectomies for primary lung cancer has not been investigated. The aim of this study was to compare the impact on the coagulation system in patients undergoing curative surgery for primary lung cancer by either VATS or open lobectomies. METHODS: In total, 62 patients diagnosed with primary lung cancer were allocated to either VATS (n = 32) or open lobectomies (n = 30). All patients received subcutaneous injections with dalteparin (Fragmin®) 5000 IE once daily. The coagulation was assessed pre- and intraoperatively, and the first 2 days postoperatively by standard coagulation blood tests, thromboelastometry (ROTEM®) and thrombin generation. RESULTS: The open lobectomies bled more than the VATS group and had a significantly lower platelet count (109/l) on postoperative Days 1 and 2 (198 vs 231 and 194 vs 243, respectively). The open group also had a higher international normalized ratio on postoperative Days 1 and 2 compared with the VATS group (1.21 vs 1.14 and 1.17 vs 1.09, respectively). There were no differences in thromboelastometry (ROTEM®) and thrombin generation parameters. None of the included patients developed venous thromboembolic events. CONCLUSIONS: In patients undergoing curative surgery for early-stage primary lung cancer, we observed a statistical non-significant difference and a similar-sized minor impact on the coagulation system.

Video-assisted Thoracoscopic surgery (VATS) lobectomy for lung cancer does not induce a procoagulant state.

BACKGROUND: Changes in the coagulation system in patients undergoing surgery for lung cancer have been sparsely investigated and the impact of the surgical trauma on the coagulation system is largely unknown in these patients. An increased knowledge could potentially improve the thromboprophylaxis regimes. The aim of this study was to assess the coagulation profile evoked in patients undergoing curative surgery by Video-Assisted Thoracoscopic Surgery (VATS) lobectomy for primary lung cancer. METHODS: Thirty-one patients diagnosed with primary lung cancer undergoing VATS lobectomy were prospectively included. The coagulation profile was assessed preoperatively and in the first two days postoperatively using a wide range of standard coagulation tests, dynamic whole blood coagulation measured by rotational thromboelastometry (ROTEM®) and thrombin generation evaluated by calibrated automated thrombography. Patients did not receive thromboprophylactic treatment. Data was analyzed using repeated measures one-way ANOVA. RESULTS: The standard coagulation parameters displayed only subtle changes after surgery and the ROTEM® and thrombin generation results remained largely unchanged. CONCLUSIONS: Patients undergoing VATS lobectomy are normocoagulable in the preoperative state and a VATS lobectomy does not significantly influence the coagulation. TRIAL REGISTRATION: The trial is registered at ClinicalTrials.gov (Identifier: NCT01741506) and at EudraCTno. 2012-002409-23. Registered December 2012.

Coagulation profile in patients undergoing video-assisted thoracoscopic lobectomy: A randomized, controlled trial.

BACKGROUND: Knowledge about the impact of Low-Molecular-Weight Heparin (LMWH) on the coagulation system in patients undergoing minimal invasive lung cancer surgery is sparse. The aim of this study was to assess the effect of LMWH on the coagulation system in patients undergoing Video-Assisted Thoracoscopic Surgery (VATS) lobectomy for primary lung cancer. METHODS: Sixty-three patients diagnosed with primary lung cancer undergoing VATS lobectomy were randomized to either subcutaneous injection with dalteparin (Fragmin®) 5000 IE once daily or no intervention. Coagulation was assessed pre-, peri-, and the first two days postoperatively by standard coagulation blood test, thromboelastometry (ROTEM®) and thrombin generation. RESULTS: Patients undergoing potential curative surgery for lung cancer were not hypercoagulable preoperatively. There was no statistically significant difference in the majority of the assessed coagulation parameters after LMWH, except that the no intervention group had a higher peak thrombin and a shorter INTEM clotting time on the first postoperative day and a lower fibrinogen level on the second postoperative day. A lower level of fibrin d-dimer in the LMWH group was found on the 1. and 2.postoperative day, although not statistical significant. No differences were found between the two groups in the amount of bleeding or number of thromboembolic events. CONCLUSIONS: Use of LMWH administered once daily as thromboprophylaxis did not alter the coagulation profile per se. As the present study primarily evaluated biochemical endpoints, further studies using clinical endpoints are needed in regards of an optimized thromboprophylaxis approach.

Outcome after pulmonary metastasectomy: analysis of 5 years consecutive surgical resections 2002-2006.

INTRODUCTION: In this study, we analyze the results of management of pulmonary metastases in 5 years consecutive operations at our institution. We aim to define the patients who are most likely to benefit from surgery by investigating long-term survival and prognostic factors associated with prolonged survival. METHODS: The data on all consecutive patients between 2002 and 2006 were reviewed retrospectively. One hundred seventy-eight patients underwent 256 surgical resections for suspected pulmonary metastases from different primary malignancies. Prognostic factors analyzed included age, sex, surgical approach, surgical resection, number of metastases, distribution of metastases, disease-free interval, presence of synchronous metastases, recurrence of disease, prior liver resection (colorectal cancer), and tumor histology (sarcomas). RESULTS: Complete resection was achieved in 248 cases (96.8%). The mean follow-up was 61.6 months. Five-year survival with respect to primary malignancy was colorectal carcinoma (50.3%), sarcoma (21.7%), malignant melanoma (25.0%), renal cell carcinoma (51.4%), and miscellaneous malignancies (50.0%). Of the prognostic factors analyzed by univariate analysis, none was found to be significant in all the different groups of cancers. CONCLUSIONS: Pulmonary metastasectomy is a safe and effective treatment that may be associated with prolonged survival in highly selected patients. Low morbidity and mortality rates in contrast with the lack of any other effective treatment justify the aggressive approach of surgery. Thoracoscopic resection is a valid option in selected patients. In case of recurrence of pulmonary disease and if the patient fulfils the initial criteria for pulmonary metastasectomy, repeat surgery should be performed. Solid prognostic factors still need to be established.

Current status of pulmonary metastasectomy.

Malignant disease's ability to metastasize remains one of the major obstacles when treating patients with cancer. The change from loco-regional to systemic disease usually renders the patient beyond surgical treatment, as local treatment with surgery in a systemic disease is usually considered without benefit. However, numerous retrospective studies have demonstrated that resection of metastases limited to the lungs may be associated with prolonged survival. No prospective, randomized studies have been published, and most series compare highly selected patients with historical data for unresected patients. In this article, we discuss the current status on pulmonary metastasectomy. Preoperative assessment and selection of surgical candidates is covered. The different surgical strategies including surgical approach, unilateral versus bilateral exploration, lymph node dissection, and repeat surgery are discussed. Finally, we review some of the common tumors that metastasize to the lungs, the role of metastasectomy in their treatment and the prognostic factors with impact on survival.