Right Ventricle Response to Major Lung Resection (the RIVER Study).

Backgrounds: Major lung resection is associated with high postoperative morbidity and mortality, especially due to cardiorespiratory complications. Right ventricle (RV) ejection, pulmonary artery (PA) pressure, and tone are tightly coupled. Since the RV is exquisitely sensitive to changes in afterload, an acute increase in RV outflow resistance (i.e., acute pulmonary embolism [PE]) will cause acute RV dilatation and, a reduction of left ventricle compliance too, rapidly spiraling to acute cardiogenic shock and death. We investigated the changing in RV performance after major lung resection. Materials and Methods: We carried out transthoracic echocardiography (TTE) aiming at searching for the incidence of early RV systolic dysfunction (defined as tricuspid annulus plane systolic excursion [TAPSE] <17 cm, S'-tissue Doppler imaging <10 cm/s) and estimate the RV-PA coupling by the TAPSE/pulmonary artery pressures (PAPs) ratio after major lung resection. The TTE has been performed before and immediately after surgery. Results: After the end of the operation the echocardiographic parameters of the RV function worsened. TAPSE decreased from 24 (21 ÷ 28) to 18 (16 ÷ 22) mm (P = 0.015) and PAPs increased from 26 (25 ÷ 30) to 30 (25 ÷ 39) mmHg (P = 0.013). TAPSE/PAPs ratio decreased from 0.85 (0.80 ÷ 0.90) to 0.64 (0.54 ÷ 0.79) mm/mmHg (P = 0.002). Conclusions: In line with previous reports, after major lung resection the increase in afterload reduces the RV function, but the impairment remains clinically not relevant. The different clinical picture of an acute cor pulmonale due to PE implies that the pathogenesis of cardiac failure involves more pathways than the mere mechanic occlusion of the blood flow.

Lung ultrasound could reduce X-ray after major lung resection.

OBJECTIVES: This study evaluated the role of ultrasound in postoperative care after major lung resection. BACKGROUND: High accuracy of lung ultrasound imaging was proved in various medical fields. The experience with ultrasound after thoracic surgery is limited. METHODS: Patients scheduled for major lung resection were consecutively included in a prospective study comparing two modalities of imaging examinations, namely those employing ultrasound and X-ray in the diagnoses of pneumothorax and pleural effusion. Two examinations were performed. One after recovery from anaesthesia, the second before chest tube removal. RESULTS: Forty-eight patients underwent 87 examinations. X-ray and ultrasound examinations showed substantial and fair agreements for pneumothorax (Cohen's kappa coefficients 0.775 and 0.397) and slight and substantial agreements for pleural effusion (Cohen's kappa coefficients 0.036 and 0.611). The sensitivity bounds for pneumothorax were 45.5-58.5 % at the first and 29.7-59.4 % at the second examination. Sensitivity bounds for pleural effusion were 0-86.2 % at the first and 32.6-36.9 % at the second examination. Except for two cases of pneumothorax being missed by X-ray imaging, the rest of mismatches were clinically irrelevant conditions with no impact on clinical decision and patient's outcome. CONCLUSION: The use of ultrasound can reduce the number of X-ray examinations and thus lower the radiation exposure after major lung resections (Tab. 4, Ref. 30).

Comparison of non-intubated and intubated video-assisted thoracoscopic surgeries of major pulmonary resections for lung cancer-a meta-analysis.

OBJECTIVE: The aim of this study was to compare the safety feasibility and safety feasibility of non-intubated (NIVATS) and intubated video-assisted thoracoscopic surgeries (IVATS) during major pulmonary resections. METHODS: A meta-analysis of eight studies was conducted to compare the real effects of two lobectomy or segmentectomy approaches during major pulmonary resections. RESULTS: Results showed that the patients using NIVATS had a greatly shorter hospital stay and chest-tube placement time (weighted mean difference (WMD): - 1.04 days; 95% CI - 1.50 to - 0.58; P < 0.01) WMD - 0.71 days; 95% confidence interval (CI), - 1.08 to - 0.34; P < 0.01, respectively) while compared to those with IVATS. There were no significant differences in postoperative complication rate, surgical duration, and the number of dissected lymph nodes. However, through the analysis of highly selected patients with lung cancer in early stage, the rate of postoperative complication in the NIVATS group was lower than that in the IVATS group [odds ratio (OR) 0.44; 95% CI 0.21-0.92; P = 0.03, I2 = 0%]. CONCLUSIONS: Although the comparable postoperative complication rate was observed for major thoracic surgery in two surgical procedures, the NIVATS method could significantly shorten the hospitalized stay and chest-tube placement time compared with IVATS. Therefore, for highly selected patients, NIVATS is regarded as a safe and technically feasible procedure for major thoracic surgery. The assessment of the safety and feasibility for patients undergoing NIVATS needs further multi-center prospective clinical trials.

Perioperative Factors for Predicting the Need for Postoperative Intensive Care after Major Lung Resection.

Postoperative management after major lung surgery is critical. This study evaluates risk factors for predicting mandatory intensive care unit (ICU) admission immediately after major lung resection. We retrospectively reviewed patients for whom the surgeon requested an ICU bed before major lung resection surgery. Patients were classified into three groups. Univariable and multivariable logistic regression analyses were performed, and a clinical nomogram was constructed. Among 340 patients, 269, 50, and 21 were classified into the no need for ICU, mandatory ICU admission, and late-onset complication groups, respectively. Predictive postoperative diffusion capacity of the lung for carbon monoxide (47.2 (interquartile range (IQR) 43.3-65.7)% versus vs. 67.8 (57.1-79.7)%; p = 0.003, odds ratio (OR) 0.969, 95% confidence interval (CI) 0.95-0.99), intraoperative blood loss (400.00 (250.00-775.00) mL vs. 100.00 (50.00-250.00) mL; p = 0.040, OR 1.001, 95% CI 1.000-1.002), and open thoracotomy (p = 0.030, OR 2.794, 95% CI 1.11-7.07) were significant predictors for mandatory ICU admission. The risk estimation nomogram demonstrated good accuracy in estimating the risk of mandatory ICU admission (concordance index 83.53%). In order to predict the need for intensive care after major lung resection, preoperative and intraoperative factors need to be considered.