Psychological distress prior to surgery is related to symptom burden and health status in lung cancer survivors.

PURPOSE: Patients with lung cancer experience a variety of distressing symptoms which could adversely affect quality of life. The aim of this study was to determine whether psychological distress prior to surgery is associated to health status and symptom burden in lung cancer survivors. METHODS: A longitudinal observational study with 1-year follow-up was carried out. Health status was measured by the WHO Disability Assessment Scale (WHO-DAS 2.0), the Euroqol-5 dimensions (EQ-5D) and the Pittsburgh Sleep Quality Index (PSQI). Symptoms severity included dyspnoea (Multidimensional Profile of Dyspnoea); pain (Brief Pain Inventory); fatigue (Fatigue Severity Scale); and cough (Leicester Cough Questionnaire). RESULTS: One hundred seventy-four lung cancer patients were included. Patients in the group with psychological distress presented a worse self-perceived health status, functionality and sleep quality. The group with psychological distress also presented higher dyspnoea, fatigue and pain. CONCLUSION: Patients with psychological distress prior surgery present with a greater symptom burden and a poorer self-perceived health status, lower functionality and sleep quality, than patients without distress 1 year after the lung resection.

Predictors for 30-day readmission after pulmonary resection for lung cancer.

BACKGROUND: The purpose of this study was to assess the rate, cause, and factors associated with readmissions following pulmonary resection for lung cancer and their relationship with 90-day mortality. METHODS: A prospective cohort study was conducted of 379 patients who underwent surgery for lung cancer at the university hospitals Granada, Spain between 2012 and 2016. RESULTS: The rate of readmissions within 30 postoperative days was 6.2%. The most common reason for readmission was subcutaneous emphysema (21.7%), pneumonia (13%), and pleural empyema (8.5%). A higher probability of requiring urgent readmission was associated with a higher Charlson index (OR 2.0,95% confidence interval 1.50-2.67, P = 0.001); peripheral arterial vasculopathy (OR 4.8, 95%CI 1.27-18.85, P = 0.021); a history of stroke (OR 8.2, 95%CI 1.08-62.37, P = 0.04); postoperative atelectasis (OR 4.7, 95%CI 1.21-18.64, P = 0.026); and air leaks (OR 12.6, 95%CI 4.10-38.91, P = 0.001).The prediction multivariable model for readmission represents an area under the curve (ROC) of 0.90. Mortality at 90 postoperative days in the group of readmitted patients was 13% versus 1.5 for the group of patients who did not require readmission (P < 0.001). CONCLUSIONS: The factors predictive for readmission can help design individualized outpatient follow-up plans and programs for the reduction of readmissions.

Musculoskeletal Disorders Related to Upper Limb Disability after One-Year Lung Cancer Resection.

Lung resection represents the main curative treatment in lung cancer; however, this surgical process leads to several disorders in tissues and organs. Previous studies have reported cardiovascular, pulmonary, and muscular disturbances that affect the functional capacity of these patients in the short, mid, and long term. However, upper limb impairment has been scarcely explored in the long term, despite the relevance in the independence of the patients. The aim of this study was to characterize the upper limb impairment in survivors of lung cancer one year after pulmonary resection. In this observational trial, patients who underwent lung cancer surgery were compared to control, healthy subjects matched by age and gender. Upper limb musculoskeletal disorders (shoulder range of motion, pain pressure threshold, nerve-related symptoms) and functional capacity (upper limb exercise capacity) were evaluated one-year post-surgery. A total of 76 survivors of lung cancer and 74 healthy subjects were included in the study. Significant differences between groups were found for active shoulder mobility (p < 0.05), widespread hypersensitivity to mechanical pain (p < 0.001), mechanosensitivity of the neural tissue (p < 0.001), and upper limb exercise capacity (p < 0.001). Patients who undergo lung cancer surgery show upper limb musculoskeletal disorders and upper limb functional impairment after a one-year lung resection. This clinical condition could limit the functionality and quality of life of patients with lung cancer.

[Surgical management of descending necrotizing mediastinitis]. / Tratamiento quirúrgico de la mediastinitis necrosante descendente.

INTRODUCTION: Descending necrotizing mediastinitis (DNM) is a serious infection which occurs as a complication of oropharyngeal infection. Its surgical management and the routine transthoracic approach remain controversial. In this article we report our experience in the management of this disease, and review the different surgical approaches that have been reported in the medical literature. MATERIAL AND METHODS: A retrospective review was made of the clinical records of 29 patients treated between 1988 and 2009. Several demographic variables were analyzed, origin of the initial infection, stage of the disease according to Endo's classification, surgical technique and outcome. RESULTS: Surgical treatment consisted of both cervical and mediastinal drainage and radical debridement. The mediastinal drainage was made through a transcervical approach in 10 cases and transthoracic in 19, depending on the extent of the mediastinitis. The outcome was satisfactory in 24 patients and 5 died (mortality 17.2%). CONCLUSIONS: According to our results and the conclusions of the main authors, we recommend a prompt and aggressive surgery with a transthoracic approach in cases of widespread DNM.

Surgical Risk Following Anatomic Lung Resection in Thoracic Surgery: A Prediction Model Derived from a Spanish Multicenter Database. / Riesgo quirúrgico tras resección pulmonar anatómica en cirugía torácica. Modelo predictivo a partir de una base de datos nacional multicéntrica.

INTRODUCTION: The aim of this study was to develop a surgical risk prediction model in patients undergoing anatomic lung resections from the registry of the Spanish Video-Assisted Thoracic Surgery Group (GEVATS). METHODS: Data were collected from 3,533 patients undergoing anatomic lung resection for any diagnosis between December 20, 2016 and March 20, 2018. We defined a combined outcome variable: death or Clavien Dindo grade IV complication at 90 days after surgery. Univariate and multivariate analyses were performed by logistic regression. Internal validation of the model was performed using resampling techniques. RESULTS: The incidence of the outcome variable was 4.29% (95% CI 3.6-4.9). The variables remaining in the final logistic model were: age, sex, previous lung cancer resection, dyspnea (mMRC), right pneumonectomy, and ppo DLCO. The performance parameters of the model adjusted by resampling were: C-statistic 0.712 (95% CI 0.648-0.750), Brier score 0.042 and bootstrap shrinkage 0.854. CONCLUSIONS: The risk prediction model obtained from the GEVATS database is a simple, valid, and reliable model that is a useful tool for establishing the risk of a patient undergoing anatomic lung resection.

Reduced exercise capacity and self-perceived health status in high-risk patients undergoing lung resection.

BACKGROUND: Lung resection represents the main curative treatment modality of non-small cell lung cancer. Patients with high-risk to develop postoperative pulmonary complications have been classified as "high-risk patients." Characterizing this population could be important to improve their approach and rehabilitation. AIM: To identify the differences between high and low-risk patients in exercise capacity and self-perceived health status after hospitalization. METHODS: A longitudinal observational prospective cohort study was carried out. Patients undergoing lung resection were recruited from the "Hospital Virgen de las Nieves" (Granada) and divided into two groups according to the risk profile criteria (age ≥ 70 years, forced expiratory volume in 1 s ≤ 70% predicted, carbon monoxide diffusion capacity ≤ 70% predicted or scheduled pneumonectomy). Outcomes included were exercise capacity (Fatigue Severity Scale, Unsupported Upper-Limb Exercise, handgrip dynamometry, Five Sit-to-stand test, and quadriceps hand-held dynamometry) and patient-reported outcome (Euroqol-5 dimensions 5 Levels Visual Analogue Scale). RESULTS: In total, 115 participants were included in the study and divided into three groups: high-risk, low-risk and control group. At discharge high-risk patients presented a poorer exercise capacity and a worse self-perceived health status (P < 0.05). One month after discharge patients in the high-risk group maintained these differences compared to the other groups. CONCLUSION: Our results show a poorer recovery in high-risk patients at discharge and 1 mo after surgery, with lower self-perceived health status and a poorer upper and lower limb exercise capacity. These results are important in the rehabilitation field.

Inpatient Step Counts, Symptom Severity, and Perceived Health Status After Lung Resection Surgery.

BACKGROUND: The clinical relevance of inpatient step counts after lung surgery remains unknown. OBJECTIVE: The aim of this study was to identify those factors related to physical activity measured by step count, during the inpatient stay, and its relationship with symptom severity and perceived health status at hospital admission, discharge, and 1 month after discharge. METHODS: We studied the inpatient step count of 73 participants who underwent lung resection surgery. The number of steps was measured using a triaxial accelerometer. The health status and the severity of symptoms were examined at hospital admission, discharge, and 1 month after discharge. RESULTS: Of the 73 participants, 35 were active and 38 were sedentary during the hospitalization. The mean number of steps walked during 3 inpatient days was 6689 ± 3261 and 523 ± 2273 (P < .001) for the active and sedentary groups, respectively. The dyspnea and fatigue scores in the sedentary group across data collection points (hospital admission, discharge, and follow-up) were significantly worse (P < .01). In regard to pain, the sedentary group presented worse results, than the active group, at discharge and follow-up (P < .01). The correlation analysis indicated significant but weak correlations (r < 0.500) between inpatient steps per day and symptom severity at 1-month follow-up (T2) after surgery. CONCLUSION: Inpatient step count may be a risk factor for symptom severity and perceived health status during hospitalization and within the first month after lung resection surgery. IMPLICATIONS FOR PRACTICE: Nurses should consider recommending physical activity during hospitalization for patients after lung resection.

Risk factors for the development of complications after surgical treatment for bronchopulmonary carcinoma. / Factores de riesgo para el desarrollo de complicaciones tras tratamiento quirúrgico del carcinoma broncopulmonar.

INTRODUCTION: The most suitable treatment in most early-stage lung cancer patients is surgical resection. Despite previously assessing each patient's status being relevant to detect possible complications inherent to surgery, no consensus has been reached on which factors are "high risk" in such patients. Our study aimed to analyse the morbidity and the mortality incidence associated with this surgery in our setting with a multicentre study and to detect risk parameters. METHODS: A prospective analysis study with 3,307 patients operated for bronchopulmonary carcinoma in 24 hospitals. Study variables were age, TNM, gender, stage, smoking habit, surgery approach, surgical resection, ECOG, neoadjuvant therapy, comorbidity, spirometric values, and intraoperative and postoperative morbidity and mortality. A multivariate logistic regression analysis of the morbidity and mortality predictor factors was done. RESULTS: We recorded 34.2% postoperative morbidity and 2.1% postoperative mortality. Gender, myocardial infarction, angina, ECOG ≥1, COPD, DLCO <60%, clinical pathological status, surgical resection and surgery approach were shown as morbidity and mortality predictor factors in lung cancer surgery in our series. CONCLUSIONS: The main variables to consider when assessing the lung cancer patients to undergo surgery are gender, myocardial infarction, angina, ECOG, COPD, DLCO, clinical pathological status, surgical resection and surgery approach.

Spanish Video-Assisted Thoracic Surgery Group: Method, Auditing, and Initial Results From a National Prospective Cohort of Patients Receiving Anatomical Lung Resections.

INTRODUCTION: Our study sought to know the current implementation of video-assisted thoracoscopic surgery (VATS) for anatomical lung resections in Spain. We present our initial results and describe the auditing systems developed by the Spanish VATS Group (GEVATS). METHODS: We conducted a prospective multicentre cohort study that included patients receiving anatomical lung resections between 12/20/2016 and 03/20/2018. The main quality controls consisted of determining the recruitment rate of each centre and the accuracy of the perioperative data collected based on six key variables. The implications of a low recruitment rate were analysed for "90-day mortality" and "Grade IIIb-V complications". RESULTS: The series was composed of 3533 cases (1917 VATS; 54.3%) across 33 departments. The centres' median recruitment rate was 99% (25-75th:76-100%), with an overall recruitment rate of 83% and a data accuracy of 98%. We were unable to demonstrate a significant association between the recruitment rate and the risk of morbidity/mortality, but a trend was found in the unadjusted analysis for those centres with recruitment rates lower than 80% (centres with 95-100% rates as reference): grade IIIb-V OR=0.61 (p=0.081), 90-day mortality OR=0.46 (p=0.051). CONCLUSIONS: More than half of the anatomical lung resections in Spain are performed via VATS. According to our results, the centre's recruitment rate and its potential implications due to selection bias, should deserve further attention by the main voluntary multicentre studies of our speciality. The high representativeness as well as the reliability of the GEVATS data constitute a fundamental point of departure for this nationwide cohort.

Liquid biopsy beyond of cancer: Circulating pulmonary cells as biomarkers of COPD aggressivity.

BACKGROUND: Pulmonary parenchymal destruction is consequence of Chronic Obstructive Pulmonary Disease (COPD), which results in degradation of the extracellular matrix and the appearance of peripheral pulmonary cells. The aim of this study is to demonstrate the feasibility of the detection and isolation of Circulating Pulmonary Cells (CPCs) in peripheral blood of patients with COPD. METHODS: 17 COPD patients were enrolled in this prospective study to isolate CPCs. Peripheral blood samples for CPC analysis were processed using positive immunomagnetic methods combined with a double immunocytochemistry. Two antibodies, anti-cytokeratin and anti-CD44v6 were used to confirm the epithelial nature of the isolated cells and their lung origin respectively. RESULTS: CK/CD44v6 positive CPCs were identified in 6 of 17 COPD patients (35.2% of the total) (range: 1-2 cells). No CPCs were detected in any of the 10 healthy volunteers. The COPD CPCs + patients showed a trend towards greater severity of the disease. CONCLUSIONS: This study suggest the feasibility to detect CPCs in peripheral blood of patients with COPD and its potential use as prognostic marker.

Half the deaths after surgery for lung cancer occur after discharge.

INTRODUCTION: Mortality following surgery for lung cancer increases at 90 days. The objective of this study was to determine the rate, factors, time to death, hospital stay until discharge, time to death after discharge and causes of mortality at 90 days following surgery for lung cancer. METHODS: A prospective follow-up study was performed in a cohort of 378 patients who underwent surgery for lung cancer between January 2012 and December 2016. Data on preoperative status, postoperative complications, and mortality were collected. RESULTS: Rates of mortality were 1.6% vs. 3.2% at 30 and 90 days, respectively. Half of deaths occurred between 31 and 90 postoperative days following discharge. The variables found to be related to mortality at 90 days were a Charlson Index >3 (p < 0.001), a history of stroke (p = 0.036), postoperative pneumonia (p = 0.001), postoperative pulmonary or lobar collapse (p = 0.001), reintubation (p < 0.001) and postoperative arrhythmia (p = 0.0029). The risk of mortality was also observed to be associated with the type of surgical technique -being higher for thoracotomy as compared to video-assisted thoracoscopy (VATS) (p = 0.011) -, and hospital readmission after discharge (p < 0.001). Adjusted odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. Multivariate analysis revealed that a Charlson Index >3 (p = 0.001) OR 2.0 (1.55,2.78), a history of stroke (p = 0.018) OR 5.1 (1.81, 32.96) and postoperative pulmonary or lobar collapse (p = 0.001) OR 8.5 (2.41,30.22) were independent prognostic factors of mortality. The most common causes of death were related to respiratory (58.3%) and cardiovascular (33.2%) complications. CONCLUSIONS: Mortality at 90 days following surgery for lung cancer doubles 30-day mortality, which is a relevant finding of which both, patients and healthcare should be aware. Half the deaths within 90 days after surgery for lung cancer occur after discharge. Specific outpatient follow-up programs should be designed for patients at a higher risk of 90-day mortality.

Impact of major video-assisted thoracoscopic surgery on care quality.

BACKGROUND: The objective of this study was to investigate the impact of a program of major video-assisted surgery on care quality in a Unit of Thoracic Surgery. METHODS: A descriptive comparative study was conducted of 793 major thoracic procedures performed between 2009 and 2012. Quality indicators and hospital performance before [2009-2010] and after (2011 and 2012) the implementation of the program. RESULTS: The incidence of surgical complications decreased significantly from 6.32%/7.88% (2009/2010, respectively) to 1.87%/1.67% (2011/2012, respectively) [95% CI for 7.08% (4.20-9.96%); 95% CI for 1.76% (0.44-3.08%) P<0.001, respectively]. The mean hospital stay was reduced from 8.5/7.8 days in 2009/2010, respectively, to 6.3/5.8 days in 2011/2012, respectively. Mortality rates were 0.57%, 0.60%, 0.93% and 0.43% in 2009, 2010, 2011, and 2012, respectively (P=0.624, 95% CI: -0.6, 0.7). The percentages of emergency readmissions in 2009/2010 were 1.16%/1.23%, respectively vs. 2.80%/0.84% in 2011/2012. CONCLUSIONS: The implementation of the video-assisted thoracic surgery (VATS) program in the unit of Thoracic Surgery Care resulted in a significant improvement in care quality, with a reduction of length of hospital stay, but without any changes in mortality or the percentage of readmissions at 30 post-operative days.

Factores de riesgo para el desarrollo de complicaciones tras tratamiento quirúrgico del carcinoma broncopulmonar / Risk factors for the development of complications after surgical treatment for bronchopulmonary carcinoma

INTRODUCCIÓN: El tratamiento más adecuado en la mayoría de los pacientes con cáncer de pulmón en estadio inicial es la resección quirúrgica. A pesar de evaluar anteriormente que el estado de cada paciente sea el adecuado para detectar posibles complicaciones inherentes a la intervención quirúrgica, no se ha alcanzado ningún consenso sobre los factores que son de «alto riesgo» en esos pacientes. Nuestro estudio tuvo como objetivo analizar la morbilidad y la incidencia de mortalidad asociada con esta intervención quirúrgica en nuestro entorno con un estudio multicéntrico y descubrir los parámetros de riesgo. MÉTODOS: Se trata de un estudio de análisis prospectivo con 3.307 pacientes operados de carcinoma broncopulmonar en 24 hospitales. Las variables de estudio fueron edad, sistema TNM, sexo, estadio, tabaquismo, abordaje quirúrgico, resección quirúrgica, escala ECOG, tratamiento neoadyuvante, comorbilidad, valores espirométricos y morbimortalidad intra- y postoperatoria. Se realizó un análisis de regresión logística multivariante de los factores pronósticos de morbilidad y mortalidad. RESULTADOS: Registramos el 34,2% de morbilidad postoperatoria y el 2,1% de mortalidad postoperatoria. Sexo, infarto de miocardio, angina, ECOG ≥ 1, EPOC, DLCO < 60%, estado clínico patológico, resección quirúrgica y abordaje quirúrgico aparecieron como factores pronósticos de morbilidad y mortalidad en cirugía de cáncer de pulmón en nuestra serie. CONCLUSIONES: Las principales variables que deben tenerse en cuenta al evaluar a pacientes con cáncer de pulmón para realizarles una intervención quirúrgica son sexo, infarto de miocardio, angina, ECOG, EPOC, DLCO, estado clínico patológico, resección quirúrgica y abordaje quirúrgico

INTRODUCTION: The most suitable treatment in most early-stage lung cancer patients is surgical resection. Despite previously assessing each patient's status being relevant to detect possible complications inherent to surgery, no consensus has been reached on which factors are "high risk" in such patients. Our study aimed to analyse the morbidity and the mortality incidence associated with this surgery in our setting with a multicentre study and to detect risk parameters. METHODS: A prospective analysis study with 3,307 patients operated for bronchopulmonary carcinoma in 24 hospitals. Study variables were age, TNM, gender, stage, smoking habit, surgery approach, surgical resection, ECOG, neoadjuvant therapy, comorbidity, spirometric values, and intraoperative and postoperative morbidity and mortality. A multivariate logistic regression analysis of the morbidity and mortality predictor factors was done. RESULTS: We recorded 34.2% postoperative morbidity and 2.1% postoperative mortality. Gender, myocardial infarction, angina, ECOG ≥1, COPD, DLCO <60%, clinical pathological status, surgical resection and surgery approach were shown as morbidity and mortality predictor factors in lung cancer surgery in our series. CONCLUSIONS: The main variables to consider when assessing the lung cancer patients to undergo surgery are gender, myocardial infarction, angina, ECOG, COPD, DLCO, clinical pathological status, surgical resection and surgery approach

Emergent pneumonectomy for lung gangrene: does the outcome warrant the procedure?

BACKGROUND: Sloughing and gangrene of a complete lung are only very infrequently encountered complications of necrotizing pneumonia and fulminant pulmonary abscess formation. Thus far the role of emergent pneumonectomy is not established. METHODS: The outcome of patients who underwent anatomic lung resection for lung gangrene at 3 centers for thoracic surgery during the last 13 years was retrospectively analyzed. Only cases of necrotizing pneumonia were included whereas malignant lesions were excluded. RESULTS: Overall 44 patients were indentified (average age 56.3 years). Pulmonary sepsis (27 of 44), pleural empyema (29 of 44), persistent air leakage (14 of 44), and respiratory failure with mechanical ventilation (14 of 44) were present preoperatively. The mean Charlson comorbidity index was 2.77. Procedures were segmentectomy (7), lobectomy (26), and pneumonectomy (11). In-hospital mortality was 7 of 44; 2 following pneumonectomy and 5 after lobectomy. In comparing the pneumonectomy group with the lobectomy group we found no significant differences in age (p=0.59), Charlson comorbidity index (p=0.18), and postoperative mortality (p=1). Charlson comorbidity index 3 or greater (odds ratio [OR], 8.41; 95% confidence interval [CI], 0.88 to 421.71; p=0.04), preoperative pleural empyema (OR, 3.56; 95% CI, 0.37 to 179.62; p=0.39) and preoperative persistent air leak (OR, 7.34; 95% CI, 1.00 to 89.98; p=0.02) were associated with higher risk for fatal outcome. Furthermore, patients with sepsis (p=0.03) and patients sustaining acute renal failure (p=0.04) had significantly higher mortality. CONCLUSIONS: Pulmonary sepsis and its complications as well as preexisting comorbidity are the major reasons for fatal outcome, whereas the extent of surgical resection shows no significant influence. Emergent pneumonectomy as ultimate ratio is not only justified but also life saving. Further improvement seems achievable by earlier surgical intervention before the onset of pulmonary sepsis.