Risk factors and short-term outcomes of postoperative pulmonary complications after VATS lobectomy.

BACKGROUND: Postoperative pulmonary complications (PPCs) are associated with poor outcomes following thoracotomy and lung resection. Video-assisted thoracoscopic surgery (VATS) for lobectomy is now frequently utilised as an alternative to thoracotomy, however patients remain at risk for development of PPC. There is little known of the short-term outcome associated with PPC following VATS lobectomy and if there are any potential risk factors that could be modified to prevent PPC development; our study aimed to investigate this. METHODS: A prospective observational study of consecutive patients undergoing VATS lobectomy for lung cancer over a 4-year period in a regional centre was performed (2012-2016). Exclusion criteria included re-do VATS or surgery for pulmonary infection. All patients received physiotherapy as necessary from postoperative day 1 (POD1) and PPC was determined using the Melbourne Group Scale. Outcomes included hospital LOS, intensive therapy unit (ITU) admission and hospital mortality. RESULTS: Of the 285 patients included in the study, 137 were male (48.1%), the median (IQR) age was 69 (13) years and the mean (±SD) FEV1% predicted was 87% (±19). Patients that developed a PPC (n = 21; 7.4%) had a significantly longer hospital LOS (4 vs. 3 days), higher frequency of ITU admission (23.8% vs. 0.5%) and higher hospital mortality (14.3% vs. 0%) (p < 0.001). PPC patients also required more physiotherapy contacts/time, emergency call-outs and specific pulmonary therapy (p < 0.05). Current smoking and COPD diagnosis were significantly associated with development of PPC on univariate analysis (p < 0.05), however only current smoking was a significant independent risk factor on multivariate analysis (p = 0.015). CONCLUSIONS: Patients undergoing VATS lobectomy remain at risk of developing a PPC, which is associated with an increase in physiotherapy requirements and a worse short-term morbidity and mortality. Current smoking is the only independent risk factor for PPC after VATS lobectomy, thus vigorous addressing of preoperative smoking cessation is urgently needed.

Smoking and timing of cessation on postoperative pulmonary complications after curative-intent lung cancer surgery.

BACKGROUND: Smoking is a risk factor for postoperative pulmonary complications (PPC) following non-small cell lung cancer (NSCLC) surgery. The optimal timing for preoperative smoking cessation has not been identified. Our study aimed to observe the impact of preoperative smoking cessation on PPC incidence and other postoperative outcomes including long-term survival. METHODS: A prospective study included consecutive patients following resection for NSCLC in a regional thoracic centre over a 4-year period (2010-2014). Patients were stratified according to self-reported preoperative smoking status. The primary endpoint was PPC incidence, which was assessed from postoperative day one onwards using the Melbourne Group Scale. Secondary endpoints included short-term outcomes (hospital length of stay [LOS], intensive therapy unit [ITU] admission, 30-day hospital readmission rate) and long-term survival. RESULTS: Four hundred and sixty-two patients included 111 (24%) current smokers, 55 (12%) ex-smokers <6 weeks, 245 (53%) ex-smokers ≥6 weeks and 51 (11%) never smokers. PPC occurred in 60 (13%) patients in total. Compared to never smokers, current smokers had a higher frequency of PPC (22% vs. 2%, p = 0.004), higher frequency of ITU admission (14% vs. 0%; p = 0.001) and a longer median (IQR) hospital LOS (6 [5] vs. 5 [2]; p = 0.001). In the ex-smokers there was a trend for a lower frequency of PPC (<6 weeks, 10.9% vs. ≥6 weeks, 11.8%) and ITU admission (<6 weeks, 5.5% vs. ≥6 weeks, 4.5%), but there was no difference between the <6 weeks or ≥6 weeks ex-smoking groups prior to surgery. There was no significant difference in long-term survival found between the groups of differing smoking status (median follow-up 29.8 months, 95%CI 28.4-31.1). CONCLUSION: Current smokers have higher postoperative morbidity; this risk reduces following smoking cessation but 6 weeks does not appear to identify a time-point where differences in outcomes are noted.

Long-term impact of developing a postoperative pulmonary complication after lung surgery.

INTRODUCTION: Postoperative pulmonary complications (PPC) such as atelectasis and pneumonia are common following lung resection. PPCs have a significant clinical impact on postoperative morbidity and mortality. We studied the long-term effects of PPCs and sought to identify independent risk factors. METHODS: A prospective observational study involved all patients following lung resection in a regional thoracic centre over 4 years. PPCs were assessed daily in hospital using the Melbourne group scale based on chest X-ray, white cell count, fever, purulent sputum, microbiology, oxygen saturations, physician diagnosis and intensive therapy unit (ITU)/high-dependency unit readmission. Follow-up included hospital length of stay (LOS), 30-day readmissions, and mortality. RESULTS: 86 of 670 patients (13%) who had undergone a lung resection developed a PPC. Those patients had a significantly longer hospital LOS in days (13, 95% CI 10.5-14.9 vs 6.3, 95% CI 5.9 to 6.7; p<0.001) and higher rates of ITU admissions (28% vs 1.9%; p<0.001) and 30-day hospital readmissions (20.7% vs 11.9%; p<0.05). Significant independent risk factors for development of PPCs were COPD and smoking (p<0.05), not age. Excluding early postoperative deaths, developing a PPC resulted in a significantly reduced overall survival in months (40, 95% CI 34 to 44 vs 46, 95% CI 44 to 47; p=0.006). Those who developed a PPC had a higher rate of non-cancer-related deaths (11% vs 5%; p=0.020). PPC is a significant independent risk factor for late deaths in non-small cell lung cancer patients (HR 2.0, 95% CI 1.9 to 3.2; p=0.006). CONCLUSIONS: Developing a PPC after thoracic surgery is common and is associated with a poorer long-term outcome.

Potentially modifiable factors contribute to limitation in physical activity following thoracotomy and lung resection: a prospective observational study.

BACKGROUND: Early mobility is considered important in minimising pulmonary complication, length of stay (LOS) and enhancing recovery following major surgery. We aimed to observe and measure the reduction in early postoperative physical activity following major thoracic surgery, identifying any potentially limiting factors, and factors predictive of reduced activity. METHODS: Patients undergoing thoracotomy and lung resection were prospectively observed for the purposes of this study. All patients were routinely assisted to mobilise by physiotherapists from postoperative day 1, and continued daily with exercise and progression of mobility as per usual practice. Physical activity was measured with SenseWear Pro 3 armband physiologic motion sensors between postoperative day 1-4. The motion sensors recorded step count, time spent in 'sedentary'/ 'moderate' activity, and energy expenditure. Frequency of postoperative pulmonary complication (PPC) and postoperative LOS were also observed. Multivariate analyses were performed using forward stepwise logistic regression; results are displayed as odds ratio (95% confidence intervals). RESULTS: n = 99, median (interquartile range) steps 472 (908) over combined postoperative days 2/ 3, sedentary activity (< 3 METs) 99%. Less active subjects reported significantly more pain on day 2 and 3 (p = 0.013/ 0.00 respectively) (p < 0.001). On regression analysis age ≥ 75 years, predicted FEV1 < 70% and poor preoperative activity were predictive of lower postoperative activity. Factors limiting mobility on day 1 included pain and dizziness. Median LOS was longer (p = 0.013) (6 vs. 5 days) in less active patients and frequency of PPC was 20% vs 4% (p = 0.034). CONCLUSION: Physical activity following major thoracic surgery is generally very limited, with less active patients demonstrating longer LOS. Factors limiting immediate postoperative mobility were largely modifiable, some of the factors predictive of lower activity were also possibly modifiable/amenable to physiotherapy or pulmonary rehabilitation. Prompt assessment and recognition of these factors is needed in future, with timely and effective management incorporated into care pathways to maximise each patients potential to mobilise postoperatively. TRIAL REGISTRATION: ISRCTN52709424.