Association of performance in a stair-climbing test with complications and survival after lung cancer resection in the video-assisted thoracoscopic surgery era: population-based outcomes.

INTRODUCTION: With a population-based cohort in the video-assisted thoracoscopic surgery (VATS) era, we aimed to evaluate the value of the stair-climbing test (SCT) on short- and long-term outcomes of lung cancer surgery. METHODS: All patients operated due to primary lung cancer in Central Finland and Ostrobothnia from 2013 to June 2020 were included. For the analysis, clinical variables including the outcome of SCT and cause-specific mortality were available. Short- and long-term outcomes were compared between <11 m (n=66) and >12 m SCT (n=217) groups. RESULTS: Patients with poor performance (<11 m) had more comorbidities and worse lung function but did not differ in tumour stage or treatment. No differences between groups were observed in major morbidity rate (10.6% versus 11.1%, p=0.918) or median hospital stay (5 (IQR 4-7) versus 4 (IQR 3-7), p=0.179). At 1-year, fewer patients were alive and living at home in the climbing <11 m group (81.3%) compared to the >12 m group (94.2%), p=0.002. No difference was observed in cancer-specific 5-year survival. Non-cancer-specific survival (62.9% versus 83.1%, p<0.001) and overall survival (49.9% versus 70.0%, p<0.001) were worse in the <11 m group. After adjustment for confounding factors, SCT remained as a significant predictor for non-cancer-specific (HR 4.28; 95% CI 2.10-8.73) and overall mortality (HR 2.38; 95% CI 1.43-3.98). CONCLUSIONS: With SCT-based exercise testing, VATS can be performed safely, with a similar major morbidity rate in the poor performance group (<11 m) compared to >12 m group. Poor exercise performance increases non-cancer-specific mortality. Being a major predictor of survival, exercise capacity should be included in prognostic models.

Outcome of valve sparing root replacement for diverse indications.

OBJECTIVES: We report the mid-term outcomes of valve-sparing aortic root replacement (VSRR) in a cohort including patients with bicuspid aortic valve (BAV), connective tissue disorder (CTD), aortic dissection (AD), and congenital heart disease (CHD). Design. From 2005 to 2017, 174 patients underwent VSRR with the reimplantation technique. The mean age was 46 ± 14 years. The mean follow-up time was 4.8 ± 2.8 years. The indication for operation was aortic aneurysm for 127 (73%), aortic insufficiency (AI) for 38 (22%), and AD for 9 patients (5%). Preoperatively, 53 patients (31%) had ≥ moderate AI. BAV, CTD (Marfan or Loyes-Dietz), previous Ross procedure, or CHD was present in 57 (33%), 28 (16%), 7 (4%) and 12 patients (7%), respectively. Concomitant aortic valve repair was performed for 103 patients (59%). Results. Thirty-day mortality was zero. Four patients underwent aortic valve replacement (AVR) during follow-up. Kaplan-Meier estimates for survival, freedom from AVR, and freedom from ≥ moderate AI or reoperation were 96, 98, and 97% at 5 years. There was no difference in survival, freedom from AVR, or freedom from ≥ moderate AI or reoperation in patients with and without BAV, CTD, leaflet repair, or preoperative ≥ moderate AI. In Cox regression analysis, BAV, CTD, aortic valve repair, preoperative ≥ moderate AI, or aortic dimension were not risk factors for reoperation or valve dysfunction. Conclusions. Mid-term outcomes of VSRR for patients with diverse indications in terms of survival, reoperation rate, and valve dysfunction rate were excellent in a center with a limited annual volume of VSSR.

Cerebral Oximetry Monitoring in Patients Undergoing Surgery for Stanford Type A Aortic Dissection.

OBJECTIVES: The aim of this study was to evaluate the prognostic impact of cerebral regional oxygen saturation (crSO2) in patients undergoing surgery for Stanford type A aortic dissection (TAAD). DESIGN: Observational, retrospective, institutional study. SETTING: University hospital. PARTICIPANTS: A total of 152 patients who underwent surgery for TAAD from June 2009 to December 2018 at the authors' institution. INTERVENTIONS: Surgery for TAAD using continuous perioperative monitoring of crSO2 with near-infrared cerebral oximetry (INVOS, Medtronic, MN). MEASUREMENTS AND RESULTS: The rates of postoperative stroke/global brain ischemia were 22.4% and of hospital mortality 14.5%. Age, hemoglobin, and cardiogenic shock were independent predictors of nadir crSO2 from both frontal areas at arrival to the operating room. Repeated measures test showed that changes in crSO2 between the first measurement at operating room arrival, at the start of surgery, and at the end of surgery were not significant when measured on the right frontal area (p = 0.632), left frontal area (p = 0.608), as a nadir value from both frontal areas (p = 0.690), and as a difference between frontal areas (p = 0.826) in patients with and without major neurologic complications. Patients who had a nadir crSO2 <40% anytime during the perioperative period, had a numerically higher rate of major neurologic complications (27.3% v 20.4%, p = 0.354), but this difference did not reach statistical significance. The incidence of nadir of crSO2 value <40% at operating room arrival (5.9%, p = 1.000), at the start of surgery (5.3%, p = 0.685), and at the end of surgery (1.3%, p = 1.000) was rather low and not associated with these adverse events. CONCLUSIONS: Derangements in crSO2 detected by cerebral oximetry before and during surgery for TAAD did not predict postoperative stroke and/or global brain ischemia.

Extended resections and other special cases in lung cancer surgery: Real-world population-based outcomes.

BACKGROUND: Lung cancer invading outside a lobe centrally or peripherally, or presenting with synchronous or metachronous tumors, requires a special approach. Here, we aimed to evaluate the rate and outcomes of surgery of these patients in a medium-volume practice using real-world, population-based data. METHODS: All patients (n = 269) on whom lung cancer surgery was performed in Central Finland and Ostrobothnia between January 2013 and December 2019 were included. A total of 40 patients with sleeve (n = 18) or other extended resections (n = 9), multifocal diseases (n = 14), and other operated synchronous cancers (n = 3) required an extended or otherwise special surgical approach (extended group). Short- and long-term outcomes were compared to high-risk (n = 72) and normal patient groups (n = 157). RESULTS: The rate of extended resection was 14.9%. The rates of PET-CT (95%), invasive staging (35%), and brain imaging (42.5%) were highest in extended group compared to other groups. Extended group had larger and higher rate of stage III tumors than high-risk and normal groups. All extended group patients underwent anatomic lung resection with better lymph node yield than the other two groups, with a neoadjuvant and/or adjuvant treatment rate of 70.0%. Major complications occurred in 7.5% in the extended group, 19.4% in the high-risk group, and 6.4% in the normal group; at one year, alive and living at home rates were 88.2%, 83.3%, and 97.8%, and overall five-year survival rates 75.6%, 62.4%, and 63.9% (P = 0.287), respectively. CONCLUSIONS: After guideline-based evaluation, a significant rate of these special cases can be resected with a low complication rate and good long-term survival in real-world practice. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Extended resections for lung cancer include tumors spreading outside the lung The rate of extended resection was 14.9% in a population-based setting Major complications occurred in 7.5% and five-year survival was 75.6% What this study adds Complication rate and long-term outcome were similar compared to normal patients Guideline-based evaluation results with excellent outcome in real-world practice.

Thoracoscopic segmentectomy with simple routine bronchoscopic inflation for intersegmental plane identification: short and mid-term outcomes compared with lobectomy.

BACKGROUND: The technical concepts of thoracoscopic segmentectomy are still evolving. In this study we present a simple bronchoscopy-based intersegmental demarcation technique with short- and mid-term outcomes compared between thoracoscopic segmentectomy and lobectomy. METHODS: All 105 consecutive patients with lung cancer intended to treat with video-assisted thoracoscopic surgery (VATS) segmentectomy were compared to 110 consecutive VATS lobectomies. Short- and mid-term outcome comparison included complications, length of hospital stay, pulmonary functions, and 3-year progression-free and overall survival. Mid-term outcomes were adjusted for age, sex, comorbidities, pulmonary functions, histology, stage and adjuvant treatment. RESULTS: Segmentectomy patients had more comorbidities (P=0.006), worse pulmonary functions (FEV1%, P=0.005; DLCO/va, P=0.011), poor exercise capacity (P=0.043) and were considered high-risk patients more often (41.9% vs. 25.5%, P=0.011). Major complication rates did not differ between the groups (P=0.718). Mean length of hospital stay decreased after segmentectomy (4.7 vs. 5.9 days, P=0.033). Following segmentectomy, FEV1% slightly improved (1.0%). After lobectomy, the mean decline of FEV1% was 8.1% (P<0.001). Respectively, in high-risk patients, 2.1% improvement and 9.9% decline (P=0.027) were observed. Overall mortality hazard after segmentectomy was similar to that for lobectomy (unadjusted HR 0.80, 95% CI: 0.45-1.44, adjusted HR 0.87, 95% CI: 0.43-1.76). When considering only stage I non-small cell lung cancer, 3-year overall survival after segmentectomy and lobectomy were 86.8% vs. 79.8% (P=0.412) and 3-year recurrence-free survival 93.0% vs. 89.7%, P=0.450. CONCLUSIONS: Following segmentectomy, regardless of worse surgical candidates, hospital stay was shorter. Furthermore, preservation of lung function also in high-risk patients, was observed without compromising mid-term oncologic outcomes.

Thoracoscopic surgery for lung cancer is associated with improved survival and shortened admission length: a nationwide propensity-matched study.

OBJECTIVES: Population-based studies comparing long-term survival after minimally invasive and open surgery for lung cancer are lacking. The aim of this study was to compare long-term survival rates between minimally invasive [video-assisted thoracoscopic surgery (VATS)] and open surgery for lung cancer in an unselected nationwide setting. METHODS: Patients undergoing minimally invasive (n = 710) or open (n = 2814) lung resection for lung cancer between 2004 and 2014 were identified from nationwide complete registries in Finland. Propensity score matching resulted in groups of 632 patients who had VATS and 632 who had a thoracotomy. The primary outcome was the 1-year survival rate. Secondary outcomes were 30-day, 90-day and 5-year survival rates and the length of surgical admission. Cox models were adjusted for sex, age, comorbidity, centre size, year of surgery, histological diagnosis, stage and adjuvant therapy. RESULTS: In the propensity-matched cohort, the 1-year survival rate was 90.8% [confidence interval (CI) 88.3-92.8%] after VATS and 87.1% (CI 84.3-89.6%) after open surgery. The 5-year survival rate in the propensity-matched cohort was 59.6% (CI 54.9-63.9%) after VATS and 53.3% (CI 48.6-57.7%) after open surgery. The 30-day mortality rates showed no differences between approaches, but the 90-day mortality rate was better after VATS when adjusted for patient-, tumour- and operation-specific features (hazard ratio 0.56, 95% CI 0.30-0.92; P = 0.024). CONCLUSIONS: According to this population-based nationwide study from Finland, minimally invasive surgery for lung cancer is associated with improved long- and short-term survival rates, supporting the use of VATS as a primary surgical method for treating lung cancer. Due to the complexity of confounding factors in this study, one should, however, interpret the results critically. Additional studies are needed.

Real-world guideline-based treatment of lung cancer improves short- and long-term outcomes and resection rate: A population-based study.

OBJECTIVES: Recent guidelines for the treatment of lung cancer include comprehensive lists of recommendations for pre-operative risk evaluation, staging, and surgery. Our aim was to evaluate whether the implementation of these in a population-based real-world setting would improve outcomes. MATERIALS AND METHODS: All patients diagnosed with primary lung cancer in Central Finland and Ostrobothnia between January 1, 2006, and December 31, 2017, were identified from registry data (N = 2116), including patients who underwent surgical resection (n = 303). Data were divided into two periods, old and modern, according to which international guidelines were followed. RESULTS: Between surgical patients of the old and modern periods, significant changes occurred in the rate of pre-operative stair climbing tests (3.7 % vs. 68.6 %, p < 0.001), the use of positron emission computed tomography (18.7 % vs. 75.7 %, p < 0.001), and invasive staging (3.7 % vs. 26.0 %, p < 0.001). In surgery, the rate of VATS (2.2 % vs. 81.1 %, p < 0.001), segmentectomy (1.5 % vs. 27.2 %, p < 0.001), and extended resections (5.2 % vs. 13.6 %, p = 0.015) increased. However, between these periods, the rate of pneumonectomy decreased from 7.5 % to 1.2 % (p = 0.005) and bilobectomy from 9.0%-1.8% (p = 0.004). The overall resection rate increased from 10.5%-19.7 %, mainly due to a higher number of high-risk patients (12.7 % vs. 34.3 %, p < 0.001). Patients faced fewer major complications (21.6 % vs. 8.9 %, p = 0.002) and had shorter hospital stays (9 days, IQR 7-11 vs. 5 days, IQR 3-7; p < 0.001). In the modern period, patients underwent adjuvant therapy less often than in the old period (35.1 % vs. 22.5 %, p = 0.015). Recurrence-free 5-year survival rate improved, however, from 64.0%-76.8% (p < 0.001). CONCLUSIONS: The introduction of guideline-based modern patient evaluation and treatment was associated with improved short- and long-term outcomes of lung cancer surgery.

Trends and results of lung cancer surgery in Finland between 2004 and 2014.

OBJECTIVES: The aim of this study was to investigate the current trends and results of lung cancer surgery in Finland at the population level. METHODS: Three compulsory national registries provided the data on surgical treatment of lung cancer during 2004 and 2014. Outcomes of interest were all-cause mortality, population level surgical rates and frequencies of resections. The data were divided into 2 eras to analyse changes in treatment strategies and baseline characteristics: 2004-2009 and 2010-2014. RESULTS: A total of 3621 patients underwent lung resections for cancer during the study period. The mean age of the patients was 65.8 years. During the study period, the patients were older and Charlson comorbidity index score of the patients increased (P < 0.001 for both). Simultaneously, the rate of surgery (from 12.8% to 14.4%, P = 0.001) and the rate of video-assisted thoracoscopic surgery increased (from 7.3% to 31.9%, P < 0.001). The rate of pneumonectomy decreased from 12.7% to 7.5% (P < 0.001). Mortality was 2.3% at 30 days and 4.3% at 90 days without significant differences between eras. Overall survival was 85% at 1 year and 50.2% at 5 years. Long-term survival improved significantly during the study from 53% to 60.1% at 4 years (P < 0.001). CONCLUSIONS: This nationwide population-based study demonstrates an improvement in long-term outcome after lung cancer surgery despite an increasing age and comorbidity burden concomitantly with an increasing rate of surgery. This suggests that video-assisted thoracoscopic surgery can be offered to more patients with more comorbidities while still improving lung cancer survival.

Expanding indications for valve-sparing aortic root reconstruction: early and midterm results.

BACKGROUND: Valve-sparing aortic root reconstruction (VSRR) is an accepted method to treat patients with aortic root dilation. The role of the VSRR is less well defined for patients with bicuspid aortic valve, severe aortic valve insufficiency, congenital heart defects, and type A aortic dissection. We studied the clinical outcome of patients who underwent VSRR for expanded indications. METHODS: Seventy-eight patients underwent VSRR between the 2005 and 2012. Seventy-two patients (92%) underwent reimplantation and 6 patients (8%) were operated on with the remodeling technique. The mean age was 51 ± 12 years (range 24 to 73). For 71 patients (91%), the operation was elective, and for 7 (9%; all with type A aortic dissection), on an emergency basis. Preoperatively, the degree of aortic insufficiency was graded as 2+ or greater for 27 patients (35%). Connective tissue disorder (Marfan or Loeys-Dietz), bicuspid aortic valve, or congenital heart disease was present in 15 (19%), 15 (19%), and 7 patients (9%), respectively. Concomitant aortic valve leaflet repair was performed for 39 patients (50%). The mean follow-up time was 2.4 ± 1.7 years (range, 0.1 to 7.0). RESULTS: Thirty-day mortality was zero. The rate of postoperative complications was low: stroke 3%, renal failure 3%, prosthesis infection 1%, and low cardiac output syndrome 1%. Survival was 100% at 1 year and 97% at 5 years. Freedom from recurrent aortic valve insufficiency (≥2+) during the follow-up was 94%. CONCLUSIONS: The midterm results of VSRR in terms of survival, freedom from recurrent aortic valve insufficiency, and the need for reoperation are excellent, even for high-risk patients.