Preoperative serum lactate dehydrogenase level as a predictor of major complications following thoracoscopic lobectomy: a propensity-adjusted analysis.

OBJECTIVES: Despite the positive effects of a thoracoscopic approach on improving postoperative outcomes, the risk of major complications following thoracoscopic lobectomy is not negligible. We sought to assess the usefulness of the preoperative determination of serum biomarkers to refine risk stratification in this patient population. METHODS: From 2009 to 2017, 626 patients (285 women, 341 men; median age: 67 years) underwent thoracoscopic lobectomy or anatomical segmentectomy for confirmed or suspected early-stage lung cancer or metastasis at our institution. Preoperative serum biomarkers, including albumin, C-reactive protein, haemoglobin and lactate dehydrogenase (LDH), were examined as predictors of postoperative cardiopulmonary complications using logistic regression analyses followed by causal inference. RESULTS: The 90-day mortality, cardiopulmonary complication and overall morbidity rates were 1.0%, 13.1% and 18.1%, respectively. Although serum albumin, C-reactive protein and haemoglobin were not associated with cardiopulmonary complications in regression analyses, preoperative serum LDH level emerged as an independent morbidity predictor (odds ratio 1.008, 95% confidence interval 1.002-1.013; P = 0.006). The causal inference using the covariate balancing generalized propensity score methodology demonstrated similar results and an approximately positive linear relationship between the odds of cardiopulmonary complications and preoperative serum LDH level. For every 100 U/l increase in preoperative serum LDH, a 2-fold increase in the odds of cardiopulmonary complications was observed. CONCLUSIONS: Our results suggest that the preoperative serum LDH level is an independent predictor of 90-day cardiopulmonary complications following thoracoscopic lobectomy or segmentectomy, even in properly selected patients. Therefore, we recommend incorporating early serum LDH measurements as a readily available method into the risk assessment process prior to major lung resection.

Impact of comorbidity burden on morbidity following thoracoscopic lobectomy: a propensity-matched analysis.

BACKGROUND: Given the positive effect of a thoracoscopic approach on improving postoperative outcomes, it is reasonable to speculate whether an increased comorbidity burden is related to higher morbidity following thoracoscopic lobectomy. We sought to evaluate the impact of comorbidity burden on adverse postoperative outcomes in this patient population. METHODS: A retrospective review of our institutional database included 512 patients undergoing thoracoscopic lobectomy for early-stage non-small cell lung cancer (NSCLC) from 2009 through 2016. Comorbidity burden was assessed by the Charlson comorbidity index (CCI) and classified as high (CCI ≥3) or low (CCI <3) grade. Propensity score matching and random effects model were performed. RESULTS: Patients included 228 women and 284 men with a median age of 67 years. High and low comorbidity burdens were found in 193 and 319 patients, respectively. The postoperative mortality, pulmonary and cardiovascular complication rates and overall morbidity in patients with high comorbidity burden were comparable to those with low comorbidity burden (1.6% vs. 0.6%, 9.3% vs. 8.5%, 6.2% vs. 6.0%, 24.4% vs. 22.9%, respectively). Similar results were seen after propensity score matching, which balanced differences in demographics and preoperative characteristics between the comorbidity groups. On the analyses of propensity-matched data using generalized linear mixed model, a high comorbidity burden was not related to greater postoperative complication rates. CONCLUSIONS: Our results suggest that thoracoscopic lobectomy can be performed with low mortality and reasonable morbidity in lung cancer patients presenting with multiple comorbid diseases. The presence of a high comorbidity burden measured by CCI does not have a perceptible impact on adverse postoperative outcomes following thoracoscopic lobectomy.

American Society of Anesthesiologists physical status facilitates risk stratification of elderly patients undergoing thoracoscopic lobectomy.

OBJECTIVES: Accurate risk assessments are particularly important for elderly patients being considered for lobectomy. Considering the positive effects of the thoracoscopic approach on postoperative outcomes, we sought to review the reliability of the established risk factors for elderly patients undergoing thoracoscopic lobectomy. METHODS: From January 2009 to March 2016, 441 patients in our institution underwent thoracoscopic lobectomy for early-stage lung cancer. Clinical outcomes were compared between elderly (>70 years, n = 176) and younger patients (n = 265). RESULTS: There was no significant difference in postoperative mortality and morbidity between elderly and younger patients. In the regression analyses restricted to elderly patients, American Society of Anesthesiologists physical status (ASA-PS) was the single strong predictor of postoperative morbidity. The odds of pulmonary and cardiopulmonary complications increased nearly 6- and 3-fold, respectively, in those with ASA-PS Grade 3 compared with patients with ASA-PS Grade <3. Additionally, male gender was found to have a possible causal effect of pulmonary complication in elderly patients. After confounder adjustment using propensity score matching, the generalized linear mixed model revealed more than an 8-fold increase in the odds of pulmonary complications in elderly men compared with elderly women. To check the robustness of the above-mentioned finding, inverse probability of treatment weighting was used as an alternative analysis indicating a weaker but still substantively significant effect of male gender, with an odds ratio >3. CONCLUSIONS: Our results suggest that ASA-PS is a strong predictor of morbidity among elderly patients considered for thoracoscopic lobectomy. Compared with elderly women, elderly men are particularly prone to postoperative pulmonary complications.

Albumin-glutaraldehyde glue for repair of superficial lung defect: an in vitro experiment.

BACKGROUND: Albumin-glutaraldehyde glue gained a widespread acceptance in repair of superficial lung defects associated with alveolar air leaks (AAL). As its sealing efficacy has not yet been thoroughly corroborated by clinical studies, we sought to assess the properties of commercially available albumin-glutaraldehyde glue (BioGlue™) in an in vitro lung model. METHODS: The lower lobe of freshly excised swine lung (n = 10) was intubated and ventilated. A focal superficial parenchymal defect (40 × 25 mm) was created on the inflated lung. AAL was assessed with increasing inspired tidal volume (TVi). After glue application, AAL was assessed until burst failure occurred. To evaluate glue elasticity, the length of defect was recorded in the inflated lung. RESULTS: Superficial parenchymal defects resulted in AAL increasing with ascending TVi. Multiple linear regression analysis revealed strong correlation between AAL and maximal inspiratory pressure. There was one application error. At TVi = 400, 500, 600, 700, 800 and 900 ml, BioGlue™ achieved complete sealing in nine, six, five, four two and one specimens, respectively. Mean burst pressure was 38.0 ± 4.2 cmH2O. All sealant failures were cohesive. BioGlue™ allowed an expansion of covered lung defects of 1.5 ± 1.7 mm. CONCLUSIONS: Our in vitro tests demonstrated a high sealing efficacy of BioGlue™ for repair of superficial lung defects. Due to the rigid nature, caution should be taken to use this kind of sealant in trapped lungs.

Sniffer dogs as part of a bimodal bionic research approach to develop a lung cancer screening.

Lung cancer (LC) continues to represent a heavy burden for health care systems worldwide. Epidemiological studies predict that its role will increase in the near future. While patient prognosis is strongly associated with tumour stage and early detection of disease, no screening test exists so far. It has been suggested that electronic sensor devices, commonly referred to as 'electronic noses', may be applicable to identify cancer-specific volatile organic compounds in the breath of patients and therefore may represent promising screening technologies. However, three decades of research did not bring forward a clinically applicable device. Here, we propose a new research approach by involving specially trained sniffer dogs into research strategies by making use of their ability to identify LC in the breath sample of patients.