Total intravenous anesthesia decreases hospital stay but not incidence of postoperative pulmonary complications after lung resection surgery: a propensity score matching study.

BACKGROUND: There is no consensus regarding the superiority of volatile or total intravenous anesthesia (TIVA) in reducing the incidence of postoperative pulmonary complications (PPCs) after lung resection surgery (LRS). Thus, the aim of this study was to investigate the different anesthetic regimens and the incidence of PPCs in patients who underwent LRS. We hypothesized that TIVA is associated with a lower incidence of PPCs than volatile anesthesia. METHODS: This was a retrospective cohort study of patients who underwent LRS at Taipei Veterans General Hospital between January 2016 and December 2020. The patients' charts were reviewed and data on patient characteristics, perioperative features, and postoperative outcomes were extracted and analyzed. The patients were categorized into TIVA or volatile anesthesia groups and their clinical data were compared. Propensity score matching was performed to reduce potential selection bias. The primary outcome was the incidence of PPCs, whereas the secondary outcomes were the incidences of other postoperative events, such as length of hospital stay (LOS) and postoperative nausea and vomiting (PONV). RESULTS: A total of 392 patients each were included in the TIVA and volatile anesthesia groups. There was no statistically significant difference in the incidence of PPCs between the volatile anesthesia and TIVA groups. The TIVA group had a shorter LOS (p < 0.001) and a lower incidence of PONV than the volatile anesthesia group (4.6% in the TIVA group vs. 8.2% in the volatile anesthesia group; p = 0.041). However, there were no significant differences in reintubation, 30-day readmission, and re-operation rates between the two groups. CONCLUSIONS: There was no significant difference between the incidence of PPCs in patients who underwent LRS under TIVA and that in patients who underwent LRS under volatile anesthesia. However, TIVA had shorter LOS and lower incidence of PONV which may be a better choice for maintenance of anesthesia in patients undergoing LRS.

Hyperoxemia post thoracic surgery - Does it matter?

Introduction: Post-operative oxygen therapy is used to prevent hypoxemia and surgical site infection. However, with improvements of anesthesia techniques, post-operative hypoxemia incidence is declining and the benefits of oxygen on surgical site infection have been questioned. Moreover, hyperoxemia might have adverse effects on the pulmonary and cardiovascular systems. We hypothesized hyperoxemia post thoracic surgery is associated with post-operative pulmonary and cardiovascular complications. Methods: Consecutive lung resection patients were included in this post-hoc analysis. Post-operative pulmonary and cardiovascular complications were prospectively assessed during the first 30 post-operative days, or hospital stay. Arterial blood gases were analyzed at 1, 6 and 12 h after surgery. Hyperoxemia was defined as arterial partial pressure of oxygen (PaO2)>100 mmHg. Patients with hyperoxemia duration in at least two adjacent time points were considered as hyperoxemic. Student t-test, Mann-Whitney U test and two-tailed Fisher exact test were used for group comparison. P values < 0.05 were considered statistically significant. Results: Three hundred sixty-three consecutive patients were included in this post-hoc analysis. Two hundred five patients (57%), were considered hyperoxemic and included in the hyperoxemia group. Patients in the hyperoxemia group had significantly higher PaO2 at 1, 6 and 12 h after surgery (p < 0.05). Otherwise, there was no significant difference in age, sex, comorbidities, pulmonary function tests parameters, lung surgery procedure, incidence of post-operative pulmonary and cardiovascular complications, intensive care unit and hospital length of stay and 30-day mortality. Conclusion: Hyperoxemia after lung resection surgery is common and not associated with post-operative complications or 30-day mortality.

Hypoxemia in thoracoscopic lung resection surgery using a video double-lumen tube versus a conventional double-lumen tube: A propensity score-matched analysis.

Background: Malposition of the double-lumen tubes (DLTs) may lead to hypoxemia during one-lung ventilation (OLV). Video double-lumen tubes (VDLTs) enable continuous observation of DLT position and avoid displacement. We aimed to investigate whether VDLTs could reduce the incidence of hypoxemia during OLV compared with conventional double-lumen tubes (cDLT) in thoracoscopic lung resection surgery. Methods: This was a retrospective cohort study. Adult patients who underwent elective thoracoscopic lung resection surgery and required VDLTs or cDLTs for OLV at Shanghai Chest Hospital from January 2019 to May 2021 were included. The primary outcome was the incidence of hypoxemia during OLV between VDLT and cDLT. Secondary outcomes included bronchoscopy use, the degree of PaO2 decline, and arterial blood gas indices. Results: A total of 1,780 patients were finally analyzed in propensity score-matched cohorts (VDLT vs. cDLT 1:1 n = 890). The incidence of hypoxemia decreased from 6.5% (58/890) in cDLT group to 3.6% (32/890) in VDLT group (Relative Risk [RR]: 1.812, 95% CI: 1.19-2.76, p = 0.005). The use of bronchoscopy was reduced by 90% in VDLT group (VDLT 10.0% (89/890) vs. cDLT 100% (890/890), p < 0.001). PaO2 after OLV was 221 [136.0-325.0] mmHg in cDLT group compared to 234 [159.7-336.2] mmHg in VDLT group, p = 0.003. The percentage of PaO2 decline was 41.4 [15.4-61.9] % in cDLT group, while it was 37.7 [8.7-55.9] % in the VDLT group, p < 0.001. In patients who suffered from hypoxemia, there were no significant differences in arterial blood gas indices or the percentage of PaO2 decline. Conclusion: VDLTs reduce the incidence of hypoxemia and the use of bronchoscopy during OLV compared with cDLTs. VDLT may be a feasible option for thoracoscopic surgery.

Computed tomography volumetric analysis for predicting postoperative lung function for segmentectomy.

OBJECTIVES: We compared the computed tomographic (CT) volumetric analysis and anatomical segment counting (ASC) for predicting postoperative forced expiratory volume in 1 s (FEV1) and diffusing capacity for carbon monoxide (DLCO) in patients who had segmentectomy for early-stage lung cancer. METHODS: A total of 175 patients who had segmentectomy for lung cancer and had postoperative pulmonary function test were included. CT volumetric analysis was performed by software, which could measure total lung and target segment volume from CT images. ASC and CT volumetric analysis were used to determine predicted postoperative (PPO) values and the concordance and difference of these values were assessed. The relationship between PPO values and actual postoperative values was also investigated. RESULTS: The PPO-FEV1 and PPO-DLCO showed high concordance between 2 methods (concordance correlation coefficient = 0.96 for PPO-FEV1 and 0.95 for PPO-DLCO). There was no significant difference between PPO values as determined by 2 methods (P = 0.53 for PPO-FEV1, P = 0.25 for PPO-DLCO) and actual postoperative values [P = 0.77 (ASC versus actual) and P = 0.20 (CT versus actual) for FEV1; P = 0.41 (ASC versus actual) and P = 0.80 (CT versus actual) for DLCO]. We subdivided the patients according to poor pulmonary function test, the number of resected segments and the location of the resected lobe. All subgroup analyses revealed no significant difference between PPO values and actual postoperative values. CONCLUSIONS: Both CT volumetric analysis and ASC showed high predictability for actual postoperative FEV1 and DLCO in segmentectomy.

Hospital case-volume and mortality after lung cancer surgery: A population-based retrospective cohort study.

OBJECTIVES: Recent advances in lung cancer treatment warrants reassessment of the volume-outcome association in lung cancer surgery. This study reassessed the relationship between surgical case-volume and both in-hospital and long-term mortality after lung cancer surgery using a current database to reflect recent advances. MATERIALS AND METHODS: Using the database of the National Health Insurance Service in Korea, data of all adult patients who underwent lung cancer surgery in Korea between 2005 and 2019 were obtained. Hospitals were categorized by the annual number of lung cancer surgeries. Risk-adjusted in-hospital and 1, 3, 5-year mortality after surgery were assessed. RESULTS: A total of 84,194 lung cancer surgeries were performed in 163 centers during the study period. High-volume centers were defined as > 200 cases/year, medium-volume centers as 60-200 cases/year, and low-volume centers as < 60 cases/year. After adjustment, in-hospital mortality was significantly lower in high-volume centers (1.03%) compared to medium-volume centers (2.06%, adjusted odds ratio [OR], 1.43; 95% confidence interval [CI], 1.23-1.65; P < 0.001), and low-volume centers (3.08%, OR, 1.32; 95% CI, 1.16-1.51; P < 0.001). Long-term mortality was also significantly lower in high-volume centers compared to the other groups. CONCLUSION: High-volume centers showed lower in-hospital and long-term mortality compared to centers with less case-volume.

Influence of postoperative complications on long-term outcome after oncologic lung resection surgery. Substudy of a randomized control trial.

Lung resection surgery (LRS) causes an intense local and systemic inflammatory response. There is a relationship between inflammation and postoperative complications (POCs). Also, it has been proposed that the inflammation and complications related with the surgery may promote the recurrence of cancer and therefore deterioration of survival. We investigated the association between inflammatory biomarkers, severity of POCs and long-term outcome in patients who were discharged after LRS. This is a prospective substudy of a randomized control trial. We established three groups based in the presence of POCs evaluated by Clavien-Dindo (C-D) classification: Patients with no postoperative complications (No-POCs group) (C-D = 0), patients who developed light POCs (L-POCs group) (C-D = I-II), and major POCs (M-POCs group) (C-D = III, IV, or V). Kaplan-Meier curves and Cox regression model were created to compare survival and oncologic recurrence in those groups. Patients who developed POCs (light or major) had an increase in some inflammatory biomarkers (TNF-α, IL-6, IL-7, IL-8) compared with No-POCs group. This pro-inflammatory status plays a fundamental role in the appearance of POCs and therefore in a shorter life expectancy. Individuals in the M-POCs group had a higher risk of death (HR = 3.59, 95% CI 1.69 to 7.63) compared to individuals in the No-POCs group (p = 0.001). Patients of L-POCs group showed better survival than M-POCs group (HR = 2.16, 95% CI 1.00 to 4.65, p = 0.049). Besides, M-POCs patients had higher risk of recurrence in the first 2 years, when compared with L-POCs (p = 0,008) or with No-POCs (p = 0.002). In patients who are discharged after undergoing oncologic LRS, there is an association between POCs occurrence and long term outcome. Oncologist should pay special attention in patients who develop POCs after LRS.

Comparison between lung perfusion scan and single-photon emission computed tomography/computed tomography for predicting postoperative lung function after pulmonary resection in patients with borderline lung function.

OBJECTIVES: We compared the usefulness of single-photon emission computed tomography/computed tomography (SPECT/CT) and lung perfusion scintigraphy (LPS) for predicting postoperative lung function by comparing patients with borderline lung function. METHODS: A total of 274 patients who underwent simultaneous LPS and SPECT/CT and had a forced expiratory volume in 1 s (FEV1) or diffusing capacity for carbon monoxide (DLCO) under 80% were included. The % uptake by LPS was calculated by the posterior-oblique method. The concordance and difference of the % uptake, predicted postoperative (ppo) FEV1 and ppoDLCO as determined by 2 methods were evaluated. The association between ppo values and actual postoperative FEV1 and DLCO was examined. Subgroup analysis was conducted in redo-operation cases. RESULTS: The % uptake of each lobe, except the right middle lobe, showed fair concordance (concordance correlation coefficients for right upper, middle, lower, left upper and lower lobe = 0.61, 0.37, 0.71, 0.66 and 0.69, respectively). ppoFEV1 and ppoDLCO also revealed high concordance between both methods (concordance correlation coefficient = 0.93 for ppoFEV1 and concordance correlation coefficient = 0.92 for ppoDLCO) without a significant difference (P = 0.42 for ppoFEV1; P = 0.31 for ppoDLCO). Both ppoFEV1 and ppoDLCO showed a significantly high correlation with the actual FEV1 (r = 0.77, P < 0.01 for LPS, r = 0.77, P < 0.01 for SPECT/CT) and DLCO (r = 0.62, P < 0.01 for LPS, r = 0.62, P < 0.01 for SPECT/CT). High concordance of % uptake, ppoFEV1 and ppoDLCO was present in redo-operation patients. CONCLUSIONS: Both LPS and SPECT/CT showed high predictability for actual postoperative lung function, and LPS showed good performance to estimate ppoFEV1 and ppoDLCO with reference to SPECT/CT, even in redo-operation cases.

Asymptomatic Congenital Lung Malformations: Timing of Resection Does Not Affect Adverse Surgical Outcomes.

Background: Optimal timing for resection of asymptomatic congenital lung malformations (CLMs) remains controversial. The aim of this study is to define optimal timing for surgical intervention of patients with CLMs and define clinical variables that affect surgical outcomes. Methods: An IRB-approved retrospective analysis was conducted for patients undergoing surgery for CLMs between 2012 and 2017. Subjects were divided into cohorts based on timing of operative intervention. "Early intervention" was defined as surgery within 4 months of birth; "intermediate intervention"-between 4 and 6 months; and "late intervention"-6-12 months. Surgical outcomes including intraoperative estimated blood loss (EBL), surgical time, post-operative pneumothorax, length of time chest tube stayed in, and hospital length of stay were compared among the three groups using Fisher's exact test or Chi-squared test for categorical variables and one-way analysis of variance test for continuous variables. Results: We analyzed 63 patients who underwent surgery for CLM. There were no significant differences in baseline characteristics. Timing of surgery did not significantly correlate with post-operative outcomes. Specifically, there was no difference in operative time, EBL, post-operative pneumothorax, or length of hospital stay among the early, intermediate, and late intervention groups. Even after controlling for cyst-volume ratio (CVR), timing of surgery still did not affect post-operative outcomes. Conclusions: Surgical outcomes for resection of CLMs are not significantly affected by timing of surgery. We advocate for early intervention to decrease the incidence of associated complications that can occur with later intervention.

Validation study of the dynamic parameters of pulse wave in pulmonary resection surgery. / Estudio de validación de los parámetros dinámicos de onda de pulso en cirugía de resección pulmonar.

INTRODUCTION: In lung resection surgery, restrictive fluid therapy is recommended due to the risk of acute lung injury. In contrast, this recommendation increases the risk of hypoperfusion. Guided fluid therapy allows individualization of fluid intake. The use of dynamic volume response parameters is not validated during one-lung ventilation. The main objective is the validation of dynamic parameters, stroke volume variation (SVV) and pulse pressure variation (PPV), during lung resection surgery as fluid response predictors, after the administration of 250ml crystalloid volume loads, if IC<2.5ml/min/m2 and if SVV≥8% and/or PPV≥10%. MATERIAL AND METHODS: Pilot, prospective, observational and single centre study. Twenty-five patients monitored with the PiCCO system were included during open lung resection surgery with the patient in a lateral position, one lung ventilation with tidal volume (TV): 6ml/kg and open chest. Hemodynamic variables were collected before and after volume loading. The results were classified into two groups: volume responders (increase IC≥10% and/or VSI≥10% after volume loading) and non-responders (no increase or increase IC<10% and/or VSI<10% after volume loading). We assess the diagnostic efficacy of SVV and PPV by analyzing the AUC (area under curve) in the ROC curves. RESULTS: In the analysis of ROC curves, SVV and PPV did not reach a discriminative value (AUCSVV: 0.47; AUCPPV: 0.50), despite the decrease in the threshold value of SVV and PPV to initiate an overload of volume during one-lung ventilation, in lateral position and open chest. CONCLUSIONS: The results obtained show that the values of the dynamic parameters of volume response (SVV≥8% and PPV≥10%) do not discriminate against responders patients and non-responders during open lung resection surgery.

Effect of intraoperative paravertebral or intravenous lidocaine versus control during lung resection surgery on postoperative complications: A randomized controlled trial.

BACKGROUND: Use of minimally invasive surgical techniques for lung resection surgery (LRS), such as video-assisted thoracoscopy (VATS), has increased in recent years. However, there is little information about the best anesthetic technique in this context. This surgical approach is associated with a lower intensity of postoperative pain, and its use has been proposed in programs for enhanced recovery after surgery (ERAS). This study compares the severity of postoperative complications in patients undergoing LRS who have received lidocaine intraoperatively either intravenously or via paravertebral administration versus saline. METHODS/DESIGN: We will conduct a single-center randomized controlled trial involving 153 patients undergoing LRS through a thoracoscopic approach. The patients will be randomly assigned to one of the following study groups: intravenous lidocaine with more paravertebral thoracic (PVT) saline, PVT lidocaine with more intravenous saline, or intravenous remifentanil with more PVT saline. The primary outcome will be the comparison of the postoperative course through Clavien-Dindo classification. Furthermore, we will compare the perioperative pulmonary and systemic inflammatory response by monitoring biomarkers in the bronchoalveolar lavage fluid and blood, as well as postoperative analgesic consumption between the three groups of patients. We will use an ANOVA to compare quantitative variables and a chi-squared test to compare qualitative variables. DISCUSSION: The development of less invasive surgical techniques means that anesthesiologists must adapt their perioperative management protocols and look for anesthetic techniques that provide good analgesic quality and allow rapid rehabilitation of the patient, as proposed in the ERAS protocols. The administration of a continuous infusion of intravenous lidocaine has proven to be useful and safe for the management of other types of surgery, as demonstrated in colorectal cancer. We want to know whether the continuous administration of lidocaine by a paravertebral route can be substituted with the intravenous administration of this local anesthetic in a safe and effective way while avoiding the risks inherent in the use of regional anesthetic techniques. In this way, this technique could be used in a safe and effective way in ERAS programs for pulmonary resection. TRIAL REGISTRATION: EudraCT, 2016-004271-52; ClinicalTrials.gov, NCT03905837 . Protocol number IGGFGG-2016 version 4.0, 27th April 2017.

Atrial fibrillation after lung surgery: incidence, underlying factors, and predictors.

INTRODUCTION: Cardiac complications are the second most common cause of morbidity and mortality in patients subjected to thoracic surgery after respiratory complications. Postoperative arrhythmia is one of the most common cardiac complications in these patients. It leads to morbidity, increased hospitalization, and high costs for patients. AIM: To determine the incidence of atrial fibrillation after lung resection and determine the underlying factors and predictors of this problem. MATERIAL AND METHODS: The participants in this study were composed of all patients who were subjected to lung resection surgery in the past 4 years. The demographic data of the patients and possible postoperative complications, including the incidence of atrial fibrillation, were extracted from patient records. The statistical analysis of data was performed after data collection. RESULTS: The incidence of postoperative atrial fibrillation (POAF) in the present study was 7.6% (n = 20), mostly in patients who had a lung parenchyma resection. It occurred due to malignancy (n = 16), squamous cell carcinoma (n = 9), adenoid cystic carcinoma (n = 5), and metastasis (n = 2). The POAF occurred in 34.2% of pneumonectomy cases and 4.5% of lobectomy cases, out of whom 60% were male. There was a significant difference between the two groups of arrhythmia and non-arrhythmia groups regarding the age range. The mean ages of patients with and without arrhythmias were 56.45 ±18.2 and 44.76 ±17.2, respectively. CONCLUSIONS: Pulmonary malignant pathologies are more likely to develop POAF due to the need for lung resection and possibly mediastinal lymphadenectomy that stimulates the heart and pericardium and the vagus nerve.

Predictive value of plasma cytokines for acute kidney injury following lung resection surgery: prospective observational study / Valor preditivo das citocinas plasmáticas para lesão renal aguda após cirurgia de ressecção pulmonar: estudo observacional prospectivo

Abstract Background and objectives: Patients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury. Methods: We prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra-operative periods of one-lung ventilation periods. Fiberoptic broncho-alveolar lavage was performed in each lung before and after one-lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. acute kidney injury was diagnosed within 48 h of surgery based on acute kidney injury criteria. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re-admission, and short-term and long-term mortality. Results: The incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin-6 at 6 h was the most predictive cytokine of acute kidney injury (cut-off point at 4.89 pg.mL-1). Conclusions: Increased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin-6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.

Resumo Justificativa e objetivos: Os pacientes submetidos à cirurgia de ressecção pulmonar apresentam risco de desenvolver lesão renal aguda pós-operatória. A determinação dos níveis de citocinas permite detectar uma resposta inflamatória precoce. Investigamos a relação temporal entre o estado inflamatório perioperatório e o desenvolvimento de lesão renal aguda após cirurgia de ressecção pulmonar. Além disso, avaliamos o impacto da lesão renal aguda no desfecho e analisamos a viabilidade das citocinas para prever este tipo de lesão. Métodos: No total, foram analisados prospectivamente 174 pacientes agendados para cirurgia eletiva de ressecção pulmonar com períodos intraoperatórios de ventilação monopulmonar. Lavado bronco-alveolar com fibra óptica foi realizado em cada pulmão antes e após os períodos de ventilação monopulmonar para análise das citocinas. Os níveis de citocina foram medidos a partir de amostras de sangue arterial em cinco momentos. A lesão renal aguda foi diagnosticada dentro de 48 horas após a cirurgia, com base nos critérios para sua verificação. Analisamos a associação entre lesão renal aguda e complicações cardiopulmonares, tempo de internação em unidade de terapia intensiva e de internação hospitalar, reinternação em unidade de terapia intensiva e mortalidade a curto e longo prazos. Resultados: A incidência de lesão renal aguda no estudo foi de 6,9% (12/174). Os pacientes com lesão renal aguda apresentaram níveis mais altos de citocinas plasmáticas após a cirurgia, mas não foram detectadas diferenças nas citocinas alveolares. Embora nenhum paciente tenha precisado de terapia renal substitutiva, os com lesão renal aguda apresentaram maior incidência de complicações cardiopulmonares e aumento da mortalidade geral. A interleucina-6 plasmática em seis horas foi a citocina mais preditiva de lesão renal aguda (ponto de corte em 4,89 pg.mL-1). Conclusões: O aumento dos níveis plasmáticos de citocinas no pós-operatório está associado à lesão renal aguda após cirurgia de ressecção pulmonar no estudo, o que piora o prognóstico. A interleucina-6 plasmática pode ser usada como um indicador precoce para pacientes com risco de desenvolver lesão renal aguda após cirurgia de ressecção pulmonar.

[Predictive value of plasma cytokines for acute kidney injury following lung resection surgery: prospective observational study]. / Valor preditivo das citocinas plasmáticas para lesão renal aguda após cirurgia de ressecção pulmonar: estudo observacional prospectivo.

BACKGROUND AND OBJECTIVES: Patients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury. METHODS: We prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra-operative periods of one-lung ventilation. Fiberoptic broncho-alveolar lavage was performed in each lung before and after one-lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. Acute kidney injury was diagnosed within 48h of surgery based estabilished criteria for its diagnosis. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re-admission, and short-term and long-term mortality. RESULTS: The incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery, but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin-6 at 6h was the most predictive cytokine of acute kidney injury (cut-off point at 4.89pg.mL-1). CONCLUSIONS: Increased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin-6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.

Sevoflurane did not show better protective effect on endothelial glycocalyx layer compared to propofol during lung resection surgery with one lung ventilation.

BACKGROUND: The endothelial glycocalyx layer (EGL) coats the alveolar capillary endothelium and plays important roles in pulmonary vascular protection, modulation, and hemostasis. Ischemia-reperfusion, which occurs during lung resection surgery with one lung ventilation (OLV), can damage the EGL. Sevoflurane is known for its protective effect against ischemia-reperfusion injury. Therefore, we hypothesized that lung resection surgery produces EGL damage and sevoflurane protects the EGL better than the intravenous anesthetic propofol. METHODS: Seventy-eight patients undergoing pulmonary resection were randomly allocated into the sevoflurane (n=38) and propofol (n=40) groups. All patients received OLV and protective ventilation under sevoflurane- or propofol-based anesthesia. The concentrations of EGL injury markers (heparan sulfate and human syndecan-1) and an inflammatory marker (vascular cell adhesion molecule-1) were measured from blood samples drawn at five time points (after induction, 60 min after OLV, 120 min after OLV, end of OLV, and end of surgery). RESULTS: OLV increased the concentrations of EGL injury markers; heparan sulfate concentrations increased from 120 minutes after OLV (120 minutes after OLV: sevoflurane, 13.3±6.8 ng/mL, P<0.05; propofol, 14.8±6.9 ng/mL, P<0.05). Human syndecan-1 concentrations also increased from 120 minutes after OLV (120 minutes after OLV: sevoflurane, 20.4±8.9 ng/mL, P<0.05; propofol, 20.5±11.8 ng/mL, P>0.05). However, no difference in EGL injury markers was observed between the sevoflurane and propofol groups at any time point. Vascular cell adhesion molecule-1 concentrations did not show any temporal changes in either group. CONCLUSIONS: Lung resection surgery with OLV produced EGL damage without any increase in inflammation. Although shedding of heparan sulfate induced by EGL injury during lung resection surgery with OLV, was less than propofol, it was not statistically significant.

Which is Better - A Standalone Ventilation or Perfusion Scan or Combined Imaging to Predict Postoperative FEV1 in One Seconds in Patients Posted for Lung Surgeries with Borderline Pulmonary Reserve.

INTRODUCTION: Forced expiratory volume in one second (FEV1) is an independent predictor for respiratory morbidity. Reports are varied and controversial substantiating the use of either lung perfusion (Q) or ventilation (V) scintigraphy as a single stage investigation to predict postoperative (ppo) FEV1 in patients scheduled for lung resection surgeries. It is said that there is no additional benefit by performing both V/Q scan. As per one of the recommendations, no further respiratory function tests are required for a lobectomy if the postbronchodilator FEV1 is >1.5 l. We wanted to study the ppo FEV1 in patients with FEV1 of <1.5 L scheduled for lung surgeries. Being a high-risk population, we wanted to assess (a) whether the ppo changes by this combined V/Q imaging and (b) whether the incidence of respiratory complication in the postoperative setting of this subgroup is different, (c) and study the short- and long-term clinical outcome. MATERIALS AND METHODS: Fifty-two high-risk patients (with comorbidities) and borderline preoperative FEV1 of 1.5 L or less planned for lung resection were enroled in this prospective study. V and Q scans were performed, and tracer uptake percentage was tabulated. RESULTS: Tracer uptake in each lung was quantitated. Manual method of ROI drawing is preferred in high risk patients with reduced pulmonary reserve over the automatic method. Based on uptake patterns by V/Q scans, 4 different types of patterns were tabulated. Eighty-eight percentage of centrally placed tumors showed the difference in uptake patterns. Chronic obstructive pulmonary disease patients usually showed more modest ventilatory defects (categorised as type 2 or 3). Lung tumours produce erratic uptake patterns (Type 4) which depend heavily on their location and extent. The range of FEV1 predicted was 0.6-1.38 L/min. CONCLUSION: We recommend that combined imaging should be performed in patients with borderline pulmonary reserve to derive the benefit of surgery as it provides a realistic ppo FEV1 in patients with moderate to severely damaged lung. Centrally placed hilar or bronchial tumors (even those <2 cm in size), produce discrepancies in V/Q distribution pattern. Patient who was thought ineligible for surgery due to low baseline FEV1 may be actually be operable by this combined imaging if uptake pattern is better in V or Q scan with a good outcome. Accurate estimation of postop FEV1 in fact helps the surgical team to implement measures to prepare high risk patients to reduce postoperative complications, enable faster weaning from ventilatory support and ensure favourable prognosis.

Single-lung ventilation with bronchofibroscopy during lung resection surgery. / Oxigenación unilobar con fibroscopio durante cirugía de resección pulmonar.

Lung isolation using one-lung ventilation is common during thoracic surgery procedures, as it allows proper visualisation and manipulation of the lung to be operated on. Selective lobar blockade has been described in patients that do not tolerate one-lung ventilation, and is usually achieved using endobronchial blockers. However, it depends on endobronchial blocker availability, its complexity regarding proper positioning, and the need for constant monitoring to ensure the correct placement of the bronchial seal. In the clinical case to be described, a new method was used to increase the available surface for oxygen exchange. This was accomplished by means of direct supply of oxygen through the bronchoscope's working channel to one of the not-to-be operated-on, non-ventilated lung lobes. With this technique, the surgeon had an optimal operating field, oxygenation from one-lung ventilation improved and no perioperative complications were found.

Pulmonary venous thrombosis secondary to radiofrequency ablation of the pulmonary veins.

BACKGROUND: Pulmonary Vein Thrombosis (PVT) is a rare and underdiagnosed entity produced by local mechanical nature mechanisms, vascular torsion or direct injury to the vein. PVT has been described in clinical cases or small multicenter series mainly in relation to pulmonary vein stenosis, metastatic carcinoma, fibrosing mediastinitis, as an early surgical complication of lung transplantation lobectomy and radiofrequency ablation performed in patients with atrial fibrillation, although in some cases the cause is not known. CASE: We report the case of a 57 years old male with history of atrial fibrillation treated by radiofrequency ablation who was admitted in our center because of a two-week history of consistent pleuritic pain in the left hemithorax and low-grade hemoptysis and a lung consolidation treated as a pneumonia with antibiotic but not responding to medical therapy. In view of the poor evolution of the patient, computed tomography angiography was performed with findings of PVT and secondary venous infarction and anticoagulation therapy was optimized. At the end, pulmonary resection was performed due to hemorrhagic recurrence. CONCLUSION: PVT remains a rare complication of radiofrequency ablation and other procedures involving pulmonary veins. Clinical suspicion and early diagnosis is crucial because is a potentially life-threatening entity.