Risk factors for post‐operative pulmonary complications in lung cancer patients after video‐assisted thoracoscopic lung resection: Results of the German Thorax Registry

Abstract

Objective: Post-operative pulmonary complications (PPCs) represent the most frequent complications after lung surgery. The aim of this study was to identify the modifiable risk factors for PPCs after video-assisted thoracoscopic surgery (VATS) in lung cancer patients.Methods: Data of this retrospective study were extracted from the German Thorax Registry, an interdisciplinary and multicenter database of the German Society of Anesthesiology and Intensive care medicine and the German Society of ThoracicSurgery. Univariate and multivariate stepwise logistic regression analysis of patientspecific and procedural risk factors for PPCs were conducted. Results:We analyzed 376 patients with lung cancer who underwent VATS bilobectomy (n = 2), lobectomy (n = 258) or segmentectomy (n = 116) in 2016 and 2017. Onehundred fourteen patients (114/376; 30%) developed PPCs. Two patients died within 30 days after surgery. In the univariate analysis, patients of the PPC group showed significantly more often a body mass index (BMI) ≤ 19 kg/m 2 ; a pre-operative forced expiratory volume in 1 second (FEV 1 ) ≤ 60%; a pre-operative arterial oxygen partial pressure (p a O 2 ) ≤ 60 mm Hg; a higher rate of prolonged duration of surgery (≥2 hours [h]) and a higher frequency of intraoperative blood loss ≥500 mL. The multivariate stepwise logistic regression analysis revealed 4 independent risk factors: FEV 1 ≤ 60%(1.9[1.1-3.4] OR [95% CI], P = 0.029); p a O 2 ≤ 60 mm Hg (4.6[1.7-12.8] OR [95% CI], P = 0.003; duration of surgery ≥2 hours (2.7[1.5-4.7] OR [95% CI], P = 0.001) and intraoperative crystalloids ≥6 mL/kg/h (2.9[1.2-7.5] OR [95% CI], P = 0.023). Conclusion:Intraoperative amount of crystalloid fluids should be kept below 6 mL/ kg/h and duration of surgery should be below 2 hours to avoid an increased risk for PPCs.

Developing a minimally-invasive anaesthesiological approach to non-intubated uniportal video-assisted thoracoscopic surgery in minor and major thoracic surgery

“…Previous data collected from three major studies show a faster recovery and low complication rates for nonintubated procedures, while surgical results seem to be similar (12)(13)(14). But according to a European and a more recent German survey (German Thorax Registry), adoption of niVATS for major lung surgery in Europe still is very rare (15,16). The biggest published case study from Hungary reports sixteen patients who underwent uniportal niVATS for anatomical lung resections (17).…”

Exercise training as part of lung cancer therapy

“…11,12 The reported incidence of post-operative pulmonary complications following surgery varies in the literature due to the wide variety of measurement tools utilized, but they are understood to occur more commonly in patients with chronic obstructive pulmonary disease (COPD), those with smoking history or poor lung function [12][13][14][15] as well as in patients whose surgery involved a thoracotomy (compared to video-assisted thoracic surgery), [12][13][14] increased use of intraoperative crystalloids 15 or a surgical procedure of ≥2 h in duration. 15 Furthermore, following surgery, lung function, exercise capacity and the physical function domain of HRQoL have consistently been shown to immediately decrease, [16][17][18][19][20][21] with partial to minimal recovery of lung function and exercise capacity at 6-12 months following surgery. 16,18,20,21 Lastly, nearly half of the patients who are alive 2 years after surgery continue to experience increased dyspnoea and fatigue when compared with preoperative levels.…”

“…Although surgical resection offers a chance of cure, post‐operative pulmonary complications such as respiratory failure, pneumonia, myocardial infarction and arrhythmias are not uncommon 11,12 . The reported incidence of post‐operative pulmonary complications following surgery varies in the literature due to the wide variety of measurement tools utilized, but they are understood to occur more commonly in patients with chronic obstructive pulmonary disease (COPD), those with smoking history or poor lung function 12–15 as well as in patients whose surgery involved a thoracotomy (compared to video‐assisted thoracic surgery), 12–14 increased use of intraoperative crystalloids 15 or a surgical procedure of ≥2 h in duration 15 . Furthermore, following surgery, lung function, exercise capacity and the physical function domain of HRQoL have consistently been shown to immediately decrease, 16–21 with partial to minimal recovery of lung function and exercise capacity at 6–12 months following surgery 16,18,20,21 .…”

“…Preoperative exercise training aims to maximize exercise capacity for the patient and in turn minimize the post‐operative burden for both the patient and health system. Prevention of post‐operative pulmonary complications is particularly important as they are associated with increased intensive care admissions, length of hospital stay and hospital readmissions, as well as early and late mortality in this population 12,14,15 . Preoperative exercise programmes in published randomized controlled trials (RCT) were generally short in duration and opportunistically used the time period whilst the patient was awaiting surgery, which was commonly less than 4 weeks 28 .…”

The Protocol For The Prehabilitation For Thoracic Surgery Study: A Randomized Pragmatic Trial Comparing A Short Home-Based Multimodal Program To Aerobic Training In Patients Undergoing Video-Assisted Thoracoscopic Surgery Lobectomy

“…The necessity of prehabilitation is widely recognized in the thoracic surgery community because thoracic surgery is associated with functional impairments and a relatively high incidence of PPCs [12]. Until recently, most of the preoperative interventions that have been implemented in thoracic surgery patients have been unimodal, and the majority of previous studies have focused on exercise-based training programs, particularly aerobic exercises [13][14][15].…”