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Vol. 98. Issue 4.
Pages 226-234 (April 2020)
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233
Vol. 98. Issue 4.
Pages 226-234 (April 2020)
Original article
DOI: 10.1016/j.cireng.2020.03.003
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Risk Factors for the Development of Complications After Surgical Treatment for Bronchopulmonary Carcinoma
Factores de riesgo para el desarrollo de complicaciones tras tratamiento quirúrgico del carcinoma broncopulmonar
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Miriam Estors-Guerreroa, Aránzazu Lafuente-Sanchisb,
Corresponding author
alafuente@hospital-ribera.com

Corresponding author.
, Florencio Quero-Valenzuelac, José Marcelo Galbis-Carvajala, Silvana Crowleyd, Ángel Carvajale, Carmen Payaa, Antonio Cuetoc
a Servicio de Cirugía Torácica, Hospital Universitario de La Ribera, Alzira (Valencia), Spain
b Servicio de Genética-Biología Molecular, Hospital Universitario de la Ribera, Alzira (Valencia), Spain
c Servicio de Cirugía Torácica, Hospital Virgen de las Nieves, Granada, Spain
d Servicio de Cirugía Torácica, Hospital Universitario Puerta de Hierro, Madrid, Spain
e Servicio de Cirugía Torácica, Hospital Son Dureta, Palma de Mallorca, Spain
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Tables (6)
Table 1. Hospitals That Have Participated in the Study.
Table 2. Grade Complication of Patients’ Morbidity.
Table 3. Univariate Analysis Results for the Association Between Patients’ Characteristics and Morbidity/mortality.
Table 4. Univariate Analysis Results for the Association Between Patients’ Comorbidity and Morbidity/Mortality.
Table 5. Patients’ Morbidity.
Table 6. Multivariate Analysis for the Association Between Patients’ Variables and Morbidity/Mortality.
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Abstract
Introduction

The most suitable treatment in most early-stage lung cancer patients is surgical resection. Despite previously assessing each patient's status being relevant to detect possible complications inherent to surgery, no consensus has been reached on which factors are “high risk” in such patients. Our study aimed to analyze the morbidity and the mortality incidence associated with this surgery in our setting with a multicentre study and to detect risk parameters.

Methods

A prospective analysis study with 3307 patients operated for bronchopulmonary carcinoma in 24 hospitals. Study variables were age, TNM, gender, stage, smoking habit, surgery approach, surgical resection, ECOG, neoadjuvant therapy, comorbidity, spirometric values, and intraoperative and postoperative morbidity and mortality. A multivariate logistic regression analysis of the morbidity and mortality predictor factors was done.

Results

We recorded 34.2% postoperative morbidity and 2.1% postoperative mortality. Gender, myocardial infarction, angina, ECOG ≥1, COPD, DLCO <60%, clinical pathological status, surgical resection and surgery approach were shown as morbidity and mortality predictor factors in lung cancer surgery in our series.

Conclusions

The main variables to consider when assessing the lung cancer patients to undergo surgery are gender, myocardial infarction, angina, ECOG, COPD, DLCO, clinical pathological status, surgical resection and surgery approach.

Keywords:
Lung cancer
Surgery
Morbidity
Mortality
Resumen
Introducción

El tratamiento más adecuado en la mayoría de los pacientes con cáncer de pulmón en estadio inicial es la resección quirúrgica. A pesar de evaluar anteriormente que el estado de cada paciente sea el adecuado para detectar posibles complicaciones inherentes a la intervención quirúrgica, no se ha alcanzado ningún consenso sobre los factores que son de «alto riesgo» en esos pacientes. Nuestro estudio tuvo como objetivo analizar la morbilidad y la incidencia de mortalidad asociada con esta intervención quirúrgica en nuestro entorno con un estudio multicéntrico y descubrir los parámetros de riesgo.

Métodos

Se trata de un estudio de análisis prospectivo con 3.307 pacientes operados de carcinoma broncopulmonar en 24 hospitales. Las variables de estudio fueron edad, sistema TNM, sexo, estadio, tabaquismo, abordaje quirúrgico, resección quirúrgica, escala ECOG, tratamiento neoadyuvante, comorbilidad, valores espirométricos y morbimortalidad intra- y postoperatoria. Se realizó un análisis de regresión logística multivariante de los factores pronósticos de morbilidad y mortalidad.

Resultados

Registramos el 34,2% de morbilidad postoperatoria y el 2,1% de mortalidad postoperatoria. Sexo, infarto de miocardio, angina, ECOG ≥1, EPOC, DLCO <60%, estado clínico patológico, resección quirúrgica y abordaje quirúrgico aparecieron como factores pronósticos de morbilidad y mortalidad en cirugía de cáncer de pulmón en nuestra serie.

Conclusiones

Las principales variables que deben tenerse en cuenta al evaluar a pacientes con cáncer de pulmón para realizarles una intervención quirúrgica son sexo, infarto de miocardio, angina, ECOG, EPOC, DLCO, estado clínico patológico, resección quirúrgica y abordaje quirúrgico.

Palabras clave:
Cáncer de pulmón
Intervención quirúrgica
Morbilidad
Mortalidad
Full Text
Introduction

Nowadays, bronchopulmonary carcinoma (BC) is the main cause of death by cancer worldwide. In early stages, surgical resection is still the most suitable treatment for most patients, and assessing each patient's status is of utmost importance before operating and foreseeing the appearance of any complications inherent to this treatment.1 One in every five stage-I non-cell lung cancer (NSCLC) patients is considered to be at high risk for postoperative complications2 and mortality rates of 2.2% have been published for patients undergoing NSCLC resection.3

Several factors have been proved to increase surgical risk for BC resection and impact patient outcomes. They include among others: age, chronic obstructive lung diseases (COPD), former myocardial infarction (MI), smoking and/or carbon monoxide diffusing capacity (DLCO) under 60%.4,5 Different risk staging models have been recently developed trying to propose tools for chest surgeons.3,5,6 To date, however, no consensus has been reached about the definition of “high risks” in such patients, finding only weak recommendations in the literature. This makes selecting the plan to be followed in each patient a difficult task.

This study aimed to analyze the incidence of morbidity and mortality associated with BC resection in our setting by a multicentre study with patients from 24 Spanish departments of Thoracic, and to evaluate the risk factors that impact morbidity and mortality, which must be considered in order to plan the most suitable therapeutic strategies for each patient. This analysis also provides us with a valuable tool to assess the outcomes in our network.

Patients and MethodsPatients

This study is a prospective analysis that includes 3307 patients with suspected NSCLC undergoing surgery with curative purpose in 24 Spanish departments of Thoracic Surgery from 1 June 2012 to 30 November 2014. Patients with unresectable disease undergoing exploratory thoracotomies were excluded. All the involved hospitals recorded the same data for the disease, treatment and patient progress, being cares reviewed by the individual surgeons. Later, an external data manager collected data in a uniform manner. An auditory ensured the proper collection of data. Histology different from BC were excluded. The European guidelines criteria were followed for the surgery, neoadjuvant therapy and posterior diagnosis.7

The study variables were chosen according to previous literature7,8 and they were defined in advance and agreed by all the authors: age, stage, gender, pathological stage, smoking habit, surgery approach, surgical resection, clinical status, neoadjuvant therapy (chemotherapy or chemo-radiotherapy), comorbidity, spirometric values (DLCO, forced expiratory volume in one second (FEV1), and intraoperative and postoperative morbidity and mortality. Postoperative morbidity and mortality was assessed by considering the first 30 days for the purpose. Tumors were staged using the 7ª Revision in the International System for Staging Lung Cancer (TNM). The Eastern Cooperative Oncology Group (ECOG) scale was used for classifying clinical status (Table 1).

Table 1.

Hospitals That Have Participated in the Study.

Hospital General de Asturias 
Hospital General de Valencia 
Hospital de Jaén 
Hospital U. N. S. de la Candelaria (Tenerife) 
Hospital Clínico de Madrid 
Hospital de Palma de Mallorca 
Hospital Puerta de Hierro (Madrid) 
Hospital de Albacete 
Hospital Clínic (Barcelona) 
Hospital Sagrado Corazón (Barcelona) 
Hospital Virgen del Rocío (Sevilla) 
Hospital Gregorio Marañón (Madrid) 
Hospital Germans Trias i Pujol 
Hospital U. Virgen de las Nieves (Granada) 
Hospital Carlos Haya (Málaga) 
Hospital de Alicante 
Hospital de la Ribera (Alzira, Valencia) 
Hospital La Paz (Madrid) 
Hospital A Coruña 
Hospital Islas Cies (Vigo) 
Hospital Reina Sofía (Córdoba) 
Hospital U. de Girona Dr. Josep Trueta 
Hospital Universitario Donostia 
Hospital de Santiago de Compostela 

All complications collected in data had clinical transcendence. To analyze morbidity, the systematic classification of operative morbidity into five normalized groups (Table 2), proposed by Dindo et al.,9 was used. It helped to make an objective comparison of surgical procedures and patient series, and also between different surgeons and operating teams. Hemorrhage was considered a complication when it was >200ml/h with hemodynamic instability and/or a total of 1500ml, and air leak when it lasted at least 5 days. A possible occurrence of atelectasis was reviewed after surgery in all patients. Hypoxia was considered when <60 O2mmhg, angina pectoris in the absence of obstructive coronary artery disease and myocardial infarction when coronary artery was obstructed. All myocardial infarction were remote. Ischemic cardiomyopathy was considered when patients suffered simultaneously angina pectoris and myocardial infarction.

Table 2.

Grade Complication of Patients’ Morbidity.

Grade  Definition  n  Percentage 
Minor complication
No pharmacological or other treatment is required  786  23.7% 
II  Minor intervention or extra pharmacological treatment is needed  565  17% 
Major complication
III  Surgical, radiological or endoscopic surgery, or multiple treatments, is required     
IIIa  Intervention does not require general anesthesia  129  3.9% 
IIIb  Intervention requires general anesthesia  94  2.8% 
IV  Treatment in intensive care and life support unit is needed     
IVa  Dysfunction of a single organ  49  1.5% 
IVb  Multiorganic dysfunction  30  0.9% 
Patient's death caused by the complication  71  2.1% 

Each patient was enrolled after acceptance of informed consent document. Study protocol was approved by the ethics committees of the Hospitals involved in the study and conducted in accordance with the Declaration of Helsinki.

Statistical Analysis

Categorical variables were expressed as absolute values and percentages (%). A multivariate logistics regression analysis was done to analyze the correlation between morbidity (including minor and major complications), mortality and clinical characteristics of patients (age, TNM, gender, pathological stage, smoking habit, surgery approach, surgical resection, ECOG, neoadjuvant therapy, comorbidity, spirometric values). The correlation between clinical characteristics and intraoperative mortality was not shown due to limited number of patients in this group (n=3). Variables showing a minimum significance threshold on the univariate analysis were included for the multivariate test. Level of significance was considered for a P-value of ≤.05. Statistical analysis was run with the SPSS package, v. 20.0 (SPSS Inc, Chicago, IL, USA).

Results

Table 3 offers the clinical-pathological characteristics of the patients included in our study. From 3307 cases, 77.6% were male, with a median age of 66 years. Adenocarcinoma was the most frequent histological subtype (55.1%). Distribution by stages was as follows: I: 55.1%, II: 24.9%, III: 14%, IV: 1.9%. A total of 263 patients (8%) received neoadjuvant treatment. The most frequent surgery approach was thoracotomy (67%). Lobectomy was the most widely performed surgical resection (71.8%). Regarding comorbidity (Table 4), COPD criteria (28.4%) was the most frequent, followed by ischemic cardiomyopathy (9.2%), vascular disease (8.1%) and atrial fibrillation (6.7%).

Table 3.

Univariate Analysis Results for the Association Between Patients’ Characteristics and Morbidity/mortality.

Variable  n  Percentage  Postoperative    Intraoperative 
      Mortality  Morbidity  Morbidity 
      P  P  P 
Age (years)
<65  1400  42.33%  .005*  .049*  .044* 
65–79  1732  52.37%       
>79  175  5.29%       
Gender
Female  741  22.40%  .000***  .000***  .045* 
Male  2566  77.60%       
Histology
Adenocarcinoma  1704  51.52%       
Squamous  1212  36.64%  .234  .078  .551 
Large cell tumor  96  2.90%       
Microcytic  28  0.84%       
Adenosquamous  55  1.66%       
Others  212  6.41%       
Pathological stage
1821  55.06%       
II  825  24.94%  .043*  .049*  .039* 
III  463  14%       
IV  63  1.90%       
Complete response  28  0.85%       
Not known  107  3.23%       
Neoadjuvant treatment
Yes  263  7.95%  .150  .298  .345 
No  3044  92.05%       
Smoking status
Smoker  1042  31.51%       
Former Smoker  1751  52.95%  .029*  .000***  .046* 
Never-smoker  393  11.88%       
Not known  121  3.66%       
Surgery approach
Toracotomy  2233  67.52%       
VATS  1030  31.15%  .003***  .045*  .039* 
Others  44  1.33%       
Surgical resection
Pneumonectomy  314  9.49%       
Lobectomy  2376  71.85%  .005***  .034*  .045* 
Bilobectomy  169  5.11%       
Anatomical segmentectomy  143  4.2%       
Wegde  308  9.31%       
General state
ECOG 0  1988  60.11%       
ECOG 1  1090  32.96%  .005***  .002***  .047* 
ECOG 2  109  3.30%       
ECOG 3  0.24%       
ECOG 4  0.06%       
No assessable  110  3.33%       
Comorbidity
Yes  2832  85.64% 
No  475  14.36%       

Video-assisted-Thoracic Surgery (VATS).

The Eastern Cooperative Oncology Group scale (ECOG).

Table 4.

Univariate Analysis Results for the Association Between Patients’ Comorbidity and Morbidity/Mortality.

Previous Disease  n  Percentage  Postoperative    Intraoperative 
      Mortality  Morbidity  Morbidity 
      P  P  P 
Ischemic cardiomyopathy  304  9.19%  .144  .067  .125 
Myocardial infarction  128  3.87%  .036*  .005***  .032* 
Angina pectoris  54  1.63%  .020*  .056  .044* 
Atrial fibrillation  221  6.68%  .043*  .060  .443 
Vascular disease  267  8.07%  .030*  .106  .456 
Valvular hearth disease  69  2.08%  .148  .138  .160 
Atelectasis  25  0.76%  .045*  .020*  .455 
COPD  940  28.42%  .000***  .000***  .048* 
Lung disease  25  0.76%  .043*  .002***  .043* 
Stroke sequel  78  2.36%  .017*  .328  .425 

Chronic obstructive lung diseases (COPD).

We recorded an intraoperative morbidity of 7.5%. We found 279 complications, being the most frequent hypoxia (<60 O2mmh) (2.7%), hemorrhage (by iatrogenic section of artery or vein) (1.8%) and costal fracture (1.7%). Postoperative morbidity was 34.2%, where air leaks (10.6%), arrhythmia (6.3%) and pneumonia (6.2%) stood out (Table 5). Overall, we found that the majority of patients’ complications were minor (78.4%; Table 2). Intraoperative mortality was 0.1%. 30-days postoperative mortality rate was 2.1% (69 patients). From them, 41 had undergone lobectomy, 19 pneumonectomy, 5 sublobar resection and 4 bilobectomy, which means a higher rate of deaths in pneumonectomy (6.1% pneumonectomy vs 1.7% lobectomy, 2.4% bilobectomy and 1.1% sublobar resection).

Table 5.

Patients’ Morbidity.

Complication  n  Percentage of Total Patients  Percentage on Morbidity 
Intraoperative
Arrhythmia  39  1.18%  13.98% 
Hypoxia  89  2.69%  31.90% 
Hemorrhage  61  1.84%  21.86% 
Costal fracture  55  1.66%  19.71% 
Others  35  1.06%  12.54% 
Mortality  0.09%  – 
N° total complications  279     
N° patients with complications  249     
Postoperative
Pneumonia  204  6.17%  14.12% 
Hemoptysis  0.18%  0.41% 
Atelectasis  191  5.78%  13.22% 
Intubation  57  1.72%  3.94% 
Pleural effusion  70  2.12%  4.84% 
Air leaks  355  10.6%  24.57% 
Arrhythmia  208  6.29%  14.39% 
Ischemic Cardiopathy  12  0.36%  0.83% 
Pulmonary edema  35  1.06%  2.42% 
Infarction  0.15%  0.35% 
Hemorrhage  121  3.66%  8.37% 
Fistula  38  1.15%  2.63% 
Empyema  31  0.94%  2.14% 
Infection  20  0.60%  1.38% 
Dehiscence  12  0.36%  0.83% 
Others  80  2.42%  5.54% 
Mortality  69  2.08%  – 
N° total complications  1445     
N° patients with complications  1132     

Univariate analysis of the association between patients’ characteristics and morbidity/mortality are shown in Tables 3 and 4. Regarding the pre-surgery factors that influenced intraoperative and postoperative morbidity and mortality (Table 6), the multivariate analysis show that those patients with a background of MI (OR 1.4; 95%CI: 1–2.1), angina (OR 1.7; 95%CI: 1–3), DLCO <60% (OR 1.4; 95%CI: 1.1–1.7) and major resection (OR 1.3; 95%CI: 1–1.6) presented a higher probability of intraoperative morbidity. The patients with a background of MI (OR 1.4; 95%CI: 1–2.1), COPD (OR 1.4; 95%CI: 1.2–1.7), lung disease (OR 3.1; 95%CI: 1.3–7.2), ECOG ≥2 (OR 1.7; 95%CI: 1.1–2.6), DLCO <60% (OR 1.6; 95%CI: 1.3–2.1) and major resection (OR 2.1; 95%CI: 1.6–2.7) presented a higher probability of postoperative morbidity. Females (OR 0.6; 95%CI: 0.4–0.7) and the patients undergoing for Video-assisted-Thoracic Surgery (VATS) (OR 0.6; 95%CI: 0.5–0.7) were less likely to present postoperative morbidity.

Table 6.

Multivariate Analysis for the Association Between Patients’ Variables and Morbidity/Mortality.

Intraoperative Morbidity  Exp(B)  I.C. 95%  P  Exp(B)  30 Days-Morbidity  P 
Variable          I.C. 95%   
Gender  1.083  0.902–1.300  .391  0.565  0.458–0.696  .000 
Age (<80/≥80)  0.917  0.670–1.254  .586  1.230  0.887–1.704  .214 
Smoking status  0.915  0.724–1.156  .456  0.976  0.748–1.274  .860 
Myocardial infarction  1.461  1.022–2.088  .038  1.470  1.017–2.124  .040 
Angina pectoris  1.754  1.014–3.036  .045  1.277  0.724–2.254  .398 
Atelectasis  0.909  0.405–2.042  .817  2.109  0.937–4.746  .072 
Pneumonia  0.967  0.592–1.579  .893  1.188  0.716–1.972  .504 
COPD  0.949  0.804–1.119  .533  1.453  1.224–1.724  .000 
Lung disease  0.422  0.172–1.031  .058  3.017  1.271–7.162  .012 
DLCO (<60/≥60)  1.426  1.156–1.758  .001  1.653  1.330–2.054  .000 
FEV1 (<60/≥60)  1.178  0.933–1.486  .169  0.824  0.647–1.048  .114 
Surgery approach (VATS vs Thoracotomy)  0.936  0.805–1.087  .386  0.638  0.539–0.753  .000 
Surgical resection (Minor vs major)  1.290  1.036–1.607  .023  2.107  1.632–2.719  .000 
ECOG (0 vs 1/2)  1.336  0.894–1.995  .157  1.715  1.149–2.560  .008 
Stage  0.970  0.648–1.452  .883  0.878  0.574–1.343  .548 
Intraoperative mortality          30 days-mortality   
Gender  –  –  –  0.180  0.042–0.770  .021 
Age (<80/≥80)  –  –  –  1.506  0.578–3.928  .402 
Smoking status  –  –  –  1.529  0.354–6.609  .570 
Myocardial infarction  –  –  –  2.121  0.858–5.244  .103 
Angina pectoris  –  –  –  4.009  1.286–12.497  .017 
Atelectasis  –  –  –  1.532  0.194–12.094  .686 
Pneumonia  –  –  –  2.895  0.979–8.562  .055 
COPD  –  –  –  2.124  1.246–3.621  .006 
Lung disease  –  –  –  2.964  0.564–15.578  .199 
DLCO (<60/≥60)  –  –  –  1.066  0.537–2.116  .854 
FEV1 (<60/≥60)  –  –  –  0.871  0.426–1.781  .705 
Surgery approach (VATS vs Thoracotomy)  –  –  –  0.307  0.138–0.682  .004 
Surgical resection (Minor vs major)  –  –  –  2.116  0.811–5.517  .125 
Stage  –  –  –  0.345  0.128–0.927  .035 
ECOG (0 vs 1/2)  –  –  –  2.910  1.258–6.731  .013 
Stroke sequel  –  –  –  3.378  1.259–9.064  .016 
Vascular disease  –  –  –  1.492  0.728–3.06  .274 
Fibrillation  –  –  –  1.549  0.678–3.535  .299 

Chronic obstructive lung diseases (COPD).

Carbon monoxide diffusing capacity (DLCO).

Forced expiratory volume in one second (FEV1).

Video-assisted-Thoracic Surgery (VATS).

The Eastern Cooperative Oncology Group scale (ECOG).

On the other hand, the patients with a background of angina (OR 4; 95%CI: 1.3–12.5), COPD (OR 2.1; 95%CI: 1.2–3.6), prior stroke with sequelae (OR 3.4; 95%CI: 1.2–9.1) and ECOG ≥1 (OR 2.9; 95%CI: 1.2–6.4) had a higher probability of postoperative mortality, while females (OR 0.2; 95%CI: 0.1–0.8), the patients operated for VATS (OR 0.3; 95%CI: 0.1–0.7), and stage I and II patients (OR 0.3; 95%CI: 0.1–0.9) presented a lower probability of postoperative mortality.

Discussion

Surgical resection continues to be the treatment of choice in early stages of NSCLC, and its results depend on both correct oncological assessments and careful overall perioperative selection, which prevent complications inherent to this treatment from appearing.1–3

In our series, we found an intraoperative morbidity of 7.5% and a postoperative morbidity within the first 30 days of 34.2%. Postoperative and intraoperative mortality were of 2.1% and 0.1%, respectively. These data agree with the figures described in the literature.2,3,10 The decrease in postoperative mortality found in latest studies was particularly significant when comparing to the Sociedad Española de Patología del Aparato Respiratorio (SEPAR) study reporting morbidity and mortality rates of 35.2% and 6.8%, respectively, for patients undergoing thoracotomy between 1993 and 1997.1 Several issues may explain this positive tender in quality of surgery for NSCLC, such as a better patient selection for surgery (thanks to the introduction of PET images within preoperatory clinical staging tools), and the implementation of perioperative programs of respiratory rehabilitation.

In our study, we found that surgical complications resulting from BC resection were mainly minor, highlighting air leaks (10.6%), which were more frequent than those found in other series.1 Cardiac arrhythmia was the most frequently observed complication behind persistent air leaks, and was also the most frequent postoperative medical complication. It is usually described in most similar studies, with rates ranging between 3.8 and 40% after lung cancer surgery.

One of the most important predictors of morbimortality after NSCLC surgical resection is patient clinical status before surgery.11 As expected, this variable was significantly statistical in our series in the patients with ECOG values above or equal to 1, who presented a higher probability of intra- and postoperative morbidity and mortality.

One of the most controversial questions is whether age is a limiting factor for lung surgery, specifically in patients aged over 80.12 In our series, octogenarian patients shown similar morbidity and mortality rates than other age groups. Many studies corroborate this finding,4,13,14 concluding that octogenarian patients can be submitted to lung resection. We ought not to forget that these patients are more fragile and we must always contemplate the sublobar surgery as an alternative, provided it is feasible, and by VATS since this approach is less aggressive.

In recent decades, the proportion of females diagnosed with BC has significantly increased in Spain1 probably related to social smoking habits. As previously reported in literature,5 in our series, females presented lower postoperative morbidity and mortality rates, probably due to lower comorbidity. As it is well-known, a high percentage of patients with BC present clinical COPD criteria, being it considered a risk for lung surgery.2 In our sample, 28.4% of the patients had COPD, whose presence has been statistically related with both mortality and postoperative morbidity. The structural lesions that this pathology causes increase the dead space, imbalanced ventilation-perfusion quotients, hemodynamic changes in lung capillaries and altered diffusion, which increase the efforts made to breath and can lead to respiratory failure, which is the main cause of death during lung resection surgery.15

Low FEV1 values are associated with increased cardiorespiratory morbidity and mortality.16,17 After performing a multivariate analysis in our sample, for which we dichotomised the FEV1 values into higher than or equal to 60% and into lower than 60% according to previous literature,18 we observed that this variable did not act as an independent risk factor for morbidity and mortality. However, as we mentioned, COPD has been statistically related to morbidity and mortality, and we should not forget that FEV1 is one of the clinical criteria used to define obstructive lung disease.

Establishing a cut off of 60% for DLCO, we found that DLCO acted as a risk factor for morbidity, but not for mortality. Preoperative DLCO <60 have been associated with 25% mortality and 40% morbidity in patients who underwent lung resection surgery. Low predicted DLCO values act as a predictor of cardiorespiratory complications, and of mortality even in patients with FEV1 that fall within normality limits. Brunelli et al.19 found a weak correlation between preoperative DLCO values and forced volume expired in the first second (FEV1%) values and systematic postoperative DLCO calculations, which improves predicting the lung resection risk. This is currently the reason why the guidelines of the American College of Chest Physicians8 and those of the European Respiratory Society and the European Society of Thoracic Surgeons20 recommend taking preoperative DLCO measurements in all candidate patients for lung resection surgery. In our study we did not find DLCO as an independent risk factor for mortality but it should be taken into account that DLCO is other of the clinical criteria used to define COPD.

Ischemic cardiomyopathy is a high risk factor for lung resection surgery with an incidence ranging between 11% and 17%. Its presence implies a 3% risk for cardiac complications.21,22 We obtained a similar incidence in our series. Those patients with a background of angina prior to surgery have a higher intraoperative morbidity probability. Similarly, those patients who have suffered MI before surgery present higher postoperative morbidity.

Video-assisted surgery appears to offer the similar results to conventional open approaches, and refers to the possibility of achieve optimal oncological resections.23,24 Several studies13,25,26 have suggested that performing lung resections by VATS in qualified centers is associated with lower morbidity. We coincide with these studies because in our series, the VATS surgical approach was statistically associated with lower morbidity. We also found lower postoperative mortality for those patients who underwent VATS, which also agrees with previous results.5,16

Sublobar resections have obtained excellent oncological results in tumors <2cm, and have shown a lower perioperative morbidity risk.27 The advantages of minor resections include maintaining lung function, a lower risk of perioperative morbidity and mortality, the possibility of patients tolerating future resections if a second primary lung tumor and/or recurring tumors appear/s, and a simple surgical procedure, plus the possibility of carrying it out by less invasive techniques. The current main disadvantage of such operations is the increased risk of loco-regional recurrence. It has been shown that 5-year survival rate for segmentectomy in tumors <3cm is similar to lobectomy.28 However wedge resection is correlated to worse survival.29

It is noteworthy that the pathological status of the patients in our series was also observed to act as a mortality predictor factor. Thus stages I and II patients presented a lower mortality probability. This may be due to the fact that surgical resection and surgery approach employed in early stages are less aggressive, and also because these patients received no neoadjuvant therapy, which could perhaps impact morbidity.

We acknowledge limitations to our analysis. From the different Hospitals that participated in the study, we are unable to assess the effects, if any, that the different surgeons, their work team or the hospital's volume have on the development of patients’ complications. Furthermore, we analyzed complications altogether, rather than evaluating individual complications separately. Finally, other variables not contemplated in the study could have a role in patients’ morbidity and mortality.

Despite these limitations, our study has several strengths. The large numbers of patients from different regions included in the study reflects the current practice patterns across the nation, and it may serve to guide surgeons in appropriate patient selection. Further, these findings may serve to stimulate the implementation of better perioperative protocols designed to reduce the incidence of postoperative complications among BC patients.

In summary, we found that MI, DLCO <60%, major resection, angina, COPD and lung disease are the comorbidities related to intraoperative and postoperative morbidity during BC surgery, causing mainly minor complications, being the most frequent air leaks, arrhythmia, pneumonitis and hypoxia. On the other hand, mortality appears to be related mainly to angina, prior stroke or ECOG ≥1.

Conclusions

We recorded a postoperative morbidity and mortality of 34.2% and 2.1%, respectively. Gender, MI, angina, ECOG ≥1, COPD, DLCO <60%, tumoral pathological status, and surgical resection and surgery approach worked as predictor factors of morbidity and mortality in lung cancer surgery in our series.

Conflict of Interest

None declared.

Funding

This study was funded by a grant by Sociedad Española de Cirugía Torácica (SECT).

Acknowledgments

None declared.

References
[1]
J.L. Duque, R. Rami-Porta, A. Almaraz, M. Castanedo, J. Freixinet, A. Fernández de Rota, et al.
Parámetros de riesgo en la cirugía del carcinoma broncogénico.
Arch Bronconeumol, 43 (2007), pp. 143-149
[2]
M.S. Sancheti, J.N. Melvan, R.L. Medbery, F.G. Fernández, T.W. Gillespie, Q. Li, et al.
Outcomes after surgery in high-risk patients with early stage lung cancer.
Ann Thorac Surg, 101 (2016), pp. 1043-1051
[3]
P.E. Falcoz, M. Conti, L. Brouchet, S. Chocron, M. Puyraveau, M. Mercier, et al.
The Thoracic Surgery Scoring System (Thoracoscore): Risk model for in-hospital death in 15,183 patients requiring thoracic surgery.
J Thorac Cardiovasc Surg, 133 (2007), pp. 325-332
[4]
M. Guerra, P. Neves, J. Miranda.
Surgical treatment of non-small-cell lung cancer in octogenarians.
Interact Cardiovasc Thorac Surg, 16 (2013), pp. 673-680
[5]
A. Brunelli, M. Salati, G. Rocco, G. Varela, D. van Raemdonck, H. Decaluwe, et al.
European risk models for morbidity (EuroLung1) and mortality (EuroLung2) to predict outcome following anatomic lung resections: an analysis from the European Society of Thoracic Surgeons database.
Eur J Cardiothorac Surg, 51 (2017), pp. 490-497
[6]
B.D. Kozower, S. Sheng, S.M. O’Brien, M.J. Liptay, C.L. Lau, D.R. Jones, et al.
STS database models: predictors of mortality and major morbidity for lung cancer resection.
Ann Thorac Surg, 90 (2010), pp. 875-881
[7]
D. Dindo, N. Demartines, P.A. Clavien.
Classification of surgical complications: a new proposals with evaluation in a cohort of 6336 patients and results of a survey.
[8]
A. Brunelli, A.W. Kim, K.I. Berger, D.J. Addrizzo-Harris.
Physiologic evaluation of the patients with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.
Chest, 143 (2013), pp. e166S-e190S
[9]
G.L. Colice, S. Shafazand, J.P. Griffi n, R. Keenan, C.T. Bolliger.
American College of Chest Physicians. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition).
Chest, 132 (2007), pp. 161S-177S
[10]
A. Green, J. Hauge, M. Iachina, E. Jakobsen.
The mortality after surgery in primary lung cancer: results from the Danish Lung Cancer Registry.
Eur J Cardiothorac Surg, 49 (2016), pp. 589-594
[11]
A. Rojas, M. Opazo, M. Hernández, P. Ávila, D. Villalobos.
Evaluación preoperatoria y predictores de morbimortalidad en resección de cáncer de pulmón.
Rev Med Chile, 143 (2015), pp. 759-776
[12]
T.K. Owonikoko, C.C. Ragin, C.P. Belani, A.B. Oton, W.E. Gooding, E. Taioli, et al.
Lung cancer in elderly patients: an analysis of the surveillance, epidemiology, and end results database.
J Clin Oncol, 25 (2007), pp. 5570-5577
[13]
T.D. Yan, C. Cao, T.A. D‘Amico, T.L. Demmy, J. He, H. Hansen, et al.
Video-assisted thoracoscopic surgery lobectomy al 20 years: a consensus statement.
Eur J Cardiothorac Surg, 45 (2014), pp. 633-639
[14]
M.A. Cañizares, E. García, M. Blanco, J. Soro, R. Carrasco, E. Peña, et al.
Is age a predisposing factor of postoperative complications after lung resection for primary pulmonary neoplasms?.
[15]
G. Varela, L. Molins, J. Astudillo, J.M. Borro, E. Canalís, J. Freixinet, et al.
Experiencia piloto de benchmarking en cirugía torácica: comparación de la casuística e indicadores de calidad en resección pulmonar.
Arch Bronconeumol, 42 (2006), pp. 267-272
[16]
P.E. Falcoz, M. Puyraveau, P.A. Thomas, H. Decaluwe, M. Hürtgen, R.H. Petersen, et al.
Video-assisted thoracoscopic surgery versus open lobectomy for primary non-small-cell lung cancer: a propensity-matched analysis of outcome from the European Society of Thoracic Surgeon database; ESTS Database Committee and ESTS Minimally Invasive Interest Group.
Eur J Cardiothorac Surg, 49 (2016), pp. 602-609
[17]
M.F. Berry, N.R. Villamizar-Ortiz, B.C. Tong, W.R. Burfeind Jr., D.H. Harpole, T.A. D’Amico, et al.
Pulmonary function tests do not predict pulmonary complications after thoracoscopic lobectomy.
Ann Thorac Surg, 89 (2010), pp. 1044-1051
[18]
M.K. Ferguson, J. Siddique, T. Karrison.
Modeling major lung resection outcomes using classification trees and multiple imputation techniques.
Eur J Cardiothorac Surg, 34 (2008), pp. 1085-1089
[19]
A. Brunelli, M.A. Refai, M. Salati, A. Sabbatini, N.J. Morgan-Hughes, G. Rocco.
Carbon monoxide lung diffusion capacity improves risk stratification in patients without airflow limitation: evidence for systematic measurement before lung resection.
Eur J Cardiothorac Surg, 29 (2006), pp. 567-570
[20]
A. Brunelli, A. Charloux, C.T. Bolliger, G. Rocco, J.P. Sculier, G. Varela, et al.
European Respiratory Society and European Society of Thoracic Surgeons joint task force on fitness for radical therapy. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy).
Eur Respir J, 34 (2009), pp. 17-41
[21]
A. Brunelli, G. Varela, M. Salati, M.F. Jimenez, C. Pompili, N. Novoa, et al.
Recalibration of the revised cardiac risk index in lung resection candidates.
Ann Thorac Surg, 90 (2010), pp. 199-203
[22]
A. Brunelli, S.D. Cassivi, J. Fibla.
External validation of the recalibrated thoracic revised cardiac risk index for predicting the risk of major cardiac complications after lung resection.
Ann Thorac Surg, 92 (2011), pp. 445-448
[23]
M.A. Cañizares, J.E. Rivo, M. Blanco, A. Toscano, E.M. García, M.J. Purrinos.
Influence of delay of surgery on the survival of patients with bronchogenic carcinoma.
Arch Bronconeumol, 43 (2007), pp. 165-170
[24]
T. Shiraishi, T. Shirakusa, M. Hiratsuka, S. Yamamoto, A. Iwasaki.
Video-assisted thoracoscopic surgery lobectomy for c-T1N0M0 primary lung cancer: its impact on locoregional control.
Ann Thorac Surg, 82 (2006), pp. 1021-1026
[25]
F. Detterbeck.
Thoracoscopic versus open lobectomy debate: the pro argument.
GMS Thorac Surg Sci, 6 (2009),
[26]
M. Sakuraba, H. Miyamoto, S. Oh, K. Shiomi, S. Sonobe, N. Takahashi, et al.
Video-assisted thoracoscopic lobectomy vs. conventional lobectomy via open thoracotomy in patients with clinical stage IA non-small-cell lung carcinoma.
Interact Cardiovasc Thorac Surg, 6 (2007), pp. 614-617
[27]
J.P. Wisnivesky, C.I. Henschke, S. Swanson, D.F. Yankelevitz, J. Zulueta, S. Marcus, et al.
Limited resection for the treatment of patients with stage IA lung cancer.
Ann Thorac Surg, 251 (2010), pp. 550-554
[28]
M. Okada, T. Koike, M. Higashiyama, Y. Yamato, K. Kodama, N. Tsubota.
Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study.
J Thorac Cardiovasc Surg, 132 (2006), pp. 769-775
[29]
M. Okada, W. Nishio, T. Sakamoto, K. Uchino, T. Yuki, A. Nakagawa, et al.
Effect of tumor size on prognosis in patients with non-small cell lung cancer: the role of segmentectomy as a type of lesser resection.
J Thorac Cardiovasc Surg, 129 (2005), pp. 87-93

Please cite this article as: Estors-Guerrero M, Lafuente-Sanchis A, Quero-Valenzuela F, Galbis-Carvajal JM, Crowley S, Carvajal Á, et al. Factores de riesgo para el desarrollo de complicaciones tras tratamiento quirúrgico del carcinoma broncopulmonar. Cir Esp. 2020;98:226–234.

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