HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Duque, J. L. Articles by Heras, F. Search for Related Content PubMed PubMed Citation Articles by Duque, J. L. Articles by Heras, F.

Ann Thorac Surg 1997;63:944-950
© 1997 The Society of Thoracic Surgeons

---

Original Article: General Thoracic

Early Complications in Surgical Treatment of Lung Cancer: A Prospective, Multicenter Study

Thoracic Surgery Service and Preventive Medicine Service, Hospital Universitario, Valladolid, Spain

Accepted for publication November 4, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment Appendix 1 References

 
Background. We prospectively analyzed the postoperative morbidity, mortality rate, and risk factors in 605 patients who underwent thoracotomy for bronchogenic carcinoma.

Methods. Patients were categorized by postsurgical tumor stage: I, 287 patients (47.4%); II, 49 patients (8.1%); IIIA, 154 patients (25.5%); IIIB, 80 patients (13.2%); IV, 16 patients (2.7%); unavailable, 19 patients (3.1%). Two hundred ninety-four patients (48.6%) underwent lobectomy, 172 (28.4%) pneumonectomy, 20 (3.3%) bilobectomy, 29 (4.8%) segmentectomy, 27 (4.5%) wedge resection, and 63 (10.4%) exploratory thoracotomy. The importance of the factors that influence the morbidity and mortality rates was calculated from their relative risks. Univariate and multivariate methods for a logistic regression model were used for this analysis.

Results. Postoperative complications developed in 196 patients (32.4%); there were 165 (27.3%) cases of operation-related complications and 152 (25.1%) cases of respiratory and cardiovascular complications. The morbidity rate was highest in patients with preexisting vascular disease (50.9%; odds ratio [OR], 2.20) or insulin-dependent diabetes mellitus (52.4%; OR, 2.77) and in patients who underwent pneumonectomy (40.1%; OR, 1.82). Forty patients (6.6%) died postoperatively, most commonly of respiratory failure (67.5%). The mortality rate was highest in patients with postoperative morbidity (OR, 31.9) or vascular disease (15.8%; OR, 2.83) and in patients who underwent pneumonectomy (13.4%; OR, 4.9).

Conclusions. Postoperative complications are more likely to develop in patients with peripheral vascular disease or insulin-dependent diabetes mellitus, or both. Postoperative mortality was found to be significantly higher in patients with vascular disease and those who underwent pneumonectomy.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment Appendix 1 References

 
Surgical resection is the best therapeutic option for patients with bronchogenic carcinoma. However, the results depend on the precise determination of the anatomic extent of the tumor and perioperative management, which includes careful patient selection and appropriate postoperative care.

The surgical treatment for bronchogenic carcinoma is not free of complications [1–3], however. Some are directly related to the treatment; others arise as the result of preexisting conditions. Such postoperative complications may significantly darken the prognosis in patients with this disease. A thorough analysis of all possible postoperative complications, including their etiology and incidence, is therefore mandatory during the planning of treatment in patients with disease that has been diagnosed early. We report here the postoperative morbidity and mortality and the risk factors identified in 605 prospectively studied patients who underwent surgical treatment for bronchogenic carcinoma in Spain.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment Appendix 1 References

 
From October 1, 1993, to September 30, 1994, 605 consecutive patients underwent thoracotomy for the management of bronchogenic carcinoma in 16 hospitals in Spain. Data from all patients were prospectively entered on standard data collection forms, and the information gathered included demographic, clinical, biologic staging, therapeutic, pathologic, and follow-up information [4]. These forms were registered by the Grupo Cooperativo de Carcinoma Broncogénico de la Sociedad Española de Neumología y Cirugía Torácica. All known prognostic variables were included, and the methods of analysis were described for each to ensure reproducibility. The TNM system published in 1986 by the American Joint Committee on Cancer International Classification, and partially modified in 1992 [5, 6], was used for classification and staging. The Eastern Cooperative Oncology Group [6] scale was used to categorize clinical status. Comorbidity was defined as the occurrence of bronchogenic carcinoma in association with other diseases. The extent of the surgical procedure was classified according to the slightly modified recommendations of the Sociedad Española de Neumología y Cirugía Torácica [7]. A standard procedure consists of lung resection and mediastinal lymph node dissection. An extended procedure consists of the resection of neighboring anatomic structures invaded by the tumor in addition to the lung resection and mediastinal lymph node dissection.

The patient characteristics are summarized in Table 1. The forced vital capacity, forced expiratory volume in 1 second predicted postoperatively, arterial oxygen pressure, and arterial carbon dioxide pressure were analyzed in every patient. A forced vital capacity of more than 50% was found in 583 patients. The forced expiratory volume in 1 second was above 2,500 mL in 166 patients, between 2,500 and 2,000 mL in 201 patients, between 2,000 and 1,500 mL in 158 patients, and between 1,500 and 1,000 mL in 67 patients; data were not available for the remaining 13 patients.

A descriptive quantitative and qualitative evaluation of morbidity and mortality was done during the first 30 days postoperatively. Postoperative complications were divided into the following four groups: (1) complications directly related to operation (air leak, residual pleural space, empyema, bronchopleural fistula, hemothorax, and wound infection); (2) respiratory complications (pneumonia, respiratory failure, atelectasis, and mechanical ventilation for longer than 72 hours); (3) cardiovascular complications (arrhythmia, pulmonary thromboembolism, acute myocardial infarction, and acute cerebrovascular accident); and (4) complications affecting other organs (gastrointestinal tract bleeding, renal failure). The possible contribution of other factors to morbidity and mortality, such as age, sex, smoking history, previous diseases, respiratory function, type of surgical procedure, and adjuvant therapy, was also analyzed. In the univariate analysis, the significance of each factor registered for the dependent variables, morbidity and mortality, was evaluated using ² analysis for categoric data. Factors with a univariate significance level of p < 0.25 were initially included as independent variables in the analysis. Forward and backward, stepwise logistic regression analysis was used to determine the effect of risk factors on morbidity and mortality. The final model included factors that remained significant with a p value of less than 0.10. This analysis was completed in 495 patients with complete information on all factors considered in this model.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment Appendix 1 References

 
The morbidity rate was 32.4% (196 patients). A total of 361 complications were identified, the most common being those directly related to operation and those that were respiratory and cardiac in origin. The most common complications were cardiac arrhythmia and air leaks (Table 2). The morbidity rate in patients who had preexisting cardiac and vascular disease or who had insulin-dependent diabetes mellitus was significantly higher than that in patients without these problems. Patients over 70 years of age and those who were smokers had a higher, but not statistically significant, morbidity rate. The morbidity rate was lower, but not significantly so, in female patients. Morbidity rates in those patients with a predicted postoperative forced expiratory volume in 1 second of approximately 800 mL, a 30% theoretical value, or both, and in those with an arterial oxygen pressure of less than 60 mm Hg were higher, but the differences did not reach statistical significance. Regarding the variables related to therapy, pneumonectomy was associated with high morbidity rates (Tables 3 to 5).

In the logistic regression model (Table 6), the risk of morbidity was increased in patients with concomitant peripheral vascular disease (odds ratio [OR], 2.20), those with insulin-dependent diabetes mellitus (OR, 2.77), those who had undergone pneumonectomy (OR, 1.82), and those who had respiratory disease (OR, 1.49).

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment Appendix 1 References

The incidence of cardiovascular disorders was generally found to be less than that in other series, with cardiac rhythm abnormalities the most common such complication (6.8%) in this series. This is in the lower limit of the range of reported values of 3.8% to 37% [10]. Cardiac arrhythmias have been reported to occur in from 9% to 24% of patients undergoing pneumonectomy (15.7% in this series) [10, 11] and are common in patients over 70 years of age (10.7% in this series) and in those with an arterial oxygen pressure of less than 60 mm Hg (17.6% in this series). Their causes have been analyzed [10, 11].

In general, arrhythmias do not represent a serious threat unless the resulting changes in cardiac output modify the hemodynamic balance, which leads to a cycle of hypoxemia and arrhythmia. Atrial flutter and atrial fibrillation have been reported to increase mortality risk; however, these arrhythmias can usually be controlled with digitalis [10]. Indeed, in our series, they were not found to influence the global mortality when they occurred in isolation.

Surgically related complications were the most common complications (27.3%) in this series, with air leaks (6.8%) and residual pleural spaces (4.6%) the most frequent ones. Empyema and bronchopleural fistula (both 4.4%) occurred less frequently but were more clinically relevant. Their incidence is in the upper limit of other reported values [3, 12]. As reported previously [1, 9, 13], these complications are of great clinical relevance and occur more frequently after pneumonectomy (in 21 of 28 patients [75%] in our series). The right side is especially prone to this complication, as pointed up by the fact that 16 of the 21 patients (76%) in this series who suffered such complications had undergone a right-sided pneumonectomy. Bronchopleural fistula is the most series postoperative complication and is usually associated with a poor quality of life and high mortality rate (13.3% in this series).

Respiratory complications constitute a highly interrelated group, in that pain, inefficient cough, and hypoventilation may lead to atelectasis, pneumonia, and respiratory failure. The frequencies noted in this series (3.6%, 5.3%, and 5.1%, respectively) are similar to those noted in previous studies [3, 13].

The average postoperative mortality rate is approximately 3.5% (range, 1% to 7.1%) [1, 3, 8, 9, 13, 14], with the 6.6% (40 patients) noted in this series in the upper range. The many pneumonectomies (28.4%) and the high comorbidity rate (83.3%) may have contributed to the relatively high mortality rate in our series. It has been reported that the mortality rate associated with pneumonectomies increases from 8.6% to 19% in patients with concomitant diseases [12].

Postoperative morbidity and death have also been linked to other factors, such as age [2, 14], cardiovascular disorders [2], compromised pulmonary reserve [1, 9, 12], and to some therapeutic procedures [1, 15]. All these have therefore been considered as risk factors.

Age greater than 70 years has been considered a risk factor for both morbidity and death. However, controversy exists regarding this point [2, 14–17]. The difference in results noted for various series may originate from the fact that different criteria were used to select patients undergoing lung resection or from the fact that the extent of surgical resection varied in different series. A mortality rate of 7% was found in a multicenter study [2] that included 453 patients over 70 years of age who had undergone operation for bronchogenic carcinoma. We also found a relative increase in the morbidity and mortality rates in the patients in this age group in our series, but the differences did not reach statistical significance.

A history of diseases or the existence of concomitant diseases clearly increases the morbidity risk and to a minor degree the mortality risk. Cardiac or vascular diseases and, to a lesser extent, diabetes mellitus and respiratory disease are the preexisting disorders that predispose the most to postoperative morbidity and death.

Cardiac disorders are commonly accepted [1] as important risk factors, and our morbidity rate of 43.7% and mortality rate of 11.2% in patients with such disorders agree with this. However, in the multivariate analysis, cardiac disorders appear as risk factors only if the model included the factors' significance as p < 0.15.

However, peripheral vascular disease is not usually analyzed as an isolated risk factor but conjointly with cardiovascular diseases. We believe that it should be analyzed separately, partly because it is responsible for a significant increase in the morbidity and mortality rates and also because surgeons may have to decide whether the vascular or pulmonary disorder should be treated first. Because of the relevance of peripheral vascular disease as a risk factor, it may be necessary to also evaluate the severity of the disease and its anatomic location to arrive at a correct preoperative assessment in these patients.

Diabetes mellitus is an underestimated risk factor, although it is well known to increase the risk of pulmonary infection [18]. This stems from the fact that diabetic microangiopathy alters the diffusion capacity and thus impairs pulmonary function. Respiratory dynamics may also be affected by muscular disorders [19]. A morbidity OR of 1.9 has been previously reported for patients with such disorders [15]. In our series the morbidity (41.3%) and mortality (10.8%) rates were higher in patients with diabetes than in those without diabetes, but these differences were not statistically significant. However, differences in the morbidity rates were significant only when patients with insulin-dependent diabetes mellitus were considered in the analysis.

Preoperative pulmonary function has been considered a predictive variable of postoperative morbidity and death [1, 9, 12, 20]. However, in our series, there was a moderate, nonsignificant increase in the morbidity and mortality rates in patients with a postoperative by predicted forced expiratory volume in 1 second of approximately 800 mL (morbidity rates, 36.5%; mortality rate, 6.3%); in patients with a postoperatively predicted forced expiratory volume in 1 second that was 30% of the theoretical value (morbidity rate, 41.4%, mortality rate, 4.9%); and in patients with arterial oxygen pressures of less than 60 mm Hg (morbidity rate, 47.1%; mortality rate, 5.9%). Arterial oxygen pressures of less than 60 mm Hg appear as risk factors only in less strict regression models (p < 0.15). This discrepancy may result from the fact that only the 30-day mortality rate was considered in the present study. The mortality rate in these patients may increase later on.

The contribution of neoadjuvant therapy to postoperative morbidity and death should also be analyzed. Unfortunately, this has seldom been done. In a series of 13 patients who received neoadjuvant therapy, high morbidity (62%) and mortality (23%) rates were noted [21]. They were greatly influenced by pneumonectomy. A lower incidence of complications was reported for another series [22]. In the present series, we detected a nonsignificant increase in the morbidity rate (39%) and an even lesser increase in the mortality rate (7.3%) in patients who had received neoadjuvant therapy preoperatively (see Table 5).

The incidence of postoperative complications and the mortality rates in patients who had undergone lesser lung resections (wedge resections and segmentectomies) and lobectomies are clearly less than the rates associated with pneumonectomies (morbidity rate, 40.1%; mortality rate, 13.3%). Pneumonectomy is recognized, with some exceptions [3], as one of the primary risk factors [1, 13, 15]. The average mortality rate associated with pneumonectomy is approximately 8%, with reported values ranging between 4.6% and 20% [1, 9, 12, 15, 20]. In the present series the mortality rate associated with pneumonectomies was in the upper limit of the range (p < 0.001). Right-sided pneumonectomy is associated with a higher, but not statistically significant, mortality rate (15.28% versus 12%). Extended procedures are also associated with a distinctly greater risk (morbidity rate, 36.6%; mortality rate, 9.9%) than standard procedures.

Finally, the mortality rate is highest in patients with postoperative complications, which clearly indicates that postoperative morbidity indicates a poor prognosis.

In conclusion, our analysis of a large series of patients who underwent operation for bronchogenic carcinoma in Spain revealed high postoperative morbidity and mortality rates. On the basis of our findings we concluded that patients with a history of peripheral vascular disease or with concurrent insulin-dependent diabetes mellitus and respiratory disease are more likely to suffer postoperative complications and therefore require a thorough preoperative assessment. Those patients with vascular disease, those who undergo pneumonectomy, and those with a postoperative complication, especially respiratory failure, need to be closely monitored because their postoperative mortality risk is significantly increased.

	Appendix 1

Top Footnotes Abstract Introduction Patients and Methods Results Comment Appendix 1 References

 
Coordinators: José Luis Duque, MD (Hospital Universitario, Valladolid), Angel López Encuentra, MD (Hospital Universitario 12 de Octubre, Madrid), Ramón Rami Porta, MD (Hospital Mutua de Terrasa, Barcelona). Members and co-workers: Juan Casanova, MD, and Joaquin Pac, MD (Hospital de Cruces, Bilbao); Manuel Castanedo, MD, and José María Matilla, MD (Hospital Universitario, Valladolid); Antonio Fernandez de Rota, MD, and Carlos Pages, MD (Hospital Carlos Haya, Málaga); Federico Gonzalez Aragoneses, MD, and Nicolas Moreno, MD (Hospital Gregorio Marañón, Madrid); Jorge Freixenet, MD, and M^aJosé Roca, MD (Hospital Ntra. Sra. del Pino, Las Palmas); Nicolas Llobregat, MD, and José Antonio Garrido, MD (Hospital Universitario del Aire, Madrid); Nuria Mañes, MD, and José María García Prim, MD (Fundación Jimenez Díaz, Madrid); Miguel Mateu, MD, and Guadalupe González Pont, MD (Mutua de Terrasa, Barcelona); José Luis Martín de Nicolás, MD, and Pablo Gámez, MD (Hospital Universitario 12 de Octubre, Madrid); Jesús Rodriguez, MD, and Feliciano Alvarez, MD (Complejo Hospitalario, Oviedo); Abel Sánchez Palencia, MD (Hospital Virgen de las Nieves, Granada); Antonio José Torres García, MD, and Ana Gómez, MD (Hospital Universitario S. Carlos, Madrid); Juan Torres Lanza, MD, and J. J. Rivas, MD (Hospital Juan Canalejo, La Coruña); Gonzálo Varela Simó, MD, and Marcelo Jimenez, MD (Complejo Hospitalario, Salamanca); Andrés Varela Ugarte, MD, and Mar Córdoba, MD (Clínica Puerta de Hierro, Madrid); Yat Wah Pun, MD (Hospital de "La Princesa," Madrid).

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment Appendix 1 References

 
^* The coordinators and the members of the Grupo Cooperativo de Carcinoma Broncogénico de Sociedad Española de Neumología y Cirugía Torácica are listed in Appendix 1.

Address reprint requests to Dr Duque, Servicio de Cirugía Torácica, Hospital Universitario, c/ Ramón y Cajal s/n, 47005 Valladolid, Spain.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment Appendix 1 References

 

1. Nagasaki F, Flehinger BJ, Martini N. Complications of surgery in the treatment of carcinoma of the lung. Chest 1982;82:25–9.[Abstract/Free Full Text]
2. Ginsberg RJ, Hill LD, Eagan RT, et al. Modern thirty-day operative mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 1983;86:654–8.[Abstract]
3. Deslauriers J, Ginsberg RJ, Piantadosi S, Fournier B. Prospective assessment of 30-day operative morbidity for surgical resections in lung cancer. Chest 1994;106:329s–30s.
4. Grupo Cooperativo del Carcinoma Broncogénico-SEPAR (GCCB-S). Cirugía del carcinoma broncogénico en España. Estudio descriptivo. Arch Bronconeumol 1995;31:303–9.[Medline]
5. Mountain CF. A new international staging system for lung cancer. Chest 1986;89:225s–35s.
6. American Joint Committee on Cancer. Manual for staging of cancer, 4th ed. Philadelphia: Lippincott, 1992:115–22.
7. Grupo de Trabajo de SEPAR Sobre Carcinoma Broncogénico. Normativa sobre nomenclatura y clasificación del carcinoma broncogénico. Barcelona, Spain: Ediciones Doyma SA, 1986.
8. Kearney DJ, Lee TH, Reilly JJ, DeCamp MM, Sugarbaker DJ. Assessment of operative risk in patients undergoing lung resection. Importance of predicted pulmonary function. Chest 1994;105:753–9.[Abstract/Free Full Text]
9. Markos J, Mullan BP, Hillman DR, et al. Preoperative assessment as a predictor of mortality after lung resection. Am Rev Respir Dis 1989;139:902–10.[Medline]
10. Asamura H, Naruke T, Tsuchiya R, Goya T, Kondo H, Suemasu K. What are the risk factors for arrhythmias after thoracic operations? A retrospective multivariate analysis of 267 consecutive thoracic operations. J Thorac Cardiovasc Surg 1993;106:1104–10.[Abstract]
11. Krowka MJ, Pairolero PC, Trastek VF, Payne WS, Bernatz PF. Cardiac dysrhythmia following pneumonectomy. Clinical correlates and prognostic significance. Chest 1987;91:490–5.[Abstract/Free Full Text]
12. Patel RL, Townsend ER, Fountain SW. Elective pneumonectomy: factors associated with morbidity and operative mortality. Ann Thorac Surg 1992;54:84–8.[Abstract]
13. Roeslin N, Morand G. Complications et mortalité de la chirurgie du cancer bronchique. Rev Pneumol Clin 1992;48:231–6.[Medline]
14. Osaki T, Shirakusa T, Kodate M, Nakanishi R, Mitsudomi T, Ueda H. Surgical treatment of lung cancer in the octogenarian. Ann Thorac Surg 1994;57:188–93.[Abstract]
15. Romano PS, Mark DH. Patient and hospital characteristics related to in-hospital mortality after lung cancer resection. Chest 1992;101:1332–7.[Abstract/Free Full Text]
16. Borrelly J, Grosdidier G, Sibille P. L'exèrése du néoplasme bronchique chez les sujets de 70 ans et plus. A propos d'une série de 193 exérèses. Ann Chir 1992;46:130–3.[Medline]
17. Damhuis RAM, Schütte PR. Resection rates and postoperative mortality in 7,899 patients with lung cancer. Eur Respir J 1996;9:7–10.[Abstract]
18. Hansen LA, Prakash UBS, Colby THV. Pulmonary complications in diabetes mellitus. Mayo Clin Proc 1989;64:791–9.[Medline]
19. Wanke Th, Farmanek D, Auninger M, Popp W, Zwick H, Irsigler K. Inspiratory muscle performance and pulmonary function changes in insulin-dependent diabetes mellitus. Am Rev Resp Dis 1991;143:97–100.[Medline]
20. Marshall MC, Olsen GN. The physiologic evaluation of the lung resection candidate. Clin Chest Med 1993;14:305–20.[Medline]
21. Fowler WC, Langer CJ, Curran WJ, Keller SM. Postoperative complications after combined neoadjuvant treatment of lung cancer. Ann Thorac Surg 1993;55:986–9.[Abstract]
22. Depierre A, Jacouler P. Traitements adjuvants des cancers bronchiques non á petites cellules opérés. Rev Pneumol Clin 1992;48:237–41.[Medline]

This article has been cited by other articles:

				Z. Mansour, E. A. Kochetkova, N. Santelmo, P. Meyer, J.-M. Wihlm, E. Quoix, and G. Massard Risk factors for early mortality and morbidity after pneumonectomy: a reappraisal. Ann. Thorac. Surg., December 1, 2009; 88(6): 1737 - 1743. [Abstract] [Full Text] [PDF]

				R. Kazan, D. Bracco, and T. M. Hemmerling Reduced cerebral oxygen saturation measured by absolute cerebral oximetry during thoracic surgery correlates with postoperative complications Br. J. Anaesth., December 1, 2009; 103(6): 811 - 816. [Abstract] [Full Text] [PDF]

				M. F. Berry, J. Hanna, B. C. Tong, W. R. Burfeind Jr, D. H. Harpole, T. A. D'Amico, and M. W. Onaitis Risk factors for morbidity after lobectomy for lung cancer in elderly patients. Ann. Thorac. Surg., October 1, 2009; 88(4): 1093 - 1099. [Abstract] [Full Text] [PDF]

				P. K. Mishra, R. Pandey, M. J. Shackcloth, J. McShane, A. D. Grayson, M. H. Carr, and R. D. Page Cardiac comorbidity is not a risk factor for mortality and morbidity following surgery for primary non-small cell lung cancer Eur. J. Cardiothorac. Surg., March 1, 2009; 35(3): 439 - 443. [Abstract] [Full Text] [PDF]

				D. M. Radu, F. Jaureguy, A. Seguin, C. Foulon, M. D. Destable, J. Azorin, and E. Martinod Postoperative Pneumonia After Major Pulmonary Resections: An Unsolved Problem in Thoracic Surgery Ann. Thorac. Surg., November 1, 2007; 84(5): 1669 - 1673. [Abstract] [Full Text] [PDF]

				P. W. Smith, H. Wang, L. M. Gazoni, K. R. Shen, T. M. Daniel, and D. R. Jones Obesity Does Not Increase Complications After Anatomic Resection for Non-Small Cell Lung Cancer Ann. Thorac. Surg., October 1, 2007; 84(4): 1098 - 1106. [Abstract] [Full Text] [PDF]

				P. G. Sfyridis, E. I. Kapetanakis, N. E. Baltayiannis, N. V. Bolanos, D. S. Anagnostopoulos, A. Markogiannakis, and A. Chatzimichalis Bronchial Stump Buttressing With an Intercostal Muscle Flap in Diabetic Patients Ann. Thorac. Surg., September 1, 2007; 84(3): 967 - 971. [Abstract] [Full Text] [PDF]

				D. Amar, H. Zhang, B. Park, P. M. Heerdt, M. Fleisher, and H. T. Thaler Inflammation and outcome after general thoracic surgery Eur. J. Cardiothorac. Surg., September 1, 2007; 32(3): 431 - 434. [Abstract] [Full Text] [PDF]

				H. Weinstein, A. T. Bates, B. E. Spaltro, H. T. Thaler, and R. M. Steingart Influence of Preoperative Exercise Capacity on Length of Stay After Thoracic Cancer Surgery Ann. Thorac. Surg., July 1, 2007; 84(1): 197 - 202. [Abstract] [Full Text] [PDF]

				A. Shaw Genetics of postoperative complications following thoracic surgery. Seminars in Cardiothoracic and Vascular Anesthesia, December 1, 2006; 10(4): 327 - 345. [Abstract] [PDF]

				E. J. Chae, J. B. Seo, S. Y. Kim, K.-H. Do, J.-N. Heo, J. S. Lee, K. S. Song, J. W. Song, and T.-H. Lim Radiographic and CT Findings of Thoracic Complications after Pneumonectomy RadioGraphics, September 1, 2006; 26(5): 1449 - 1468. [Abstract] [Full Text] [PDF]

				O. Schussler, M. Alifano, H. Dermine, S. Strano, A. Casetta, S. Sepulveda, A. Chafik, S. Coignard, A. Rabbat, and J.-F. Regnard Postoperative Pneumonia after Major Lung Resection Am. J. Respir. Crit. Care Med., May 15, 2006; 173(10): 1161 - 1169. [Abstract] [Full Text] [PDF]

				M. J. Licker, I. Widikker, J. Robert, J.-G. Frey, A. Spiliopoulos, C. Ellenberger, A. Schweizer, and J.-M. Tschopp Operative mortality and respiratory complications after lung resection for cancer: impact of chronic obstructive pulmonary disease and time trends. Ann. Thorac. Surg., May 1, 2006; 81(5): 1830 - 1837. [Abstract] [Full Text] [PDF]

				K. Wiebe, H. Baraki, P. Macchiarini, and A. Haverich Extended pulmonary resections of advanced thoracic malignancies with support of cardiopulmonary bypass Eur. J. Cardiothorac. Surg., April 1, 2006; 29(4): 571 - 577. [Abstract] [Full Text] [PDF]

				S.-i. Takeda, H. Maeda, M. Koma, Y. Matsubara, N. Sawabata, M. Inoue, T. Tokunaga, and M. Ohta Comparison of surgical results after pneumonectomy and sleeve lobectomy for non-small cell lung cancer.: Trends over time and 20-year institutional experience Eur. J. Cardiothorac. Surg., March 1, 2006; 29(3): 276 - 280. [Abstract] [Full Text] [PDF]

				Y. Matsubara, S.-i. Takeda, and T. Mashimo Risk Stratification for Lung Cancer Surgery: Impact of Induction Therapy and Extended Resection Chest, November 1, 2005; 128(5): 3519 - 3525. [Abstract] [Full Text] [PDF]

				D. N. Nan, M. Fernandez-Ayala, C. Farinas-Alvarez, R. Mons, F. J. Ortega, J. Gonzalez-Macias, and M. C. Farinas Nosocomial Infection After Lung Surgery: Incidence and Risk Factors Chest, October 1, 2005; 128(4): 2647 - 2652. [Abstract] [Full Text] [PDF]

				J. Belda, M. Cavalcanti, M. Ferrer, M. Serra, J. Puig de la Bellacasa, E. Canalis, and A. Torres Bronchial Colonization and Postoperative Respiratory Infections in Patients Undergoing Lung Cancer Surgery Chest, September 1, 2005; 128(3): 1571 - 1579. [Abstract] [Full Text] [PDF]

				E. Perrot, B. Guibert, P. Mulsant, S. Blandin, I. Arnaud, P. Roy, L. Geriniere, and P.-J. Souquet Preoperative Chemotherapy Does Not Increase Complications After Nonsmall Cell Lung Cancer Resection Ann. Thorac. Surg., August 1, 2005; 80(2): 423 - 427. [Abstract] [Full Text] [PDF]

				C. Ludwig, E. Stoelben, M. Olschewski, and J. Hasse Comparison of Morbidity, 30-Day Mortality, and Long-Term Survival After Pneumonectomy and Sleeve Lobectomy For Non-Small Cell Lung Carcinoma Ann. Thorac. Surg., March 1, 2005; 79(3): 968 - 973. [Abstract] [Full Text] [PDF]

				L. Trodella, P. Granone, S. Valente, S. Margaritora, G. Macis, A. Cesario, R. M. D'Angelillo, V. Valentini, G. M. Corbo, V. Porziella, et al. Neoadjuvant concurrent radiochemotherapy in locally advanced (IIIA-IIIB) non-small-cell lung cancer: long-term results according to downstaging Ann. Onc., March 1, 2004; 15(3): 389 - 398. [Abstract] [Full Text] [PDF]

				M. Licker, M. de Perrot, A. Spiliopoulos, J. Robert, J. Diaper, C. Chevalley, and J.-M. Tschopp Risk Factors for Acute Lung Injury After Thoracic Surgery for Lung Cancer Anesth. Analg., December 1, 2003; 97(6): 1558 - 1565. [Abstract] [Full Text] [PDF]

				D. R. Jones, B. M. Stiles, C. E. Denlinger, P. Antippa, and T. M. Daniel Pulmonary segmentectomy: results and complications Ann. Thorac. Surg., August 1, 2003; 76(2): 343 - 349. [Abstract] [Full Text] [PDF]

				V. Ambrogi, E. Pompeo, S. Elia, G. R. Pistolese, and T. C. Mineo The impact of cardiovascular comorbidity on the outcome of surgery for stage I and II non-small-cell lung cancer Eur. J. Cardiothorac. Surg., May 1, 2003; 23(5): 811 - 817. [Abstract] [Full Text] [PDF]

				G. Varela, N. Novoa, M.F. Jimenez, and G. Santos Applicability of logistic regression (LR) risk modelling to decision making in lung cancer resection Interactive CardioVascular and Thoracic Surgery, March 1, 2003; 2(1): 12 - 15. [Abstract] [Full Text] [PDF]

				P. H. Hollaus, G. Wilfing, P. N. Wurnig, and N. S. Pridun Risk factors for the development of postoperative complications after bronchial sleeve resection for malignancy: a univariate and multivariate analysis Ann. Thorac. Surg., March 1, 2003; 75(3): 966 - 972. [Abstract] [Full Text] [PDF]

				F. J. Algar, A. Alvarez, A. Salvatierra, C. Baamonde, J. L. Aranda, and F. J. Lopez-Pujol Predicting pulmonary complications after pneumonectomy for lung cancer Eur. J. Cardiothorac. Surg., February 1, 2003; 23(2): 201 - 208. [Abstract] [Full Text] [PDF]

				A.U. Neuenschwander, J.H. Pedersen, M. Krasnik, and H. Tonnesen Impaired postoperative outcome in chronic alcohol abusers after curative resection for lung cancer Eur. J. Cardiothorac. Surg., August 1, 2002; 22(2): 287 - 291. [Abstract] [Full Text] [PDF]

				M.-C. Aubry, J. L. Myers, W. W. Douglas, H. D. Tazelaar, T. L. W. Stephens, T. E. Hartman, C. Deschamps, and V. S. Pankratz Primary Pulmonary Carcinoma in Patients With Idiopathic Pulmonary Fibrosis Mayo Clin. Proc., August 1, 2002; 77(8): 763 - 770. [Abstract] [PDF]

				M. Licker, A. Spiliopoulos, J.-G. Frey, J. Robert, L. Hohn, M. de Perrot, and J.-M. Tschopp Risk Factors for Early Mortality and Major Complications Following Pneumonectomy for Non-small Cell Carcinoma of the Lung* Chest, June 1, 2002; 121(6): 1890 - 1897. [Abstract] [Full Text] [PDF]

				A. Brunelli, M. Al Refai, M. Monteverde, A. Borri, M. Salati, and A. Fianchini Stair Climbing Test Predicts Cardiopulmonary Complications After Lung Resection* Chest, April 1, 2002; 121(4): 1106 - 1110. [Abstract] [Full Text] [PDF]

				M. Ioanas, J. Angrill, X. Baldo, F. Arancibia, J. Gonzalez, T. Bauer, E. Canalis, and A. Torres Bronchial bacterial colonization in patients with resectable lung carcinoma Eur. Respir. J., February 1, 2002; 19(2): 326 - 332. [Abstract] [Full Text] [PDF]

				G. Myrdal, G. Gustafsson, M. Lambe, L.G. Horte, and E. Stahle Outcome after lung cancer surgery. Factors predicting early mortality and major morbidity Eur. J. Cardiothorac. Surg., October 1, 2001; 20(4): 694 - 699. [Abstract] [Full Text] [PDF]

				J. Martin, R. J. Ginsberg, A. Abolhoda, M. S. Bains, R. J. Downey, R. J. Korst, T. L. Weigel, M. G. Kris, E. S. Venkatraman, and V. W. Rusch Morbidity and mortality after neoadjuvant therapy for lung cancer: the risks of right pneumonectomy Ann. Thorac. Surg., October 1, 2001; 72(4): 1149 - 1154. [Abstract] [Full Text] [PDF]

				J. A. BARBERA, V. I. PEINADO, S. SANTOS, J. RAMIREZ, J. ROCA, and R. RODRIGUEZ-ROISIN Reduced Expression of Endothelial Nitric Oxide Synthase in Pulmonary Arteries of Smokers Am. J. Respir. Crit. Care Med., August 15, 2001; 164(4): 709 - 713. [Abstract] [Full Text] [PDF]

				H. L. Porte, T. Jany, R. Akkad, M. Conti, P. A. Gillet, A. Guidat, and A. J. Wurtz Randomized controlled trial of a synthetic sealant for preventing alveolar air leaks after lobectomy Ann. Thorac. Surg., May 1, 2001; 71(5): 1618 - 1622. [Abstract] [Full Text] [PDF]

				G. Varela, R. Cordovilla, M.F. Jimenez, and N. Novoa Utility of standardized exercise oximetry to predict cardiopulmonary morbidity after lung resection Eur. J. Cardiothorac. Surg., March 1, 2001; 19(3): 351 - 354. [Abstract] [Full Text] [PDF]

				A. Bernard, L. Ferrand, O. Hagry, L. Benoit, N. Cheynel, and J.-P. Favre Identification of prognostic factors determining risk groups for lung resection Ann. Thorac. Surg., October 1, 2000; 70(4): 1161 - 1167. [Abstract] [Full Text] [PDF]

				J. W. Asaph, J. R. Handy Jr, G. L. Grunkemeier, E. C. Douville, A. C. Tsen, R. C. Rogers, and J. F. Keppel Median sternotomy versus thoracotomy to resect primary lung cancer: analysis of 815 cases Ann. Thorac. Surg., August 1, 2000; 70(2): 373 - 379. [Abstract] [Full Text] [PDF]

				J. B. Shrager, E. S. Lambright, C. M. McGrath, P. M. Wahl, M. E. Deeb, J. S. Friedberg, and L. R. Kaiser Lobectomy with tangential pulmonary artery resection without regard to pulmonary function Ann. Thorac. Surg., July 1, 2000; 70(1): 234 - 239. [Abstract] [Full Text] [PDF]

				W. Dyszkiewicz, K. Pawlak, and L. Gasiorowski Early post-pneumonectomy complications in the elderly Eur. J. Cardiothorac. Surg., March 1, 2000; 17(3): 246 - 250. [Abstract] [Full Text] [PDF]

				M. K. Ferguson and T. Karrison DOES PNEUMONECTOMY FOR LUNG CANCER ADVERSELY INFLUENCE LONG-TERM SURVIVAL? J. Thorac. Cardiovasc. Surg., March 1, 2000; 119(3): 440 - 448. [Abstract] [Full Text] [PDF]

				P. Macchiarini, J. Wain, S. Almy, and P. Dartevelle EXPERIMENTAL AND CLINICAL EVALUATION OF A NEW SYNTHETIC, ABSORBABLE SEALANT TO REDUCE AIR LEAKS IN THORACIC OPERATIONS J. Thorac. Cardiovasc. Surg., April 1, 1999; 117(4): 751 - 758. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Duque, J. L. Articles by Heras, F. Search for Related Content PubMed PubMed Citation Articles by Duque, J. L. Articles by Heras, F.