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Ann Thorac Surg 2000;70:1161-1167
© 2000 The Society of Thoracic Surgeons

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Original articles: general thoracic

Identification of prognostic factors determining risk groups for lung resection

^a Department of Thoracic Surgery, France

Address reprint requests to Dr Bernard, Hôpital Universitaire, 2 bd Marechal de Lattre de Tassigny, BP 1542, 21034 Dijon CEDEX, France
e-mail: alain.bernard{at}chu-dijon.fr

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Pulmonary resection belongs to a group of surgical procedures with significant morbidity and mortality. The aims of this study were to classify postoperative complications and to identify prognostic factors determining risk group.

Methods. In a prospective study 500 patients undergoing lung resection (wedge resection, n = 141; lobectomies, n = 245; bilobectomies, n = 12; and pneumonectomies, n = 102) were included. In 178 patients (36%) pulmonary resections were extended to structures or thoracic organs. Sleeve resection of the bronchus to preserve lung parenchyma was performed in 22 patients.

Results. Classification of postoperative complications fell into four categories: patients without postoperative complications; patients with moderate complications (n = 137); patients with severe complications (n = 38); and death (n = 33). Factors adversely affecting postoperative complications by multivariate analysis included pulmonary pathology, bronchoplastic technique, forced expiratory volume in 1 second (FEV₁), extended resection, type of lung resection, comorbidity indices, and preoperative chemotherapy. Four risk groups were determined. Risk group I (n = 60) with the best prognosis included patients with FEV₁ greater than or equal to 80% undergoing wedge resection for a benign lesion or metastasis. Risk group II (n = 161) included patients with FEV₁ greater than or equal to 80% undergoing major pulmonary resection for a benign lesion or metastasis or lung cancer, or patients with FEV₁ less than 80% undergoing wedge resection for benign lesion or metastasis. Risk group III (n = 233) with a fair prognosis included patients with comorbidity indices less than 4 and FEV₁ greater than or equal to 80% undergoing extended pulmonary resection for a benign lesion or metastasis or lung cancer, or patients with FEV₁ less than 80% and emphysema. Risk group IV (n = 46) with the worst prognosis included patients with FEV₁ less than 80% undergoing an extended lung resection or bronchoplastic procedures for a benign lesion or metastasis or lung cancer, or patients with comorbidity indices greater than or equal to 4 undergoing extended lung resection for lung cancer.

Conclusions. In a prospective study, based on these prognostic factors, a practical, easy-to-use risk group system of lung resection is proposed as a tool to aid the decision to perform lung resection.

	Introduction

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Pulmonary resection belongs to the group of surgical procedures with significant morbidity and mortality. Significant ventilatory impairment is caused not only by parenchyma amputation but also by deterioration of respiratory mechanics. Some studies reported a decrease of postoperative mortality rate for resectional operations for lung cancer [1]. New techniques of perioperative and postoperative care have led to a further decline in postoperative complication rates [1]. Over the past years, the mean age of patients has increased; more and more patients 75 years old or more are being seen by thoracic surgeons.

Often in patients with pulmonary pathology, the rate of coexistent medical conditions is high. Pulmonary resection is associated with comorbid disease, which explains a high rate of postoperative complications [2]. For risk assessment of pulmonary resection, analysis must be adjusted for comorbidity disease [3].

Lung cancer represents the major reason for which patients undergo pulmonary resectional surgery. Often, extended resection is necessary because of the size or localization of the pulmonary tumor so as to perform a curative resection.

To answer these questions about postoperative complications after pulmonary resection, we performed a prospective study. The aims of this study were to classify postoperative complications and to identify prognostic factors determining risk group.

	Material and methods

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Selection of patients
From January 1996 to December 1998, 500 patients who underwent single or multiple wedge lobectomies or bilobectomies or pneumonectomies were included in this prospective study. Subjects who underwent exploratory or staging thoracotomy procedures or thoracoscopy without resection of lung parenchyma were excluded from the study. The mean age of patients was 59 ± 12 years (range 16 to 84); there were 410 males and 90 females.

Pulmonary resection was indicated for bronchectasis in 7 cases (1%), invasive aspergillosis in 7 cases (1%), emphysema in 19 cases (4%), infectious disease in 31 cases (6%), metastasis in 41 cases (8%), benign lesion in 54 cases (11%), and lung cancer in 341 cases (68%). In 10 patients with lung cancer, wedge resection was a diagnostic procedure. Of the 500 resections for pulmonary pathology, there were 141 wedge resections (28%), 245 lobectomies (49%), 12 bilobectomies (2%), and 102 pneumonectomies (20%). Video-assisted thoracic surgery was used to perform 78 wedge resections and 2 lobectomies. Through posterolateral thoracotomy, 56 wedge resections, 241 lobectomies, 12 bilobectomies, and 97 pneumonectomies were performed. Through median sternotomy, 7 wedge resections, 2 lobectomies, and 5 pneumonectomies were performed. In 178 patients (36%) pulmonary resections were extended to structures or thoracic organs: pericardium (n = 81), left atrium (n = 20), superior vena cava (n = 7), aortic adventice (n = 17), trachea or carina (n = 9), diaphragm (n = 6), parietal pleura (n = 72), and chest wall (n = 29). Sleeve resection of the bronchus to preserve lung parenchyma was performed in 22 patients. A sleeve lobectomy of the right upper lobe was performed in 7 patients, of the right lower lobe in 7 patients, of the right middle and lower lobe in 2 patients, of the upper lobe in 3 patients, and of the lower lobe in 3 patients.

Data collection
Preoperative assessment included the documentation of historic information (comorbid diseases, obesity, weight loss, and tobacco use) as well as functional status (Karnofsky index).

Associated comorbidity factors were defined as coronary artery disease (angor or myocardial infarction), congestive heart failure, peripheral vascular disease, cerebrovascular disease, chronic obstructive pulmonary disease (asthma or emphysema or bronchitis), chronic renal failure, severe liver disease (cirrhosis), and malignancy. Comorbidity indices were calculated using Romano’s method [2] for each patient by summarizing weighted comorbidity profile components. Coronary artery disease was assigned a weight of 1; congestive heart failure a weight of 3; peripheral vascular disease a weight of 2; cerebrovascular disease a weight of 1; chronic renal failure a weight of 2; diabetes a weight of 2; severe liver disease a weight of 3; chronic obstructive pulmonary disease a weight of 2; and malignancy a weight of 2. Preoperative chemotherapy or corticosteroids were included in risk factors. Preoperative pulmonary evaluation included arterial blood gas analysis (PaO₂ and PaCO₂) and spirometry, forced expiratory volume in 1 second (FEV₁) expressed to percents with regard to theoretical FEV₁, and forced vital capacity (FVC) expressed to percents with regard to theoretical FVC.

Postoperative outcomes
All patients were followed up prospectively after surgery and complications occurring during the same hospitalization as the index procedure were recorded. Complications were defined to include respirations complications: pneumonia (fever > 38°C, purulent sputum, abnormal findings on chest radiograph), atelectasis, prolonged air leak (duration of chest tube drainage > 7 days), postlobectomy space, bronchopleural fistula, empyema, adult respiratory distress syndrome, respiratory failure, mechanical ventilation for longer than 2 days, bleeding, and wound infection), cardiac complications (arrhythmias, myocardial infaction, congestive heart failure, pulmonary embolism), and acute renal failure. Operative deaths included both patients who died within 30 days after operation and those who died later but during the same hospitalization.

Statistical analysis
Multiple correspondence analysis was used to classify postoperative complications according to their gravity. Multiple correspondence analysis allowed regrouping variables that had a strong association [3]. Prognostic factors for postoperative complications were identified through univariate analysis using ² tests. After univariate analysis, variables that had a probability lower than 0.1 were included in multivariate logistic regression for multinomial data to identify prognostic factors [4]. Adjusted odds ratios with 95% confidence intervals were calculated by exponentiating the logistic coefficients estimates. Next, regression tree analyses were performed according to the method of Breiman and associates [5] by considering the prognostic factors. These regression tree analyses using hierarchical classification were performed to determine different risk groups [5]. The algorithm used the ² values as criterion for amalgamating subgroups [5].

	Results

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Classification of postoperative complications
In the graphical display of multiple correspondence analysis (Fig 1), some variables that had a strong association allowed determination of four categories of patients. The first category consisted of patients without postoperative complications (Fig 1). The second category included a group of variables: pneumonia, atelectasis, prolonged air leak, postlobectomy space, bleeding, arrhythmias, and wound infection (Fig 1); this category corresponded to moderate complications that could be cared for in a thoracic surgery care unit. The third category included a variable with a strong association such as adult respiratory distress syndrome, respiratory failure, mechanical ventilation for longer than 2 days, myocardial infaction, congestive heart failure, acute renal failure, bronchopleural fistula, or empyema (Fig 1); this category corresponded to severe complications requiring coverage in an intensive care unit. Finally, the fourth category consisted of patients who died during hospitalization (Fig 1). Among 208 patients (42%) developing postoperative complications, 137 patients (27%) had moderate complications, 38 patients (8%) had severe complications, and 33 patients (7%) died (Table 1).

View larger version (14K): [in this window] [in a new window]   Fig 1. Graphic display of multiple correspondence analysis: Axis 1 corresponds to the alive and dead patients. Axis 2 corresponds to various not-mortal complications; the further the type of complication went from 0, the more severe it was. This display shows that a strong association between some variables determined four categories: (1) patients without complications, (2) patients with moderate complications, (3) patients with severe complications, and (4) death. (ARDS = adult respiratory distress syndrome.)

	Comment

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At present, no study has used this classification for postoperative complications. Our classification also agrees with a treatment of postoperative complications; indeed, moderate complications can be treated in a general thoracic unit; on the other hand, severe complications would be cared for in an intensive care unit. Our classification allows a more realistic description of postoperative complications, and it could be used to make prospective studies more homogeneous.

A postoperative mortality rate of 1% to 12% has been reported in previous studies [6–15]. This great variability could be explained by pulmonary disease or by the type of procedure [6–15]. Studies that reported pulmonary resection for lung cancer had higher mortality rates than other studies [11–15]. In the majority of studies [11–18], the crude mortality rates after major lung resections are still significant: 3% to 12% for pneumonectomy, 3% to 5% for lobectomy, and 1% to 3% for wedge resection, respectively. Extended lobectomy involving the chest wall, pleura, pericardium, or diaphragm are associated with increased mortality [6–15].

The frequency of bronchopleural fistula after pneumonectomy has ranged between 4% and 9% [16–18]. Bronchopleural fistula remains a severe complication because the mortality rates range from 29% to 79% in our data and in the literature review of Kopec and associates [17].

Bronchoplastic techniques are associated with increased morbidity, particularly pneumonia and bronchopleural fistula in our data. Other authors [19, 20] reported mortality rates ranging from 5% to 10%. In patients with poor pulmonary reserve, needing preservation of as much lung tissue as possible, bronchoplastic techniques are indicated. Reinforcement of a closed bronchial anastomosis with a muscle flap could reduce dehiscence.

The literature has identified numerous risk factors for poor outcomes after pulmonary resection: age, type and extent of surgery, abnormal spirometry, male sex, and comorbidity [11, 12, 15, 21, 22]. However, the sample sizes in most of these studies have been too small to apply multivariate statistical methods. Among studies reporting that being 75 years of age or older increases a postoperative mortality [11, 12, 15], two studies [12, 15]did not adjust for comorbidity and spirometry. Lung resection can be performed routinely in patients 75 years of age and older without comorbid disease.

Most of the studies identified FEV₁ lower than 80% as a risk factor [21–25]. For these patients, Markos and coworkers [10] recommend the following strategy: if predicted postoperative FEV₁ is higher than 40%, pneumonectomy is possible; if predicted postoperative FEV₁ is less than 30%, the degree of risk to perform a pneumonectomy appears to be prohibitive. Between these two values, these authors recommend using the diffusing capacity of carbon monoxide.

In our data, patients undergoing preoperative chemotherapy for lung cancer had lower postoperative complications rates than other patients. During treatment by chemotherapy, patients who stopped using tobacco were prepared for thoracic surgery. By analogy, two studies [6, 9] demonstrated that preoperative preparation with physiotherapy and medication reduces risks of postoperative complications.

Extended surgery is also a risk factor reported in the literature [11, 15]. Chest wall resections that cause deteriorating respiratory mechanics are responsible for postoperative pneumonia and atelectasis.

These risk group systems may provide for a possible improvement of selection of patients in risk group IV for lung resection. Patients in risk group III could benefit from a true preoperative program of pulmonary rehabilitation to decrease postoperative morbidity and mortality. For patients in the same risk group, aggressive postoperative care can be designed to reduce postoperative complications. The patients who belong to risk group I or II can have standard preoperative evaluation and postoperative management.

In conclusion, lobectomy and pneumonectomy remain a procedure with a high risk of postoperative complications. Using the expertise of the surgeon, anesthesiologist, pulmonologist, and respiratory therapist may minimize those risks. In a prospective study, based on these prognostic factors, a practical, easy-to-use risk grouping system of lung resection is proposed as a tool to aid the decision to perform lung resection.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) 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 Author home page(s): Alain Bernard Jean-Pierre Favre Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bernard, A. Articles by Favre, J.-P. Search for Related Content PubMed PubMed Citation Articles by Bernard, A. Articles by Favre, J.-P.