Ann Thorac Surg 2003;76:1816-1820
© 2003 The Society of Thoracic Surgeons
Original article: general thoracic
Obstacles for shortening hospitalization after video-assisted pulmonary resection for lung cancer
Kazuhiro Ueda, MDa*,
Yoshikazu Kaneda, MDa,
Hisashi Sakano, MDa,
Toshiki Tanaka, MDa,
Tao-Sheng Li, MDa,
Kimikazu Hamano, MDa
a First Department of Surgery, Yamaguchi University School of Medicine, Ube Yamaguchi, Japan
Accepted for publication June 6, 2003.
* Address reprint requests to Dr Ueda, First Department of Surgery, Yamaguchi University School of Medicine, 1-1-1 Minami-Kogushi, Ube Yamaguchi 755-8505, Japan.
e-mail: kaueda{at}po.cc.yamaguchi-u.ac.jp
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Abstract
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BACKGROUND: Video-assisted thoracic surgery for lung cancer facilitates early postoperative recovery when patients are treated by critical pathway management. Thus, we developed an original programed regimen for postoperative management, evaluated the validity of this regimen, and analyzed clinical factors influencing postoperative recovery.
METHODS: Forty consecutive patients with suspicious lung cancer undergoing anatomic pulmonary resection with video-assisted thoracic surgery were enrolled in this prospective study. After surgery, all patients who underwent anatomic resection were managed using our programed regimen; a patient was considered recovered when the regimen had been completed.
RESULTS: On final pathologic examination, 37 cases were determined to have lung cancer and underwent anatomic resection. The mean number of resected segments was 3.6. There were no complications caused by postoperative management. The mean day of postoperative recovery was 3.7 days and median, 3 days. Significant preoperative factors related to recovery were age, breathlessness, performance status, radiologic emphysema, partial pressure of arterial oxygen, and predictive postoperative forced expiratory volume in 1 second. The overall number of these risk factors was specifically related to postoperative recovery (p < 0.01): the rate of recovery on postoperative day 3 was 100% in patients with no risk, 68% in those with one to three risks, and 22% in those with four to six risks.
CONCLUSIONS: Our original regimen is useful as a critical pathway for the management of lung cancer patients undergoing video-assisted thoracic surgery. Furthermore, we created specific criteria to identify risk factors related to postoperative recovery that may be useful in planning hospitalization for patients undergoing video-assisted thoracic surgery.
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Introduction
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Once video-assisted pulmonary resection for clinically localized lung cancer had achieved excellent outcomes [1–3], this practice was rapidly popularized throughout the world. Preserving postoperative respiratory function and reducing wound pain are the main advantages that video-assisted thoracic surgery (VATS) has over conventional thoracotomy [3–5]; VATS potentially shortens hospitalization if a critical pathway is followed in postoperative management. Shortening hospitalization is also beneficial in terms of medical economics because the existing medical expense is shifting to a prospective payment system. Thus, we developed and validated an original management regimen to be used as a critical pathway for patients recovering from this type of surgery and subsequently analyzed clinical factors that influenced postoperative recovery.
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Patients and methods
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Forty consecutive patients with suspicious lung cancer undergoing anatomic pulmonary resection by VATS between September 2001 and July 2002 were enrolled in this prospective study. Patient characteristics collected before surgery included information on age, sex, smoking habits, breathlessness, performance status, body mass index, spirometry, predictive postoperative forced expiratory volume in 1 second, presence of radiologic emphysema, and preoperative arterial oxygenation. Breathlessness is defined as when a patient is unable to keep up with normal people of his or her own age on hills or stairs, which has been defined in the Pneumoconiosis Research Unit score (Hugh-Jones classification) [6]. Performance status assesses the daily living ability defined by the Eastern Cooperative Oncology Group (0 = fully active, 1 = restricted in physically strenuous activity) [7]. Radiologic emphysema is defined as evident overinflation shown on chest roentgenogram examination and low attenuation areas in every lobe shown on chest computed tomographic scan.
After single-lung ventilation was established, the patient was flexed in the lateral decubitus position. A thoracoscope was introduced through the seventh or eighth intercostal space at the midaxillary line. An anterolateral minithoracotomy (6 to 8 cm long) was placed in the fifth intercostal space. Rib spreading was allowed only when the intercostal space was not wide enough for the resected specimen to fit through. One or two additional 5- to 10-mm incisions were made at the posterior axillary line to handle insertion of a variety of instruments. During anatomic resection, an endoscopic stapler (Ethicon, Tokyo, Japan) was used to divide the lung parenchyma and incomplete fissures, and excise the bronchi. The pulmonary arteries or veins were also divided by endoscopic stapler if the diameter of the vessels was greater than 3 mm. After an anatomic resection and mediastinal lymphadenectomy, a water-seal test was performed to ensure pneumostasis. Bronchial stumps were never reinforced by suturing. Evident pulmonary fistulas in the surgical stump were closed by suturing and finally sealed by fibrin glue. A 20F chest tube was placed within the hemithorax, and the wounds were closed.
All patients were managed postoperatively according to the program found in Table 1.
The patient was regarded as recovered from the operation when all seven steps had been completed.
Postoperative percentages of patients recovered on each postoperative day (POD) were calculated, and the differences in the recovery rates between the groups were analyzed by log-rank test. The linear dependence of days of postoperative recovery and the actual postoperative hospitalization was assessed by linear regression analysis. A p value of less than 0.05 was determined to be statistically significant.
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Results
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Among the 40 patients, 3 had benign tumors that were identified intraoperatively without undergoing anatomic pulmonary resection. The remaining 37 patients with lung cancer were the subjects of the following analysis. The treatment modality was segmentectomy in 3 patients, bilobectomy in 1, and lobectomy in 33. Intrathoracic adhesions extending to more than two segments were proven in 8 patients and were peeled through the VATS procedure. The mean number of resected segments per patient was 3.6 (range, 1 to 7). The VATS procedure was completed in 34 cases and converted to thoracotomy in 3 patients because of either inflammatory adhesion in the hilum or uncontrolled bleeding. The time to completion of the seven steps is shown in Table 1. The mean duration of postoperative chest tube drainage was 3.1 days, and median, 2 days. Two minor morbidities occurred postoperatively: 1 patient was complicated by chylothorax that was treated by conservative therapy, and the other patient required reoperation because of persistent air leakage on POD 14. There was no complication, such as a subsequent pneumothorax or the collection of pleural effusion, caused by the chest tube removal. Mean duration of oxygen support was 2.3 days, and median, 2 days. There was no complication such as bronchopulmonary spasm after the cessation of oxygen support. Pneumonia, surgical site infection, or other infections did not occur postoperatively. The mean length of time required before patients were able to take meals was 1.4 days, and median, 1 day, whereas the mean length of time required before patients were able to walk unassisted was 1.9 days, and median, 2 days. Finally, the mean length of time required to recover from an operation was 3.7 days, and median, 3 days. The percentage of recovered patients on POD 1 was 27%, on POD 3 was 62%, and on POD 5 was 86%. Significant risk factors for prolonged recovery were age greater than or equal to 65 years (p = 0.023), breathlessness (p < 0.036), performance status = 1 (p = 0.011), radiologic emphysema (p = 0.023), preoperative partial pressure of arterial oxygen less than 80 mm Hg (p = 0.008), and predictive postoperative forced expiratory volume in 1 second less than 60% (p = 0.011; Table 2).
Sex, smoking habits, body mass index, preoperative percentage of predictive vital capacity, and preoperative percentage of predictive forced expiratory volume in 1 second were all insignificant determinants of postoperative recovery rate (Table 2). Six patients had no risk factors, whereas the other 31 had from one to six (mean, 2.5) risk factors. From the viewpoint that the overall number of risk factors would indicate the severity of respiratory disorder, we evaluated the relationship between the number of risk factors and the recovery rate. The percentage of recovered patients on POD 3 was 100% in patients without any risk factors (n = 6), 68% in patients with one to three risk factors (n = 22), and 22% in patients with four to six risk factors (n = 9; Fig 1). The recovery rate was significantly different among these risk factor groups (p = 0.0013). The relationship between the day of postoperative recovery and the actual postoperative hospitalization was analyzed to assess how completion of the seven steps of the regimen influenced postoperative hospitalization: there was a significant correlation between the day of recovery (average, 3.7 days; range, 1 to 17 days) and the hospitalization (average, 15 days; range, 3 to 28 days; r = 0.31, p = 0.0003; Fig 2).
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Fig 2. The relationship between the day of postoperative recovery and the postoperative hospitalization. There is a significant correlation between the day of recovery (average, 3.7 days) and hospitalization (average, 15 days; r = 0.31, p = 0.0003).
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Comment
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Now that medical expenses are being shifted to a prospective payment system, limiting the hospitalization after surgery will benefit not only the patients, but also the hospital management in terms of cost-effectiveness. Thus, we designed this study to address how to urge the patients to postoperative recovery and determine when it is safe to send the patient home. Although the actual postoperative hospitalization was significantly related to the day of postoperative recovery, the postoperative hospitalization in this series was much longer than that of another report [2]: in Japan, patients are not imposed with excessive financial burden by prolonged hospitalization, and as a result, some elect to stay in hospital long after physiologic recovery from surgery. During the hospital stay after recovery, 2 patients underwent postoperative chemotherapy, 2 underwent treatment of another disease, and 1 was complicated by transient atrial fibrillation, which was resolved by an oral antiarrhythmic drug. No other treatment was given to the patients after the seven steps of the postoperative management regimen were over, except for routine surgical wound care. Thus, we affirm that it is reasonably safe to send the patient home after the completion of the regimen.
Early removal of chest drainage tubes is critical factor in postoperative recovery. Recent studies found newer products such as a synthetic sealant [8, 9] or methods such as water-seal drainage [10] only minimally effective in shortening hospitalization by reducing bronchoalveolar air leakage. However, the amount of pleural drainage as a limiting factor in the removal of chest drainage tubes remains controversial [11, 12]. Our data show that even though the average pleural drainage during the first day after surgery was 225 mL (range, 0 to 700 mL) and the average pleural drainage during the last day before removal of the drainage tube was 168 mL (range, 15 to 490 mL), no patient required subsequent chest drainage for the collection of pleural effusion. Although our VATS procedure included complete lymphadenectomy as reported previously [1], the amount of pleural drainage is not a limiting factor for removal of chest drainage tubes except in situations in which there is hemorrhage or air leakage.
Epidural analgesia was most often discontinued on POD 1 unless the operative procedure had been converted to conventional thoracotomy. Although incisional pain was enhanced after analgesia discontinuation, no patient required subsequent intravenous or intramuscular narcotics. Nomori and coworkers [13] also recommended short-term epidural analgesia because long-term analgesia significantly enhanced incisional pain after discontinuation. Because there are other local analgesic methods such as intercostal nerve cryoanalgesia [11] or paravertebral nerve block [14], the optimal method for controlling incisional pain in patients undergoing VATS requires further study.
Oxygen support was discontinued on POD 1 unless the patients complained of dyspnea and had a saturation of oxygen less than 95%. A previous study showed that postoperative arterial oxygenation declined transiently until POD 4 but recovered to the preoperative value before POD 7 [4]. In our series, we also evaluated the perioperative arterial oxygenation of patients breathing room air and found no significant time-dependent recovery in the partial pressure of arterial oxygen during a 3-day postoperative period (68 ± 8 mm Hg on POD 0, 69 ± 11 mm Hg on POD 1, and 72 ± 9 mm Hg on POD 3 [mean ± SD]; Fig 3).
This result indicates that selected patients can be weaned from oxygen support even on the day of surgery.
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Fig 3. Perioperative change in the partial pressure of arterial oxygen (mm Hg) of patients breathing room air (n = 37). The partial pressure of arterial oxygen was significantly decreased after the operation (#p < 0.05 versus preoperative value [Pre]), and no significant time-dependent recovery during a 3-day postoperative period (68 ± 8 mm Hg on POD 0, 69 ± 11 mm Hg on POD 1, and 72 ± 9 mm Hg on POD 3 [mean ± standard deviation]) was observed. (POD = postoperative day.)
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Six preoperative risk factors were determined to prolong postoperative recovery. Furthermore, the overall number of risk factors predicted the postoperative recovery rate, possibly because most of the risk factors were related to the respiratory system, and patients with multiple risk factors would be those with severe respiratory disorders. Although further study is required, preoperative respiratory functions such as vital capacity or forced expiratory volume were not related to postoperative recovery; these functional variables may not always parallel the degree of respiratory system changes.
In conclusion, our original regimen developed to manage patients after video-assisted pulmonary resection for lung cancer was validated and may be a critical pathway for postoperative recovery. Statistically, six preoperative risk factors were defined as prolonging postoperative recovery, and the overall number of these risk factors specifically predicted postoperative recovery rate. These criteria are useful in planning the hospitalization of patients undergoing this type of surgery, as well as in alerting surgeons to high-risk patients.
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References
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Top
Abstract
Introduction
= without any risk factors (n = 6); 
= with overall 1 to 3 risk factors (n = 22); 
= with overall 4 to 6 risk factors (n = 9). (POD = postoperative day.)