Screening for Frailty in Thoracic Surgical Patients.

BACKGROUND: The presence of frailty or prefrailty in older adults is a risk factor for postsurgical complications. The frailty phenotype can be improved through long-term resistance and aerobic training. It is unknown whether short-term preoperative interventions targeting frailty will help to mitigate surgical risk. The purpose of this study was to determine the proportion of frail and prefrail patients presenting to a thoracic surgical clinic who could benefit from a frailty reduction intervention. METHODS: A prospective cohort study was performed at a single-site thoracic surgical clinic. Starting October 1, 2014, surgical candidates 60 years of age or older who consented to be screened were included. Patients were screened using an adapted version of Fried's phenotypic frailty criteria: weakness (grip strength), slow gait (15-foot walk), unintentional weight loss, self-reported exhaustion, and low self-reported physical activity (Physical Activity Scale for the Elderly). Prefrailty was identified when participants demonstrated one to two frailty characteristics; frailty was identified when participants demonstrated three to five frailty characteristics. RESULTS: Of 180 eligible patients, 126 consented, and 125 completed screening. Thirty-nine participants (31%) were not frail, 71 (57%) were prefrail, and 15 (12%) were frail. Exhaustion was the most common frailty symptom (34%). Frailty prevalence did not significantly differ among men and women (men: 10%, women: 14%; p = 0.75). CONCLUSIONS: We found a high proportion of prefrail and frail patients among patients deemed candidates for thoracic surgical procedures. This finding indicates that frailty may be underrecognized. Substantial numbers of patients may be considered for a presurgical frailty reduction intervention.

Training in minimally invasive lobectomy: thoracoscopic versus robotic approaches.

BACKGROUND: Skills required for thoracoscopic and robotic operations likely differ. The needs and abilities of trainees learning these approaches require assessment. METHODS: Trainees performed initial components of minimally invasive lobectomies using thoracoscopic or robotic approaches. Component difficulty was scored by trainees using the NASA task load index (NASATLX). Performance of each component was graded by trainees and attending surgeons on a 5-point ordinal scale (naïve, beginning learner, advanced learner, competent, master). RESULTS: Eleven surgical trainees performed 87 replications among three lobectomy components (divide pulmonary ligament; dissect level 7/8/9 nodes; dissect level 4/5 nodes). Before performance NASATLX scores did not differ among components or between surgical approaches. Trainees' after performance NASATLX scores appropriately calibrated task load for the components. After performance NASATLX scores were significantly lower for thoracoscopy than before performance estimates; robotic scores were similar before surgery and after performance. Task load was higher for robotic than for thoracoscopic approaches. Trainees rated their performance higher than did attending surgeons in domains of knowledge and thinking, but ratings for other domains were similarly low. Ratings for performance improved significantly as component performance repetitions increased. CONCLUSIONS: Trainees did not differentiate task load among components or surgical approaches before attempting them. Task load scores differentiated difficulty among initial components of lobectomy, and were greater for robotic than for thoracoscopic approaches. Trainees overestimated their level of cognitive performance compared with attending physician evaluation of trainee performance. The study provides insights into how to customize training for thoracoscopic and robotic lobectomy and identifies tools to assess training effectiveness.

Diffusing capacity predicts long-term survival after lung resection for cancer.

OBJECTIVES: Predictors of long-term survival for patients with lung cancer assist in individualizing treatment recommendations. Diffusing capacity (DLCO) is a predictor of complications after resection for lung cancer. We sought to determine whether DLCO is also prognostic for long-term survival after lung resection for cancer. METHODS: We assessed survival among patients in our prospective database who underwent lung resection for cancer between 1980-2006. Potential prognostic factors for all-cause mortality were evaluated by computing average annual hazard rates, and variables significantly associated with survival were included in multivariable Cox modelling. Multiple imputation was used to address missing values. RESULTS: Among 854 unique patients, there were 587 deaths. The median follow-up time from surgery was 9.6 years. Predictors of survival included age, stage, performance status, body mass index, history of myocardial infarction, renal function and DLCO. On univariate analysis, the hazard ratio increased incrementally compared with those with a DLCO of ≥ 80% (70-79%, 1.12; 60-69%, 1.29; <60%, 1.35). On multivariable analysis, DLCO was an independent predictor of long-term survival for all patients (corrected for all other important covariates; HR 1.04 per 10-point decrement; 95% CI 1.00-1.08; P = 0.05). Its prognostic ability for long-term survival was above and beyond its influence on operative mortality. CONCLUSIONS: DLCO is an independent and clinically important determinant of long-term survival after major lung resection for cancer, a finding that is not generally known. Knowledge of this may help improve selection of patients for lung resection and may help tailor the extent of resection, when possible, in order to appropriately balance operative risk with long-term outcomes.

Validation of a modified scoring system for cardiovascular risk associated with major lung resection.

OBJECTIVES: The well-known revised cardiac risk index (RCRI) has recently been modified based on factors and outcomes specific to thoracic surgery patients (ThRCRI). We explored the accuracy of this modified scoring system in predicting cardiovascular morbidity after major lung resection. METHODS: We analyzed outcomes from a prospective database of patients undergoing major lung resection 1980-2009. ThRCRI score was based on weighted factors for serum creatinine, coronary artery disease, cerebrovascular disease and extent of lung resection. Target adverse outcomes included pulmonary embolism, myocardial infarction, cardiac arrest, pulmonary edema and cardiac death. RESULTS: A total of 1255 patients (mean age 61.8 years; 649 men) underwent lobectomy or bilobectomy (1070; 85%) or pneumonectomy (185; 15%) for cancer (1037; 83%) or other problems. Severe cardiovascular complications occurred in 30 patients (2.4%), an incidence similar to that in the published derivation group (3.3%). ThRCRI median scores in patients without and with severe CV complications were 0 and 1.5 (P < 0.001). Score categories yielded incremental risks of cardiovascular complications (0: 0.9%; 1-1.5: 4.5%; ≥ 2: 12.8%; P < 0.001). The Hosmer-Lemeshow test demonstrated no significant difference between expected and observed outcomes (P = 0.11). CONCLUSIONS: The incidences of severe postoperative cardiovascular complications were similar in the published derivation group and the current validation group. The ThRCRI score successfully stratified risk for postoperative cardiovascular events after major lung resection in the validation group. The expected risk in the validation group was similar to the observed risk, indicating that ThRCRI accurately predicted specific risk rather than just relative risk. Further evaluation of the utility of this scoring system is warranted.

Prediction of major pulmonary complications after esophagectomy.

BACKGROUND: Pulmonary complications are the most frequent morbid event after esophagectomy. Understanding factors that are associated with pulmonary complications may help in patient selection and postoperative management. METHODS: We performed a retrospective review of patients who underwent esophagectomy between 1980 and 2009. Univariate analysis was used to identify potential covariates for the development of major pulmonary complications. Multivariable logistic regression analysis was used to identify predictors of complications. A scoring system was developed, and its ability to predict complications was assessed. RESULTS: A total of 516 patients (382 men [74%]) with a mean age of 59.0±12.5 years underwent esophagectomy for cancer (398 [77%]) or benign disease. Major pulmonary complications occurred in 197 patients (38%) and were associated with a 10-fold increase in operative mortality (2.5% vs 28%; p<0.001). Independent predictors included patient age, forced expiratory volume in 1 second (% predicted), diffusion capacity of the lung for carbon monoxide (% predicted), performance status, serum creatinine, current cigarette use, and transthoracic resection. The scoring system (based on weighted scores for the first 4 covariates listed above) predicted pulmonary complications with an accuracy of 70.8% (p<0.001). Score groups identified an incremental risk of complications of 0 to 2, 12%; 3 to 4, 18%; 5 to 6, 46%; 7 to 8, 52%; and 9 to 13, 60% (p<0.001). CONCLUSIONS: Major pulmonary complications are frequent after esophagectomy and can be predicted using commonly available clinical information. A scoring system identifying the risk of such complications may assist in patient selection and in providing appropriate resources for postoperative management of higher-risk patients.

Estimating lung resection risk: a pilot study of trainee and practicing surgeons.

BACKGROUND: Most surgeons believe that experience-based risk estimates for major lung resection are reliable. Elements that influence such estimates are poorly understood. METHODS: Clinical vignettes were created for patients who underwent lung resection; 48 patients who had major complications were matched to 48 patients without complications. Ten senior surgical trainees and 9 practicing thoracic surgeons blinded to outcomes estimated the risk of complications using a seven-point scale (uninformed estimates). After review of a calculated risk score, risk was again estimated (informed estimates). RESULTS: Risk estimates did not differentiate between patient groups with and without complications (4.8 versus 4.9; p=0.94 for trainees; 4.5 versus 4.2; p=0.21 for practicing surgeons). The accuracy of predicting complications was only fair, but was better for practicing surgeons than for trainees (58% versus 51%; p=0.041). Risk estimates correlated moderately well with baseline pulmonary function and possibly with age, but not with performance status or extent of resection. Knowledge of a calculated risk score resulted in more frequent alterations of trainee risk scores, improved interobserver agreement in both groups, and aligned trainee and practicing surgeon estimates more closely. CONCLUSIONS: Surgeon estimates are not accurate in predicting lung resection complications using vignette-based, matched-pair methodology. Practicing surgeons and trainees base risk estimates on limited objective clinical data. Trainee estimates are more susceptible to modification by a standard risk score than are estimates of practicing surgeons. Prospective studies are necessary to further explore the etiology, accuracy, and utility of surgeon risk estimates.

Quality of life and mood in older patients after major lung resection.

BACKGROUND: The increasing percentage of older patients undergoing lung resection for cancer necessitates a better understanding of long-term outcomes in this population. We studied the associations among quality of life, mood, clinical factors, and age after major lung resection. METHODS: Outcomes for quality of life and mood questionnaires were compared with clinical factors for older (> or = 70 years) and younger (< 70 years) patients who recovered from major lung resection for stage I or II lung cancer from 1996 to 2006 and were without evidence of recurrence. RESULTS: Of 221 eligible patients, 124 completed questionnaires; 55 (44%) were older (age 76 +/- 4 years). The time from resection was 2.6 +/- 1.6 years. Despite similar comorbidities, older patients were more likely to experience pulmonary (11% versus 3%; p = 0.14), cardiovascular (9% versus 1%; p = 0.087), or any complications (25% versus 12%; p = 0.045). Quality of life function, mood, and symptom scores were similar between the two groups except older patients experienced worse physical function (p = 0.067), fatigue (p = 0.068), and dyspnea (p = 0.094). Postoperative pulmonary complications were related to physical function and dyspnea scores. Covariates for worst quartile scores were percent predicted forced expiratory volume in the first second (physical function, role function, fatigue, pain, and dyspnea) and pulmonary complications (physical function). CONCLUSIONS: Quality of life after recovery from lung resection is similar for older and younger patients despite an increased frequency of postoperative complications among older patients. Important quality of life and symptom score differences are related to percent predicted forced expiratory volume in the first second. This information may help with patient selection and preoperative counseling.