A Modified Calculation Improves the Accuracy of Predicted Postoperative Lung Function Values in Lung Cancer Patients.

PURPOSE: Preoperative pulmonary function testing is mandatory for non-small cell lung cancer (NSCLC) surgery. The predicted postoperative FEV1 (ppoFEV1) is used for further risk stratification. We compared the ppoFEV1 with the postoperative FEV1 (postFEV1) in order to improve the calculation of the ppoFEV1. METHODS: 87 patients voluntarily received an FEV1 assessment 1 year after surgery. ppoFEV1 was calculated according to the Brunelli calculation. Baseline characteristics and surgical procedure were compared in a uni- and multivariate analysis between different accuracy levels of the ppoFEV1. Parameters which remained significant in the multinominal regression analysis were evaluated for a modification of the ppoFEV1 calculation. RESULTS: Independent factors for a more inaccurate ppoFEV1 were preoperative active smoking (odds ratio (OR) 4.1, confidence interval (CI) 3.6-6.41; p = 0.01), packyears (OR 4.1, CI 3.6-6.41; p = 0.008), younger age (OR 1.1, CI 1.01-1.12; p = 0.03), and patients undergoing pneumectomy (OR 5.55, CI 1.35-23.6; p = 0.01). For the customized ppoFEV1 we excluded pneumonectomies. For patients < 60 years, an additional lung segment was added to the calculation. ppoFEV1 = preFEV1 × [Formula: see text]. For actively smoking patients with more than 30 packyears we subtracted one lung segment from the calculation ppoFEV1 = PreFEV1 × [Formula: see text]. CONCLUSION: We were able to enhance the predictability of the ppoFEV1 with modifications. The modified ppoFEV1 (1.828 l ± 0.479 l) closely approximates the postFEV1 of 1.823 l ± 0.476 l, (0.27%) while the original ppoFEV1 calculation is at 1.78 l ± 0.53 (2.19%). However, if patients require pneumectomy, more complex techniques to determine the ppoFEV1 should be included to stratify risk.

[Chest wall replacement]. / Thoraxwandersatz.

The optimal surgical reconstruction of chest wall defects especially in the context of posttraumatic, oncological and congenital etiologies has a large impact on the recovery of the patients. Regardless of the etiology, various complications, such as a generally impaired respiratory physiology in an unstable thorax or decreased pulmonary clearance associated with acute and chronic pulmonary infections, may impair the recovery of affected patients. The postoperative occurrence of an intrathoracic dead space may lead to a difficult to treat empyema. Each thoracic wall defect must be accurately assessed and treated according to size, depth and location on the chest. The complexity of this condition and the resulting complications require the highest degree of surgical care which should be interdisciplinary both preoperatively and postoperatively.

[Role of Laser Resection in Pulmonary Metastasectomy]. / Die Rolle der Laserresektion in der Lungenmetastasenchirurgie.

Objectives This review presents laser resection as treatment option in pulmonary metastasectomy and summarizes the current evidence. Moreover, it includes the comparison of laser resection and common techniques used in lung metastasectomy. Methods We performed a systematic literature research in Medline and the Cochrane library to detect case series and even randomized trials. All included studies underwent qualitative analysis. Results Laser metastasectomy is a safe procedure. Data regarding relevant clinical end points as hospitalization, duration of chest tube drainage and long-term survival are heterogeneous and still controversial. Laser enucleation decreases the resection volume. Therefore, it leads to a significant reduction of parenchymal loss. Survival rates after laser metastasectomy are equal to the outcome after resection using other techniques. Conclusions Laser resection is a parenchyma-sparing method. Hence, it offers radical metastasectomy even in case of multiple pulmonary lesions or impaired lung capacity.

[Pulmonary metastasectomy in renal cell carcinoma]. / Lungenmetastasenchirurgie beim Nierenzellkarzinom.

BACKGROUND: In patients with isolated meta- or synchronous pulmonary metastases from renal cell cancer, lung metastasectomy could be an appropriate treatment option after successful treatment of primary cancer. OBJECTIVES: Presentation of lung metastasectomy as a treatment option in patients with pulmonary metastatic renal cell cancer and the postoperative outcome. Description of alternative treatment modalities focusing on "targeted therapies". MATERIALS AND METHODS: Systematical literature research and qualitative analysis of studies on patients undergoing lung metastasectomy after primary nephrectomy published since 01 January 2000. We assessed operative findings, survival data, and prognostic factors. RESULTS: Pulmonary metastasectomy results in a median postmetastasectomy survival of 26-94 months. The 5­year survival rates vary between 33 and 58%. The patients' prognosis depends on a prolonged disease-free interval and complete resection of all suspected metastases. In particular, number and location of lung metastases should play a minor role for the indication for lung metastasectomy. CONCLUSIONS: Pulmonary metastasectomy should be considered the treatment of choice in selected patients with successfully resected primary cancer showing no evidence of extrapulmonary metastases and having guaranteed operability and complete resection.

[Surgical therapy of lung metastases from head and neck cancer]. / Chirurgische Therapie pulmonaler Metastasen von Kopf-Hals-Tumoren.

Pulmonary metastasectomy is an established procedure in oncological therapeutic concepts. A systematic literature search and an analysis of all studies published since 01.01.2000 should evaluate the advantage of pulmonary metastasectomy for patients with primary head and neck cancer. Lung metastases develop in 1.9-13% of head and neck cancer patients. Following metastasectomy, patients reach a median survival of 9.5-78 months and 5-year survival rates of up to 58% are achieved. Intrathoracic recurrence occurs in 18.4-81.8% of patients, selected instances of which can be successfully treated by remetastasectomy. Patients with squamous cell carcinoma have the worst prognosis, but could also become long-term survivors (≥ 60 months). Pulmonary metastasectomy is frequently the only potentially curative therapeutic approach and offers a better long-term survival than nonsurgical therapies. Lung metastasectomy is thus the treatment of choice in selected patients with pulmonary metastases from primary head and neck cancer.

Outcome prediction in cardiac surgery: the first logistic scoring model for cardiac surgical intensive care patients.

BACKGROUND: In the process of risk stratification, a logistic calculation of mortality risk in percentage is easier to interpret. Unfortunately, there is no reliable logistic model available for postoperative intensive care patients. The aim of this study was to present the first logistic model for postoperative mortality risk stratification in cardiac surgical intensive care units. This logistic version is based on our previously presented and established additive model (CASUS) that proved a very high reliability. METHODS: In this prospective study, data from all adult patients admitted to our ICU after cardiac surgery over a period of three years (2007-2009) were collected. The Log-CASUS was developed by weighting the 10 variables of the additive CASUS and adding the number of postoperative day to the model. Risk of mortality is predicted with a logistic regression equation. Statistical performance of the two scores was assessed using calibration (observed/expected mortality ratio), discrimination (area under the receiver operating characteristic curve), and overall correct classification analyses. The outcome measure was ICU mortality. RESULTS: A total of 4054 adult cardiac surgical patients was admitted to the ICU after cardiac surgery during the study period. The ICU mortality rate was 5.8%. The discriminatory power was very high for both additive (0.865-0.966) and logistic (0.874-0.963) models. The logistic model calibrated well from the first until the 13th postoperative day (0.997-1.002), but the additive model over- or underestimated mortality risk (0.626-1.193). CONCLUSION: The logistic model shows statistical superiority. Because of the precise weighing the individual risk factors, it offers a reliable risk prediction. It is easier to interpret and to facilitate the integration of mortality risk stratification into the daily management more than the additive one.

Comparison between Sequential Organ Failure Assessment score (SOFA) and Cardiac Surgery Score (CASUS) for mortality prediction after cardiac surgery.

BACKGROUND: Our purpose was to evaluate and compare the accuracy of the "Sequential Organ Failure Assessment" score (SOFA) and the "Cardiac Surgery Score" (CASUS) for the prediction of mortality after cardiac surgery. METHODS: Between January 1, 2007 and December 31, 2008 we prospectively included all consecutive adult patients admitted to our intensive care unit (ICU) after cardiac surgery. Both scoring systems were calculated daily from the 1st day in the ICU (day of operation) until the 7th ICU day. We evaluated the ICU mortality prediction of both models using calibration and discrimination statistics. RESULTS: 2801 patients (29.6% females) were included. Mean age was 66.9 ± 10.7 years. Intensive care unit mortality was 5.2%. The calibration of the "Sequential Organ Failure Assessment Score" and "Cardiac Surgery Score" was reliable for all days (p ≥ 0.05). CASUS was more accurate in predicting survival and mortality compared to SOFA for all days, as evidenced by the larger areas under the Receiver Operating Characteristic curves. CONCLUSIONS: Both CASUS and SOFA are reliable mortality prediction tools after cardiac surgery. However, CASUS was more accurate in predicting the individual patient's risk of mortality. Thus, use of the CASUS in cardiac surgery intensive care units is recommended.

Prognostic value of daily cardiac surgery score (CASUS) and its derivatives in cardiac surgery patients.

BACKGROUND: We aimed to validate the usefulness of CASUS derivatives for cardiac surgery patients and their reliability for daily decision making. METHODS: We included, prospectively, the data of all adult cardiac surgery patients who had an ICU stay of at least 12 hours between 20 January 2003 and 14 October 2005 in the Department of Cardiothoracic Surgery of the University of Cologne, Germany. Data were collected until ICU discharge and included initial, maximum, mean, and total CASUS values. δ CASUS (difference from initial value) was calculated at 48 and 96 hours postoperatively. The predictive efficacy of the derivatives was tested with calibration and discrimination statistics. RESULTS: 2372 patients were included with a mean age of 66.2 ± 11.2 years. ICU mortality was 3.6 % (n =85). Mean ICU stay was 3.0 ± 6.1 days. The discrimination was very good for all derivatives (area under the curve ranged between 0.988 and 0.926). The calibration was also good except for the total CASUS, which showed a significant difference between the expected and observed mortality. Increased δ CASUS at 48 hours (1038 patients) and 96 hours (435 patients) correlated with an increase in mortality (23.1 % and 42.9 %, respectively), and conversely a decreased mortality rate was observed with decreasing values (1.9 % and 3.8 %, respectively). CONCLUSION: CASUS derivatives including δ CASUS have a good prognostic value for cardiac surgery patients with regard to the prediction of mortality and survival during ICU stay, with the exception of total CASUS which was not informative.