Manipulation under anesthesia after primary knee arthroplasty in Sweden: incidence, patient characteristics and risk of revision.

Background and purpose - The incidence of manipulation under anesthesia (MUA) after knee arthroplasty surgery has been reported to vary between 0.5% and 10%. We evaluated the incidence of MUA after primary knee arthroplasty in Sweden, the demographics of the patients and the risk of revision. Patients and methods - Between 2009 and 2013, 64,840 primary total and unicompartmental knee arthroplasties (TKA and UKA) were registered in the Swedish Knee Arthroplasty Register (SKAR). MUAs performed between 2009 and 2014 were identified through the in- and outpatient registers of the Swedish National Board of Health and Welfare. Pertinent data were verified through medical records and patient demographics and revisions were obtained from the SKAR. Results - 1,258 MUAs were identified. Of these, 1,078 were 1st-time MUAs, performed within 1 year after the primary knee arthroplasty. The incidence of MUA was 1.7% and the incidence varied between hospitals from 0% to 5%. The majority were performed after TKA (98%), in younger patients (65% < 65 years), women (64%), and relatively healthy persons (88% had ASA ≤ 2). The cumulative risk of revision at 10 years was 10% (95% CI 8.6-12), similar for men and women. Interpretation - In Sweden, MUA is a rather uncommon measure after knee arthroplasty, especially after UKA. The CRR at 10 years was doubled compared to the general knee arthroplasty population. The frequency of the procedure varies between hospitals but in general it is performed more frequently in healthier and younger patients.

Incidental detection by computed tomography is an independent prognostic factor for survival in patients operated for nonsmall cell lung carcinoma.

We studied the rate of incidental detection of lung carcinomas and its effect on long-term survival in a nationwide cohort of patients operated for nonsmall cell lung cancer (NSCLC). All patients operated for NSCLC in Iceland during 1991-2010 were included. Demographic and clinicopathological features were compared in patients diagnosed incidentally using chest radiography or computed tomography (CT), and in those with symptomatic presentation. Multivariate analysis was used to evaluate prognostic factors. Out of 508 patients, 174 (34%) were diagnosed incidentally; in 26% of cases by chest radiography and in 8% by CT. The CT-detected tumours were significantly smaller than symptomatic tumours, diagnosed at earlier TNM (tumour, node and metastasis) stages and more often of adenocarcinoma histology. 5-year cancer-specific survival for symptomatic versus incidentally diagnosed patients detected by chest radiography and CT was 41%, 57% and 68%, respectively (p=0.003). After adjusting for stage, the hazard ratio (HR) for NSCLC mortality was significantly lower for incidental diagnosis by CT (HR 0.55, 95% CI 0.31‒0.98; p=0.04) compared to incidental diagnosis by chest radiography (HR 0.95, 95% CI 0.70‒1.27; p=0.71) or symptomatic diagnosis (HR 1.0). One-third of surgically treated NSCLCs were detected incidentally, with an increasing rate of incidental CT diagnosis. NSCLC patients diagnosed incidentally by CT appear to have better survival than those diagnosed incidentally by chest radiography, and particularly those who present with symptoms.

Resection rate and operability of elderly patients with non-small cell lung cancer: Nationwide study from 1991 to 2014.

OBJECTIVES: An increasing number of elderly patients are diagnosed with non-small cell lung cancer (NSCLC). We compared the surgical resection rate, operability and survival in this age group (≥75 years) to younger patients using centralized databases in Iceland. METHODS: The study population comprised all patients diagnosed with NSCLC in Iceland from 1991 to 2014. A total of 140 elderly patients (≥75 years) with NSCLC underwent pulmonary resection and were compared with 550 surgically resected patients less than 75 years, with respect to resection rate, short and long-term survival and complications of surgery. Reasons for exclusion from surgery were registered for elderly surgical candidates (stages IA-IIB). RESULTS: Surgical resection rate in the elderly group was 18% compared to 32% in the younger age group ( P < 0.001). The most frequent reasons for not operating on elderly patients in stages IA-IIB were poor pulmonary function (58%), heart disease (17%) or multiple comorbidities (17%). The rate of major complications following surgery was comparable in the elderly versus the younger age group, 13 vs 11%, respectively ( P = 0.578). The same was true for 30 day mortality (2 vs 1%, P = 0.397). Five-year overall survival was 40% vs 44% ( P = 0.019) and cancer-specific survival 51% vs 50% ( P = 0.802). CONCLUSIONS: Elderly patients with resectable NSCLC according to stage are frequently excluded from surgery due to comorbid conditions. Although the operated patients may represent a selected group, their favourable 30-day and long-term survival indicate that more elderly patients with NSCLC could be operated on.

[Intensive care unit admissions following lobectomy or sublobar resections for non-small cell lung cancer]. / Innlagnir a gjorgaeslu aftir bladnam og fleygskurdi vid lungnakrabbameini.

INTRODUCTION: Following resection for non-small cell lung cancer (NSCLC), patients are usually admitted to the post-anesthesia care unit (PACU)for a few hours before admission to a general ward (GW). However, some patients need ICU-admission, either immediately post-surgery or from the PACU or GW. The aim of this study was to investigate the indications and risk factors for ICU-admission. MATERIAL AND METHODS: A retrospective study of 252 patients who underwent lobectomy, wedge resection or segmentectomy for NSCLC in Iceland during 2001-2010. Data was retrieved from medical records and patients admitted to the ICU compared to patients not admitted. RESULTS: Altogether 21 patients (8%) were admitted to the ICU, median length-of-stay being one day (range 1-68). In 11 cases (52%) the reasons for admission were intraoperative problems, usually hypotension or excessive bleeding. Ten patients were admitted from the GW (n=4) or PACU (n=6), due to hypotension (n=4), heart and/or respiratory failure (n=4) and reoperation for bleeding (n=2). There were three ICU-readmissions. Patients admitted to the ICU were six years older (p=0.004) and more often had chronic obstructive pulmonary disease and/or coronary artery disease. Tumor size, pTNM-stage, length of operation and the ratio of patients receiving TEA (thoracic epidural anaesthesia) were similar between groups. Over two-thirds of the ICU-patients had minor complications and around half had major complications, compared to 30% and 4%, respectively, for controls. CONCLUSION: ICU-admissions are infrequent following non-pneumonectomy lung resections for NSCLC, these patients being older with cardiopulmonary comorbidities. In half of the cases, admission to the ICU directly follows surgery and ICU-readmissions are few.

Resection rate and outcome of pulmonary resections for non-small-cell lung cancer: a nationwide study from Iceland.

BACKGROUND: The proportion of patients with non-small-cell lung cancer (NSCLC) who undergo surgery with curative intent is one measure of effectiveness in treating lung cancer. To the best of our knowledge, surgical resection rate (SRR) for a whole nation has never been reported before. We studied the SRR and surgical outcome of NSCLC patients in Iceland during a recent 15-year period. METHODS: This was a retrospective study of all pulmonary resections performed with curative intent for NSCLC in Iceland from 1994 to 2008. Information was retrieved from medical records and from the Icelandic Cancer Registry. Patient demographics, postoperative tumor, node, metastasis stage, overall survival, and complication rates were compared over three 5-year periods. RESULTS: Of 1530 confirmed cases of NSCLC, 404 were resected, giving an SRR of 26.4%, which did not change significantly during the study period. Minor and major complication rates were 37.4% and 8.7%, respectively. Operative mortality rates were 0.7% for lobectomy, 3.3% for pneumonectomy, and 0% for lesser resection. Five-year survival after all procedures was 40.7% and improved from the first to the last 5-year period (34.8% versus 43.8%, p = 0.04). Five-year survival for stages I and II together was 46.8%, with no significant change in stage distribution between periods. Five-year survival after pneumonectomy was 22.0%, which was significantly lower than for lobectomy (44.6%) and lesser resection (40.7%) (p < 0.005). Unoperated patients had a 5-year survival of 4.8%, as compared to 12.4% for all the NSCLC patients together. CONCLUSION: Compared with most other published studies, the SRR of NSCLC in Iceland is high. Short-term outcome is good, with a low rate of major complications and an operative mortality of only 1.0%. Five-year survival improved significantly over the study period.

[Postoperative complications following lobectomy for lung cancer in Iceland during 1999-2008]. / Fylgikvillar bladnámsadgerda vid lungnakrabbameini á Islandi 1999-2008.

OBJECTIVE: Non small cell lung cancer (NSCLC) is the second most common cancer in Iceland. We studied the indications and surgical outcome of lobectomy for NSCLC in Iceland. MATERIALS AND METHODS: 213 consecutive patients underwent lobectomy for NSCLC between 1999 and 2008. Data on indications, histology, TNM-stage and complications were analysed, and logistic regression used to assess outcome predictors. RESULTS: The majority of patients (60%) were referred because of symptoms, whereas 40% were asymptomatic. Adenocarcinoma (62%) and squamous cell carcinoma (29%) were the most frequent histological types. Operative staging showed that 59.6% of cases were stage I, 17.8% were stage II, 7% were stage IIIA and 14.6% were stage IIIB or IV. Mediastinoscopy was performed in 13.6% of cases. Mean operative time was 128 min., operative bleeding 580 ml and median hospital stay 10 days. Sixteen patients (7.5%) had major complications and 36 (17.5%) had minor complications, such as atrial fibrillation and pneumonia. Twelve patients required reoperation, most often due to bleeding, but two had empyema and one had a bronchopleural fistula. Older patients with high ASA scores and extensive smoking history were at increased risk for complications. No patient died within 30 days of surgery whereas two (0,9%) died within 90 days of surgery. CONCLUSIONS: The results of lobectomy for NSCLC in Iceland are excellent in relation to operative mortality and short term complications.

[Factors predictive of survival after lobectomy for non-small cell lung cancer in Iceland during 1999-2008]. / Forspárbaettir lífshorfa eftir bladnám vid lungnakrabbameini á Islandi 1999-2008.

OBJECTIVE: To study the impact of TNM stage and various preoperative functional parameters on survival in patients who underwent lobectomy for non-small cell lung cancer (NSCLC) in Iceland from 1999 to 2008. MATERIALS AND METHODS: Retrospective study including 213 patients (mean age 66.9 yrs, equal male/female ratio) that underwent lobectomy for NSCLC. Tumors were staged by the TNM staging system, survival was estimated by the Kaplan-Meier method and prognostic factors of survival studied using the Cox proportional hazards regression model. RESULTS: Survival at 1 year was 82.7% and 45.1% at 5 years. Operative mortality at 30 days was 0%. Most tumors were found to be in stage I (59.6%) or stage II (17.8%) and 7% were stage IIIA, whereas 14.6% were in stage IIIB or IV. Using multivariate analysis; advancing stage, increasing tumor size, reduced lung function and history of arrhythmia, predicted worse survival, whereas adenocarcinoma histology was a positive prognostic factor (HR 0.5, p=0.002) when compared to other histological types. CONCLUSIONS: Survival for patients undergoing lobectomy for operable non-small cell lung cancer in Iceland is comparable with other studies. Advanced stage, tumor size, reduced lung function and arrhythmia were negative predictors of survival, but in contrast to many but not all studies adenocarcinoma histology predicted a better prognosis compared to other tumor types.

[Results of pneumonectomy for non-small cell lung cancer in Iceland]. / Arangur lungnabrottnámsadgerda vid lungnakrabbameini á Islandi.

OBJECTIVE: Study the indications, complications and surgical outcome of pneumonectomy for non small cell lung cancer (NSCLC) in Iceland MATERIAL AND METHODS: A retrospective study of all pneumonectomies performed for NSCLC in Iceland from 1988 to 2007. Information was obtained from medical records and data on operative indications, postoperative TNM stage, complications, survival and survival predictors was analysed. RESULTS: 77 patients (64% males) with mean age of 62.3 yrs. were operated on, 44% on the right side. Mediastinoscopy was performed in 31% of cases. Most patients were stage I or II (58%), but 17 and 21% were stage III A and IIIB, respectively. Mean operation time was 161 min., bleeding 1.1 L and hospital stay 11 days. Atrial fibrillation (21%), pneumonia (6.5%), empyema (5.5%) and respiratory failure (5%) were the most common complications. Three (3.9%) patients died within 30 days from surgery. Five year survival was 20.7%. Age, history of COPD, adenocarcinoma histology and advanced TNM stage were independent predictors of poor survival. CONCLUSIONS: Pneumonectomies for NSCLC in Iceland have a low rate of complications and operative mortality. However, long term survival is lower than expected, and many patients (27%) were in advanced stages. This is most likely due to inadequate preoperative staging.