Short-term perioperative treatment with ambroxol reduces pulmonary complications and hospital costs after pulmonary lobectomy: a randomized trial.

OBJECTIVE: To assess in a randomized clinical trial the influence of perioperative short-term ambroxol administration on postoperative complications, hospital stay and costs after pulmonary lobectomy for lung cancer. METHODS: One hundred and forty consecutive patients undergoing lobectomy for lung cancer (April 2006-November 2007) were randomized in two groups. Group A (70 patients): ambroxol was administered by intravenous infusion in the context of the usual therapy on the day of operation and on the first 3 postoperative days (1000 mg/day). Group B (70 patients): fluid therapy only without ambroxol. Groups were compared in terms of occurrence of postoperative complications, length of stay and costs. RESULTS: There were no dropouts from either group and no complications related to treatment. The two groups were well matched for perioperative and operative variables. Compared to group B, group A (ambroxol) had a reduction of postoperative pulmonary complications (4 vs 13, 6% vs 19%, p=0.02), and unplanned ICU admission/readmission (1 vs 6, 1.4% vs 8.6%, p=0.1) rates. Moreover, the postoperative stay and costs were reduced by 2.5 days (5.6 vs 8.1, p=0.02) and 2765 Euro (2499 Euro vs 5264 Euro, p=0.04), respectively. CONCLUSIONS: Short-term perioperative treatment with ambroxol improved early outcome after lobectomy and may be used to implement fast-tracking policies and cut postoperative costs. Nevertheless, other independent trials are needed to verify the effect of this treatment in different settings.

Performance at symptom-limited stair-climbing test is associated with increased cardiopulmonary complications, mortality, and costs after major lung resection.

BACKGROUND: Exercise tests are increasingly used during preoperative evaluation before lung resection. This study assessed the association between performance at the symptom-limited stair-climbing test and postoperative cardiopulmonary morbidity, mortality, and costs after major lung resections. METHODS: As part of their routine preoperative evaluation, 640 patients who had lobectomy (n = 533) or pneumonectomy (n = 107) for lung cancer from January 2000 through April 2007 performed a preoperative symptom-limited stair-climbing test. Sensitivity/specificity analysis was used to identify the best cutoff values of altitude climbed (number of steps x height of the step in m) associated with outcome. Univariate and multivariate regression analyses (validated by bootstrap) were used to test associations between preoperative and operative factors and postoperative cardiopulmonary complications, mortality, and postoperative costs. RESULTS: The altitude reached at the stair-climbing test was reliably associated with increased cardiopulmonary complications (p = 0.04), mortality (p = 0.02), and costs (p < 0.0001). In patients who climbed less than 12 m, cardiopulmonary complications, mortality, and costs were 2-fold (p < 0.0001), 13-fold (p < 0.0001), and 2.5-fold higher, respectively, than in patients who climbed more than 22 m. CONCLUSIONS: Performance at a maximal stair-climbing test was reliably associated with postoperative morbidity and mortality. We recommend the use of this simple and economic test in all lung resection candidates. Patients who perform poorly at the stair-climbing test should undergo a formal cardiopulmonary exercise test with measurement of oxygen consumption to optimize their perioperative management.

Oxygen desaturation during maximal stair-climbing test and postoperative complications after major lung resections.

OBJECTIVE: Non-univocal conclusions have been published regarding the definition of oxygen desaturation in relation to postoperative outcome. We aimed to verify whether oxygen desaturation during a maximal stair-climbing test was associated with postoperative cardiopulmonary complications and to assess which definition of oxygen desaturation (oxygen saturation <90% or desaturation >4% with respect to rest level) discriminated better between complicated and uncomplicated patients. METHODS: Five hundred and thirty-six patients performing a maximal stair-climbing test prior to major lung resection were analyzed. All patients performed the test on room air. Patients with and without cardiopulmonary complications were compared in terms of several preoperative and operative characteristics by univariate analysis, including the presence of oxygen desaturation at peak exercise (saturation <90% or desaturation >4%). Logistic regression analysis was then performed and validated by bootstrap procedure to identify predictors of complications and to see whether the exercise oxygen desaturation retained its significancy after multivariable adjustment. RESULTS: Twenty-seven patients had an exercise oxygen saturation below 90%, but this parameter was not significantly associated with complications. Seventy-five patients experienced an exercise desaturation greater than 4%, which was a significant result associated with postoperative complications at univariate analysis (p=0.008) (36% complication rate). After adjusting for age, ppoFEV1, ppoDLCO, type of operation, height reached at stair-climbing test and cardiac co-morbidity, a desaturation greater than 4% retained its significance at logistic regression and proved to be stable at bootstrap. CONCLUSIONS: A stair-climbing test is an intense constant workload exercise, challenging a large amount of muscle mass, and appears particularly appropriate to elicit oxygen desaturation, which in turn may be a reliable marker of deficits in the oxygen transport system. A desaturation >4% appears a better cut-off definition than a saturation level <90% in predicting the occurrence of complications. The risk of complications was approximately two-fold higher in patients with oxygen desaturation >4% at peak exercise.

Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax: clinical and economic analysis in comparison to the traditional approach.

We aimed to verify the clinical and economic effects of uniportal video-assisted thoracic surgery (VATS) in patients with primary spontaneous pneumothorax (PSP) compared to traditional three-port VATS technique. We analyzed 51 consecutive patients (23 three-port VATS and 28 uni-port VATS), treated by bullectomy and pleural abrasion, to detect differences between the two groups with regard to intraoperative management, postoperative course, pain, paraesthesia and costs. Data about pain and paraesthesia were collected by telephonic interview within a minimum follow-up period of six months. Compared to three-port VATS, patients treated by the uni-port VATS were discharged more quickly (3.8 days vs. 4.9 days, P=0.03) and experienced paraesthesia less frequently (35% vs. 94%, P<0.0001). No difference in chronic pain was observed between the two groups (numeric pain score: 0.6 uni-port vs. 1.3 three-port, P=0.2). Compared to three-port VATS, we found a significant reduction in postoperative costs for the patients operated on by the uni-port technique (euro1407 vs. euro1793, P=0.03), without any increase in surgical costs. In conclusion, uniportal VATS appears to offer better clinical (postoperative stay and rate of paraesthesia) and economic (postoperative costs) results than the standard three-port VATS for treating primary spontaneous pneumothorax.

Evaluation of expiratory volume, diffusion capacity, and exercise tolerance following major lung resection: a prospective follow-up analysis.

BACKGROUND: Lung resections determine a variable functional reduction depending on the extent of the resection and the time elapsed from the operation. The objectives of this study were to prospectively investigate the postoperative changes in FEV(1), carbon monoxide lung diffusion capacity (Dlco), and exercise tolerance after major lung resection at repeated evaluation times. METHODS: FEV(1), Dlco, and peak oxygen consumption (Vo(2)peak) calculated using the stair climbing test were measured in 200 patients preoperatively, at discharge, and 1 month and 3 months after lobectomy or pneumonectomy. Preoperative and repeated postoperative measures were compared, and a time-series, cross-sectional regression analysis was performed to identify factors associated with postoperative Vo(2)peak. RESULTS: One month after lobectomy, FEV(1), Dlco, and Vo(2)peak values were 79.5%, 81.5%, and 96% of preoperative values and recovered up to 84%, 88.5%, and 97% after 3 months, respectively. One month after pneumonectomy, FEV(1) percentage of predicted, Dlco percentage of predicted, and Vo(2)peak values were 65%, 75%, and 87% of preoperative values, and were 66%, 80%, and 89% after 3 months, respectively. Three months after lobectomy, 27% of patients with COPD had improved FEV(1), 34% had improved Dlco, and 43% had improved Vo(2)peak compared to preoperative values. The time-series, cross-sectional regression analysis showed that postoperative Vo(2)peak values were directly associated with preoperative values of Vo(2)peak, and postoperative values of FEV(1) and Dlco, and were inversely associated with age and body mass index. CONCLUSIONS: Our findings may be used during preoperative counseling and for deciding eligibility for operation along with other more traditional measures of outcome.

Predicted versus observed FEV1 in the immediate postoperative period after pulmonary lobectomy.

OBJECTIVE: Scanty information can be found regarding ppoFEV1% correlation with true FEV1% in the immediate days after surgery, when most cardio-respiratory complications are developed. This prospective multicentric investigation aims to describe the evolution of FEV1 in a series of uneventful lobectomy cases before hospital discharge, and to identify factors associated with the variation of postoperative residual FEV1, with the ratio between the actual and the predicted postoperative FEV1 measured during the first 6 postoperative days. METHODS: One hundred and sixty-one patients submitted to lobectomy were prospectively enrolled in the study. Patients with chest wall resections and postoperative complications were excluded. Data from a total of 125 patients were thus used for the analysis. The following clinical variables were recorded: age, preoperative FEV1, ppoFEV1, presence of chronic obstructive pulmonary disease (COPD), surgical approach (VATS or muscle-sparing thoracotomy), side (right or left) and site (upper or lower) of resection, type of analgesia (epidural or intravenous), and daily visual analogue pain score (VAS). FEV1 was measured in every patient at hospital admission and daily until discharge or up to postoperative day 6. Random effects time-series cross-sectional regression analyses were performed to identify factors associated with variation of postoperative residual function (100-(preoperative FEV1-postoperative FEV1/preoperative FEV1 x 100)), and of FEV1 ratio ((actual postoperative FEV1 x 100)/ppoFEV1). For these analyses, the dependent variables (postoperative residual function and FEV1 ratio) and the pain score were analysed as panel longitudinal data. The regression analyses were subsequently validated by bootstrap procedure. RESULTS: FEV1% was lower at first postoperative day and increased gradually up to day 6 but mean values never reached ppoFEV1%. Pain scores decreased from day 1 to day 6. Preoperative FEV1 (p<0.0001) and postoperative pain score (p<0.0001) resulted independently and reliably inversely associated with postoperative residual FEV1 (model R2, 0.16). Preoperative FEV1 (p=0.001), postoperative pain score (p<0.0001), and epidural analgesia (p=0.04) resulted independently and reliably associated with postoperative FEV1 ratio (model R2, 0.13). CONCLUSION: Current methods of prediction of postoperative FEV1 greatly underestimated the real functional loss in the immediate postoperative period. Therefore, for the purpose of a more accurate risk stratification we need to correct the traditional prediction of postoperative FEV1.