Taylor Lauren J, Julliard Walker A, Maloney James D
Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin, Madison, WI, USA.
Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
J Thorac Dis. 2018 Feb;10(2):1072-1076. doi: 10.21037/jtd.2018.01.100.
Despite the importance of preoperative risk-stratification, there is a lack of consensus on how to identify high-risk patients for pulmonary resection. Enrollment criteria for national trials propose one definition based on preoperative pulmonary function tests. We sought to examine the value of preoperative forced expiratory volume in 1 second (FEV1) and diffusion capacity for carbon monoxide (DLCO) to predict short-term outcomes following pulmonary resection. Using our institutional Society of Thoracic Surgeons (STS) database we identified 419 consecutive lung cancer patients who presented to our institution for pulmonary resection between 2012 and 2016. We identified patients as "high risk" based on the national trial criteria of FEV1 or DLCO ≤50%. Our primary outcome was any postoperative complication within 30 days of surgery. Secondary outcomes included cardiac and pulmonary complications, 30-day readmission, and discharge disposition. DLCO ≤50% was associated with any postoperative complication (P=0.03), but not predictive of cardiac events, pulmonary complications, or 30-day readmission. There were no significant differences in any of these short-term outcomes for patients with FEV1 ≤50%. On multivariable analysis, neither FEV1 nor DLCO ≤50% were significantly associated with occurrence of postoperative complication (OR =1.67, 95% CI: 0.60-4.63; OR =1.66, 95% CI: 0.96-2.86, respectively). Notably, DLCO ≤50%-but not FEV1-was associated with discharge to a skilled facility on univariate (P=0.01) and multivariable analysis (OR =2.54; 95% CI: 1.08-5.99; P=0.03). This association between DLCO and discharge to a skilled facility persisted when DLCO was used as a continuous variable. For all-comers presenting to our institution for lung cancer resection, classification based on FEV1 or DLCO ≤50% may not reliably identify those at highest risk for short-term postoperative complications. While our findings suggest caution when using pulmonary parameters in isolation, the potential value of DLCO as a proxy for underlying comorbidity warrants further investigation.
尽管术前风险分层很重要，但对于如何识别肺切除手术的高危患者尚无共识。全国性试验的纳入标准基于术前肺功能测试提出了一种定义。我们试图研究术前一秒用力呼气量（FEV1）和一氧化碳弥散量（DLCO）对预测肺切除术后短期结局的价值。利用我们机构的胸外科医师协会（STS）数据库，我们确定了2012年至2016年间连续419例因肺癌前来我院接受肺切除手术的患者。根据FEV1或DLCO≤50%的全国性试验标准，我们将患者确定为“高危”。我们的主要结局是术后30天内的任何术后并发症。次要结局包括心脏和肺部并发症、30天再入院率和出院处置情况。DLCO≤50%与任何术后并发症相关（P=0.03），但不能预测心脏事件、肺部并发症或30天再入院率。FEV1≤50%的患者在任何这些短期结局方面均无显著差异。在多变量分析中，FEV1和DLCO≤50%均与术后并发症的发生无显著相关性（OR分别为1.67，95%CI：0.60-4.63；OR为1.66，95%CI：0.96-2.86）。值得注意的是，在单变量（P=0.01）和多变量分析（OR=2.54；95%CI：1.08-5.99；P=0.03）中，DLCO≤50%（而非FEV1）与转至专业护理机构出院相关。当将DLCO用作连续变量时，DLCO与转至专业护理机构出院之间的这种关联仍然存在。对于所有前来我院进行肺癌切除术的患者，基于FEV1或DLCO≤50%进行分类可能无法可靠地识别出术后短期并发症风险最高的患者。虽然我们的研究结果表明单独使用肺参数时需谨慎，但DLCO作为潜在合并症替代指标的潜在价值值得进一步研究。
