Zhang Ruoyu, Dippon Jürgen, Friedel Godehard
Department of General and Thoracic Surgery, Justus-Liebig-University Giessen, Giessen, Germany.
Department of Thoracic Surgery, Chest Hospital Schillerhoehe, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
J Thorac Dis. 2019 Jan;11(1):222-230. doi: 10.21037/jtd.2018.12.44.
Given the wide adoption of thoracoscopic lobectomy and positive effect of the thoracoscopic approach for improving postoperative outcomes, questions have arisen regarding the validity of previously published risk assessment models. We sought to review the reliability of the established predictors for patients undergoing thoracoscopic lobectomy.
From January 2009 to May 2017, 606 patients (275 women, 331 men; median age 67 years) underwent thoracoscopic lobectomy or segmentectomy for confirmed or suspected early-stage lung cancer or metastasis at our institution. Logistic regression analyses were performed to determine the predictors of postoperative complications, followed by assessments of causal inference.
The postoperative mortality, pulmonary complication, cardiovascular complication and overall morbidity rates were 1.0%, 8.9%, 5.8% and 18.0%, respectively. While the American Society of Anesthesiologists physical status (ASA-PS) emerged as an independent morbidity predictor, only a slightly significant association between lung function determinants and overall morbidity was found in the univariable regression analyses. Regarding causal inference, inverse probability of treatment weighting using propensity scores revealed 2- and 1.7-fold increases in the odds of cardiopulmonary complications and overall morbidity in patients with ASA-PS grade 3 or 4 compared with those with ASA-PS grade 1 or 2 (OR =2.116, 95% CI: 1.252-3.577, P=0.005; OR =1.740, 95% CI: 1.095-2.765, P=0.019, respectively).
Our results suggested that the current physiologic evaluation algorithm is also applicable to major lung resection via thoracoscopic approach. ASA-PS is an easily assessable factor capable of predicting major complications following thoracoscopic lobectomy in patients properly selected in compliance with the current guideline. It is recommended to incorporate the ASA-PS into the existing algorithm for more accurate risk stratification in this patient population.
鉴于胸腔镜肺叶切除术的广泛应用以及该手术方式对改善术后结局的积极作用，此前发表的风险评估模型的有效性受到质疑。我们旨在评估已确立的预测指标对接受胸腔镜肺叶切除术患者的可靠性。
2009年1月至2017年5月，606例患者（275例女性，331例男性；中位年龄67岁）在我院接受胸腔镜肺叶切除术或肺段切除术，用于确诊或疑似早期肺癌或转移瘤。进行逻辑回归分析以确定术后并发症的预测因素，随后进行因果推断评估。
术后死亡率、肺部并发症、心血管并发症和总体发病率分别为1.0%、8.9%、5.8%和18.0%。虽然美国麻醉医师协会身体状况分级（ASA-PS）是独立的发病预测因素，但在单变量回归分析中，仅发现肺功能指标与总体发病率之间存在微弱的显著关联。关于因果推断，使用倾向评分的逆概率处理加权显示，与ASA-PS 1或2级患者相比，ASA-PS 3或4级患者发生心肺并发症和总体发病的几率分别增加2倍和1.7倍（OR =2.116，95%CI：1.252 - 3.577，P =0.005；OR =1.740，95%CI：1.095 - 2.765，P =0.019）。
我们的结果表明，当前的生理评估算法也适用于胸腔镜下的大型肺切除术。ASA-PS是一个易于评估的因素，能够预测按照当前指南适当选择的患者接受胸腔镜肺叶切除术后的主要并发症。建议将ASA-PS纳入现有算法，以便对该患者群体进行更准确的风险分层。
