CLINICAL-EPIDEMIOLOGICAL STUDY ON THE INCIDENCE OF POSTOPERATIVE COMPLICATIONS AFTER PULMONARY RESECTION FOR LUNG CANCER

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1 Rev. Med. Chir. Soc. Med. Nat., Iaşi 2014 vol. 118, no. 4 SURGERY ORIGINAL PAPERS CLINICAL-EPIDEMIOLOGICAL STUDY ON THE INCIDENCE OF POSTOPERATIVE COMPLICATIONS AFTER PULMONARY RESECTION FOR LUNG CANCER M. Bosînceanu 1, C. Sandu 1, Luminița Roxana Ionescu 1, C. Roată 1, L. Miron 2 Regional Cancer Institute - Iasi 1. Surgical Clinic II - Department of Cardiac and Thoracic Surgery 2. Medical Oncology Clinic CLINICAL-EPIDEMIOLOGICAL STUDY ON THE INCIDENCE OF POSTOPERATIVE COMPLICATIONS AFTER PULMONARY RESECTION FOR LUNG CANCER (Abstract): Aim: To determine the relationship between the characteristics of a group of lung cancer patients, lung cancer surgeries, and the incidence of early and/or late postoperative complications. Material and methods: The study included a group of 115 lung cancer patients aged 40 to 85 years, 76.5% men, 60.91% living in urban areas, who received surgical treatment in the interval January 2013-August Data were collected from electronic medical records and survey sheets and processed and interpreted using Pearson correlation index (p-value of 0.05 was considered statistically significant and of <0.005 highly statist i- cally significant), and chi 2, y, 1c = 25% tests. All statistical analyses were performed using the SPSS statistical software package version Results: Of the 115 patients 7.8% were in the years age group and 87.8% in the years age group (p 0.001). Most patients were males (76.5%, p <0.001), and 60.9% of the patients were living in urban areas (p 0.05). The difference in the prevalence of smokers (76.5%) vs. non smokers (23.5%) was highly statistically significant (p <0.005). Active smoking of one pack of cigarettes per day for more than 10 years was recorded in 54.8%. The presence of co morbidities (17 events) and the distribution of neoplastic lesions in the five anatomical areas required the perfo r- mance of lobectomies, bilobectomies or pneumectomies. The incidence of early (14 entities) and late postoperative complications (7 entities) depended on patient s general condition, nature of co morbidities, location and stage of neoplastic lesions, and surgical complexity. Conclusions: Lung cancer, in various locations and stages, most commonly affected males aged years, from urban areas, smokers, with various co morbidities. Surgeries performed in these patients were often laborious and with a relatively low incidence of posto p- erative complications. Keywords: LUNG CANCER, CANCER SURGERY, CO MORBIDI- TIES, POSTOPERATIVE COMPLICATIONS. It has been long recognized that surgery has an important role in healing when the cancer is located in the organ of origin (1, 2). In the case of late interventions, with risks of metastasis, surgery has to be associated with other therapeutic procedures. Thus, curative surgery, radical or conservative, may be replaced with a tumor size reduction surgery, removal of metastases or palliative or reconstructive and rehabilitation surgery (3, 4, 5). Because in practice about two thirds of 1040

2 Clinical-epidemiological study on the incidence of postoperative complications after pulmonary resection for lung cancer cancer patients present with advanced disease oncologic surgery has to be part of a multimodal approach associating depending on circumstances various pre- and postoperative adjuvant therapies (6,7,8). Depending on patient s general condition, malignant disease stage, anatomic location and histological type, surgical procedures are associated with or followed by various complications with minor or alarming implications that require the surgeon and the multidisciplinary team to consider how treatment might affect patient's quality of life (9, 10, 11). MATERIAL AND METHODS The study included a group of 115 lung cancer patients, aged years, 88 (76.5%) males and 27 (23.5%) females, 70 (60.9%) from urban areas and 45 (39.1%) from rural areas, who underwent surgery (lobectomy + bilobectomy: 77.8% and pneumonectomy: 25.2%) in the interval January August 2014 at the II nd Surgical Clinic, Department of Cardiac and Thoracic Surgery of the Iaşi Regional Cancer Institute. Data were collected from electronic medical records and survey sheets and processed and interpreted using Pearson correlation index (p-value of 0.05 was considered statistically significant and of <0.005 highly statistically significant), and chi 2, y, 1c = 25% tests. All statistical analyses were performed using the SPSS statistical software package version RESULTS AND DISCUSSION Age distribution of the 115 lung cancer patients who received surgical therapy showed that 7.8% were in the year age group, 4.3% in the year age group (significant difference: p 0.05) compared to 87.8% in the year age groups (very highly significant difference compared to the previous ones, p <0.001) (tab. I, fig. I). TABLE I Age group distribution of the study patients Age group % Cumulative percentage % % % Total no. of cases y = 0,0167x + 12,694 R² = 2E age group (years) Fig. 1. Age group distribution of the surgically treated lung cancer patients 1041

3 M. Bosînceanu et al. Sex distribution showed highly significant differences (p<0.001) in favor of males (76.5% males and 23.5% females). Urban-rural distribution showed that 60.9% of patients lived in urban areas compared 39.1% in rural areas (p 0.05). The intensity and duration of smoking proved to be a major risk factor for lung carcinogenesis. Eighty-eight (76.5%) of the 115 study patients were active smokers, of which 54.8% smoked one pack of cigarettes per day, 52.2% for over 10 years, and 20.9% smoked 2 packs per day for more than 10 years. The difference between the prevalence of smokers (76.5%) and nonsmokers (23.5%) was highly statistically significant (p <0.005) with the mention that the 27 (23.5%) non smokers reported: intensive long-term exposure to passive smoking (19: 70.3%); construction work, inhalation of dust and particles (6: 22.2%) to which a miner and a carpenter (3.7% each) were added (tab. II). TABLE II Assessment of the intensity and duration of smoking in the 115 lung cancer study patients Intensity (no. packs cigarettes/day) Packs/ day cases Duration (years) <10 >10 % cases % cases % Note: active smokers: 88 (76.5%); nonsmokers: 27 (23.5%); passive smokers: 19 (70.3%); constructors: 6 (22.2%); miners: 1 (3.7%); carpenters: 1 (3.7%). Types of surgery and postoperative course depended on the presence of co morbidities, often with associative action in the same patient (12). In the 115 patients included in the study we identified 17 categories of co morbidity with variable frequency from 33.9% for hypertension, to 8.7% and 7.8% for heart failure, tuberculosis, anemia, and type 2 diabetes mellitus. Two patients (1.7%) presented synchronous lung cancer and 6 (5.2%) metachronous cancer (rectum: 2; skin: 2; breast, ENT, 1 case) (tab. III). The distribution of neoplastic lesions in the 5 anatomic areas showed that the most common location was in the right upper lobe (37.4%) followed by the left upper lobe (29.5%) and right lower lobe (16.5%). The incidence decreased to 8.7% for the left lower lobe and 7.9% for the right middle lobe (tab. IV, fig. 2). The types of surgery (lobectomy, bilobectomy, or pneumonectomy) depended on the location and stage of the tumor (13). Right upper lobectomy was performed in 27% of the 115 cases, followed by left upper lobectomy and left pneumon-ectomy in 14.8% and 14.0%, respectively. Right lower lobectomy, right pneumon-ectomy and left lower lobectomy were performed in 12.1%, 11.3% and 10.4% of the cases. Middle lower bilobectomy and right middle 1042

4 Clinical-epidemiological study on the incidence of postoperative complications after pulmonary resection for lung cancer lobectomy were performed in a similar number of cases (6/5.2%). Thus, lobectomy and bilobectomy were performed in 86 (77.8%) and pneumonectomy in 27 (25.2%) of the 115 patients, with a moderately significant difference (p 0.05) (tab.v). TABLE III Frequency of complications in our study group Comorbidity cases % 1. Hypertension Heart failure Tuberculosis Anemia Type 2 diabetes mellitus COPD Ischemic cardiomyopathy Thrombophlebitis lower extremities Obesity Myocardial infarction Hepatitis C Hepatitis B Bronchiectasis Stroke Chronic bronchitis Pulmonary emphysema Pulmonary fibrosis Synchronous cancer (lung) Metachronous cancer (rectum 2; skin: 2; breast: 1;ENT:1) TABLE IV Anatomical distribution of neoplastic broncho pulmonary lesions in the 115 surgically treated patients Anatomic area of cases % 1. Right upper lobe Left upper lobe Right lower lobe Left lower lobe Right middle lobe Total

5 M. Bosînceanu et al. % of total right medium lobe y = 7,98x - 3,94 R² = 0, left lower lobe right lower lobe left upper lobe anatomic area Fig. 2. Anatomical distribution of neoplastic bronchopulmoary lesions in the surgically treated patients TABLE V Types of surgery (lobectomy or pneumonectomy) performed in the 115 study patients Category % 1. Right upper lobe 31 27,0 2. Left upper lobe 17 14,8 3. Left pneumonectomy 16 14,0 4. Right lower lobe 14 12,1 5. Right pneumonectomy 13 11,3 6. Left lower lobe 12 10,4 7. Right middle and lower lobe 6 5,2 8. Right middle lobe 6 5,2 9. Total lobectomy+bilobectomty 86 77,8 10. Total pneumonectomy 29 25, right upper lobe Postoperative complications (14 entities) showed a variable dispersion and resulted from numerous factors related to patient s general condition, nature of co morbidities, location and stage of cancer lesions and surgical complexity (14, 15). Of the early complications the following had an incidence of 6 to 11.3%: subcutaneous emphysema, atrial fibrillation, lung expansion defects and lobar or segmental atelectasis. An incidence of 2.5 to 4.3% was recorded for nosocomial pneumonia, multiple organ dysfunctions, including cardio respiratory arrest, recurrent nerve paralysis and anemia. Cardiac arrhythmias, prolonged air leak, hemorrhage, ischemic stroke, acute respiratory failure and myocardial infarction were reported in 0.8 to 1044

6 Clinical-epidemiological study on the incidence of postoperative complications after pulmonary resection for lung cancer 1.7% of the cases. Late postoperative complications showed a relatively low incidence (0.8 to 4.3%) and were represented by: postoperative empyema, bronchial stump fistula, pleurisy, pulmonary embolism, pneumothorax, bronchopneumonia and sepsis (tab. VI). TABLE VI Postoperative complications A. Early Complication of cases % 1. Subcutaneous emphysema Atrial fibrillation Lung expansions defects Lobar or segmental atelectasis Nosocomial pneumonia Multiple organ dysfunctions with cardio respiratory arrest Recurrent nerve paralysis Anemia Cardiac arrhythmia Prolonged air leak Hemorrhage Ischemic stroke Acute respiratory failure requiring prolonged intubation and temporary tracheostomy Myocardial infarction B. Late Complication of cases % 1. Empyema in the operated hemithorax Bronchial stump fistula Pleurisy Pulmonary embolism Pneumothorax Bronchopneumonia Sepsis CONCLUSIONS Our study showed a significantly higher incidence of lung cancer in various locations in men aged years, living in urban areas, long-term active smokers, and presenting varied and multiple co morbidities. All patients received surgery, often laborious, and the incidence of early or late postoperative complications was relatively low. 1045

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