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Year : 2018  |  Volume : 20  |  Issue : 1  |  Page : 7-11

Prediction of postoperative pulmonary complications in lung cancer surgery: Is proportion of emphysema important?

1 Ege University School of Medicine, Department of Thoracic Surgery, Izmir, Turkey
2 Dr. Suat Seren Chest Diseases and Thoracic Surgery Training and Research Hospital Department of Thoracic Surgery, Izmir, Turkey
3 Çiğli Training and Research Hospital Department of Thoracic Surgery, Izmir, Turkey
4 Dr. Suat Seren Chest Diseases and Thoracic Surgery Training and Research Hospital Department of Radiology, Izmir, Turkey

Date of Web Publication4-May-2018

Correspondence Address:
Dr. Tevfik Ilker Akcam
Department of Thoracic Surgery, Ege University School of Medicine, Izmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejop.ejop_8_18

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OBJECTIVE: Preoperative evaluation in thoracic surgery is highly important to determine surgical suitability, estimate postoperative pulmonary complications, and for patient follow-up. However, there is neither a definite explanation about the possible complications nor a gold standard method.
MATERIALS AND METHODS: In this study, 297 patients undergoing anatomic lung resection for primary lung carcinoma were retrospectively evaluated. To form a homogeneous group, all factors that increase the rate of pulmonary complication were excluded except emphysema. Patients who did not meet these criteria were removed from the study. The study continued with 104 other patients. This patient subgroup was divided into groups according to Goddard Classification– Score (GdCS). The correlation between GdCS and other variables was statistically investigated.
RESULTS: According to the GdCS of 104 patients, the patient distribution was as follows: 10 patients (9.6%) were G0, 28 patients (26.9%) were G1, 42 patients (40.4%) were G2, 22 patients (21.2%) were G3, and 2 patients (1.9%) were G4. Thirty-five (33.6%) of 104 patients had a pulmonary complication during the postoperative follow-up. The average drainage time was longer for higher GdCS scores, and the rate of exposition to a pulmonary complication was higher in the patients with increased GdCS.
CONCLUSION: In view of these findings, Goddard's scoring for chronic obstructive pulmonary disease-emphysema patients was considered likely to be an indicative parameter in the preoperative evaluation and postoperative follow-up of thoracic surgery patients.

Keywords: Emphysema, Goddard classification, lung resection

How to cite this article:
Akcam TI, Kaya SO, Akcay O, Samancilar O, Sevinc S, Susam S, Ceylan KC. Prediction of postoperative pulmonary complications in lung cancer surgery: Is proportion of emphysema important?. Eurasian J Pulmonol 2018;20:7-11

How to cite this URL:
Akcam TI, Kaya SO, Akcay O, Samancilar O, Sevinc S, Susam S, Ceylan KC. Prediction of postoperative pulmonary complications in lung cancer surgery: Is proportion of emphysema important?. Eurasian J Pulmonol [serial online] 2018 [cited 2021 Dec 6];20:7-11. Available from: https://www.eurasianjpulmonol.com/text.asp?2018/20/1/7/231814

  Introduction Top

Preoperative evaluation is very important in thoracic surgery for the determination of the surgical suitability, estimation of the postoperational pulmonary complications, and patient follow-up.[1],[2] Due to emergent operative methods and perioperative medical care facilities, surgical mortality and morbidity have decreased; however, as well as the risk group, postoperative pulmonary complications are still significant due to the increased number of patients in the advanced age group.[3]

In the preoperative evaluation, the first objective is to estimate postoperative complications, and the second objective is to reduce complication risks.[4],[5],[6] For this purpose, the planned operations can be determined, and undesirable events can be prevented, according to the results of preoperative evaluations. Respiratory function tests, exercise tests, diffusion, and scintigraphic scannings provide important information about the remaining postoperative lung resistance of the patients.[7] Nonetheless, there is neither a definite explanation about the possible complications nor a gold standard method.[8]

Operational difficulty and possible incidence of complications increase, particularly in patients with emphysema and bullous lung pathology.[9] From this perspective, “Goddard Classification – Score” (GdCS) which was developed by Goddard and used for radiological classification of the patients with chronic obstructive pulmonary disease (COPD)-emphysema was used for the evaluation of the patients that undergone lung resection for lung cancer.[10]

Although GdCS is a radiological classification for COPD patients, it is not used for preoperative evaluation by thoracic surgeons. In this study, GdCS is applied for this specific reason to help predict postoperative pulmonary complications before initial lung cancer surgery. The patients were categorized according to GdCS. The purpose of the present study was to investigate whether this scoring method could be an option for preoperative evaluation, particularly against postoperative pulmonary complications. Thus, the relation between the proportion of emphysema and morbidity was investigated, and we tried to develop an estimated risk prediction.

  Materials and Methods Top

One hundred and four were retrospectively evaluated between January 2011 and October 2013. Among 297 patients who had undergone anatomic lung resection due to primary lung carcinoma for the past 2 years. To obtain a homogeneous patient group, all factors that increase the rate of pulmonary complication were excluded except emphysema. Therefore, patients who underwent pneumonectomy, chest wall resection, neoadjuvant treatment, or bronchoplastic– sleeve resections were excluded from the study. To form a homogeneous group, patients who did not meet these criteria were removed from the study. and continued to study with the other 104 patients. Age, gender, drainage time, postoperative pulmonary complications, and smoking duration of the remaining this 104 patients were recorded. Pulmonary function test was performed preoperatively in all patients. Forced expiratory volume in 1 s (FEV1) values were recorded.

These 104 patients were classified according to GdCS by a blinded radiologist. By this method of evaluation, both of the lungs are divided into three different zones, and each zone is scored individually according to thorax computerized tomography scans. Normal parenchymal tissue is scored as “0” (zero), whereas 75%–100% destroyed parenchymal tissue is scored as 4. The maximum evaluation score is 24.[10],[11] Hence, patients with no parenchymal pathology were in Group G0, patients with 0%–25% of parenchyma pathology and lack of vascularity were in Group G1, patients with 25%–50% of parenchyma pathology-lack of vascularity were in Group G2, patients with 50%–75% of parenchyma pathology-lack of vascularity were in Group G3, and patients with 75%–100% parenchyma damage were in Group G4 [Figure 1]. The correlation between GdCS and postoperative pulmonary complications are examined.
Figure 1: Parenchyma damage degree and loss of vascularity. (a) 0%–25% of parenchyma degeneration-loss of vascularity. (b): 25%–50% degeneration-loss of vascularity. (c): 50%–75% of degeneration-loss of vascularity (d): 75%–100% nearly total parenchyma damage

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The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 and 2008.

Statistical analysis

Statistical analysis was carried out using SPSS version 20.0 software (IBM statistics for Windows version 20, IBM Corporation, Armonk, New York, United States). was used for all statistical analyses. Descriptive statistical variables were presented as the mean ± standard deviation or percentages (%). The Kolmogorov–Smirnov test was used to test the fitness of the distribution of quantitative variables; parametric methods were used to analyze variables that showed normal distribution and equal variance, whereas nonparametric methods were used to analyze variables that showed normal distribution and unequal variance. Correlation between groups was calculated using Spearman test. One-way ANOVA was used for associated samples, whereas the Mann–Whitney U-test and Chi-squared tests were used for variables that were not normally distributed. Data were analyzed in 95% confidence intervals, and values of P < 0.05 were considered statistically significant. All patients gave written informed consent.

  Results Top

There were 100 male and 4 female patients in the study. The mean age of the patients was 61.25 ± 8.49 (40–79) years. Fifty-one (49%) patients were diagnosed with squamous cell carcinoma, 46 (44%) patients with adenocarcinoma, and seven (7%) patients as large cell neuroendocrine tumor. When GdCS scores of these 104 patients were calculated, 10 (9.6%) patients were in Group G0, 28 (26.9%) patients were in Group G1, 42 (40.4%) patients were in Group G2, 22 (21.2%) patients were in Group G3, and 2 (1.9%) patients were in Group G4. The low patient number in Group G4 was attributed to the medical unsuitability for operation.

The mean drainage day was 9.79 ± 7.28/day (3–48). Average drainage increased with increasing GdCS (G0: 5.6 ± 1.72/day [3–21]; G1: 6.5 ± 0.67/day [3–15]; G2: 10.93 ± 1.24/day [4–48]; G3: 13.64 ± 1.68/day [4–34]; G4: 10.5 ± 3.5/day [7–14]; P = 0.002]) [Table 1].
Table 1: The correlation between Goddard Classification Score and drainage duration

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During the postoperative follow-up, pulmonary complications developed in 35 of the 104 patients (33.6%). There was a prolonged air leak in 22 patients (21.1%), atelectasis requiring bronchoscopy in seven patients (6.7%), pneumonia in three patients (2.8%), and empyema in three patients (2.8%). According to the distribution of the patients, the incidence rate of a pulmonary complication was high in the patients with high GdCS (P < 0.05) [Table 2].
Table 2: The correlation between Goddard Classification Score and complications

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During the comparison of patients' FEV1 percentages and GdCS, there was no significant correlation, although FEV1 values decreased in patients with increased GdCS (P = 0.182) [Table 3].
Table 3: The correlation between Goddard Classification Score and forced expiratory volume in the 1st s

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To achieve a general approach, mean FEV1 percentages of patients with pulmonary complications were analyzed independently from other parameters. While mean FEV1 was lower in the group with complications, this decrease had no effect on the development of pulmonary complications. This was analyzed by dividing the patients into more specific subgroups. Mean FEV1 percentages for GdCS groups were calculated, and the potential effect of these percentages on pulmonary complication rates was investigated. The incidence of complications showed a marked increase with decreasing mean FEV1 percentage, but this was not statistically significant [Table 4].
Table 4: The correlation between forced expiratory volume in the 1st s and complications

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Smoking status of the patients included in the study was classified under three subgroups. Patients who smoked 20 packages/year were in Group I, patients who smoked 20–50 packages/year were in Group II, and patients who smoked ≥50 packages/year with a smoking history were in Group III. According to these categories, as well as GdCS groups, there was a generally homogeneous distribution, and the smoking rate of category II was higher in Groups G2 and G3 compared to the other groups.

  Discussion Top

Emphysema is defined as the abnormal dilation and comorbid alveolar destruction of the air spaces in the distal terminal bronchiole.[12] Emphysema is an important cause of mortality and morbidity worldwide.[13] Therefore, many studies have been conducted, particularly on the effects and detection of emphysema, and some studies are still ongoing. There is not enough study that is such an important issue for thoracic surgery. Although there is a frightening picture by surgeons, there is no objective data on the patient. In this study, the patient has been expressed with numerical values as possible. It was found that the increase in the degree of emphysema increased the incidence of postoperative complications and extended the duration of the average drainage day. Although it was not statistically significant, the increase in the level of emphysema, the FEV1 value decreased together. It is possible to calculate these values because of the possibility of CT in today's technology. Computed tomography (CT) has been shown to be the most effective means to detect emphysema; lung parenchyma affected by emphysema is observed as low-density areas in CT, and the number and caliber of parenchymal vessels decrease.[14] Chest X-ray can provide limited information to reveal emphysema.[15] CT constitutes the core of the evaluation, which shows the presence, penetration, and distribution of emphysema. It is easier to detect emphysema, particularly by using high-resolution CT.[16] The minimum intensity projection method can be used to evaluate 1 mm sections and mild emphysema. This method clarifies the lowest density areas of the lung while making the remaining normal parenchyma and veins less visible. To detect latent emphysema, this method has been shown to be more sensitive compared to HRCT.[17]

There are two methods to determine emphysema, namely, the observer-based semi-quantitative method [10],[18] and the quantitative method through software. When pathological results were compared, they were found to be correlated in both ways.[19] In a study to determine the automation awareness, two different methods were compared to investigate the expected benefit in patients who underwent lung volume reduction surgery. In conclusion, studies have shown that evaluation using automated systems does not contribute significantly to the evaluations by semi-quantitative scoring methods that are performed by experienced observers.[20]

The most common semi-quantitative method is Goddard's method.[10] Studies have shown that this evaluation can be performed by radiologists or lung experts.[21] In another study that used GdCS as the reference, Asai et al.[22] investigated the degree of emphysema and pneumothorax development in cases that underwent needle biopsy, and the authors stated that structural lung deformities did not contribute to pneumothorax development. On the other hand, the current study revealed that high GdCS, i.e., increased parenchyma degeneration – contributed to the development of complications. In a similar work, Sevinc et al.[11] have shown that the degree of emphysema and therefore, GdCS are linked to a prolonged air leak and pneumothorax episodes. In this context, it was found that complications were more common in those with high GdCS in our study.

Limitations of subjective visual evaluation, CT characteristics of emphysema morphology, and digital features of CT data increase the interest in an objective, quantitative evaluation methods that can be performed by using the various automated software.[23] The most frequent quantitative evaluation method is densitometric analysis. One of the parameters used in this analysis is relatively low-density area. It is defined as the ratio of emphysematous parenchymal areas with a density lower than a predefined threshold value (determined from previous studies).[14],[19] Earlier studies have shown that the presence of a low parenchymal density area is parallel to pulmonary function test results and pathology results.[19],[24] Although GdCS was set as the reference in the present study, mean FEV1 was evaluated. The increase in emphysema caused a prominent decrease in FEV1, but this was not statistically significant. The authors of the current study reached the conclusion that significance could be achieved by using a larger patient population. Some of the studies that support this notion have stated that FEV1 alone cannot be effective in determining postoperative complications, and it should be combined with exercise tests.[25] In this study, the incidence of pulmonary complications showed a marked increase with decreasing mean FEV1 percentage, but this was not statistically significant also. Overall, the authors concluded that the GdCS value could be more sensitive to indicate the rate of complications, compared to mean FEV1 percentage.

  Conclusion Top

General postoperative complications in chest surgery were evaluated in the present study. The observed complication rate of 33.6% was similar compared to the literature.[26] In conclusion, considering the findings of this study within the indicated complication rates, the authors found that the Goddard scoring system, which was developed for COPD-emphysema patients, could be used as a guiding parameter for preoperative evaluation of thoracic surgery patients, and their postoperative follow-up. Measurement of the degree of emphysema by a nonquantitative measurement method may cause distress in the exact determination of the data. In addition, there are additional factors that may cause complications in the thoracic surgery patients. However, the isolated effect of the degree of emphysema has been mentioned in this study. The authors believe that the use of GdCS in existing preoperative evaluation parameters, provided that it is supported by other clinical studies, will provide a new preoperative parameter.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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