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Moreover&#44; several multivariate models have been developed in recent years with the aim of improving the selection of patients for surgery&#46; The steering committee of the ESTS database has recently developed Eurolung 1 and 2&#44; two robust models for calculating the adjusted risk of hospital morbidity and mortality in candidates for anatomical lung resection surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> These models are based on the retrospective analysis of a population of 47<span class="elsevierStyleHsp" style=""></span>960 patients included in the ESTS database who underwent surgery between July 2007 and August 2015&#46; Eurolung 1 and 2 were created to serve as tools for quality control and for risk stratification in thoracic surgery&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although the risk of morbidity and mortality has declined in recent years&#44; the temporal trend in risk of death and complications based on the current ESTS models has not yet been assessed&#46; The objective of this study was to apply the Eurolung 1 and 2 risk models to a series of patients who underwent anatomical lung resection in the last 20 years&#44; in order to&#58; &#40;1&#41; assess and compare the risk of postoperative cardiorespiratory morbidity and mortality in 3 successive time periods and &#40;2&#41; identify variations in the selection of patients and surgical practices that have led to changes in the risk of death and postoperative complications&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Method</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Population</span><p id="par0020" class="elsevierStylePara elsevierViewall">This is a retrospective analysis of a series of 2435 consecutive cases who underwent anatomical lung resection &#40;lobectomy&#44; segmentectomy&#44; bilobectomy&#44; or pneumonectomy&#41; for lung cancer between 1994 and 2017 in our hospital&#46; Patient data were collected prospectively in an institutional database&#46; In order to increase the quality of the data included in the registry&#44; the completeness and accuracy of each entry is controlled by a data manager at two different time points&#58; first&#44; when the patient is discharged from the hospital&#44; and later&#44; at the time when the final histological result is entered in the definitive medical reports&#46; Ninety-four cases with missing data were excluded from the study&#44; representing 3&#46;9&#37; of the total&#44; so the study population included 2341 cases&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">For this study&#44; the population was divided into 3 time periods&#58; the first period included 976 cases undergoing anatomical lung resection between 1994 and 2006 &#40;cases prior to the construction of the current ESTS database&#41;&#59; the second period included 945 patients undergoing surgery between 2007 and 2015 &#40;cases that were used for the construction of the Eurolung 1 and 2 models&#41;&#44; and the third period included 420 patients undergoing surgery between 2016 and 2017 &#40;after the recruitment of cases for the construction of the models&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Dependent Variables</span><p id="par0030" class="elsevierStylePara elsevierViewall">We analyzed the risk of cardiorespiratory morbidity and mortality at 30 days calculated from Eurolung models 1 and 2 in the three study time periods&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The following equation was used to estimate the risk of morbidity &#40;Eurolung 1&#41;&#58; logit &#40;morbidity&#41;&#58; &#8722;2&#46;465&#43;0&#46;497&#95;male sex &#40;coded 1 for men and 0 for women&#41;&#43;0&#46;026&#95;age&#43;0&#46;231&#95;coronary disease &#40;CD&#41; &#40;coded 1 for presence of CD&#41;&#43;0&#46;371&#95;cerebrovascular accident &#40;CVA&#41; &#40;coded 1 for presence of CVA&#41;&#43;0&#46;152&#95;chronic kidney disease &#40;CKD&#41; &#40;coded 1 for presence of CKD&#41;&#8722;0&#46;015&#95;ppoFEV1&#37;&#43;0&#46;514&#95;extended resections &#40;coded 1 for presence of extended resection&#41;&#43;0&#46;497&#95;thoracotomy &#40;coded 1 for thoracotomy and 0 for VATS&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following equation was used to estimate 30-day mortality &#40;Eurolung 2&#41;&#58; logit &#40;mortality&#41;&#58; &#8722;5&#46;82&#43;0&#46;903&#95;male sex &#40;coded 1 for men and 0 for women&#41;&#43;0&#46;044&#95;age&#43;0&#46;264&#95;coronary disease &#40;coded 1 for presence of CD&#41;&#43;0&#46;582&#95;CVA &#40;coded 1 for presence of CVA&#41;&#8722;0&#46;064&#95;body mass index &#40;BMI&#41;&#43;0&#46;300&#95;extended resection &#40;coded 1 for extended resection&#41;&#43;0&#46;929&#95;pneumonectomy &#40;coded 1 for pneumonectomy and 0 for smaller resections&#41;&#43;0&#46;894&#95;thoracotomy &#40;coded 1 for thoracotomy 1 and 0 for VATS&#41;&#8722;0&#46;009&#95;FEV1&#37;ppo&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Independent Variables</span><p id="par0045" class="elsevierStylePara elsevierViewall">The same risk variables included in the Eurolung 1 and 2 models were used<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a>&#58; sex&#44; age&#44; BMI&#44; forced expiratory volume in 1 second predicted postoperative &#40;ppoFEV1&#37;&#41;&#44; CD&#44; CVA&#44; CKD&#44; surgical approach &#40;thoracotomy or video-assisted thoracoscopic surgery &#91;VATS&#93;&#41;&#44; extended resection &#40;associated with chest wall&#44; Pancoast tumors&#44; resection of the atrium or superior vena cava&#44; resection of the diaphragm&#44; vertebral resection&#44; pleuro-pneumonectomy&#44; pneumonectomy with tracheoplasty&#44; intrapericardial pneumonectomy&#41;&#44; and pneumonectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The indication for resection and final pathological diagnosis were not taken into account for study purposes&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical Analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">The individual probabilities of morbidity and mortality were maintained as new variables&#46; We then applied the analysis of variance &#40;ANOVA&#41; to compare those probabilities among the three study periods and constructed box plots to represent the differences graphically&#46; Finally&#44; we constructed a weighted polynomial regression model &#40;LOESS&#41; to graphically represent the evolution of the probability of each dependent variable with respect to time&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We also calculated the frequency of different independent variables included in the Eurolung 1 and 2 models for each time period&#46; The frequency difference of dichotomous variables &#40;sex&#44; cardiac or cerebrovascular comorbidity&#44; surgical approach&#44; extended resection&#44; and pneumonectomy&#41; was compared using a Chi-squared test&#44; while the mean of the continuous variables &#40;age&#44; BMI&#44; ppoFEV1&#37;&#41; was compared using ANOVA&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The statistical analysis was conducted using the STATA 15&#46;1 statistical software package &#40;Stata Corp&#46;&#44; College Station&#44; TX&#44; USA&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Population Description</span><p id="par0070" class="elsevierStylePara elsevierViewall">The study population is composed of 2341 patients with a mean age of 65&#46;1 years &#40;&#177;10&#46;2&#41;&#44; a ppoFEV1&#37; of 60&#46;1&#37; &#40;&#177;20&#46;8&#41; and a proportion of 82&#46;7&#37; men&#46; A total of 86&#46;5&#37; &#40;2024&#41; procedures were performed by lateral or posterior thoracotomy without muscle section&#44; and 317 &#40;13&#46;5&#37;&#41; were performed by VATS&#46; The procedures performed were&#58; 306 pneumonectomies &#40;of which 85 were extended and 11 were tracheoplasties&#41;&#44; 134 bilobectomies &#40;25 extended&#41;&#44; 1804 lobectomies &#40;238 extended and 84 with bronchoplastic resection&#41;&#44; and 97 anatomical segmentectomies&#46; Total mortality at 30 days was 56 cases &#40;2&#46;4&#37;&#41;&#44; and 371 cases &#40;15&#46;8&#37;&#41; presented 1 or more cardiorespiratory complications&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The probability of complications and death after lung resection&#44; calculated using the Eurolung 1 and 2 models&#44; respectively&#44; is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The probability that the differences between the values are due to chance is &#60;&#46;0001&#46; <a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a> represent the polynomial regression models weighted for morbidity and mortality&#44; respectively&#44; revealing a clear decline in both variables over time&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The relative frequency of binary variables in the last period differed from the previous 2 periods&#44; except in the case of CD&#44; which remained unchanged &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The prevalence of CVA and CKD increased with time&#44; reaching 2&#46;4&#37; and 4&#46;6&#37; in the last period&#44; respectively&#46; With regard to changes in surgical practices&#44; the percentages of pneumonectomy and extended resections in the first and third period fell by more than 20&#37; and 12&#37;&#44; respectively&#44; and the number of cases undergoing VATS increased dramatically in the last period&#44; eventually representing more than 60&#37; of all surgeries performed&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">With regard to continuous variables &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; more older patients underwent surgery in the last period compared with previous periods&#46; ppoFEV1&#37; was also greater in the last two periods&#44; compared with the first &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The main results of the study show that the probability of 30-day mortality and cardiorespiratory morbidity according to Eurolung 1 and 2 after anatomical lung resection has declined over the past 20 years in our unit&#46; Both risks are lower in the last period compared with the 2 previous periods&#46; This temporal trend is consistent with the mortality and morbidity figures reported by the ESTS in their annual reports&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The prevalence of variables that influence the risk of death and cardiopulmonary complications has also changed over time&#46; Patients undergoing surgery in the last 2 years were older than in the 2 preceding periods&#44; probably as a result of increased life expectancy of the population&#46; Age is considered by some authors to be an important risk factor for morbidity after lung resection&#46; Patients older than 70 years are more than twice as likely to develop complications after lung resection compared with younger patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#8211;5</span></a> However&#44; Ogawa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> showed that postoperative complications in elderly patients with lung cancer were independent of age&#44; and Stamenovic et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> found that patients older than 80 years did not have a higher risk of developing complications after lung resection than patients in their 70s&#46; Nevertheless&#44; it is important to remember that&#44; in general&#44; there is a selection bias when evaluating octogenarian patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> In any case&#44; the average age of patients undergoing lung resection has increased over time without increasing the risk of death and complications&#44; although it should be pointed out that the average age of patients in the third period barely reaches 67 years&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Life expectancy has increased in parallel with the prevalence of comorbidities&#46; Thus&#44; for example&#44; the percentage of patients with a history of CVA and CKD has increased in the last 2 periods compared with the first&#46; Improved management of these diseases has most likely delayed the increase of associated morbidity&#46; CD and BMI&#44; however&#44; have not changed significantly over time&#46; Wang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> found that age &#40;70 years or older&#41; and ppoFEV1&#37; &#40;70&#37; or lower&#41; combined with CD were independent prognostic factors for major postoperative complications&#46; According to our results&#44; ppoFEV1&#37; has increased over time&#44; especially when we compare the last 2 periods with the first&#46; This finding may be explained by the decline in the number of pneumonectomies performed in the last 2 periods&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Surgical practices have also evolved over time&#58; only 4&#37; of the procedures performed in the last period were pneumonectomies&#46; Pneumonectomy continues to be a high-risk procedure that is associated with high rates of mortality and morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> For this reason&#44; various strategies aimed at preserving the parenchyma have been developed and widely adopted&#44; with the dual objective of ensuring complete resection of the tumor while preserving lung function&#46; As a result&#44; the number of pneumonectomies has fallen dramatically&#44; a trend that is due&#44; among other factors&#44; to an increase in the number of bronchoplastic resections performed and improvements in early detection&#46; These factors were not analyzed in this study&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Fewer extended resections were performed in recent years&#44; probably also due to earlier diagnosis and treatment of lung cancers&#46; Our results show a rate of 8&#46;6&#37; of extended resections in the last 2 years&#44; comparable to the percentage given in the annual ESTS report of 2018&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> A study by Berry et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> underlines the importance of extended resections and thoracotomy as relevant risk factors for morbidity after lung resection surgery&#46; The percentage of thoracotomies also decreased significantly in the last period&#46; Several studies<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">10&#8211;12</span></a> have shown that lobectomy performed via VATS is superior to the open approach in terms of early outcomes&#44; and&#44; more recently&#44; a paired case control study using data from the ESTS registry<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> confirmed that lobectomy via VATS is associated with a lower incidence of complications and mortality compared with thoracotomy&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Finally&#44; the percentage of women undergoing anatomical lung resection in the last two years has increased&#44; due in large part to the progressively increasing prevalence of lung cancer in women&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> According to the 2012 report of the Spanish Society of Medical Oncology&#44; the incidence of lung cancer in women was 5&#46;67&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> The increase in lung cancer incidence and mortality among women reflects changing trends in smoking&#44; which reached its peak among women in the USA almost 20 years later than in men&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> Additionally&#44; after adjusting for the level of tobacco exposure&#44; women have an increased risk of cancer compared with men&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> In contrast&#44; women have lower morbidity and mortality after surgery for lung cancer&#46; The risk of complications is almost 3 times higher in men&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;7&#44;16</span></a> because women tend to be younger and have fewer comorbidities than men&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The increase in the percentage of minimally invasive surgeries and female patients&#44; along with the falling numbers of pneumonectomies and extended resections may be the most important factors that have led to a reduction in the risk of morbidity and mortality after anatomical lung resection&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Study Limitations</span><p id="par0125" class="elsevierStylePara elsevierViewall">The most important limitation of our research is that the risk models were constructed using data from patients included in the second period&#46; However&#44; our objectives did not include validating the models&#44; so we believe that this limitation does not compromise the study results&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The Eurolung models are the most up-to-date available&#44; but data were not collected on diffusing capacity of the lung for carbon monoxide or maximum oxygen consumption&#44; parameters that are considered predictive of postoperative morbidity and mortality&#59; it might have been interesting to know how these variables have evolved over time and how they have influenced the risks of postoperative morbidity and mortality&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Finally&#44; this study may have the biases inherent to any retrospective analysis&#46; Although complications were well defined and standardized variables were used&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> we cannot rule out data entry errors&#44; misclassification&#44; or insufficient reporting&#46; Indeed&#44; we excluded 4&#37; of our total number of cases due to incomplete data&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">This study provides real data quantifying the decreasing risk of mortality and cardiorespiratory morbidity after anatomical lung resection over time&#46; According to our analysis&#44; this reduction can be attributed to the falling number of pneumonectomies and extended resections &#40;although the cause of this pattern was not analyzed&#41;&#44; and the growing use of minimally invasive procedures&#46; Other changes in the clinical characteristics of the patients referred and accepted for surgery do not seem to have influenced the outcomes&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of Interests</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to evaluate changes in the risk of cardiorespiratory mortality and morbidity calculated by Eurolung risk models 1 and 2 in the last 20 years&#44; and to identify variations in patient selection or surgical practice that might have altered the risk of death and complications after anatomical lung resections&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Method</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This was a retrospective analysis of a series of 2435 consecutive patients who underwent anatomical lung resection&#46; The population was divided into three time periods&#58; 1994&#8211;2006 &#40;976 cases&#41;&#44; 2007&#8211;2015 &#40;945 cases&#41;&#44; and 2016&#8211;2017 &#40;420 cases&#41;&#46; Eurolung models 1 and 2 were applied to the series&#44; and the individual probability of adverse effects was calculated&#46; We compared this mean probability&#44; and the prevalence or means of each of the variables included in the models in each period and plotted the evolution of the risk&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A progressive decrease was observed in both adverse effects over time&#46; The prevalence of the binary variables&#44; except for coronary heart disease&#44; was higher in the last period&#46; The percentage of pneumonectomies and extended resections fell in the last two periods and the number of cases treated with VATS increased substantially in 2016&#8211;2017&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The decline in the number of pneumonectomies and the increase in the rate of minimally invasive procedures appear to be the variables most closely associated with decreased risk&#46; Other changes in the clinical characteristics of the patients do not seem to have influenced the outcomes&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El objetivo del estudio es evaluar las modificaciones del riesgo de mortalidad y morbilidad cardiorrespiratoria calculada mediante los modelos de riesgo Eurolung 1 y 2 en los &#250;ltimos 20 a&#241;os para identificar variaciones en la selecci&#243;n de los pacientes o en la pr&#225;ctica quir&#250;rgica que hayan conducido a cambios en el riesgo de muerte y complicaciones tras resecciones anat&#243;micas pulmonares&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis retrospectivo de una serie de 2435 casos consecutivos sometidos a resecci&#243;n pulmonar anat&#243;mica&#46; La poblaci&#243;n fue dividida en tres per&#237;odos de tiempo&#58; 1994-2006 &#40;976 casos&#41;&#44; 2007-2015 &#40;945 casos&#41; y 2016-2017 &#40;420 casos&#41;&#46; Se aplicaron los modelos Eurolung 1 y 2 a la serie y se calcul&#243; la probabilidad individual de efectos adversos&#46; Se compar&#243; dicha probabilidad media&#44; as&#237; como la prevalencia o las medias de cada una de las variables que constituyen los modelos en cada per&#237;odo y se represent&#243; gr&#225;ficamente la evoluci&#243;n del riesgo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se observ&#243; un descenso progresivo de ambos efectos adversos a lo largo del tiempo&#46; La prevalencia de las variables binarias&#44; excepto enfermedad coronaria&#44; fue mayor en el &#250;ltimo per&#237;odo&#46; El porcentaje de neumonectom&#237;as y de resecciones ampliadas descendi&#243; en los dos &#250;ltimos per&#237;odos y el n&#250;mero de casos abordados por VATS se increment&#243; considerablemente en 2016-2017&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El descenso del n&#250;mero de neumonectom&#237;as y el incremento de la tasa de procedimientos m&#237;nimamente invasivos se consideran las variables m&#225;s relacionadas con la disminuci&#243;n del riesgo&#46; Otros cambios en las caracter&#237;sticas cl&#237;nicas de los pacientes no parecen haber influido en los resultados&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez Hern&#225;ndez MT&#44; Valent&#237;n NN&#44; Rodr&#237;guez Alvarado I&#44; Fuentes Gago M&#44; Varela Sim&#243; G&#44; Jim&#233;nez L&#243;pez MF&#46; Modificaci&#243;n del riesgo de mortalidad y morbilidad tras resecci&#243;n pulmonar en los &#250;ltimos 20 a&#241;os&#46; Arch Bronconeumol&#46; 2020&#59;56&#58;23&#8211;27&#46;</p>"
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Original Article
Changes in the Risk of Mortality and Morbidity After Lung Resection in the Last 20 Years
Modificación del riesgo de mortalidad y morbilidad tras resección pulmonar en los últimos 20 años
María Teresa Gómez Hernándeza,
Corresponding author
, Nuria Novoa Valentína, Israel Rodríguez Alvaradoa, Marta Fuentes Gagoa, Gonzalo Varela Simób, Marcelo F. Jiménez Lópeza
a Departamento de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, Spain
b Facultad de Medicina, Universidad de Salamanca, Salamanca, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Mortality and morbidity after anatomical lung resection have fallen in recent decades&#44; according to the annual reports of the European Society of Thoracic Surgeons &#40;ESTS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> with unadjusted mortality rates decreasing from 3&#46;9&#37; to 1&#46;7&#37; in the last 5 years and cardiorespiratory morbidity after lobectomy falling from 20&#37; in 2009 to 15&#46;2&#37; in 2018&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Numerous studies have estimated the perioperative morbidity and mortality and assessing predictive factors in patients undergoing lung resection&#46; Moreover&#44; several multivariate models have been developed in recent years with the aim of improving the selection of patients for surgery&#46; The steering committee of the ESTS database has recently developed Eurolung 1 and 2&#44; two robust models for calculating the adjusted risk of hospital morbidity and mortality in candidates for anatomical lung resection surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> These models are based on the retrospective analysis of a population of 47<span class="elsevierStyleHsp" style=""></span>960 patients included in the ESTS database who underwent surgery between July 2007 and August 2015&#46; Eurolung 1 and 2 were created to serve as tools for quality control and for risk stratification in thoracic surgery&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although the risk of morbidity and mortality has declined in recent years&#44; the temporal trend in risk of death and complications based on the current ESTS models has not yet been assessed&#46; The objective of this study was to apply the Eurolung 1 and 2 risk models to a series of patients who underwent anatomical lung resection in the last 20 years&#44; in order to&#58; &#40;1&#41; assess and compare the risk of postoperative cardiorespiratory morbidity and mortality in 3 successive time periods and &#40;2&#41; identify variations in the selection of patients and surgical practices that have led to changes in the risk of death and postoperative complications&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Method</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Population</span><p id="par0020" class="elsevierStylePara elsevierViewall">This is a retrospective analysis of a series of 2435 consecutive cases who underwent anatomical lung resection &#40;lobectomy&#44; segmentectomy&#44; bilobectomy&#44; or pneumonectomy&#41; for lung cancer between 1994 and 2017 in our hospital&#46; Patient data were collected prospectively in an institutional database&#46; In order to increase the quality of the data included in the registry&#44; the completeness and accuracy of each entry is controlled by a data manager at two different time points&#58; first&#44; when the patient is discharged from the hospital&#44; and later&#44; at the time when the final histological result is entered in the definitive medical reports&#46; Ninety-four cases with missing data were excluded from the study&#44; representing 3&#46;9&#37; of the total&#44; so the study population included 2341 cases&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">For this study&#44; the population was divided into 3 time periods&#58; the first period included 976 cases undergoing anatomical lung resection between 1994 and 2006 &#40;cases prior to the construction of the current ESTS database&#41;&#59; the second period included 945 patients undergoing surgery between 2007 and 2015 &#40;cases that were used for the construction of the Eurolung 1 and 2 models&#41;&#44; and the third period included 420 patients undergoing surgery between 2016 and 2017 &#40;after the recruitment of cases for the construction of the models&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Dependent Variables</span><p id="par0030" class="elsevierStylePara elsevierViewall">We analyzed the risk of cardiorespiratory morbidity and mortality at 30 days calculated from Eurolung models 1 and 2 in the three study time periods&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The following equation was used to estimate the risk of morbidity &#40;Eurolung 1&#41;&#58; logit &#40;morbidity&#41;&#58; &#8722;2&#46;465&#43;0&#46;497&#95;male sex &#40;coded 1 for men and 0 for women&#41;&#43;0&#46;026&#95;age&#43;0&#46;231&#95;coronary disease &#40;CD&#41; &#40;coded 1 for presence of CD&#41;&#43;0&#46;371&#95;cerebrovascular accident &#40;CVA&#41; &#40;coded 1 for presence of CVA&#41;&#43;0&#46;152&#95;chronic kidney disease &#40;CKD&#41; &#40;coded 1 for presence of CKD&#41;&#8722;0&#46;015&#95;ppoFEV1&#37;&#43;0&#46;514&#95;extended resections &#40;coded 1 for presence of extended resection&#41;&#43;0&#46;497&#95;thoracotomy &#40;coded 1 for thoracotomy and 0 for VATS&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following equation was used to estimate 30-day mortality &#40;Eurolung 2&#41;&#58; logit &#40;mortality&#41;&#58; &#8722;5&#46;82&#43;0&#46;903&#95;male sex &#40;coded 1 for men and 0 for women&#41;&#43;0&#46;044&#95;age&#43;0&#46;264&#95;coronary disease &#40;coded 1 for presence of CD&#41;&#43;0&#46;582&#95;CVA &#40;coded 1 for presence of CVA&#41;&#8722;0&#46;064&#95;body mass index &#40;BMI&#41;&#43;0&#46;300&#95;extended resection &#40;coded 1 for extended resection&#41;&#43;0&#46;929&#95;pneumonectomy &#40;coded 1 for pneumonectomy and 0 for smaller resections&#41;&#43;0&#46;894&#95;thoracotomy &#40;coded 1 for thoracotomy 1 and 0 for VATS&#41;&#8722;0&#46;009&#95;FEV1&#37;ppo&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Independent Variables</span><p id="par0045" class="elsevierStylePara elsevierViewall">The same risk variables included in the Eurolung 1 and 2 models were used<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a>&#58; sex&#44; age&#44; BMI&#44; forced expiratory volume in 1 second predicted postoperative &#40;ppoFEV1&#37;&#41;&#44; CD&#44; CVA&#44; CKD&#44; surgical approach &#40;thoracotomy or video-assisted thoracoscopic surgery &#91;VATS&#93;&#41;&#44; extended resection &#40;associated with chest wall&#44; Pancoast tumors&#44; resection of the atrium or superior vena cava&#44; resection of the diaphragm&#44; vertebral resection&#44; pleuro-pneumonectomy&#44; pneumonectomy with tracheoplasty&#44; intrapericardial pneumonectomy&#41;&#44; and pneumonectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The indication for resection and final pathological diagnosis were not taken into account for study purposes&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical Analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">The individual probabilities of morbidity and mortality were maintained as new variables&#46; We then applied the analysis of variance &#40;ANOVA&#41; to compare those probabilities among the three study periods and constructed box plots to represent the differences graphically&#46; Finally&#44; we constructed a weighted polynomial regression model &#40;LOESS&#41; to graphically represent the evolution of the probability of each dependent variable with respect to time&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We also calculated the frequency of different independent variables included in the Eurolung 1 and 2 models for each time period&#46; The frequency difference of dichotomous variables &#40;sex&#44; cardiac or cerebrovascular comorbidity&#44; surgical approach&#44; extended resection&#44; and pneumonectomy&#41; was compared using a Chi-squared test&#44; while the mean of the continuous variables &#40;age&#44; BMI&#44; ppoFEV1&#37;&#41; was compared using ANOVA&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The statistical analysis was conducted using the STATA 15&#46;1 statistical software package &#40;Stata Corp&#46;&#44; College Station&#44; TX&#44; USA&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Population Description</span><p id="par0070" class="elsevierStylePara elsevierViewall">The study population is composed of 2341 patients with a mean age of 65&#46;1 years &#40;&#177;10&#46;2&#41;&#44; a ppoFEV1&#37; of 60&#46;1&#37; &#40;&#177;20&#46;8&#41; and a proportion of 82&#46;7&#37; men&#46; A total of 86&#46;5&#37; &#40;2024&#41; procedures were performed by lateral or posterior thoracotomy without muscle section&#44; and 317 &#40;13&#46;5&#37;&#41; were performed by VATS&#46; The procedures performed were&#58; 306 pneumonectomies &#40;of which 85 were extended and 11 were tracheoplasties&#41;&#44; 134 bilobectomies &#40;25 extended&#41;&#44; 1804 lobectomies &#40;238 extended and 84 with bronchoplastic resection&#41;&#44; and 97 anatomical segmentectomies&#46; Total mortality at 30 days was 56 cases &#40;2&#46;4&#37;&#41;&#44; and 371 cases &#40;15&#46;8&#37;&#41; presented 1 or more cardiorespiratory complications&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The probability of complications and death after lung resection&#44; calculated using the Eurolung 1 and 2 models&#44; respectively&#44; is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The probability that the differences between the values are due to chance is &#60;&#46;0001&#46; <a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a> represent the polynomial regression models weighted for morbidity and mortality&#44; respectively&#44; revealing a clear decline in both variables over time&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The relative frequency of binary variables in the last period differed from the previous 2 periods&#44; except in the case of CD&#44; which remained unchanged &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The prevalence of CVA and CKD increased with time&#44; reaching 2&#46;4&#37; and 4&#46;6&#37; in the last period&#44; respectively&#46; With regard to changes in surgical practices&#44; the percentages of pneumonectomy and extended resections in the first and third period fell by more than 20&#37; and 12&#37;&#44; respectively&#44; and the number of cases undergoing VATS increased dramatically in the last period&#44; eventually representing more than 60&#37; of all surgeries performed&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">With regard to continuous variables &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; more older patients underwent surgery in the last period compared with previous periods&#46; ppoFEV1&#37; was also greater in the last two periods&#44; compared with the first &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The main results of the study show that the probability of 30-day mortality and cardiorespiratory morbidity according to Eurolung 1 and 2 after anatomical lung resection has declined over the past 20 years in our unit&#46; Both risks are lower in the last period compared with the 2 previous periods&#46; This temporal trend is consistent with the mortality and morbidity figures reported by the ESTS in their annual reports&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The prevalence of variables that influence the risk of death and cardiopulmonary complications has also changed over time&#46; Patients undergoing surgery in the last 2 years were older than in the 2 preceding periods&#44; probably as a result of increased life expectancy of the population&#46; Age is considered by some authors to be an important risk factor for morbidity after lung resection&#46; Patients older than 70 years are more than twice as likely to develop complications after lung resection compared with younger patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#8211;5</span></a> However&#44; Ogawa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> showed that postoperative complications in elderly patients with lung cancer were independent of age&#44; and Stamenovic et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> found that patients older than 80 years did not have a higher risk of developing complications after lung resection than patients in their 70s&#46; Nevertheless&#44; it is important to remember that&#44; in general&#44; there is a selection bias when evaluating octogenarian patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> In any case&#44; the average age of patients undergoing lung resection has increased over time without increasing the risk of death and complications&#44; although it should be pointed out that the average age of patients in the third period barely reaches 67 years&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Life expectancy has increased in parallel with the prevalence of comorbidities&#46; Thus&#44; for example&#44; the percentage of patients with a history of CVA and CKD has increased in the last 2 periods compared with the first&#46; Improved management of these diseases has most likely delayed the increase of associated morbidity&#46; CD and BMI&#44; however&#44; have not changed significantly over time&#46; Wang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> found that age &#40;70 years or older&#41; and ppoFEV1&#37; &#40;70&#37; or lower&#41; combined with CD were independent prognostic factors for major postoperative complications&#46; According to our results&#44; ppoFEV1&#37; has increased over time&#44; especially when we compare the last 2 periods with the first&#46; This finding may be explained by the decline in the number of pneumonectomies performed in the last 2 periods&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Surgical practices have also evolved over time&#58; only 4&#37; of the procedures performed in the last period were pneumonectomies&#46; Pneumonectomy continues to be a high-risk procedure that is associated with high rates of mortality and morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> For this reason&#44; various strategies aimed at preserving the parenchyma have been developed and widely adopted&#44; with the dual objective of ensuring complete resection of the tumor while preserving lung function&#46; As a result&#44; the number of pneumonectomies has fallen dramatically&#44; a trend that is due&#44; among other factors&#44; to an increase in the number of bronchoplastic resections performed and improvements in early detection&#46; These factors were not analyzed in this study&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Fewer extended resections were performed in recent years&#44; probably also due to earlier diagnosis and treatment of lung cancers&#46; Our results show a rate of 8&#46;6&#37; of extended resections in the last 2 years&#44; comparable to the percentage given in the annual ESTS report of 2018&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> A study by Berry et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> underlines the importance of extended resections and thoracotomy as relevant risk factors for morbidity after lung resection surgery&#46; The percentage of thoracotomies also decreased significantly in the last period&#46; Several studies<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">10&#8211;12</span></a> have shown that lobectomy performed via VATS is superior to the open approach in terms of early outcomes&#44; and&#44; more recently&#44; a paired case control study using data from the ESTS registry<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> confirmed that lobectomy via VATS is associated with a lower incidence of complications and mortality compared with thoracotomy&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Finally&#44; the percentage of women undergoing anatomical lung resection in the last two years has increased&#44; due in large part to the progressively increasing prevalence of lung cancer in women&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> According to the 2012 report of the Spanish Society of Medical Oncology&#44; the incidence of lung cancer in women was 5&#46;67&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> The increase in lung cancer incidence and mortality among women reflects changing trends in smoking&#44; which reached its peak among women in the USA almost 20 years later than in men&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> Additionally&#44; after adjusting for the level of tobacco exposure&#44; women have an increased risk of cancer compared with men&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> In contrast&#44; women have lower morbidity and mortality after surgery for lung cancer&#46; The risk of complications is almost 3 times higher in men&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;7&#44;16</span></a> because women tend to be younger and have fewer comorbidities than men&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The increase in the percentage of minimally invasive surgeries and female patients&#44; along with the falling numbers of pneumonectomies and extended resections may be the most important factors that have led to a reduction in the risk of morbidity and mortality after anatomical lung resection&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Study Limitations</span><p id="par0125" class="elsevierStylePara elsevierViewall">The most important limitation of our research is that the risk models were constructed using data from patients included in the second period&#46; However&#44; our objectives did not include validating the models&#44; so we believe that this limitation does not compromise the study results&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The Eurolung models are the most up-to-date available&#44; but data were not collected on diffusing capacity of the lung for carbon monoxide or maximum oxygen consumption&#44; parameters that are considered predictive of postoperative morbidity and mortality&#59; it might have been interesting to know how these variables have evolved over time and how they have influenced the risks of postoperative morbidity and mortality&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Finally&#44; this study may have the biases inherent to any retrospective analysis&#46; Although complications were well defined and standardized variables were used&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> we cannot rule out data entry errors&#44; misclassification&#44; or insufficient reporting&#46; Indeed&#44; we excluded 4&#37; of our total number of cases due to incomplete data&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">This study provides real data quantifying the decreasing risk of mortality and cardiorespiratory morbidity after anatomical lung resection over time&#46; According to our analysis&#44; this reduction can be attributed to the falling number of pneumonectomies and extended resections &#40;although the cause of this pattern was not analyzed&#41;&#44; and the growing use of minimally invasive procedures&#46; Other changes in the clinical characteristics of the patients referred and accepted for surgery do not seem to have influenced the outcomes&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of Interests</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to evaluate changes in the risk of cardiorespiratory mortality and morbidity calculated by Eurolung risk models 1 and 2 in the last 20 years&#44; and to identify variations in patient selection or surgical practice that might have altered the risk of death and complications after anatomical lung resections&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Method</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This was a retrospective analysis of a series of 2435 consecutive patients who underwent anatomical lung resection&#46; The population was divided into three time periods&#58; 1994&#8211;2006 &#40;976 cases&#41;&#44; 2007&#8211;2015 &#40;945 cases&#41;&#44; and 2016&#8211;2017 &#40;420 cases&#41;&#46; Eurolung models 1 and 2 were applied to the series&#44; and the individual probability of adverse effects was calculated&#46; We compared this mean probability&#44; and the prevalence or means of each of the variables included in the models in each period and plotted the evolution of the risk&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A progressive decrease was observed in both adverse effects over time&#46; The prevalence of the binary variables&#44; except for coronary heart disease&#44; was higher in the last period&#46; The percentage of pneumonectomies and extended resections fell in the last two periods and the number of cases treated with VATS increased substantially in 2016&#8211;2017&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The decline in the number of pneumonectomies and the increase in the rate of minimally invasive procedures appear to be the variables most closely associated with decreased risk&#46; Other changes in the clinical characteristics of the patients do not seem to have influenced the outcomes&#46;</p></span>"
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          1 => array:2 [
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El objetivo del estudio es evaluar las modificaciones del riesgo de mortalidad y morbilidad cardiorrespiratoria calculada mediante los modelos de riesgo Eurolung 1 y 2 en los &#250;ltimos 20 a&#241;os para identificar variaciones en la selecci&#243;n de los pacientes o en la pr&#225;ctica quir&#250;rgica que hayan conducido a cambios en el riesgo de muerte y complicaciones tras resecciones anat&#243;micas pulmonares&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis retrospectivo de una serie de 2435 casos consecutivos sometidos a resecci&#243;n pulmonar anat&#243;mica&#46; La poblaci&#243;n fue dividida en tres per&#237;odos de tiempo&#58; 1994-2006 &#40;976 casos&#41;&#44; 2007-2015 &#40;945 casos&#41; y 2016-2017 &#40;420 casos&#41;&#46; Se aplicaron los modelos Eurolung 1 y 2 a la serie y se calcul&#243; la probabilidad individual de efectos adversos&#46; Se compar&#243; dicha probabilidad media&#44; as&#237; como la prevalencia o las medias de cada una de las variables que constituyen los modelos en cada per&#237;odo y se represent&#243; gr&#225;ficamente la evoluci&#243;n del riesgo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se observ&#243; un descenso progresivo de ambos efectos adversos a lo largo del tiempo&#46; La prevalencia de las variables binarias&#44; excepto enfermedad coronaria&#44; fue mayor en el &#250;ltimo per&#237;odo&#46; El porcentaje de neumonectom&#237;as y de resecciones ampliadas descendi&#243; en los dos &#250;ltimos per&#237;odos y el n&#250;mero de casos abordados por VATS se increment&#243; considerablemente en 2016-2017&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El descenso del n&#250;mero de neumonectom&#237;as y el incremento de la tasa de procedimientos m&#237;nimamente invasivos se consideran las variables m&#225;s relacionadas con la disminuci&#243;n del riesgo&#46; Otros cambios en las caracter&#237;sticas cl&#237;nicas de los pacientes no parecen haber influido en los resultados&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez Hern&#225;ndez MT&#44; Valent&#237;n NN&#44; Rodr&#237;guez Alvarado I&#44; Fuentes Gago M&#44; Varela Sim&#243; G&#44; Jim&#233;nez L&#243;pez MF&#46; Modificaci&#243;n del riesgo de mortalidad y morbilidad tras resecci&#243;n pulmonar en los &#250;ltimos 20 a&#241;os&#46; Arch Bronconeumol&#46; 2020&#59;56&#58;23&#8211;27&#46;</p>"
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
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ISSN: 15792129
Original language: English
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