Preoperative nutritional status assessment predicts postoperative outcomes in patients with surgically resected non-small cell lung cancer

doi:10.1016/j.ejso.2018.03.026

European Journal of Surgical Oncology

Volume 44, Issue 9, September 2018, Pages 1419-1424

https://doi.org/10.1016/j.ejso.2018.03.026 Get rights and content

Abstract

Background

As nutritional status plays an important role in outcomes after surgery, this study evaluated the association between preoperative nutritional status (NS) and postoperative outcomes after major resection for lung cancer.

Methods

We identified 219 patients with a diagnosis of cancer who underwent pulmonary resection from 2010 to 2012. Preoperative NS was assessed by anthropometric and biological parameters, body mass index (BMI), and the Nutritional Risk Index (NRI). We stratified this population into 4 BMI groups: underweight, normal weight, overweight and obese and 4 NRI groups: well-nourished; mildly malnourished; moderately malnourished and severely malnourished. The outcomes measured were postoperative complications; 30-day postoperative mortality; hospital length of stay (LOS), overall survival (OS) and disease-free survival (DFS). We performed both unadjusted analysis and adjusted multivariable analysis, controlling for statistically significant variables.

Results

Mean BMI and NRI were, respectively, 26.5 ± 4.3 and 112.4 ± 3.3. There were no significant differences between BMI categories and resection type, pathological stage, or overall postoperative complications. By contrast, significant differences (p < 0.05) in postoperative complications were observed among the NRI groups. LOS was longer in underweight and/or malnourished patients. In terms of OS, we found no significant differences according to NRI and BMI; however, patients with underweight had significantly shorter DFS compared with patients with overweight and obesity (log-rank p-value = 0.001).

Conclusion

NS as measured by the NRI is an independent predictor of the risk of postsurgical complications, regardless of clinicopathologic characteristics. NRI might therefore be an useful tool for identifying early-stage lung cancer patients at risk for postoperative complications.

Introduction

Preoperative nutritional status (NS) has been associated with the risk of postoperative complications [1], [2]. Although NS is not the only important preoperative criterion in patients with lung cancer, an increasing body of evidence indicates malnourished patients are at increased risk of postoperative complications after lung surgery [3], [4], [5], [6]. Thomas et al. [7], in a study recently carried out in France, found that malnutrition increased the risk of some complications immediately after lung cancer surgery, concluding that preoperative NS should be taken into account and mitigated as much as possible prior to surgery.

Although NS has traditionally been evaluated using the Body Mass Index (BMI), this parameter is not accurate to assess malnutrition. The modified Nutritional Risk Index (NRI), developed by Buzby et al. [8], [9], has shown to be a reliable nutritional screening tool for surgical inpatients and it can also be used to preoperatively stratify surgical patients according to their risk of complications. An important advantage of the modified NRI is that it avoids the limitations regarding the assessment of the patient's usual weight.

The close association between preoperative NS and postoperative outcomes in gastrointestinal surgery is well-established [10]. In this regard, patients with preoperative malnutrition are at high risk of developing postsurgical morbidity and mortality. By contrast, in the context of lung cancer surgery, no clear guidelines and/or recommendations have been published yet with regard to the optimal NS prior to surgery.

Given this context, the aim of this prospective study was to assess the impact of preoperative NS on postoperative outcomes in patients with surgically resected non-small cell lung cancer (NSCLC). We used both BMI and NRI to assess NS and to stratify patients according to their nutritional risk and their respective value as predictors of postoperative complications and survival was examined.

Section snippets

Study population

This prospective study included 219 patients diagnosed with NSCLC and considered eligible for radical lung surgery (lobectomy, pneumonectomy, or sublobar resection). In patients with functional contraindication for lobectomy (preoperative %DLCO < 50% or V_O2 max between 10 and 15 ml/kg/min), a sublobar resection was performed. All patients signed the informed consent and this study was approved by the Institutional Review Board.

The surgery was performed between January 2010 and December 2012.

Results

The study population included 219 consecutive patients with early stage NSCLC whose tumors were surgically resected in a single center. Most patients were men (177, 80.8%) and the mean age was 62.4 ± 8.7 years. Table 1 shows the clinicopathological characteristics, surgical data, and nutritional parameters of the study population.

NS was significantly associated with past medical history. Higher BMI values were significantly correlated with hypertension, diabetes, hypercholesterolemia, and

Discussion

The main objective of this study was to determine whether preoperative nutritional status —assessed by BMI and NRI— is able to predict the likelihood of postoperative complications in patients with surgically resected early stage NSCLC. Our main finding was that the preoperative NRI score had independent predictive value of postsurgical complications regardless of the baseline sociodemographic characteristics or comorbidities.

Given the well-known association between preoperative NS and

Conflict of interest statement

The authors did not have any conflict of interest to disclose.

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We identified 605 all-cause deaths (cancer, 204; non-cancer, 401) over a median of 6.2 years of follow-up (15,385 person-years; interquartile range, 3.3–9.8 years). High ALI was observed to be consistently associated with lower risks of all-cause (hazard ratio [HR], 0.516; 95 % CI, 0.400–0.667) and non-cancer (HR, 0.414; 95 % CI, 0.291–0.588) mortality compared with low ALI in a series of adjusted models. Meanwhile, lower PHQ-9 score (0–4) was associated with lower risks of all-cause (HR, 0.686; 95 % CI, 0.521–0.903) and non-cancer (HR, 0.686; 95 % CI, 0.474–0.992) mortality compared with higher PHQ-9 score (≥10). Furthermore, joint analyses showed that high ALI was associated with a decreased risk of death among cancer survivors who were not depressive. Specifically, survivors with high ALI but not depressive symptoms had the lowest overall (HR, 0.404; 95 % CI, 0.228–0.715) risks.
In this cohort study, we observed impact of nutritional and inflammatory status and depressive symptoms on mortality among cancer survivors, with the lowest risks of death from both all causes and non-cancer being noted among the combination of high level ALI with no depression.
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We found that advanced age was a non-significant risk factor for PAL as a binary variable (OR = 1.40, 95%CrI 0.87 to 2.37, P = 0.051), while significant as a continuous variable (MD = 1.82, 95%CrI 1.04 to 2.58, P<0.001) (Fig. 3). Increased PAL risk was also significantly associated with lower body mass index (BMI)5,8,9,18–21,25–30,32,35,37–40 (MD -1.38, 95%CrI -1.81 to -0.97, P<0.001; OR 2.12, 95%CrI 1.20 to 3.45, P = 0.017) and male1–3,7,8,10,11,21–35,37–40,43–48 (OR 1.69, 95%CrI 1.45 to 1.98, P<0.001) (Fig. 4). Smoking history significantly increased PAL risk (OR 1.84, 95%CrI 1.45 to 2.31, P<0.001) with an analysis of 15 studies.2,9,18,21,23,26–28,31,32,34,36,41–43
This study aimed to comprehensively identify risk factors for the occurrence of prolonged air leak (PAL) in patients undergoing pulmonary surgery. Studies were retrieved from 3 databases, including PubMed, Web of Science, and EmBase up to 13 May 2020. We performed meta-analysis using Bayesian random effect models through divergence restricting conditional tessellation (DIRECT) algorithm. The effect size was expressed as odds ratio (OR) or mean difference (MD), each with 95% credible interval (CrI). The evidence quality was evaluated. Subgroup analyses and sensitivity analyses were conducted. Thirty-nine studies with 89006 patients were finally included. Pooled PAL incidence was 15%. Of 30 risk factors, 22 were significantly associated with increased PAL incidence. Five risk factors were ultimately selected with high evidence quality: smoking history (OR 1.84, 95%CrI 1.45 to 2.31, P<0.001), preoperative steroid use (OR 1.51, 95%CrI 0.87 to 2.65, P = 0.031), lower ratio of forced expiratory volume in 1 s and forced vital capacity (OR 1.99, 95%CrI 1.22 to 3.33, P = 0.005), non-fissureless technique (OR 2.14, 95%CrI 1.31 to 3.66, P = 0.003), and pathological TNM stage III/IV (OR 1.50, 95%CrI 1.07 to 2.12, P = 0.003). Regarding the negative impact of PAL on the personal cost and postoperative recovery, the verification of previous proposed factors and investigation of recently discovered ones both implied directions for risk stratification and the establishment of an applicable prediction model.
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En los últimos años se están implementando programas multidisciplinares que incluyen diferentes actuaciones durante el periodo pre, intra y postoperatorio, encaminadas a disminuir el estrés perioperatorio y, por tanto, a mejorar los resultados de los pacientes sometidos a intervenciones quirúrgicas. Inicialmente, estos programas se desarrollaron para cirugía colorrectal y de ahí se han ido extendiendo a otras cirugías. La cirugía torácica, considerada de elevada complejidad, al igual que otras cirugías con una alta tasa de morbimortalidad postoperatoria, puede ser una de las especialidades que más se beneficien de la implantación de estos programas. En esta revisión se presentan las recomendaciones elaboradas por diferentes especialidades implicadas en los cuidados perioperatorios de los pacientes que requieren la resección de un tumor pulmonar. Para la elaboración de las recomendaciones presentadas en esta guía se han tenido en cuenta los metaanálisis, las revisiones sistemáticas, los estudios controlados aleatorizados y no aleatorizados y los estudios retrospectivos realizados en pacientes sometidos a este tipo de intervenciones. Para la clasificación de las recomendaciones se ha empleado la escala GRADE, valorando, por un lado, el nivel de evidencia publicado sobre cada aspecto concreto, y por otro, la fuerza de la recomendación con la que los autores proponen su aplicación. Las recomendaciones consideradas más importantes para este tipo de cirugía son las que se refieren a la prehabilitación, a la minimización de la agresión quirúrgica, a la excelencia en el manejo del dolor perioperatorio y a los cuidados postoperatorios encaminados a proporcionar una rápida rehabilitación postoperatoria.
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Preoperative nutritional status assessment predicts postoperative outcomes in patients with surgically resected non-small cell lung cancer

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study population

Results

Discussion

Conflict of interest statement

Cir Esp

Chest

Clin Nutr

Ann Thorac Surg

Ann Thorac Surg

Clin Nutr

J Thorac Oncol

J Thorac Oncol

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Surgery