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Gaetano Rocco

Publications and source records attributed to Gaetano Rocco.

At least 19 recordsLinked to original sources
PubMed2006

Measured FEV1 in the first postoperative day, and not ppoFEV1, is the best predictor of cardio-respiratory morbidity after lung resection.

INTRODUCTION AND OBJECTIVE: There is a low correlation between predicted postoperative FEV1 (ppoFEV1) and FEV1 measured the days after pulmonary resection, when most complications are developed. The hypothesis of this investigation is that ppoFEV1 does not predict postoperative morbidity in patients undergoing lung resection when immediate postoperative FEV1 is considered in the predictive model. METHODS: One hundred ninety-eight consecutive patients undergoing lobectomy or pneumonectomy were included in a prospective, multiinstitutional study. INDEPENDENT VARIABLES: age, body mass index, ppoFEV1, surgical approach (VATS or muscle-sparing thoracotomy), type of analgesia (epidural or intraveous), postoperative visual analogue pain score and FEV1 measured the day after the operation. Target variable: occurrence of postoperative cardio-respiratory complications. Method of analysis: classification tree (CART) dividing the population at random in two subsets and developing a bootstrap set of 100 trees resampling training data. The relative importance of each variable and the accuracy of both initial and committee trees to predict the outcome were presented. RESULTS: One hundred seventy-seven lobectomies and 21 pneumonectomies were included. Overall cardio-respiratory morbidity was 22%. According to CART results, first day FEV1 was the most important variable to classify cases as primary splitter and as a surrogate of each primary splitter (100% importance). Patient age followed (51%) and ppoFEV1 was third (43%) with a score similar to postoperative pain score (42%) and type of analgesia (36%). Sensitivity and specificity of the initial tree were, respectively, 0.5 and 0.7; values for committee tree were 0.5 sensitivity and 0.7 specificity. CONCLUSION: Postoperative cardio-respiratory complications are more related to FEV1 measured in the first postoperative day than to ppoFEV1 value.

Age Factors↗
PubMed2006

Risk-adjusted morbidity and mortality models to compare the performance of two units after major lung resections.

OBJECTIVE: We sought to develop risk-adjusted morbidity and mortality models to compare the performance of 2 different thoracic surgery units in patients submitted to major lung resections. METHODS: Seven hundred forty-three patients (551 male and 192 female patients) who underwent lobectomy (n = 611) or pneumonectomy (n = 132) from January 2000 through August 2004 at 2 European thoracic units (519 patients in unit A and 224 patients in unit B) were analyzed. Risk-adjusted models of 30-day or in-hospital cardiopulmonary morbidity and mortality were developed by using stepwise logistic regression analyses and validated by means of bootstrap analysis. Preoperative and operative variables were initially screened by using univariate analysis. Those with a P value of less than .10 were used as independent variables in the regression analyses. The regression equations were then used to estimate the risk of outcome, and the observed and predicted outcome rates of the 2 units were compared by using the z test for comparison of proportions. RESULTS: The following regression models were developed. Predicted morbidity: lnR/1-R=-2.4+0.03Xage-0.02XppoFEV1+0.6Xcardiaccomorbidity (Hosmer-Lemeshow statistic = 6.1 [P = .6], c index = 0.65). Predicted mortality: lnR/1-R=-6.97+0.095Xage-0.042XppoFEV1 (Hosmer-Lemeshow statistic = 2.99 [P = .9], c index = 0.77). The models proved to be stable at bootstrap analyses. No differences were noted between observed and predicted outcome rates within each unit, despite an apparent unadjusted better performance of unit B. CONCLUSIONS: The use of risk-adjusted outcome models avoided misleading information derived from the unadjusted analysis of performance. Risk modeling is essential for the evaluation of the quality of care.

Aged↗
PubMed2006

Predicted versus observed FEV1 in the immediate postoperative period after pulmonary lobectomy.

OBJECTIVE: Scanty information can be found regarding ppoFEV1% correlation with true FEV1% in the immediate days after surgery, when most cardio-respiratory complications are developed. This prospective multicentric investigation aims to describe the evolution of FEV1 in a series of uneventful lobectomy cases before hospital discharge, and to identify factors associated with the variation of postoperative residual FEV1, with the ratio between the actual and the predicted postoperative FEV1 measured during the first 6 postoperative days. METHODS: One hundred and sixty-one patients submitted to lobectomy were prospectively enrolled in the study. Patients with chest wall resections and postoperative complications were excluded. Data from a total of 125 patients were thus used for the analysis. The following clinical variables were recorded: age, preoperative FEV1, ppoFEV1, presence of chronic obstructive pulmonary disease (COPD), surgical approach (VATS or muscle-sparing thoracotomy), side (right or left) and site (upper or lower) of resection, type of analgesia (epidural or intravenous), and daily visual analogue pain score (VAS). FEV1 was measured in every patient at hospital admission and daily until discharge or up to postoperative day 6. Random effects time-series cross-sectional regression analyses were performed to identify factors associated with variation of postoperative residual function (100-(preoperative FEV1-postoperative FEV1/preoperative FEV1 x 100)), and of FEV1 ratio ((actual postoperative FEV1 x 100)/ppoFEV1). For these analyses, the dependent variables (postoperative residual function and FEV1 ratio) and the pain score were analysed as panel longitudinal data. The regression analyses were subsequently validated by bootstrap procedure. RESULTS: FEV1% was lower at first postoperative day and increased gradually up to day 6 but mean values never reached ppoFEV1%. Pain scores decreased from day 1 to day 6. Preoperative FEV1 (p<0.0001) and postoperative pain score (p<0.0001) resulted independently and reliably inversely associated with postoperative residual FEV1 (model R2, 0.16). Preoperative FEV1 (p=0.001), postoperative pain score (p<0.0001), and epidural analgesia (p=0.04) resulted independently and reliably associated with postoperative FEV1 ratio (model R2, 0.13). CONCLUSION: Current methods of prediction of postoperative FEV1 greatly underestimated the real functional loss in the immediate postoperative period. Therefore, for the purpose of a more accurate risk stratification we need to correct the traditional prediction of postoperative FEV1.

Adolescent↗
PubMed2006

Carbon monoxide lung diffusion capacity improves risk stratification in patients without airflow limitation: evidence for systematic measurement before lung resection.

OBJECTIVE: In many centers, carbon monoxide lung diffusion capacity (DLCO) is still not routinely measured in all patients but only in patients with airflow limitation. The objective of the study was to assess the degree of correlation between forced expiratory volume in 1s (FEV1) and DLCO, and verify whether a low predicted postoperative DLCO (ppoDLCO) could have a role in predicting complications in patients without airflow limitation. METHODS: We analyzed 872 patients submitted to lung resection between January 2000 and December 2004 in two units measuring systematically DLCO before operation. Correlation between FEV1 and DLCO was assessed in the entire dataset and in different subsets of patients. A number of variables were then tested for a possible association with postoperative cardiopulmonary complications in patients with FEV1>80% by univariate analysis. Variables with p<0.10 at univariate analysis were used as independent variables in a stepwise logistic regression analysis (dependent variable: presence of cardiopulmonary morbidity), which was in turn validated by bootstrap analysis. RESULTS: The correlation coefficients between FEV1 and DLCO in the entire dataset and in different subsets of lung resection candidates (stratified by age, gender, cause of operation, airflow limitation) were all below 0.5, showing a modest degree of correlation. Two hundred and nineteen of the 508 patients (43%) with FEV1>80% had DLCO<80%. Moreover, in patients with FEV1>80%, logistic regression analysis showed that ppoDLCO<40% was a significant and reliable predictor of postoperative complications (p=0.004). CONCLUSION: The modest correlation between FEV1 and DLCO and the capacity of ppoDLCO to discriminate between patients with and without complications in subjects with a normal FEV1, warrants the routine measurement of DLCO in all candidates for lung resection, irrespective of their FEV1 value, in order to improve surgical risk stratification.

Aged↗
PubMed2006

Predictors of successful closure of open window thoracostomy for postpneumonectomy empyema.

BACKGROUND: Although the open window thoracostomy (OWT) represents the ideal method for drainage of postpneumonectomy empyema (PPE), several controversies exist concerning its closure. METHODS: Between January 1993 and December 2003, an OWT was created in 31 patients (29 male and 2 female) with PPE. The median age was 61 years (range, 32 to 76). In 26 patients (84%) a bronchial stump fistula developed. The OWT closure was correlated with characteristics of PPE and the timing of OWT. RESULTS: In 15 patients (48%), the OWT could be closed by obliteration of pleural cavity with antibiotic solution (3 patients) or intrathoracic muscle transposition (12 patients). A successful closure was observed in 13 of the 15 patients (87%). All patients closed by Clagett's procedure remained empyema free. Recurrent cancer (n = 4), poor functional status (n = 3), refusal of further operation (n = 2), and persistent tuberculous empyema (n = 2) were common causes of failure of OWT closure. Univariate analysis revealed that the timing of empyema development after surgery (p = 0.02) and the timing of OWT (p = 0.03) were significant predictors of thoracostomy closure. CONCLUSIONS: Late onset of PPE and immediate OWT creation are significant predictors of OWT closure. Smaller dimensions of the pleural cavity appeared to increase the likelihood of closure. When the pleural cavity shows healthy granulation tissue and no bronchopleural fistula, the Clagett's procedure is safe and effective to obliterate the pleural cavity. Obliteration by muscle flap transposition can be reserved for patients with persistent or recurrent bronchopleural fistula.

Adult↗
PubMed2006

Internal validation of risk models in lung resection surgery: bootstrap versus training-and-test sampling.

OBJECTIVE: The objective of the present analysis was to compare the performance of a lung resection mortality model developed by means of logistic regression and bootstrap analysis with that of multiple mortality models developed by using the traditional training-and-test method from the same dataset. METHODS: Eleven mortality models (1 developed by means of logistic regression and bootstrap validation and the other 10 developed by means of the traditional training-and-test random splitting of the dataset) were generated by the data of unit A (571 patients submitted to major lung resection). The performances of each of the 11 mortality models were then evaluated by assessing the distribution of the respective c-statistics in 1000 bootstrap samples derived from unit B (224 patients). RESULTS: The first model (logistic regression and bootstrap analysis) had good discrimination among the 1000 bootstrap external samples (c-statistics >0.7 in 80% of samples and >0.8 in 38% of samples). Among the 10 training-and-test models, only one model had a similar performance, whereas the others had a poorer discrimination. CONCLUSIONS: The traditional training-and-test method for risk model building proved to be unreliable across multiple external populations and was generally inferior to bootstrap analysis for variable selection in regression analysis. Therefore the use of bootstrap analysis must be recommended for every future model-building process.

Aged↗
PubMed2005

Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia.

OBJECTIVE: VATS using the conventional three ports is currently the technique of choice for blebectomy/bullectomy for spontaneous pneumothorax. However, the procedure has recently been shown to have neurological complications related to the port sites. Uniportal VATS has recently been proposed as an alternative to conventional three-port VATS. It is anticipated that the single incision will predispose to a lower incidence of neurological complications. METHODS: We report our initial single surgeon experience of uniportal VATS (n = 16) and provide a comparison of post-operative pain and residual paraesthesia to conventional three-port procedures (n = 19) for the same pathology. RESULTS: In both groups, the pneumothorax pathology was principally primary. There was no difference between the groups in terms of age, spirometry, tissue resected, drainage time and inpatient stay. A difference was, however, noted in inpatient pain scores. The uniportal group had a lower median score of 0.4 (visual analogue range 0-4) while the three-port technique reported 0.8 (P = 0.06, Mann-Whitney test). The maximum score trend was similar (1.4 vs. 2.6, respectively, P < 0.001, Mann-Whitney test). Follow-up for uniportal and three-port VATS averaged 9.4+/-6.6 and 32.1+/-9.9 months, respectively. One patient in the three-port group had a pneumothorax recurrence. Three-port VATS also had a higher residual pain score (0.5) compared to uniportal VATS (0.3). Of clinical significance was the incidence of neurological complications. Eighty-six percent of uniportal patients reported no symptoms. The remaining experienced only mild 'numbness' or 'swelling'. However, in the three-port group, only 42% reported no symptoms. A similar number experienced 'numbness'. Two females described sexual dysfunction due to altered breast sensitivity. Seventeen percent (2/12) reported 'pins and needles'. CONCLUSIONS: Uniportal VATS appears to be tolerable, safe and efficient in treating spontaneous pneumothorax in our series. Moreover, post-operative pain and paraesthesia incidence was lower than three-port VATS. Prospective randomised trials are important to evaluate this technique.

Adolescent↗
PubMed2005

The European Thoracic Surgery Database project: modelling the risk of in-hospital death following lung resection.

OBJECTIVE: To identify pre-operative factors associated with in-hospital mortality following lung resection and to construct a risk model that could be used prospectively to inform decisions and retrospectively to enable fair comparisons of outcomes. METHODS: Data were submitted to the European Thoracic Surgery Database from 27 units in 14 countries. We analysed data concerning all patients that had a lung resection. Logistic regression was used with a random sample of 60% of cases to identify pre-operative factors associated with in-hospital mortality and to build a model of risk. The resulting model was tested on the remaining 40% of patients. A second model based on age and ppoFEV1% was developed for risk of in-hospital death amongst tumour resection patients. RESULTS: Of the 3426 adult patients that had a first lung resection for whom mortality data were available, 66 died within the same hospital admission. Within the data used for model development, dyspnoea (according to the Medical Research Council classification), ASA (American Society of Anaesthesiologists) score, class of procedure and age were found to be significantly associated with in-hospital death in a multivariate analysis. The logistic model developed on these data displayed predictive value when tested on the remaining data. CONCLUSIONS: Two models of the risk of in-hospital death amongst adult patients undergoing lung resection have been developed. The models show predictive value and can be used to discern between high-risk and low-risk patients. Amongst the test data, the model developed for all diagnoses performed well at low risk, underestimated mortality at medium risk and overestimated mortality at high risk. The second model for resection of lung neoplasms was developed after establishing the performance of the first model and so could not be tested robustly. That said, we were encouraged by its performance over the entire range of estimated risk. The first of these two models could be regarded as an evaluation based on clinically available criteria while the second uses data obtained from objective measurement. We are optimistic that further model development and testing will provide a tool suitable for case mix adjustment.

Adult↗
PubMed2005

Elective transplant pneumonectomy in a 38-year-old man.

Transplant pneumonectomy is a rarely performed procedure. It is occasionally carried out in the course of retransplantation. To our knowledge, resection of a transplanted lung without its replacement and with successful outcome in the adult has not been previously reported. We present a case of elective left transplant pneumonectomy in a 38-year-old man 6 years after left single-lung transplant. At 12 months after resection, the patient remains well, with good exercise tolerance.

Adult↗
PubMed2004

Pleural partition with intrathoracic muscle transposition (muscle tent) to manage residual spaces after subtotal pulmonary resections.

The concept of separating the pleural cavity to better control residual spaces has been revisited by introducing a technique of pleural partition through transposed chest wall muscles (muscle tent). This technique has been successfully used in 3 patients with severe lung destruction due to chronic infections who required subtotal pulmonary resections.

Adult↗
PubMed2004

Uniportal VATS wedge pulmonary resections.

Since 2000, 15 patients have undergone single port (uniportal) video-assisted thoracic surgery for wedge pulmonary resection either for diagnosis of interstitial lung diseases (10 patients) or for treatment of primary spontaneous pneumothoraces (5 patients). Diagnosis was obtained in all patients and no recurrences of pneumothorax were seen at follow-up. This initial experience shows that, for specific indications, uniportal video-assisted thoracic surgery for wedge pulmonary resections can be safe and effective.

Alveolitis, Extrinsic Allergic↗