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A.J. Sharkey



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    MO22 - Advanced Disease and Outcomes (ID 103)

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      MO22.04 - Standardising the Management of Patients Following Lung Resection: Does It Improve Outcome? (ID 2114)

      10:45 - 10:50  |  Author(s): A.J. Sharkey

      • Abstract
      • Presentation
      • Slides

      Background
      There is marked variation in the management of Thoracic surgical patients post-operatively, both between individual surgeons and surgical centres. This lack of standardisation can lead to staff and patient dissatisfaction, and differing outcomes for patients. In 2012 we introduced a more standardised approach to the management of patients undergoing Thoracic surgery under the care of one consultant (Consultant A). This was based on the ‘fast-track’ protocol published in 2001 by Cerfolio et al. We aimed to determine whether this approach to patient management has affected patient outcome.

      Methods
      Data for all patients undergoing lung resection at a single centre from April 2012 to March 2013 were collected. The patients were split into two groups, those under the care of Consultant A (group A), and those under the care of the remaining 4 consultants (group B). Group A were managed according to the new standardised pathway which included; stopping the routine use of suction unless clinically required, chest drain removal with cessation of an air leak and drainage below 400mls in 24 hours, and epidural catheter removal on post-operative day 2. Those in group B were managed according to the instructions of the operating Consultant, or the surgical registrars covering the ward. Pre-operative, operative and post-operative data were collected and analysed. Patients were then propensity matched using operation and age.

      Results
      Two hundred and thirty one patients were identified. Overall mean length of stay for all patients in group A was 5.65 days (SD±4.68), and in group B; 9.97 days (SD±12.06), p<0.001. Of these patients 94 were suitable for propensity matching. There were no significant differences found in the proportion of patients with benign versus malignant pathology, the number with primary lung cancer, or in the stage of the resected primary lung cancer. In-hospital mortality for both groups was one patient (2.13%). There was a lower number of drains inserted peri-operatively in group A patients (p<0.001). Mean time to drain removal (all drains) was 3.42 days (SD±6.35) for group A and 4.24 days (SD±3.08) for group B, p=0.026. Mean length of stay for group A was 6.00 days (SD± 4.86) and for group B 10.33 days (SD±19.29), p=0.042.

      Conclusion
      Standardising care following surgery has been shown to improve patient safety, and both patient and staff satisfaction. We have found that reducing variation, and following a validated management pathway, significantly reduces the time to chest drain removal and in-hospital length of stay for patients undergoing lung resection for any pathology. We are currently analysing the various elements of the pathway to determine which specific factors impact patient outcome. Further work is required to determine the effect these differences have on patient reported outcome measures, including overall satisfaction.

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    P1.07 - Poster Session 1 - Surgery (ID 184)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 2
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      P1.07-020 - Thoracoscore and European Society Objective Score Do Not Predict Mortality in The UK Population - Is It Time For a New Risk Model? (ID 1459)

      09:30 - 09:30  |  Author(s): A.J. Sharkey

      • Abstract

      Background
      Thoracoscore and the European Society Objective Score (ESOS.01) are two risk scoring systems used to estimate risk of death as part of informed consent, and to allow risk adjusted outcomes to be evaluated. We aimed to evaluate if these are valid tools for use in the United Kingdom (UK) population.

      Methods
      A multi-centre, prospective study was carried out on patients undergoing lung resection at 6 UK centres. Data were submitted electronically using our online data collection tool. Univariate and multivariate analyses were carried out to determine the factors affecting mortality. A Receiver Operating Characteristic (ROC) analysis was performed in order to determine the ability of the Thoracoscore and ESOS.01 to predict in-hospital mortality.

      Results
      Data were submitted for 2570 patients. 345 patients were excluded due to incomplete data fields. Of the remaining 2245 patients, the observed in-hospital mortality was 31 patients (1.38%). Mean Thoracoscore was 2.66(SD±3.21). Logistic regression analysis identified gender (p=0.004, hazard ratio 4.786) and co-morbidity score (p=0.005, hazard ratio 3.289) as risk factors for mortality. A sub-analysis was performed using data from 1912 patients. In this group, mean Thoracoscore was 2.55(SD±2.94), mean ESOS.01 was 2.11(SD±1.41), and these were statistically significantly different (p<0.0001). The observed in-hospital mortality was 28 patients (1.46%). The c-index for Thoracoscore was 0.705, and for ESOS.01, 0.739. Furthermore, there was poor correlation between the two scoring systems (r=0.362).

      Conclusion
      Both Thoracoscore and ESOS.01 overestimated mortality in the UK population. There is a continued need to develop an appropriate risk prediction system for the UK.

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      P1.07-045 - Prognostic Implications of Blood Tests Performed Routinely Prior to Surgical Resection of Non-Small Cell Lung Cancer (ID 3108)

      09:30 - 09:30  |  Author(s): A.J. Sharkey

      • Abstract

      Background
      Routinely performed blood tests may yield important information regarding the risks of post-operative morbidity and survival. Whilst the association between systemic pre-operative inflammatory response and survival in NSCLC chemotherapy patients is recognized, the clinico-pathological correlates in NSCLC surgical patients are less clear.

      Methods
      NSCLC patients undergoing surgery between 29/8/2007 and 30/3/11 were included. Preoperative blood tests were retrieved from laboratory databases and correlated with prospectively collected data held in our surgical database including clinico-pathological factors, pathological TNM stage and survival. Survival analysis was performed on 17/06/13.

      Results
      722 patients underwent surgery for suspected NSCLC. In 563 (78.0%) patients (54.2% males, median age 68.5 (range 37.8 - 90.8) years), complete data for all factors enabled subsequent multivariate analysis. At the time of analysis, 377 (60%) were alive and were censored in survival analyses. In univariate analysis, the following factors were identified as poor prognostic factors; serum fibrinogen >4g/dL (p=0.011), haemoglobin <13.1g/dL (p=0.003), platelet count >370x10[9 ]or<140x10[9 ](p=0.006), ALT >63 IU/L or <17 IU/L (p=0.039), total protein >80g/L or <60g/L (p<0.001), albumin >48g/L or <35g/L (p=0.005), globulin >36g/L or <18g/L (p=0.001), cholesterol <5mmol/L (p=0.011). Other factors identified as poor prognostic factors were, age (p<0.001), male gender (p=0.033), nodal stage (p=0.001), tumour size (p=0.001), completeness of resection p=0.025), and histological grade (p=0.008). In multivariate analysis of the factors identified from the blood tests, total protein (HR 2.263 95% CI 1.357-3.775, p=0.002), globulin (HR 1.507 95% CI 1.015-2.238 p=0.042), and haemoglobin (HR 1.462 95% CI 1.091-1.958 p=0.011) Including stage, age and gender in the model, stage (HR 1.286 95% CI 1.164-1.442 p<0.001), age (HR 1.028 95% CI 1.011-1.046 p=0.001), gender (HR 1.419 95% CI 1.048-1.920 p=0.024), total protein (HR 2.503 95% CI 1.465-4.274 p=0.001) and haemoglobin (HR 1.500 95% CI 1.110-2.026 p=0.008) remained independent prognostic factors.

      Conclusion
      Although survival data are not yet fully mature, pre-operative anaemia and an abnormal serum total protein level are adverse prognostic factors for survival following lung cancer surgery, being independent of other variables including stage, age and gender. Further work is required to determine the clinical implications of these findings.

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    P2.07 - Poster Session 2 - Surgery (ID 190)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 2
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      P2.07-041 - Talc pleurodesis or IPC for malignant pleural effusion. Is it Time to change? (ID 3130)

      09:30 - 09:30  |  Author(s): A.J. Sharkey

      • Abstract

      Background
      Indwelling pleural catheters (IPCs) have a role in the management of pleural effusions. The TIME-2 trial demonstrated equivalence in dyspneoa relief for first time pleurodesis. This single centre study aimed to compare experience of patients receiving talc pleurodesis versus IPC.

      Methods
      A retrospective review of all patients undergoing IPC insertion or talc pleurodesis within a single Trust between October 2007 and September 2012. We had a policy of selective IPC insertion for trapped lung or recurrent pleural effusion, with talc pleurodesis the procedure of choice for expansile lungs. We examined resource utilisation including pre-operative intervention, length of stay (LOS), re-accumulation and re-intervention.

      Results
      130 patients were identified. 61 (47%) patients underwent talc pleurodesis; 69 had an IPC inserted. 13.1% of talc patients and 59.4 % in the IPC group had received a previous pleural intervention (p<0.001). 23.0% of the talc and 29.0% of the IPC group received their procedure on an urgent basis (p=0.44 ). Significantly more patients underwent a general anaesthetic in the talc group (IPC 26 (37.7%), talc 57 (93.4%) p<0.001). Patients treated with IPC had a significantly shorter post-operative stay than those treated with talc (IPC median 2 (range 2-46) days; talc 5 (0-36), p<0.001). Significantly fewer patients experienced re-accumulation following IPC than talc pleurodesis at 30 days (8 (11.6%) vs 19 (31.3%) p=0.006), and overall (12 (17%) vs 27(44%) p<0.001). There were no differences in post-procedure mortality (IPC 3 (4.35%), talc 1 (1.64%) p=0.372); effusion requiring re-admission to hospital (IPC 5(7.25%), talc 7 (11.5%) p=0.406, or re-intervention rates (IPC 6 (8.7%), talc 7 (11.5%) p=0.60).

      Conclusion
      Despite being used in patients with more complicated pleural effusion, IPC placement was associated with a significantly shorter post-operative length of stay and fewer cases of effusion re-accumulation. IPC placement should be considered for the treatment of pleural effusion.

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      P2.07-042 - Is plasma fibrinogen a novel independent prognostic factor in patients undergoing surgery for Non-Small Cell Lung Cancer? (ID 3131)

      09:30 - 09:30  |  Author(s): A.J. Sharkey

      • Abstract

      Background
      Plasma fibrinogen levels have been shown to correlate with outcomes in various extra-thoracic malignancies. In patients with NSCLC, positive associations have been shown between fibrinogen levels and tumour pathology, but the clinical correlates are unclear. We aimed to examine whether pre-operative fibrinogen levels are a prognostic factor in patients undergoing surgical resection for suspected NSCLC.

      Methods
      All NSCLC patients undergoing surgery between 29/8/2007 and 30/3/11 were included. Pre-operative plasma fibrinogen levels were measured and correlated with clinicopathological factors, pathological TNM stage and survival. Survival analysis was performed on 17/06/13.

      Results
      722 patients underwent surgery for suspected NSCLC. In 519 (71.9%) patients (54.5% males, median age 68.5 (range 37.8 - 90.8) years), pTNM stage and preoperative fibrinogen level were available. Median fibrinogen level was 4.1 (range 1.7 - 10.2) g/dL. 330 (63.6%) of patients had fibrinogen level > reference range (2-4g/dL). Fibrinogen correlated with tumour size (p<0.001) and pTNM stage (p<0.001), but not with nodal stage, histological grade or cell type. At the time of analysis, 309 (59.5%) patients were alive. Fibrinogen > 4g/dl (p=0.01), pTNM stage (p<0.001), Nstage (p=0.001) and tumour size (p=0.003) were univariate prognostic factors. In Cox multivariate analysis, fibrinogen level (p=0.02), pTNM stage (p<0.001), age (p<0.001) and gender (p=0.023) were independent predictors of prognosis.

      Fibrinogen <4g/dL Fibrinogen >4g/dL p
      n Median Survival n Median Survival
      StageI 125 Not reached 176 63.0 0.011
      Stage II 45 55.4 97 Not reached 0.677
      Stage III 19 42.3 57 34.5 0.396

      Conclusion
      Fibrinogen is associated with tumour size and pTNM stage. Whilst survival data are not yet mature, pre-operative fibrinogen > 4 g/dl may be a novel independent prognostic factor following surgical resection of NSCLC. Further work is required to determine the clinical implications of high fibrinogen levels, and to investigate the underlying mechanisms.