Delphi-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über das perioperative Management bei onkologischen anatomischen Lungenresektionen

Zusammenfassung

Einleitung Die anatomische Lungenresektion zur kurativen Behandlung einer malignen Grunderkrankung ist die am häufigsten durchgeführte elektive Operation in der onkologischen Thoraxchirurgie. Ziel dieses Projektes war die Erarbeitung eines Konsenses bez. der am häufigsten gestellten Fragen zum Thema perioperatives Management für elektive onkologische Lungenresektionen.

Methodik Die Arbeitsgruppe erarbeitete 2 elektronische Delphi-Fragerunden. Als Konsens wurde eine Übereinstimmung in ≥ 75% definiert. Nach der statistischen Auswertung der Ergebnisse der elektronischen Fragerunde erfolgte eine Expertenkonferenz, die in einer finalen Delphi-Abstimmung versucht hat, weiteren Konsens über strittige Themen zu erreichen.

Ergebnisse 14 Fragen bez. des perioperativen Managements für elektive onkologische Lungenresektionen konnten formuliert und abgestimmt werden. Konsens konnte für folgende Themen erreicht werden: präoperatives infektiologisches Screening, erweiterte lungenfunktionelle Diagnostik bei eingeschränkter Lungenfunktion, Verwendung eines validierten Cardiac-Risk-Assessment-Algorithmus, Überwachung des Patienten postoperativ, Thromboembolieprophylaxe, Kontrollbronchoskopie nach Bronchusmanschettenresektionen oder nach Pneumonektomie sowie Blutgasanalyse vor Entlassung. Für folgende Themen konnte kein Konsens erreicht werden: präoperative endobronchiale mikrobiologische Diagnostik, Spülung der Thoraxhöhle, standardisierte laborchemische Untersuchungen postoperativ.

Fazit Die vorliegende Arbeit fasste die Ergebnisse eines Delphi-Prozesses zusammen, der 2018/2019 mit Experten aus zertifizierten Kliniken oder hochvolumigen thoraxchirurgischen Einheiten geführt wurde. Insgesamt zeigte sich eine sehr hohe Konsensrate bez. des perioperativen Managements bei onkologischen anatomischen selektiven Lungenresektionen. Die präoperative mikrobiologische endobronchiale Diagnostik war der Hauptpunkt, wo ein Konsens nicht erreicht werden konnte.

Abstract

Background Anatomical lung resection for curative treatment of a tumour disease is the most common selective procedure in oncological thoracic surgery. The goal of the working group of the German Thoracic Surgery Society (DGT) was to achieve a consensus on the perioperative management of selective oncological lung resection procedures.

Methods The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung centres. Consensus was considered as a rate of ≥ 75%. After statistical analysis of the results, an expert meeting took place and a final Delphi process poll was used in order to reach consensus for controversial topics.

Results Fourteen questions on the perioperative management of anatomical oncological lung resections were proposed and voted on. A consensus was reached for the following topics: preoperative infectiological screening, extended respiratory diagnostics for impaired lung function, use of a cardiac risk assessment score, postoperative monitoring, prophylaxis for venous thromboembolism, control bronchoscopy after sleeve resections or pneumonectomy, blood gas test before discharge from the hospital. No consensus was reached for the following topics: preoperative endobronchial microbiological diagnostics, pleural rinsing, standardised clinical chemistry blood test postoperatively.

Conclusion Our manuscript depicts the results of a Delphi process in 2018/2019 involving experts of the German Thoracic Surgery Society from high volume departments certified for thoracic surgery and/or lung cancer surgery. In general, a very high rate of consensus was documented for the majority of the topics concerning the perioperative management of oncological anatomical selective lung resection procedures. The most important topic for which no consensus could be reached was preoperative endobronchial microbiological diagnostic testing.

Schlüsselwörter

Risikomanagement - Delphi-Konsensus - anatomische Lungenresektion

Key words

risk management - Delphi expert consensus - anatomical lung resection

Publication History

Article published online:
17 February 2020

• Literatur

• 1 Murphy MK, Black NA, Lamping DL. et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess 1998; 2: i-iv 1–88
• 2 Jones J, Hunter D. Consensus methods for medical and health services research. BMJ 1995; 311: 376-380,
• 3 Schonfeld V, Diercke M, Gilsdorf A. et al. Evaluation of the statutory surveillance system for invasive MRSA infections in Germany, 2016–2017. BMC Public Health 2018; 18: 1063 doi:10.1186/s12889-018-5971-y
• 4 Brunelli A, Charloux A, Bolliger CT. et al. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). Eur Respir J 2009; 34: 17-41 doi:10.1183/09031936.00184308
• 5 Lim E, Baldwin D, Beckles M. et al. Guidelines on the radical management of patients with lung cancer. Thorax 2010; 65 (Suppl. 03) iii1-iii27 doi:10.1136/thx.2010.145938
• 6 Fleisher LA, Beckman JA, Brown KA. et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 2007; 50: 1707-1732 doi:10.1016/j.jacc.2007.09.001
• 7 Falcoz PE, Conti M, Brouchet L. et al. The Thoracic Surgery Scoring System (Thoracoscore): risk model for in-hospital death in 15,183 patients requiring thoracic surgery. J Thorac Cardiovasc Surg 2007; 133: 325-332 doi:10.1016/j.jtcvs.2006.09.020
• 8 Thomas DC, Blasberg JD, Arnold BN. et al. Validating the Thoracic Revised Cardiac Risk Index following lung resection. Ann Thorac Surg 2017; 104: 389-394 doi:10.1016/j.athoracsur.2017.02.006
• 9 Schussler O, Alifano M, Dermine H. et al. Postoperative pneumonia after major lung resection. Am J Respir Crit Care Med 2006; 173: 1161-1169 doi:10.1164/rccm.200510-1556OC
• 10 DʼJourno XB, Rolain JM, Doddoli C. et al. Airways colonizations in patients undergoing lung cancer surgery. Eur J Cardiothorac Surg 2011; 40: 309-319 doi:10.1016/j.ejcts.2010.11.036
• 11 Ewig S, Torres A, El-Ebiary M. et al. Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury. Incidence, risk factors, and association with ventilator-associated pneumonia. Am J Respir Crit Care Med 1999; 159: 188-198 doi:10.1164/ajrccm.159.1.9803097
• 12 Encke A, Haas S, Kopp I. The prophylaxis of venous thromboembolism. Dtsch Arztebl Int 2016; 113: 532-538 doi:10.3238/arztebl.2016.0532
• 13 Schnell J, Koryllos A, Stoelben E. et al. [Perioperative anticoagulant and antiplatelet treatment in general thoracic surgery]. Zentralbl Chir 2014; 139 (Suppl. 01) S13-S21 doi:10.1055/s-0034-1382895
• 14 Venous thromboembolism in over 16 s. Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. NICE guideline NG89. 2018 Im Internet (Stand: 21.03.2018): https://www.nice.org.uk/guidance/ng89/resources/venous-thromboembolism-in-over-16s-reducing-the-risk-of-hospitalacquired-deep-vein-thrombosis-or-pulmonary-embolism-pdf-1837703092165
• 15 Thomas DC, Arnold BN, Hoag JR. et al. Timing and risk factors associated with venous thromboembolism after lung cancer resection. Ann Thorac Surg 2018; 105: 1469-1475 doi:10.1016/j.athoracsur.2018.01.072
• 16 Ludwig C, Stoelben E. A new classification of bronchial anastomosis after sleeve lobectomy. J Thorac Cardiovasc Surg 2012; 144: 808-812 doi:10.1016/j.jtcvs.2012.06.036
• 17 Ludwig C, Stoelben E, Olschewski M. et al. Comparison of morbidity, 30-day mortality, and long-term survival after pneumonectomy and sleeve lobectomy for non-small cell lung carcinoma. Ann Thorac Surg 2005; 79: 968-973 doi:10.1016/j.athoracsur.2004.08.062
• 18 Fuso L, Varone F, Nachira D. et al. Incidence and management of post-lobectomy and pneumonectomy bronchopleural fistula. Lung 2016; 194: 299-305 doi:10.1007/s00408-016-9841-z
• 19 Canet J, Gallart L, Gomar C. et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology 2010; 113: 1338-1350 doi:10.1097/ALN.0b013e3181fc6e0a
• 20 Kim ES, Kim YT, Kang CH. et al. Prevalence of and risk factors for postoperative pulmonary complications after lung cancer surgery in patients with early-stage COPD. Int J Chron Obstruct Pulmon Dis 2016; 11: 1317-1326 doi:10.2147/COPD.S105206