A simple prediction score for postoperative mortality after decortication

Decortication of the lung, either by video-thoracoscopy or thoracotomy is potentially a morbid procedure and has significantly higher mortality compared with other major thoracic procedures. Much of this difference can be attributed to other significant comorbidities and to the non-elective nature of the surgery. Our primary goal was to recognize the preoperative unique characteristics of patients who had postoperative mortality within the first 30 days. Our secondary goal was to build a score system to calculate the odds of death after decortication.

Patients who had undergone either partial or total pulmonary decortication were retrospectively identified from the 2015-2017 databases of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and were employed for this analysis. Multivariable regression models were used to evaluate the possible association of multiple risk factors with postoperative death. Factors that remained significant in the multivariable regression analysis were used to develop the Decortication Prognostic Score (DPS).

The final study population consisted of 2,315 patients. The overall observed mortality rate was 5.6%. The greatest independent risk factor for increased 30-day mortality in multivariable logistic regression analysis was disseminated cancer, followed by age ≥65 years, ventilator dependence, active hemodialysis, open wound or wound infection, partially or totally dependent preoperative functional status, preoperative systemic inflammatory response syndrome (SIRS), sepsis or septic shock, congestive heart failure (CHF), preoperative need for blood transfusion, dyspnea, and chronic obstructive pulmonary disease (COPD). Afterwards, we developed a prognostic score for calculating the odds of postoperative death. The total score was associated with a stepwise higher risk of postoperative death after decortication. Patients with a score of 1 had an associated mortality of 1.1% [odds ratio (OR): 2, 95% confidence interval (CI): 0.43-9.32, P=0.375], patients with scores 2-3 had an associated mortality of 6.6% (OR: 12.5, 95% CI: 3.04-51.36, P<0.001), and patients with scores ≥4 had an associated mortality of 27.1% (OR: 65.8, 95% CI: 15.86-273.2, P<0.001).

Preoperative factors can predict postoperative mortality after decortication. DPS may help guide surgeons with bedside decision making and heighten awareness to patients most likely to be at risk for 30-day re-intubation, failure to wean from ventilator, surgical site infections, prolong length of stay and higher mortality after decortication.