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Eur J Cardiothorac Surg 1998;14:40-45
© 1998 Elsevier Science NL
a Division of Thoracic and Cardiovascular Surgery, Hospital of Saint Raphael, 1450 Chapel Street, Orchard Building New Haven, 06511, CT, USA
b Yale New Haven Hospital, New Haven, CT, USA
Received 30 September 1997; received in revised form 10 March 1998; accepted 21 April 1998.
* Corresponding author. Tel.: +1 203 5622257; fax: +1 203 5620728.
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Abstract |
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 Top Abstract Introduction
Materials and methods
Results
Discussion
Appendix A. Conference...References |
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Key Words: Lung resection • Cancer • Elderly
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Introduction |
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TopAbstractIntroduction
Materials and methods
Results
Discussion
Appendix A. Conference...References |
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In the past 15 years, notable advances have occurred in anaesthetic management and perioperative care, with a modern trend to a decreased perioperative risk. Nevertheless, surgery in the elderly still represents a clinical challenge frequently-faced by the thoracic surgeon.
To examine this premise, we reviewed our experience with lung resection in 385 elderly patients with lung cancer, and analysed the perioperative risk over an interval of 26 years.
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Materials and methods |
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TopAbstractIntroduction
Materials and methods
Results
Discussion
Appendix A. Conference...References |
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Functional and laboratory assessment were derived entirely from the medical history, physical examination, routine blood tests, electrocardiogram and standard pulmonary function studies. Clinical and operative staging was based on history, physical exam and radiologic review including chest X-rays and CAT scans, including portions of the upper abdomen. CAT scans were more commonly performed in the modern period of the study. Mediastinoscopy was selectively used based on history, location of tumour and radiologic mediastinal assessment.
The inclusion of complications was complete and strict, and was divided in two groups. Major complications consisted of any event leading to a hospital stay greater than 11 days or ICU stay greater than 4 days, need for reoperation or additional procedures, mechanical ventilation longer than 48 h, prolonged air leaks (longer than 7 days) and serious cardiac problems. Minor complications encompassed the rest of the recorded events.
Exploratory thoracotomy, wedge biopsy or tumours with final benign histology were excluded from the study. The extended operation was defined as the resection of a pulmonary lobe associated with chest wall resection, additional parenchyma from an adjacent lobe, and or bronchoplastic procedure.
Statistical analysis was performed using chi-square and two-tailed student tests for comparison of variables. Results were considered significant at P-values less than 0.05. Block randomisation was used to select 180 patients younger than 69 years old (mean=63 years) for control comparison.
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Results |
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TopAbstractIntroduction
Materials and methods
Results
Discussion
Appendix A. Conference...References |
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One hundred and thirty one patients (34%) had non-fatal complications, and 51 of those had major events (13.2% major morbidity). The complete listing of all complications is summarised in Table 3. One hundred and ten patients suffered one complication, 20 had two events and seven had three events. Cardiovascular complications were the most common, with 51 of the 69 complications being supraventricular arrhythmias and all but one controlled pharmacologically. Forty-three patients suffered respiratory complications. Prolonged air-leak occurred in 26 patients (range 7–30 days, mean 11.5) with three of them requiring reoperation. Major atelectasis occurred in seven patients, and only three require bronchoscopy. The low incidence of retained secretions is attributed to the use of a strict policy of perioperative pulmonary physiotherapy. Other morbidity included urinary retention, often requiring surgery or prolonged hospital stay and confusion.
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The mortality and morbidity in the elderly group was compared to a control group (mean=63 years) of patients operated on during the same time period Table 4. For the elderly, the overall mortality in the early period, 11.1%, was significantly elevated above control (2.2%, P<0.05) while the 2.6% mortality in the recent era was not. The overall mortality rate after pneumonectomy (12.5%) was higher than in control patients (4.3%; P<0.05). Although the mortality decreased to 5.8% in the second period, the acute risk remains significantly elevated compared to the standard lobar resection.
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Discussion |
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TopAbstractIntroduction
Materials and methods
Results
Discussion
Appendix A. Conference...References |
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In 1992, Romano and Mark [17] stated that age was the major risk factor for increased mortality and demonstrated an incremental increase in mortality by decade of life. The adjusted odds ratio for death was 3.6 times greater in septuagenarians and 5.8 times greater for octogenarians when compared to patients younger than age 60.
In the present series, the overall mortality for the elderly was 4.2% and further declined in the modern period of the study to 2.6%. Stage was similar when comparing the early period to the modern period. Thus, one might attribute this decline to improvements in selection, a healthier population group, anaesthetic techniques, pain management, early mobilisation and improved nursing and ICU care. Many of these advances have being instituted in the past 15 years. Of the 21 patients who received preoperative chemotherapy and/or radiation therapy, we did not see a difference in morbidity and mortality.
Justification for major cancer operations in elderly patients depends on several factors. Life expectancy must exceed a patient's projected survival if the neoplasm is not treated. Second, the long-term survival in the resected patient must confirm the theoretic advantage of the operative treatment. Third, operative mortality can not negate the long-term benefit that surgery should offer. Fourth, morbidity must not be excessive or chronic in order to preserve quality of life.
We documented standard criteria of morbidity but also listed excessive length of stay (LOS) or longer than normal ICU needs. These findings were always associated with greater morbidity. Tracking LOS and ICU needs also helps to determine if resource utilisation is excessive in elderly patients.
In this series, overall morbidity was 34% but major complications did not increase. Some reasons for increased morbidity are the inherently higher incidence of genitourinary complications in the elderly population as well as neuropsychiatric symptoms frequently associated with anaesthesia and narcotics when used in the elderly. Since 97% of our patients were discharge home (ten patients requiring transient nursing home care and two needing permanent stay) we take this as further evidence to support our conclusion that morbidity is tolerable after surgery. In addition, LOS continues to decline suggesting appropriate resource utilisation.
In this review, male gender and pneumonectomy continues to carry a higher perioperative risk. For men, the overall mortality was 6.8% compared to 1.2% for women. Morbidity outcome showed a similar difference (28% vs. 40%). One can assume that co-morbid conditions in the male gender (i.e. increased incidence of cardiopulmonary disease) might account for this discrepancy. Pneumonectomy has always carried a higher mortality, well documented in current reports [18] [19] [20] [21] [22] [23] [24] [25]. For our series, a 12.5% mortality is reported, with a decline of the death rate to 5.8% in the modern period of the study. The decline is encouraging and likely related to improved selection as well as advances in perioperative care. However, it is still advisable that pneumonectomy should be undertaken with caution, but not avoided if a curative resection can be achieved.
Tumour stage was not looked at specifically in this study but we have recently reported [26] disappointing results for long-term survival in octogenarians with stage II and IIIa disease. The use of operative staging procedures (bronchoscopy, needle aspiration and mediastinoscopy) were used when so indicated by review of the patient's CT scan and when one was to consider an extended resection (i.e. T3 lesion or pneumonectomy). The majority of patients in this series were clinical and pathological stage I disease (81% of 342 lung cancer patients). This may be another reason for the continued improvement in mortality in the modern period of the study.
Although there were no significant differences in perioperative risk when stratifying patients with pulmonary disease, the use of pulmonary-function studies was liberal and lower values prompted us to further scrutinise the functional history. In such circumstances a quantitative ventilation–perfusion scan and maximal O2 consumption evaluation may be indicated. The presence of cardiac disease alerted us to potential related problems, and functional cardiac evaluation (i.e. thallium stress test, echocardiography and coronary angiography) was performed if so indicated. More importantly, a close review of patients current functional status (i.e. lifestyle activity, ability to ambulate distances or stair-climbing) seemed to be a reliable predictor of outcome in this study.
Perioperative survival in the elderly population has improved in modern days, as shown reports in Table 5. This study correlates with this trend. The final decision for resection should be based on factors such as: type and extent of the pathology, curative potential, risk of the proposed procedure, age, gender and co-morbid disease. In addition, results at a given institution should be also considered in this equation to establish the potential survival benefit in these selected group of patients.
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Acknowledgments |
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Footnotes |
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Appendix A. Conference discussion |
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TopAbstractIntroduction
Materials and methods
Results
Discussion
Appendix A. Conference...References |
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Dr Pagni: We can attribute the improvement in surgical risk to different factors. The major factor probably is patient selection and better oncologic staging prior to surgery. There have been notable improvements in perioperative management in terms of anaesthesia and pain control as well. In the modern period we have implemented a strict policy of perioperative pulmonary physiotherapy, early ambulation, the use of epidural catheters, and, coupled to that, we have a general thoracic dedicated unit, so we think that all these factors have contributed to the better outcome seen in the second group.
Dr A. Lerut (Leuven, Belgium): You said in your initial statements that, of course, you want to match your survival with what the normal life expectancy would be. So how much has been the major morbidity playing a role or affecting the late survival? Because that's then obviously coming up as an important issue.
Dr Pagni: Thank you for your comment. An answer to that is that morbidity is well tolerated by the elderly now. Proof of that is that 93% of our patients in the modern era have been able to be discharged home. Only ten patients have been transiently in a nursing home facility, and two of them stayed permanently. And that's a very low number. I think that assessment of the functional status of the patient has been very important to achieve this.
Dr Lerut: Yes, okay, that's an answer on the short-term follow-up. But in the late follow-up, how much has the 13% major morbidity that you had been influential on affecting the late survival? In other words, how many patients died later on, not from cancer recurrence, but as a consequence of a major event in the perioperative period?
Dr Pagni: We have not specifically looked at the long-term survival in this group of patients. We have recently published on the mortality and morbidity in an octogenarian group operated on for lung carcinoma, and we have seen that for stage I carcinoma of the lung, the overall 5-year survival was 57%, but in patients that had more advanced stages, they fared very poorly. So, in terms of that specific subgroup of patients, some of them part of this study, morbidity and mortality did not affect to a great degree the overall survival. Basically the higher stage was what really affected it.
Dr Lerut: And how much has been the performance status of the patient at the time of hospitalisation playing a part in excluding a patient from surgery?
Dr Pagni: That's a good question. We don't have the denominator of patients that were turned down from surgery. So we are highly selective of the patients going for resection. We have based this on a careful functional evaluation and the function status qualities over a Karnofski index of probably 80, but we have not based it on a specific number to select those patients.
Dr J. Svennevig (Oslo, Norway): I think this is a topic which is of interest to all of us, with the growing number of old patients. You reported the mortality rate of 4.2%, but in octogenarians you had a mortality rate of only 3.4%. I think we see the same phenomenon in cardiac surgery, that mortality rates may be even lower in the oldest patients, and I think that that must be because of our better patient selection. So my question to you would be, how many patients did you reject because of higher age?
Dr Pagni: Again, we don't have that denominator of patients rejected. We don't have that number. But we are very selective with patients. However, in a functional patient with a potentially curable lesion, we don't deny an operation based on age alone if we think that we can achieve a beneficial survival, even in borderline operable patients.
Dr Lerut: May I ask you how much age, and very old age, the octogenarian group, is affecting factors such as radicality of resection during the operation?
Dr Pagni: Definitely we avoid major operations in the elderly. In this study, 90% of the patients had lung cancer, and 80% of them were stage I. That speaks for the fact that we are very selective. Also in oncologic terms we try to give them a resection with a potential of cure, usually stage I, cancer. For patients with a stage II or III, usually their pathological stage is found after surgery, but in those patients pre-operatively staged, we are very selective and we try to avoid surgery, more if they need a pneumonectomy or a bilobectomy that carries a significantly higher mortality as shown in these data.
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References |
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TopAbstractIntroduction
Materials and methods
Results
Discussion
Appendix A. Conference...References |
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