HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Aoki, T. Articles by Hirono, T. Search for Related Content PubMed PubMed Citation Articles by Aoki, T. Articles by Hirono, T.

Eur J Cardiothorac Surg 2000;18:662-665
© 2000 Elsevier Science NL

Pulmonary complications after surgical treatment of lung cancer in octogenarians

^a Department of Thoracic and Cardiovascular Surgery, Niigata University School of Medicine, 1-757 Asahimachi-dori, Niigata 951-8510, Japan
^b Department of Pulmonary Surgery, National Nishi-Niigata Chuou Hospital, Niigata, Japan

Received 14 April 2000; received in revised form 20 July 2000; accepted 5 September 2000.

Corresponding author. Tel.: +81-25-227-2233; fax: +81-25-227-0780
e-mail: taoki{at}med.niigata-u.ac.jp

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Objective: The purpose of this study was to analyze the risks associated with pulmonary resection for primary non-small cell lung cancer in octogenarians to help better management in these patients. Methods: We reviewed the outcome in our 35 patients aged 80 years and older who underwent pulmonary resection between 1981 and 1998. Results: The 5-year survival rate was 39.8%. The operative mortality rate was 0% and the morbidity 60%. There were ten major pulmonary complications, including respiratory insufficiency following bacterial pneumonia and sputum retention. Preoperative arterial pO₂ was significantly lower, A-aDO₂ was significantly higher, and operation time were significantly longer in patients with pulmonary complications after surgical treatment than in patients without complications (P<0.05). Conclusions: Surgical treatment was not contraindicated for octogenarians with lung cancer. However, a relatively preoperative low arterial pO₂, high A-aDO₂, and long operation time may be risk factors for postoperative pulmonary complications in such patients. Surgeons must assess the preoperative data prudently to determine appropriate surgical strategy.

Key Words: Octogenarian • Pulmonary complication • Lung cancer • Pulmonary resection

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
The population of Japan is aging, and the proportion of patients over 80 years of age continues to increase. Lung cancer is the most frequent neoplasm in Japan, and the number of patients older than 80 with the disease is on the rise. In the past, age over 80 was a contraindication to pulmonary resection due to an increased risk of mortality rate in lung cancer surgery [1]. In addition, the morbidity rate in octogenarians undergoing pulmonary resection has been shown to be higher than that in patients under 80 [2,3]. A recent report, however, has documented a decreased postoperative mortality rate due to advances in care and improved surgical techniques [2]. In an attempt to analyze factors that may predict postoperative complications in octogenarians, we reviewed the cases of our octogenarians with lung cancer who underwent pulmonary resection.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
We studied the records of our 35 patients aged 80 years and older who underwent pulmonary resection for primary non-small cell lung cancer between 1981 and 1998. Preoperative staging has been assessed in all patients by means of chest X-ray; computed tomography of the chest, brain and upper abdomen; and bone scintigraphy of the whole body. Functional assessment of all patients who underwent pulmonary resection was based on smoking history, blood test, and renal function test. Pulmonary function was determined by spirometry and arterial blood gas measurements made at rest in all cases. The alveolar arterial oxygen tension difference (A-aDO₂) was calculated with a simplified alveolar gas equation: A-aDO₂=150-pO₂-pCO₂/0.8. Body mass index was calculated by dividing body weight (kg) by the height-square (m²). Brinkmann index was calculated by the following formula: the number of cigarettes smoked per dayxthe length of smoking history (years). In octogenarians, the cardiac stress test using a dipyridamole thallium scintigraphy was added for the assessment of potential myocardial ischemia. Perioperative data consisted of surgical procedure, anesthesia and operation times, operative morbidity and mortality occurring within 30 days, and length of postoperative hospital stay. The operations were performed by six surgeons in our team. The clinical and pathologic stages were determined according to the revised TNM classification system. Follow-up information was obtained for all survivors, either during office visits or by telephone interview with the patient or a relative.

Statistical analysis was performed using ² and unpaired t-tests. Results were considered to be significant at P-values less than 0.05. Actuarial survival was assessed by the Kaplan–Meier method.

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Pulmonary resection was performed in 35 patients who were 80 years of age or older. Patients comprised 22 men and 13 women with a mean age of 81.4 years (range 80–88 years). Seven patients had a history of hypertension or cardiac arrhythmia; three had a history of diabetes mellitus, and three had a history of cerebral vascular disease. One patient was taking oral corticosteroids for nephritis. No patient was being treated for myocardial ischemia or chronic obstructive pulmonary disease. Six patients had an abnormal electrocardiogram, but cardiac stress test showed no ischemia. Eight patients had prior treatment for malignant disease of the stomach (4), lung (3), colon (2), and thyroid (1). All were free from these malignancies at the time of surgery. Clinical status were stage IA (n=16), stage IB (n=11), stage IIB (n=4), stage IIIA (n=3), and stage IIIB (n=1).

The operative procedures were standard or extended lobectomy (n=25), and wedge or segmental resection (n=10). Systemic lymph node dissection was performed in 19 patients. All patients who did not undergo mediastinal dissection were considered to have N0 disease based on macroscopic evidence of operative findings. Patients were given a pathological status of stage IA (n=14), stage IB (n=10), stage IIB (n=5), stage IIIA (n=5), and stage IIIB (n=1).

There were no deaths within 30 days of surgery or same hospitalization. The mean postoperative hospital stay was 21.4 days, with a range of 13–52 days. Including all causes of death, the actuarial survival rate of all patients at 3 and 5 years was 61.4% and 39.8%, respectively; 14 patients had died at the time of this study. There were four cancer-related deaths, and ten patients died of other causes including pneumonia (n=7), cerebral vascular diseases (n=2), and heart disease (n=1).

Twenty-one out of the 35 patients (60%) suffered operative complications (Table 1). The mean postoperative stay for patient with pulmonary complications was 25 days and patient without pulmonary complications were discharged after a mean of 19 postoperative days (P<0.05). Pulmonary complications included six cases of sputum retention and four cases of respiratory insufficiency following bacterial pneumonia. Sputum retention was defined as the patient required intensive suctioning and respiratory failure was defined as the patient required reintubation and ventilatory support. There were 11 non-pulmonary complications; five cases of prolonged air leak persisting beyond 7 days, three cases of atrial arrhythmia, one case of gastrointestinal bleeding, one case of chylothorax, and one case of confusion. The pulmonary complications were further evaluated in combination with preoperative assessment and perioperative data (Table 2). The average arterial pO₂ was significantly lower (73.4 vs. 83.8 mmHg, P=0.002), A-aDO₂ was significantly higher (28.1 vs. 16.3 mmHg, P=0.004), and operative time was significantly longer (268 vs. 197 min, P=0.043) in patients with pulmonary complications than in patients without complications. No other factors were correlated with pulmonary complications.

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

A 5-year survival rate in our series was 39.8%, including death from all causes. This long-term result was quite similar to that of other reported statistics; 5-year survival rates have been reported between 32 and 55% (Table 3). These low survival rates derived from the fact that patients above 80 years of age tended to die of other conditions including pulmonary disease and vascular disease [7]. In the present study, the major cause of death in long-term survivors was pneumonia. Because the loss of pulmonary function with resection may cause pulmonary disease, especially pneumonia, we recognize that surgical treatment in octogenarians might be limited in terms of quality of life.

A benefit for the surgical treatment of lung cancer was considered to be the shorter length of hospital stay in octogenarians compared to other treatments [6,7]. Jacklitsch and associates reported that the reduction in operative risk while undergoing video-assisted thoracic surgery was feasible; as a result, major postoperative complications can be avoided and elderly patients enjoy a quicker return to full recovery [9]. Previous reports demonstrated preoperative percentage of a forced expiratory volume in 1 s (%FEV₁) to be the only risk factor for postoperative pulmonary complications in octogenarians; perioperative data such as extent of resection and operation time were not shown to be risk factors [4–6]. In the present study, preoperative pulmonary function was not a predictor of postoperative pulmonary complications. Three risk factors were identified: relatively low preoperative arterial PO₂, relatively higher A-aDO₂, and relatively long operation time were associated with postoperative pulmonary complications, which significantly extended hospital stay.

A previous study demonstrated that arterial blood gases alone are not a predictor of postoperative complications [10]. However, we recognize that the reduced pulmonary volume caused postoperative temporary hypoxemia [11]. The effect of pulmonary gas exchange may be worsened by respiratory muscle injury associated with thoracotomy [12]. These surgical traumas combined with preoperative low arterial pO₂ would make arterial pO₂ even lower in the postoperative period and thus are important risk factors for postoperative pulmonary complications.

Harpole and associates reported a relatively long operation time to be a risk factor for morbidity after major pulmonary resection [3]. Others, however, have reported that operation time was not associated with postoperative pulmonary complications [5]. Several factors including the lateral position, one-lung ventilation, and surgical manipulation may influence the physiological status of the lung [13]. Simple thoracotomy has caused pulmonary edema [14]. We considered that these risk factors would influence the occurrence of pulmonary complications after a relatively long period of surgery.

In conclusion, our study suggests that surgical treatment is not necessarily contraindicated for octogenarians with primary non-small cell lung cancer. However, relatively low preoperative arterial pO₂, relatively high A-aDO₂, and a relatively long operation time may be risk factors for major postoperative pulmonary complications, and surgeons must assess the preoperative data in octogenarian patients prudently to determine the appropriate surgical strategy.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 

1. Weiss W. Operative mortality and five year survival rates in patients with bronchogenic carcinoma. Am J Surg 1974;128:799-804.[Medline]
2. Wada H., Nakamura T., Nakamoto K., Maeda M., Watanabe Y. Thirty-day operative mortality for thoracotomy in lung cancer. J Thorac Cardiovasc Surg 1998;115:70-73.[Abstract/Free Full Text]
3. Harpole D.H., DeCamp M.M., Daley J., Hur K., Oprian C.A., Henderson W.G., Khuri S.F. Prognostic models of thirty-day mortality and morbidity after major pulmonary resection. J Thorac Cardiovasc Surg 1999;117:969-979.[Abstract/Free Full Text]
4. Shirakusa T., Tsutsui M., Iriki N., Matsuba K., Saito T., Minoda S., Iwasaki T., Hirota N., Kuono J. Results of resection for bronchogenic carcinoma in patients over the age of 80. Thorax 1989;44:189-191.[Abstract]
5. Osaki T., Shirakusa T., Kodate M., Nakanishi R., Mitsudomi T., Ueda H. Surgical treatment of lung cancer in the octogenarian. Ann Thorac Surg 1994;57:188-193.[Abstract]
6. Naunheim K.S., Kesler K.A., D'Orazio S.A., Fiore A.C., Judd D.R. Lung cancer surgery in the octogenarian. Eur J Cardio-thorac Surg 1994;8:453-456.[Abstract]
7. Pagni S., Federico J.A., Ponn R.B. Pulmonary resection for lung cancer in octogenarians. Ann Thorac Surg 1997;63:785-789.[Abstract/Free Full Text]
8. Miller J.I. Limited resection of bronchogenic carcinoma in the patient with impaired pulmonary function. Ann Thorac Surg 1993;56:769-771.[Abstract]
9. Jaklitsch M.T., DeCamp M.M., Liptay M.J., Harpole D.H., Swanson S.J., Mentzer S.J., Sugarbaker D.J. Video-assisted thoracic surgery in the elderly. A review of 307 cases. Chest 1996;110:751-758.[Abstract/Free Full Text]
10. Hansen M.M., Hoyt J.W. Postoperative care. In: Cohen E., ed. The practice of thoracic anesthesia. Philadelphia, PA: Lippincott, 1995:343-383.
11. Filaire M., Bedu M., Naamee A., Aubreton S., Vallet L., Normand B., Escande G. Prediction of hypoxemia and mechanical ventilation after lung resection for cancer. Ann Thorac Surg 1999;67:1460-1465.[Abstract/Free Full Text]
12. Entwistle M.D., Roe P.G., Sapsford D.J., Berrisford R.G., Jones J.G. Patterns of oxygenation after thoracotomy. Br J Anaesth 1991;67:704-711.[Abstract/Free Full Text]
13. Cohen E. Physiology of the lateral position and one-lung ventilation. In: Cohen E., ed. The practice of thoracic anesthesia. Philadelphia, PA: Lippincott, 1995:144-159.
14. Chiyotanda S. Extravascular lung water with special reference to thoracotomy, manipulation and rapid fluid transfusion. Jpn J Surg 1988;18:376-383.[Medline]

This article has been cited by other articles:

				M. Mun and T. Kohno Video-Assisted Thoracic Surgery for Clinical Stage I Lung Cancer in Octogenarians Ann. Thorac. Surg., February 1, 2008; 85(2): 406 - 411. [Abstract] [Full Text] [PDF]

				A. Dominguez-Ventura, S. D. Cassivi, M. S. Allen, D. A. Wigle, F. C. Nichols, P. C. Pairolero, and C. Deschamps Lung cancer in octogenarians: factors affecting long-term survival following resection Eur. J. Cardiothorac. Surg., August 1, 2007; 32(2): 370 - 374. [Abstract] [Full Text] [PDF]

				A. Dominguez-Ventura, M. S. Allen, S. D. Cassivi, F. C. Nichols III, C. Deschamps, and P. C. Pairolero Lung cancer in octogenarians: factors affecting morbidity and mortality after pulmonary resection. Ann. Thorac. Surg., October 1, 2006; 82(4): 1175 - 1179. [Abstract] [Full Text] [PDF]

				O. Schussler, M. Alifano, H. Dermine, S. Strano, A. Casetta, S. Sepulveda, A. Chafik, S. Coignard, A. Rabbat, and J.-F. Regnard Postoperative Pneumonia after Major Lung Resection Am. J. Respir. Crit. Care Med., May 15, 2006; 173(10): 1161 - 1169. [Abstract] [Full Text] [PDF]

				H. Matsuoka, M. Okada, T. Sakamoto, and N. Tsubota Complications and outcomes after pulmonary resection for cancer in patients 80 to 89 years of age Eur. J. Cardiothorac. Surg., September 1, 2005; 28(3): 380 - 383. [Abstract] [Full Text] [PDF]

				H. Rostad, A. Naalsund, T.-E. Strand, R. Jacobsen, O. Talleraas, and J. Norstein Results of pulmonary resection for lung cancer in Norway, patients older than 70 years Eur. J. Cardiothorac. Surg., February 1, 2005; 27(2): 325 - 328. [Abstract] [Full Text] [PDF]

				J. L. Port, M. Kent, R. J. Korst, P. C. Lee, M. A. Levin, D. Flieder, and N. K. Altorki Surgical Resection for Lung Cancer in the Octogenarian Chest, September 1, 2004; 126(3): 733 - 738. [Abstract] [Full Text] [PDF]

				M. V. Brock, M. P. Kim, C. M. Hooker, A. J. Alberg, M. M. Jordan, C. M. Roig, L. Xu, and S. C. Yang Pulmonary resection in octogenarians with stage I nonsmall cell lung cancer: a 22-year experience Ann. Thorac. Surg., January 1, 2004; 77(1): 271 - 277. [Abstract] [Full Text] [PDF]

				T. Aoki, M. Tsuchida, T. Watanabe, T. Hashimoto, T. Koike, T. Hirono, and J.-i. Hayashi Surgical strategy for clinical stage I non-small cell lung cancer in octogenarians Eur. J. Cardiothorac. Surg., April 1, 2003; 23(4): 446 - 450. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Aoki, T. Articles by Hirono, T. Search for Related Content PubMed PubMed Citation Articles by Aoki, T. Articles by Hirono, T.