Eur J Cardiothorac Surg 2003;23:26-29
© 2003 Elsevier Science NL
Factors associated with perioperative complications and long-term results after pulmonary resection for primary carcinoma of the lung
Arianne J. Ploeg,
A. Pieter Kappetein,
Robert B. van Tongeren,
Paul V. Pahlplatz,
Gerard W. Kastelein,
Paul J. Breslau*
Department of Surgery, Red Cross Hospital, Sportlaan 600, 2566 MJ, The Hague, The Netherlands
Received 9 July 2002;
received in revised form 24 September 2002;
accepted 1 October 2002.
* Corresponding author. Tel.: +31-70-3126657; fax: +31-70-3126167
e-mail: heelkunde{at}jkz-rkz.nl
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Abstract
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Objective: The aim of this study was to describe perioperative morbidity and mortality of patients presenting with resectable lung cancer and to investigate the long-term survival. Methods: We reviewed the records of 344 patients who underwent lung resection for bronchogenic carcinoma. Follow-up information was obtained from visits to the outpatient clinic. Results: Between January 1991 and December 1995 there were 263 males and 81 females included with a mean age of 65.7 years. One hundred and eight (31%) patients underwent a pneumonectomy, 159 (46%) a lobectomy, 43 (13%) a bilobectomy, four (1%) a segmental resection and 30 (9%) an explorative thoracotomy. A total of 341 complications occurred. The 30 day mortality rate was 7.9% (27 patients). Patients with a low FEV1% and older patients have a higher risk of mortality within 30 days. Postoperative myocardial infarction and pneumonia were associated with an increase in 30 day mortality. The median survival was 3.6 years for stage I, 1.9 years for stage II, 1.0 years for stage IIIa, 0.9 years for stage IIIb and 0.9 years for stage IV. Prognostic factors for the long-term survival included stage, pneumonectomy, percentage FEV1 <70, and large cell carcinoma. Conclusions: Pulmonary resection can be performed at an acceptable risk. Critical reviewing of our results made it possible to make recommendations for improvements.
Key Words: Lung cancer • Surgery • Complications • Long-term survival
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1. Introduction
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As life expectancy rises, surgeons are faced with growing numbers of patients who present with potential anatomically and oncologically resectable lung pathology. If perioperative mortality is sufficiently low, pulmonary resection improves life expectancy. Previous reports of surgical treatment for lung cancer have presented mixed results regarding operative morbidity and mortality [1–4]. Mortality rates reported for pneumonectomy vary from 8% to 15% and for lobectomy from 4% to 7%. The question arises as to whether improvement in medical care has resulted in a decline in the hospital mortality rate. The hospital mortality rate should be sufficiently low in order not to negate or substantially blunt the long-term benefit in a population with a high rate of disease recurrence or further progression of the tumor process. In order to assess mortality rates in view of the long-term survival following resectional operations for lung cancer, we analyzed the results of three different institutions.
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2. Methods
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We reviewed the records of patients who underwent lung resection for bronchogenic carcinoma between January 1991 and December 1995. Patients were operated on in three different hospitals, two regional teaching hospitals and one university hospital. In each hospital a specialized group of surgeons performed the operations. Demographic and clinical data included age, gender, cardiopulmonary functional assessment, and comorbidity. Clinical staging was based on computed tomography of the chest and upper abdomen and, if performed, on mediastinoscopy and extrathoracic imaging. Intraoperative factors included the extent of resection, blood loss, postoperative complications, the length of hospital stay, adjuvant treatment, and clinical and pathologic stage. Follow-up information was obtained from visits to the outpatient clinic up to 10 years postoperatively.
Statistical analyses were performed by logistic regression procedures to identify risk factors for hospital survival. Confidence limits are presented. Comparison of variables was performed using 
2 and two-tailed tests. Actuarial survival was assessed by the Kaplan–Meier method. Cox proportional hazard analysis was performed to identify prognostic factors for long-term survival. In all tests a P value of less than 0.05 was considered to be significant.
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3. Results
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From 1991 to 1996, 344 consecutive patients underwent thoracotomy for bronchogenic carcinoma in three different hospitals The mean age of the patients was 65.7 years (range 29–86 years); there were 263 males and 81 females. The clinical characteristics are summarized in Table 1. One hundred and fifty-nine patients (46%) underwent lobectomy, 43 (13%) a bilobectomy, 108 (31%) a pneumonectomy, four (1%) a segmental resection and 30 (9%) an exploratory thoracotomy. Eight sleeve resections were part of the group of lobectomies and bilobectomies. Five patients with stage IIIa lung cancer received neo-adjuvant radiotherapy. A total of 341 complications were identified, most directly related to operation. Arrhythmia was the most common disorder, eighty-nine (26%) patients developed an arrhythmia postoperatively, 36 (11%) patients developed congestive heart failure and five patients (2%) suffered from myocardial infarction postoperatively. Respiratory complications included 65 (19%) patients who developed pneumonia, 50 (15%) patients who developed atelectasis and five (2%) patients who required mechanical ventilation postoperatively (Table 2).
Early death was defined as death from any cause within 30 days of surgery. The 30 day mortality rate in this series was 7.9% (27 patients). Univariate analysis of the association between patient characteristics and the occurrence of early mortality showed that patients with a low FEV1% (odds ratio (OR) 0.4, confidence interval (CI) 1.0–4.0 for high FEV1%) and older patients (age, OR 1.1, CI 1.0–1.1) have a higher risk of mortality within 30 days (Table 3). Regarding complications, the risk of mortality within 30 days was increased in the logistic regression model with postoperative myocardial infarction (OR 32.4, CI 5.0–208.7), postoperative heart failure (OR 8.5, CI 3.1–23.3), postoperative mechanical ventilation (OR 13.5, CI 2.1–86.3) or pneumonia (OR 3.8, CI 1.4–10.0), empyema (OR 3.9, CI 1.0–14.7) and atelectasis (OR 4.2, CI 1.5–11.4) as predictive factors. On the basis of the univariate analysis results, multivariate analysis was performed. Postoperative myocardial infarction and pneumonia were independently associated with an increase in 30 day mortality (Table 3).
3.1. Long-term follow-up
Kaplan–Meier curves depicting long-term survival are seen in Fig. 1
. The median survival was 2.3 years, according to postoperative stages: 3.6 years for stage I, 1.9 years for stage II, 1.0 years for stage IIIa, 0.9 years for stage IIIb and 0.9 years for stage IV. Various factors possibly influencing long-term survival were investigated by performing Cox proportional hazard analysis. Prognostic factors for long-term survival included stage (stage I OR 1.0; stage II OR 1.6, CI 1.1–2.3; stage IIIa OR 2.3, CI 1.7–3.1; stage IIIb OR 2.9, CI 2.0–4.4), pneumonectomy (OR 1.4, CI 1.1–1.9), percentage FEV1 <70% (OR 1.0, CI 1.0–1.1), and large cell carcinoma (OR 1.7, CI 1.2–2.4). All factors were also independently associated with a negative effect on long-term results in a multivariate analysis (Table 4).
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4. Discussion
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The objective of this study was to identify current postoperative complications and the associated risk factors and to describe the long-term results after pulmonary resection for lung cancer. This study can be considered as population-based since we included all consecutive patients undergoing pulmonary resection in one area of the Netherlands from January 1991 until December 1995. Complications which occurred most were arrhythmia, congestive heart failure, pneumonia, atelectasis, and empyema. In a prospective study, described by Bernard [16], of 500 patients undergoing lung resection, a total of 208 complications were observed. The most frequent complications were pneumonia (22%), atelectasis (10%), arrhythmia (10%), postoperative mechanical ventilation (7%) and congestive heart failure (3%) [5]. According to other authors, most complications are cardiac or pulmonary in origin [6–8,15]. Our study showed a 26% incidence of arrhythmia, which consisted mostly of atrial fibrillation. This rather high incidence is probably related to a substantial number of pneumonectomies. Previous studies demonstrated that arrhythmia was not related to a higher mortality and could be managed with medication after lung surgery [9,10].
The 30 day mortality is consistent with that of other studies [1,2,7,8], although there is some variation in the literature, i.e. from 2.9% to 12%. This can be explained by the different definitions of early mortality and the number of pneumonectomies. In our study there is a relative high percentage of patients undergoing a pneumonectomy compared to other studies [1,7]. This is probably due to preoperative understaging. The results of Morandi show that patients undergoing pneumonectomy have higher mortality and morbidity risks and the 5 year survival rate is lower [6]. This is confirmed in other studies [11].
Bernet et al. studied the effect of age on operative mortality and long-term survival and found that perioperative risk and midterm survival were similar in younger and older patients [12]. Our data refute this hypothesis and support the conclusions of other investigators [3,4,13,15,17]. Yano and his group included 291 patients and in a multivariate analysis found age as an independent factor of increased risk for life-threatening morbidity [7]. The data in this study confirm that age is an important factor in 30 day mortality, especially in patients above 75 years of age (OR 4.3, CI 1.9–9.7).
FEV1 <70% of the expected value as measured preoperatively was found to be associated with an increased risk of 30 day mortality and long-term survival. This has previously been reported by other investigators [5,14,16].
In conclusion, pulmonary resection remains a procedure containing a high risk of postoperative complications. Older age is not a contradiction but a precise selection of patients preoperatively is necessary. In particular, great care must be taken in preoperative selection and postoperative monitoring of patients with a decreased FEV1% undergoing a pneumonectomy. Careful preoperative assessment must be undertaken for every patient concerning respiratory and cardiac status to reduce the risk of morbidity and mortality. We recommend that preoperative staging should include cervical mediastinoscopy and if necessary endoscopic ultrasonography with fine needle aspiration. Pulmonary resection can be performed at an acceptable risk of morbidity and mortality. It is still the only curative therapy for lung cancer.
This study shows that a precise registration of complications and follow-up will help us to determine the factors influencing morbidity and mortality and therefore make it possible to improve the selection of patients and treatment performed.
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Abstract
1. Introduction
