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Eur J Cardiothorac Surg 2003;23:878-882
© 2003 Elsevier Science NL

Clinical outcome versus post-mortem finding in thoracic surgery: a 10-year experience

^a Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
^b Department of Pathology, Papworth Hospital, Cambridge, UK

Received 2 October 2002; received in revised form 25 February 2003; accepted 3 March 2003.

^* Corresponding author. 64, Andes Close, Ocean Village, Southampton SO14 3HS, UK. Tel.: 44-7775-711-011; fax: +44-2380-339-054
e-mail: adrianooisw{at}yahoo.co.uk

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
Objectives: The role of post-mortem following thoracic surgery has not been previously studied. Most importantly, the clinical diagnosis of thoracic surgical mortality cannot be certain unless post-mortem analysis has been performed. Methods: Consecutive post-mortem data were collected on 110 patients between 1992 and 2001 (66.3% of all in-hospital thoracic surgical deaths). Clinically attributed causes of death were compared with post-mortem findings. Results: A total of 4302 thoracic operations were performed during the 10-year period, with overall mortality 3.8%. The mean age was 63.6 years (range 21–87) with 73.6% male. In the 110 patients undergoing post-mortem examination, the operations performed were pneumonectomy 24.5%, lobectomy 14.5%, oesophagectomy 12.7%, lung biopsy 8.2%, pleurectomy/bullectomy 6.4%, decortication 4.5%, lung volume reduction 1.8%, other thoracic 13.6%, other oesophageal 9.1%, and other procedures 4.5%. The mean time to death was 12.5 days (range 0–85). The causes of death were respiratory 47.3%, cardiac 16.4%, multiple organ failure 8.2%, sepsis 6.4%, gastrointestinal 4.5%, haemorrhage/technical failure 10%, and others 7.3%. Post-mortem revealed an unsuspected cause of death in 34 (31%) patients, comprising pulmonary 17, cardiac 5, gastrointestinal 3, haemorrhage/technical failure 2, multiple organ failure 2 and other 5. Conclusion: Post-mortem determined unsuspected diagnoses in a high proportion of patients undergoing thoracic surgery. Post-mortem continues to be the ‘gold standard’ method for attributing the cause of death. Accurate outcome data following thoracic surgery are essential for proper audit, and hence for improvements in clinical practice to occur.

Key Words: Post-mortem • Cause of death • Thoracic surgery

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
Accurate diagnosis of the cause of death in patients undergoing thoracic surgery can be difficult and the clinical presumption of the cause of death may be misleading [1]. The outcome from post-mortem analysis can yield unexpected findings about the actual causes of post-operative deaths. In patients undergoing cardiac surgery, we have previously reported that 11% patients died of unsuspected causes [2]. Despite this, the role of post-mortem following thoracic surgery has not been previously studied.

Post-mortem analysis is also a valuable tool for audit and educational purposes. It is important to learn from past mistakes and experiences so that we can improve on the surgical management and clinical outcome of thoracic surgery. In this study, the post-mortem rate is high. The aim was to determine the causes of death following thoracic surgery and to compare the presumed versus actual post-mortem causes of death.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
Post-mortem data were collected on all in-hospital thoracic surgical deaths between 1992 and 2001 in a single cardiothoracic centre. Pulmonary transplant and pulmonary thrombo-endarterectomy deaths were excluded. All patients in whom a cause of death cannot be given, must be referred to the coroner, who will require a post-mortem examination to be performed. For all other cases, the patients’ families are approached for their consent to a post-mortem examination being performed. A standardised request form was used for both hospital and coroner's post-mortem. This included the clinical details of the patient as well as the clinically suspected cause of death. The rate of coroner's post-mortem at our institution was 85% during the study period. The post-mortem rate at our institution is high and compares with a historic hospital post-mortem rate in UK of 15–20% [3,4], although this is probably much lower in more recent years.

The post-mortem request forms were analysed to obtain the presumed clinical cause of death. The post-mortem and clinical causes of death were then compared. Multiple pre-operative variables for each patient were also obtained from a hospital database recorded at the time of surgery. The variables collected included age, sex, operation, body mass index, diabetes, smoking history, haemoglobin, creatinine and pulmonary function tests such as forced expiratory volume in one second (FEV1), functional vital capacity (FVC) and total lung capacity (TLC).

Histological examination was performed on all patients, and each patient underwent standard sampling of the remaining pulmonary tissue as well as other relevant organs. Close attention was paid to the surgical field of operation, to evaluate whether there were complications directly attributable to the operative procedure. Following this, the cause of death was established. Causes of death were given in Office of population census surveys (OPCS) format, and in most cases finally attributed to the underlying disease process which had required surgical intention.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
There were 4302 thoracic operations performed during the 10-year period with 165 deaths representing an overall in-hospital mortality of (3.8%). Post-mortem examination was performed on 110 patients (66.3%). The mean age at death was 63.6 years (range 21–87) with 81 (73.6%) male and 29 (26.4%) female patients. The proportion undergoing pneumonectomy was 24.5%, lobectomy 14.5%, oesophagectomy 12.7% and other procedures 48.3%. The type and percentage of operations performed are shown in Table 1.

The pre-operative variables and the causes of death are compared in Table 6.

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

Post-mortem continues to be the ‘gold’ standard method for attributing the actual cause of death [3–5]. Accurate outcome data following thoracic surgery are essential for proper audit. Our data showed that clinical attribution of the cause of death may often be misleading. Valuable lessons can be learned from post-mortem which may possibly lead to improvement in clinical practice and hence, the outcome of thoracic surgery. We have also found that due to the limited number of pre-operative variables examined in this study, they have little clinical significance in terms of predicting the actual cause of death. Overall, it has not been possible to accurately identify pre-operatively the patients at increased risk of post-operative causes of death. However, pre-operative FEV1 tended to be lower in patients dying of respiratory causes (FEV1=1.7) and multiple organs failure (FEV1=1.5) compared with the average FEV1 in patients dying of non-respiratory causes (FEV1=1.75).

There are no previous studies of post-mortem following thoracic surgery. However, when comparing this study with previous studies of post-mortem following cardiac surgery [1,2,6], there was a considerably higher number of patients with unsuspected causes of death. In cardiac surgical patients, post-mortem revealed that 11% of the patients died of unsuspected causes of death [2], compared to the 31% of the patients following thoracic surgery in this study. The cardiac post-mortem rate at 84.4% was higher compared with the thoracic post-mortem rate of 66.3%. One explanation could be that the on-table death or immediate peri-operative mortality for thoracic surgery, which requires mandatory post-mortem examination in our hospital, are much less common than following cardiac surgery. In addition, patients undergoing thoracic surgery are more likely to have a diagnosis such as cancer, for which the clinicians may be more confident of the clinical causes of death, and possibly more reluctant to seek permission from families to perform post-mortems. However, the post-mortem rate at our institute is still very high when compared with the mean hospital post-mortem rate in UK of 15–20%.

In conclusion, post-mortem can determine unsuspected diagnoses in a clinically significant proportion of patients undergoing thoracic surgery. In addition, the data collected for pre-operative variables are insufficient to correlate with the actual cause of death found at post-mortem. A correlation study between pre-operative risk factors, peri-operative data and post-mortem findings is not possible in a study of this size. However, post-mortem information continues to be the ‘gold’ standard outcome measure, which underpins the improvements in clinical standards we all seek.

	Footnotes

 
Presented at the 16th Annual Meeting of the European Association for Cardio-thoracic Surgery, Monte Carlo, Monaco, September 22–25, 2002.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
Dr P. Macchiarini (Hannover, Germany): I have a question concerning the results. You said that the respiratory causes were the most important postmortem causes among this population. Could you eventually split the data and tell us whether or not they were related to the cancer or to other types of well-known diseases?

Dr Ooi: In the traditional teaching, cardiac is regarded as the number one cause of mortality after thoracic surgery. However in this post-mortem study, we clearly show that respiratory cause is the highest cause of mortality following all types of thoracic surgery. That's what it is, if that's what you're asking.

Dr Macchiarini: That's okay.

Dr K. Jeyasingham (Winterbourne Down, UK): I take it that this is a result of a prospective study?

Dr Ooi: Retrospective study.

Dr Jeyasingham: And therefore you did exert extra pressure for a post-mortem (PM) wherever possible?

Dr Ooi: Sorry, sir?

Dr Jeyasingham: You asked for a PM wherever possible?

Dr Ooi: Yes. Actually, at Papworth the reason for performing a post-mortem examination is if the cause of death is uncertain. Also, it is the policy of the hospital, and for the coroner, if the patient died during the operation or immediately post op. And also the family members are approached to obtain a consent for a post-mortem examination to be performed.

Dr Jeyasingham: You failed to obtain a PM in nearly 33% of your series and in only a third of those did you find unexpected causes?

Dr Ooi: Yes.

Dr Jeyasingham: And therefore, is it correct to translate this to all cases? Is it possible that where you did not obtain a PM that the cause was obvious?

Dr Ooi: Yes. Ideally postmortem should be performed in all patients so that I can give a clearer picture of the outcomes of the surgery. This is why it is very important to perform a post-mortem examination in order to know the actual cause of death.

Dr Jeyasingham: A fair proportion of your unexpected causes was pulmonary embolism.

Dr Ooi: Yes.

Dr Jeyasingham: Was it possible to correlate the pulmonary embolism to the clinical features prior to death or was it an incidental finding, because quite a few patients who die after a prolonged period of ICU care do show.

Dr Ooi: Some sort of microembolism, yes. Some of these cases that the study show, pulmonary embolism is not a coincidental finding. It's the major number one cause of death.

Dr van Raemdonck (Leuven, Belgium): You are pointing out that the postmortem report is important to have a final diagnosis of the cause of death. I want to turn it upside down and I want to say that it is important that the surgeon is there at the time of postmortem, because sometimes the pathologists will miss surgical complications that we are aware of.

Dr Ooi: Yes, it is therefore important that they work together, yes.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 

1. Lee P.N. Comparison of autopsy, clinical and death certificate diagnosis with particular reference to lung cancer. A review of the published data. APMIS Suppl 1994;45:1-42.[Medline]
2. Goodwin A.T., Goddard M., Taylor G.J., Ritchie A.J. Clinical versus actual outcome in cardiac surgery: a post-mortem study. Eur J Cardiothorac Surg 2000;17:747-751.[Abstract/Free Full Text]
3. Underwood J.C., Cotton D.W., Stephenson T.J. Audit and necropsy. Lancet 1989;I:442.
4. Mosquera D.A., Goldman M.D. Surgical audit without autopsy: tales of the unexpected. Ann R Coll Surg Eng 1993;75:115-117.[Medline]
5. Barendregt W.B., de Boer H.H., Kubat K. Autopsy analysis in surgical patients: a basis for clinical audit. Br J Surg 1992;79:1297-1299.[Medline]
6. Zehr K.J., Liddicoat J.R., Salazar J.D., Gillinov A.M., Hurban R.H., Hutchins G.M., Cameron D.E. The autopsy: still important in cardiac surgery. Ann Thorac Surg 1997;64:380-383.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Author home page(s): Andrew T. Goodwin Andrew J. Ritchie Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ooi, A. Articles by Ritchie, A. J. Search for Related Content PubMed PubMed Citation Articles by Ooi, A. Articles by Ritchie, A. J. Related Collections Esophagus - other Lung - other