One-day admission for major lung resections in septuagenarians and octogenarians: a comparative study with a younger cohort (original) (raw)
Abstract
Objectives: The proportion of elderly patients presenting with a potentially resectable lung malignancy is increasing. Due to their greater operative risk, these patients are frequently offered a lesser resection, non-surgical treatment, or no treatment at all. The goal of this study is to determine whether septuagenarians and octogenarians undergoing video-assisted major lung resections benefit from an accelerated recovery program as much as younger patients, enabling them to be discharged after an overnight hospital stay. A short length of hospital stay, per se, does not represent the actual goal of this clinical care pathway. Instead, it should be considered as a measurement of how quickly functional ability is restored. Methods: Of 65 consecutive patients who underwent major lung resections, 30 were 70 years of age or older (25 septuagenarians and five octogenarians; mean age, 75.7 years). Forty-six lobectomies, eight bilobectomies, and 11 pneumonectomies were performed using a video-assisted muscle-sparing minithoracotomy. In the elderly group, 24 lobectomies, three bilobectomies, and three pneumonectomies were performed. Patient and family education, multimodal analgesia, and an accelerated recovery program were implemented for all patients and the results were compared between the elderly group and the younger cohort. Discharge criteria included: (a), pain controlled with oral analgesics; (b), clear lungs in chest radiograph and without evidence of pneumothorax with the chest tube off suction; (c), independent ambulation; (d), adequate oxygenation; and (e), patient's acceptance and with home support. Whenever these criteria were met, regardless of how early or late during the hospital stay, the patient was released from the hospital. Results: There were no deaths within 30 days of the operation and only three complications (one in the elderly group), and none of them altered the patients’ clinical courses. The mean length of hospital stay for the whole group was 1.2 days (54 patients had an overnight hospital stay and two were outpatient procedures). The mean length of hospital stay for the elderly group was 1 day (27 patients had an overnight hospital stay and one was an outpatient procedure). None of the patients required conversion to a standard posterolateral thoracotomy and no patient required readmission related to an early discharge. Conclusions: These data show that it is feasible to create strategies to prevent or attenuate physiological derangements during surgery while performing major lung resections. As a result, an early recovery with few complications has been attained, allowing patients to consistently meet stringent discharge criteria after only an overnight hospital stay, even in the case of septuagenarians and octogenarians.
1 Introduction
Lung carcinoma is the leading cause of cancer-related deaths in males (♂) and females (♀) worldwide. Despite its relatively low incidence (16% ♂ and 13% ♀), it results in a larger number of deaths (33% ♂ and 23% ♀) than the sum of the second and third leading causes of cancer-related deaths for both sexes in the United States (incidence and mortality: prostate, 32 and 13%; colorectal ♂, 12 and 10%; breast ♀, 32 and 18%; colorectal ♀, 13 and 11%) [1]. With a 5-year relative survival rate of 10% in l970, and currently 14%, cancer of the lung represents one of the poorest improvements in the management of any type of cancer, particularly considering that the 5-year survival rate of the localized form is 47%. Due to the absence of a screening program, detection of localized cancer of the lung is infrequent (16%). Elderly patients, more often, undergo chest roentgenograms and computed tomograms for unrelated causes than any other age group; therefore, localized stage is more commonly found in these patients. One half of all cases of lung cancer occur in individuals 65 years and older, a population steadily growing [2]. In 1950, the United States population of 65 years and older was 12 million or 8% of the population. In this decade, it will increase to 40 million or 13%, and by 2050, 80 million or 20% of the population will be 65 years and older [3]. Pulmonary resection is the most effective method of controlling local disease and is the only treatment consistently associated with cure. As a result, surgeons will continue to face a growing number of elderly patients with resectable lesions of this highly lethal form of cancer. Concerns of excessive morbidity and mortality from pulmonary resections in the elderly, combined with the pervasive attitude within the medical community that chronological age, per se, should automatically exclude these patients, have led some to advocate non-operative treatment or lesser resections in this age group.
The purpose of this study is to try to define whether a minimally invasive approach combined with an accelerated recovery program benefits septuagenarians and octogenarians as much as younger patients, enabling them to recover so expeditiously that they meet discharge criteria after an overnight hospital stay.
2 Patients and methods
Of 65 consecutive patients who underwent major lung resections, 34 were females (52%) and 31 males (47%). Their age ranged from 36 to 87 years (mean age, 66.5 years). Thirty patients (46%) were 70 years of age or older (mean age, 75.7 years), 25 were 70–79 years of age (mean age, 74.2 years), and five were 80 years old or older (mean age, 83.2 years). Their mean percent of the predicted forced expiratory volume in 1 s (FEV-1) was 74% (range, 27–110%). Thirty-five (54%) were 69 years of age or younger (mean, 58.6 years) with a mean FEV-1 of 78% of the predicted value (range, 38–119%; Table 1) . Inclusion criteria: all patients with localized stage disease, regardless of their pulmonary function tests, performance status, or comorbidities. Exclusion criteria: inability to stop smoking or to participate in a simple and individualized exercise program (this program allowed wheelchair bound patients and those with previous strokes to participate).
Table 1
Patient characteristics
Extensive patient and family education, a video-assisted minimally invasive approach, and multimodal analgesia as previously reported [4,5] were used in all patients. The analgesic protocol included: (1), perioperative use of a parenteral non-steroidal anti-inflammatory drug (Ketorolac tromethamine); (2), intercostal nerve cryoanalgesia; (3), infiltration of the incision with a local anesthetic; and (4), oral analgesics in the postoperative period. Forty-six lobectomies, eight bilobectomies, and 11 pneumonectomies were performed. In the elderly group, there were 24 lobectomies, three bilobectomies, and three pneumonectomies (Table 1).
Resection was conducted using traditional steps with separate isolation and ligature of the three hilar elements. Hilar and mediastinal lymphadenectomy was performed more frequently than node sampling. The results were then compared between the elderly group and the younger cohort. Discharge criteria included: pain controlled with oral analgesics, clear lungs in chest radiograph and without evidence of pneumothorax with the chest tube off suction, independent ambulation, adequate oxygenation, the patient's acceptance and home support. Whenever these criteria were met, regardless of how early or late during the hospital stay, the patient was released from the hospital. Patients were called at least once a day after discharge for the following 5 days by the surgeon's office. In addition, patients and families had telephone access 24 h a day and were followed for at least 1 month by the surgeon's office. A chest radiograph was performed within a week from surgery at the initial follow-up office visit and whenever clinically indicated. At least three weekly follow-up office visits were routinely scheduled. Patients had access to the surgeon's office earlier and as frequently as necessary.
3 Results
There were no deaths within 30 days of the operation and only three complications that did not alter the patients’ clinical courses. One patient in the elderly group had subcutaneous emphysema after a pneumonectomy. One patient experienced left vocal cord paralysis and another patient had a prolonged air leak that required the chest tube to stay connected to a Heimlich valve for 10 days, both in the younger group. No patient required conversion to the standard posterolateral thoracotomy (Table 2) . The mean length of hospital stay for the entire group was 1.2 days. Fifty-four patients had an overnight hospital stay and two were outpatient procedures. The younger group had a total of 47 hospital days with a mean length of stay of 1.3 days (Fig. 1) . The mean length of hospital stay for the elderly group was 1 day, and the total number of hospital days was 32 for the 30 patients (Fig. 2) . None of these patients required readmission related to early discharge.
Table 2
Length of hospital stay
Fig. 1
Length of hospital stay for individual patients 69 years of age and younger.
Fig. 2
Length of hospital stay for individual septuagenarians and octogenarians.
4 Discussion
Major lung resections represent the preferred treatment for resectable non-small cell carcinoma. The risk factors associated with poor outcomes following pulmonary resections (age, smoking history, level of dyspnea, spirometry results, extent of the proposed resection, preoperative weight loss, right-sided procedures, history of prior resection, exercise endurance, and documented cardiac history) are well recognized. Notably, none of them are consistently predictive of postoperative complications and controversy persists in the literature as to whether there is an absolute predictor to establish, unambiguously, inclusion and exclusion criteria for operability [6–8]. In fact, the lower limit at which the operative mortality exceeds the benefit of the operation has not yet been defined. Age has a significant effect in postoperative mortality. According to Romano and Mark [9], patients who undergo wedge resections, segmentectomies, and lobectomies have a mortality rate of 1.5% for those 59 years of age and younger, 3.8% for those 60–69 years, 6.2% for those 70–79 years, and 9.2% for those 80 years old and older. Patients who undergo pneumonectomies have 6.2, 12.5, 18.8 and 29.2% mortality rates, respectively. A Medline search revealed a 15.4% operative mortality rate for major lung resections in highly selected groups of octogenarians (Table 3) . Unfortunately, the incidence of cancer of the lung peaks at about 75 years of age [3], considered by some to be beyond the upper age limit for resection [15]. The projected life expectancy in the United States for an 80-year-old is 6.7 years for men and 8.8 years for women [16], thus the limiting survival factor is their underlying disease.
Table 3
Reported mortality for major lung resections among octogenarians
Using a minimally invasive approach (Fig. 3) , multimodal analgesia, and an accelerated recovery program, we were able to perform major lung resections in most patients who presented with resectable lesions. Only a few of them who were not willing to quit smoking or to participate in some form of exercise program were rejected. This exercise program was customized to each individual's condition and allowed wheelchair bound patients and those with previous cerebrovascular accidents to participate. Rather than only testing cardiopulmonary fitness, we tried to establish non-physiological factors such as determination, perseverance, and willingness to cooperate. As expected, the more extensively patients participated, the faster they recovered [17]. Surprisingly, however, this happened regardless of their age and cardiopulmonary status. Paradoxically, in some cases, postresection function (after smoking cessation and a continued exercise program) actually improved from the preoperative baseline. In conclusion, this study shows that it is feasible to create strategies to prevent or attenuate physiological derangements during surgery while performing major lung resections. As a result, an early recovery with few complications has been attained, allowing patients to consistently meet stringent discharge criteria after only an overnight hospital stay, even in the case of septuagenarians and octogenarians.
Fig. 3
An 82-year-old female who had undergone a wedge resection through a posterolateral thoracotomy 2 years earlier at another institution. A redo thoracotomy was performed through the upper incision for an extended (diaphragm) right lower lobectomy as an outpatient procedure.
The author would like to thank Jean L. Burnette for her invaluable editorial assistance in preparing the manuscript and Carol Bondurant for compilation of material.
Dr H.-B. Ris (Lausanne, Switzerland): I was very impressed by your results, but I could hardly imagine that Swiss patients would accept this approach!
In our hospital, the time of discharge is determined by the duration of chest tube drainage, and the duration of chest tube drainage is related to the amount of resection and whether fissures are complete or incomplete. You have shown that patients who underwent lobectomy, for instance, that they could leave the hospital after 1 day. Were these patients then discharged with Heimlich valves? What was your attitude toward ‘prolonged’ air leak in these patients?
Dr Tovar: Frequently, we are able to remove the chest tube either the night of the operation or the day after, prior to the patient's discharge. When that is not possible, and that is the case in several instances, the patient is sent home with a chest tube connected to a Heimlich valve. Obviously, one of the limiting factors for discharge is whether the patient requires intrapleural suction. In such rare instances, the patient is kept in the hospital.
Dr T. Grodzki (Szczecin, Poland): It's really revolutionary for European thoracic surgeons to hear such news. I have two questions.
First of all, you said there were 65 consecutive patients. It means that every postoperative course was so uneventful, but, as you know, following pneumonectomy, the crisis usually comes on the third or fourth postoperative day.
You didn't mention ambulation. Who took care of those patients, what medications were given, and so on? The last question, you didn't mention any complications. There weren't any or they were treated in other institutions?
Dr Tovar: First of all, I understand the anxiety of most surgeons who perform a pneumonectomy in letting their patients go home as early as we have. We have not had the complications of atrial fibrillation and the other myriad of complications that we used to experience in the past. There were three complications in our series and they did not alter the patients’ clinical course. All three of them are mentioned in the submitted manuscript. One was a patient who had a pneumonectomy and he had a small drain tube, and during the night, the chest tube obstructed acting as a one-way valve, so it allowed air to go into the chest cavity, but it wouldn't come out. The patient developed significant subcutaneous emphysema. I removed the chest tube, made a couple of incisions in the subclavicular fossa, and the patient had an uneventful recovery, and the next morning went home. In the other two patients, one of them had a prolonged air leak and had to keep the Heimlich valve for approximately 10 days. The last patient had vocal cord paralysis related to a recurrent laryngeal nerve injury.
I agree that this indeed is a hard-to-believe series. I have had surgeons come from different parts of the world. Some thought that I was operating on simple cases, but indeed they are not. I had a physician from Spain visit who has since been able to decrease his length of hospital stay from 5 to 2 days. He initially thought he was wasting his time by coming to California. I operated on an 88-year-old man during his visit. I didn't select him. It just so happened. He said that he would never operate on a patient older than 80 years of age. The patient went home the next morning. He witnessed that.
Dr W. Weder (Zurich, Switzerland): I want to ask you to clarify Dr Grodzki's question. What type of ambulatory care do these patients require? In Europe, when we send the patient home, we usually don't see him for another 2–3 weeks. In the United States, I understand, the patient goes next-door into a hotel and you will see them frequently within the following days. So what kind of ambulatory care do these patients have?
Dr Tovar: Basically, patients have an exercise program prior to the operation. That is continued immediately postoperatively. As soon as the patient is out of the operating room and the recovery room and the patient is awake and can get out of bed, we get them out of bed. Following that, there are daily calls to the patient from my office. The family is usually involved in making sure that the patient is ambulating. The majority of our patients are local, and we make sure that they are following the prescribed protocol with their families. There is no keeping the patient in another institution. Patients go home. If they have any problems, we see them ourselves.
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