One-day admission for major lung resections in septuagenarians and octogenarians: a comparative study with a younger cohort q

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1 European Journal of Cardio-thoracic Surgery 20 (2001) 449±454 One-day admission for major lung resections in septuagenarians and octogenarians: a comparative study with a younger cohort q Eduardo A. Tovar a,b, * a Department of Cardiothoracic Surgery, University of California, Irvine Medical Center, Orange, CA, USA b Department of Cardiothoracic Surgery, St. Jude Medical Center, Fullerton, CA, USA Received 8 October 2000; received in revised form 17 May 2001; accepted 31 May 2001 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 bene t 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 ve 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. q 2001 Elsevier Science B.V. All rights reserved. Keywords: Video thoracoscopy; Lung surgery; Neoplasms, Lung; Carcinoma; Bronchogenic; Length of stay; Aged 1. Introduction Lung carcinoma is the leading cause of cancer-related deaths in males (F) and females (C) worldwide. Despite its relatively low incidence (16% F and 13% C), it results in a larger number of deaths (33% F and 23% C) than the sum of the second and third leading causes of cancer-related deaths for both sexes in the United States (incidence and q Presented at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7±11, * Suite 301, 100 E. Valencia Mesa Drive, Fullerton, CA 92835, USA. Tel.: ; fax: address: etovarmd@aol.com (E.A. Tovar). mortality: prostate, 32 and 13%; colorectal F, 12 and 10%; breast C, 32 and 18%; colorectal C, 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 /01/$ - see front matter q 2001 Elsevier Science B.V. All rights reserved. PII: S (01)

2 450 E.A. Tovar / European Journal of Cardio-thoracic Surgery 20 (2001) 449±454 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 de ne whether a minimally invasive approach combined with an accelerated recovery program bene ts 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 ve 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- ve (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 Table 1 Patient characteristics,70 years old $70 years old Total Number of patients Gender Male Female Mean age (years) 58.5 (36±69) 75.7 (70±87) 66.5 Mean FEV-1 a (%) 78 (38±119) 74 (27±110) 76 (27±119) Operations Lobectomies Bilobectomies Pneumonectomies a FEV-1, forced expiratory volume in 1 s. program (this program allowed wheelchair bound patients and those with previous strokes to participate). 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-in ammatory drug (Ketorolac tromethamine); (2), intercostal nerve cryoanalgesia; (3), in ltration 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 of ce. In addition, patients and families had telephone access 24 h a day and were followed for at least 1 month by the surgeon's of ce. A chest radiograph was performed within a week from surgery at the initial follow-up of ce visit and whenever clinically indicated. At least three weekly follow-up of ce visits were routinely scheduled. Patients had access to the surgeon's of ce 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 Table 2 Length of hospital stay,70 years old $70 years old Total Number of patients Number of hospital days Mean length of stay (days) Overnight stay Outpatient procedure 1 1 2

3 E.A. Tovar / European Journal of Cardio-thoracic Surgery 20 (2001) 449± Fig. 1. Length of hospital stay for individual patients 69 years of age and younger. 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 Fig. 2. Length of hospital stay for individual septuagenarians and octogenarians.

4 452 E.A. Tovar / European Journal of Cardio-thoracic Surgery 20 (2001) 449±454 Table 3 Reported mortality for major lung resections among octogenarians 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. 4. Discussion Number of resections Number of deaths Ginsberg et al. [10] 37 a Shirakusa et al. [11] 31 a Osaki et al. [12] 33 a Naunheim et al. [13] Harvey et al. [14] 17 a Total a Includes wedge resections and segmentectomies. Operative mortality (%) 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 bene t of the operation has not yet been de ned. Age has a signi cant 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. 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 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.

5 E.A. Tovar / European Journal of Cardio-thoracic Surgery 20 (2001) 449± 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 tness, we tried to establish nonphysiological 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. Acknowledgements 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. References [1] Boring CC, Squires TS, Tong T, Montgomery S. Cancer statistics, CA Cancer J Clin 1994;44:7±26. [2] Lee-Chiong Jr TL, Matthay RA. Lung cancer in the elderly patient. Clin Chest Med 1993;14:453±478. [3] Bureau of the Census. Projections of population of the United States by age, sex, and race: 1983±2080, Current population reports, Series P-25, No Washington, DC: Government Printing Of ce, [4] Kehlet H. Acute pain control and accelerated postoperative surgical recovery. In: Kehlet H, editor. The surgical clinics of North America, Philadelphia, PA: W.B. Saunders, pp. 431±443. [5] Tovar EA, Roethe RA, Weissig MD, Lloyd RE, Patel GR. One-day admission for lung lobectomy: an incidental result of a clinical pathway. Ann Thorac Surg 1998;65:803±806. [6] Cykert S, Kissling G, Hansen CJ. Patient preferences regarding possible outcomes of lung resection ± what outcomes should preoperative evaluations target? Chest 2000;117:1551±1559. [7] Bolliger CT, Wyser C, Roser H, Soler M, Perruchoud AP. Lung scanning and exercise testing for the prediction of postoperative performance in lung resection candidates at increased risk for complications. Chest 1995;108:341±348. [8] Dales RE, Dionne G, Leech JA, Lunau M, Schweitzer I. Preoperative prediction of pulmonary complications following thoracic surgery. Chest 1993;104:155±159. [9] Romano PS, Mark DH. Patient and hospital characteristics related to in-hospital mortality after lung cancer resection. Chest 1992;101:1332±1337. [10] Ginsberg RJ, Hill LD, Eagan RT, Thomas P, Mountain CF, Deslauriers J, Fry WA, Butz RO, Goldberg M, Waters PF, Jones DP, Pairolero P, Rubinstein L, Pearson FG. Modern thirty-day operative mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 1983;86:654±658. [11] 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. [12] 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. [13] Naunheim KS, Kesler KA, D'Orazio SA, Fiore AC, Judd DR. Lung cancer surgery in the octogenarian. Eur J Cardio-thorac Surg 1994;8:453±456. [14] Harvey JC, Erdman C, Pisch J, Beattie EJ. Surgical treatment of nonsmall cell lung cancer in patients older than seventy years. J Surg Oncol 1995;60:247±249. [15] Weiss W. Operative mortality and ve year survival rates in patients with bronchogenic carcinoma. Am J Surg 1974;128:799±804. [16] United States National Center for Health Statistics. Changing mortality patterns, health services utilization, and health care expenditures 1978±2003, Publication no Bethesda, MD: NCHS Analytical and Epidemiological Studies, Vital and Health Statistics, [17] Tovar EA. Minimally invasive approach for pneumonectomy culminating in an outpatient procedure. Chest 1998;114:1454±1458. Appendix A. Conference discussion 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 ssures 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 brillation 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 oneway valve, so it allowed air to go into the chest cavity, but it wouldn't come out. The patient developed signi cant 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

6 454 E.A. Tovar / European Journal of Cardio-thoracic Surgery 20 (2001) 449±454 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 of ce. 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.