Thoracic surgery in the elderly co-morbidity is the limit

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1 doi: /icvts Interactive CardioVascular and Thoracic Surgery 8 (2009) Institutional report - Thoracic non-oncologic Thoracic surgery in the elderly co-morbidity is the limit Stefan Limmer*, Lena Hauenschild, Christian Eckmann, Ralf Czymek, Henriette Schmidt, Hans-Peter Bruch, Peter Kujath Department of Surgery, University Hospital of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, D Luebeck, Germany Received 31 August 2008; received in revised form 16 November 2008; accepted 19 November Abstract A retrospective chart review was performed in 242 consecutive patients aged 65 years or older who were treated in an academic surgical centre between January 2004 and July A total of 249 thoracic procedures were performed in 242 patients, of whom 143 were men and 99 women with a mean age of 69.9 years (range 65 92). Overall operative mortality was 2.4%, rising to 26.4% in emergency patients. Negative predictors for perioperative mortality were: American Society of Anesthesiology (ASA) class 4, pre-existing kidney failure, leucocytosis, low haemoglobin, elevated C-reactive protein, diabetes mellitus and emergency surgery. In addition, the risk of major and minor complications resulting in a prolonged hospital stay was increased in emergency patients, patients with multiple co-morbidities and ASA class 3 or 4. Appropriate thoracic surgery can be offered to the elderly with an acceptable level of perioperative morbidity and mortality. Regardless of age, a high degree of co-morbidity or emergency surgery are the main risk factors for perioperative mortality andyor prolonged hospital stay Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Elderly patient; Thoracic surgery; Lung cancer; Operative mortality 1. Introduction Under present conditions, people aged over 65 will account for 28.7% of the total population in Germany in 2030, and 8.1% of Germany will even be older than 80. Surgery has responded to this elderly patient population with treatments adapted to the needs of these patients with their qualitative and quantitative co-morbidities. Sophisticated diagnostic tools, less traumatic surgical techniques (VATS), improved perioperative anaesthesia and pain management, postoperative intensive-care monitoring and geriatric follow-up have made almost all surgical procedures accessible to elderly and old patients today. As long ago as 1983, Ginsberg et al. postulated a significant correlation between the morbidity and mortality of thoracic surgery and the age of the patient w1x. Since then, this statement has been a constant topic of discussion, and the importance of the subject is now more relevant than ever as a result of the demographic changes taking place. Detailed conclusions on the general position of the old patient in thoracic surgery are scarce and have prompted us to undertake a retrospective analysis of our own results. 2. Patients and methods From 1 January 2004 to 31 July 2007, 242 consecutive patients aged 65 years or older underwent thoracic surgery *Corresponding author: Tel.: q49 (0) ; fax: q49 (0) address: Stefan.limmer@uk-sh.de, s-limmer@web.de (S. Limmer) Published by European Association for Cardio-Thoracic Surgery in a single institution, the Department of Thoracic Surgery. According to WHO, all patients aged 65 years or older were included in this retrospective study and broken down into three groups: patients aged years (Group 1), G70 74 years (Group 2) and 75 years or older (Group 3). Major complications were defined as any complication requiring invasive treatment (e.g. re-surgery), and minor complications were defined as those needing non-invasive treatment such as medical treatment or prolonged wound healing. Mortality was defined as any postoperative death within 30 days or any death occurring during the hospital stay in the case of patients remaining in hospital after surgical treatment. An exclusion criterion was first-time pneumothorax treated only by drainage (Bülau) Statistical analysis Statistical analysis was performed using the impairedsamples t-test for mean values. The results are presented 2 as mean values"s.d. unless otherwise stated. The x -test was used to analyse nominal data. Multivariate analysis was performed using configuration frequency analysis to test the correlation of overall mortality with the age of patients and elective surgical treatment. A P-0.05 was considered significant. 3. Results A total of 242 patients were treated from January 2004 to July Of these patients, 143 (59%) were men and

2 S. Limmer et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) (41%) were women with a mean age of years ("5.5 S.D.) and years ("4.9), respectively. The group of year-olds (Group 1) was the largest group, accounting for 55% of the patient population (ns133y78 male, 55 female), while Groups 2 and 3 were almost identical in size at 23.1% (ns56y32 male, 24 female) and 21.9% (ns53y33 male, 20 female), respectively. Overall morbidity stood at 28.5%, of which 12% constituted a major complication requiring intervention and 18.5% took the form of minor complications (Table 1). There were 61.4% resectional procedures (lobectomy in 26.4%, wedge resection in 20.2%, segmentectomy in 7.4% and chest wall resections in 7.4%), 30% emergent procedures (e.g. mediastinitis due to oesophageal rupture, hemothorax, chest trauma, lung bleeding after cardiac revascularisation, etc.), and others in 8.6%. Seventy percent of all patients (ns170) were electively treated, and 30% (ns72) underwent surgery as an emergency procedure. The large proportion of emergency patients is attributable partly to the healthcare mission of the clinic and partly to its maximum healthcare grade as a university clinic. Of the elective patients, 14.1% underwent minimal invasive treatment, while the proportion was somewhat higher among emergency patients at 18.1% (13y 72). The overall mortality of all patients (ns242) was 9.5%. In patients who underwent elective surgery (ns170), mortality was 2.4%, while in emergency cases (ns72) the mortality increased to 26.4% (P ). Four patients of the elective group died. All four had severe cardiac comorbidity, American Society of Anesthesiology (ASA) class 3 and three of them had a long-time smoking career until the operation procedure was performed. Three patients Fig. 1. Overall mortality of all patients (ns242). Configuration frequency analysis showed a highly significant mortality risk for patients in group 1, undergoing emergency surgery (asymptomatic version of the hypergeometric test, P ). died of cardiac complications. One patient had a bronchial carcinoma stage IV and died of his extended disease. Configuration frequency analysis showed a highly significant mortality risk of 22.2% for the group of yearolds (Group 1) who underwent emergency surgery. In this Table 1 Major and minor complications Treatment Elective Emergency Total Major complications Postoperative bleeding Repeat thoracotomy Pleural effusion Drainageypuncture Pleural empyema Revisionyclearance Respiratory failure 1 Tracheotomy Poor wound healing Wound managementyvac 2 2 Pneumothorax Bülau drainage Chylothorax Surgical revision 1 1 Dislocation oesophageal stent Stent replacement 1 1 Acute myocardial infarction Left cardiac catheter 2 2 Minor complications Urinary tract infection Antibiotic therapy Pleural effusion Conservative 7 7 Pneumonia Antibiotic therapy Cardiac complications Pharmacotherapy 6 6 Neurological complications 3 Physiotherapy 3 3 TIA Conservative Wound seroma, haematoma Conservative Pseudomembranous colitis Antibiotic therapy 1 1 Alcohol withdrawal delirium Pharmacotherapy 1 1 Peranal bleeding Proctorectoscopy 1 1 Pulmonary embolism Conservative 1 1 Enteritis 2 Conservative 2 2 Catheter infection Antibiotic therapy Of these 1 patient with methicillin resistent Staphylococcus aureus (MRSA) pneumonia; of these 1 patient with Norwalk virus; one case each of brachial plexus, phrenic nerve and recurrent nerve paresis.

3 414 S. Limmer et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) Table 2 Preoperative co-morbid conditions in 242 patients undergoing thoracic surgery Multiple mentions possible Number Elective Emergency Respiratory diseases 142 Chronic obstructive disorder Pneumonia Purulent infection 1 7 Cardiovascular diseases 317 Conduction disorder Ischaemic heart disease Cardiomyopathy Valve disorder Arterial hypertension Cerebrovascular disease Metabolic disorders 140 Diabetes mellitus Thyroid dysfunction 28 9 Renal failure requiring dialysis Liver dysfunction 13 9 Psychiatric disorders 99 Chronic alcohol abuse 6 6 Chronic nicotine abuse Analgesic abuse 1 Depression 3 7 Personality disorder 3 5 CNS lesions 16 Paresis or plegia 4 5 Polyneuropathy 3 Parkinson s disease 1 1 Myasthenia gravis 2 Specific infections 44 Bacterialyviral infections 8 15 Hepatitis 2 1 Tuberculosis 2 Mycoses 2 12 Salmonella typhi 2 7 multiresistant infections (3=Methicillin resistant Staph. aureus, 2=ESBL (extended spectrum beta-lactamases), 1=Stenotrophomonas maltophilia, 1=Herpes simplex virus). group, a fatal outcome could be statistically expected in 3.8 patients, whereas in fact 11 patients died (P ) (Fig. 1). All treated patients showed a mean of nine preoperatively relevant secondary disorders (median 8, range 1 29). There was an above-average proportion of cardiovascular, respiratory and metabolic primary diseases, but prior psychiatric disorders were also noted in 41% of patients (Table 2). Patient s age was not related to the number of secondary diagnoses. Patients in group 1 had a mean of 8.9 secondary diagnoses, group and group Patients with up to 12 secondary diagnoses (ns187) had a mean inpatient stay of 20.7"16.9 days, while the mean hospital stay in patients with more than 12 secondary diagnoses was more than twice as long at 47.6"33.5 days (P-0.001, Rs0.54). Co-morbidity for the duration of the hospital stay was the defining factor (Fig. 2). Statistical univariate analysis demonstrated that overall mortality was related to the ASA score, the presence of diabetes mellitus, various blood count values, the number of co-morbidities and an emergency operation (Table 3). Patients with an ASA score of 2 had a mortality rate of 2.8% vs. 7.6% in patients with an ASA score of 3. Patients with an ASA score of 4 patients had the highest mortality rate (22.9%). There was no significant benefit for ASA 2 vs. ASA Fig. 2. Correlation of the total number of co-morbidities to the duration of hospital stay (in days). 3, but increased perioperative mortality was seen in patients with ASA 4 vs. ASA 2 and 3 (P-0.006). The mortality rate for patients with up to 12 co-morbidities (ns196) was 4.6% compared with 30.4% for patients with more than 12 co-morbidities (ns46) (Ps0.001, Fisher s exact test). An elevated C-reactive peptide (C-RP) level or the presence of leucocytosis or a low haemoglobin level was associated with increased mortality. Mortality in patients with an elevated C-RP level was 12.1% vs. patients with normal blood counts (2.9%). Table 3 Univariate analysis of preoperative risk factors for hospital mortality among 242 (elective and non-elective) patients undergoing thoracic surgery, 2 (x -test) Variable n Mortality (%) P-value OR Gender Male Female n.s. Treatment Elective Emergency Nicotine abuse n.s. Alcohol abuse n.s. ASA score Class 2 and Class Diabetes mellitus a Anaemia (Hb-120 mgydl) Heart failure NYHA class 3 and n.s Hypertension n.s. Renal dysfunction Serum creatinine G n.s. Leucocytosis )9000yml Elevated C-reactive protein )5 mgydl CAD n.s. NYHA, New York Heart Association; ASA, American Society of Anesthesiology a physical status. Fisher s exact test.

4 S. Limmer et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) Table 4 Univariate analysis of preoperative risk factors for prolonged hospital stay among 219 (elective and non-elective) patients undergoing thoracic surgery Variable n Days mean value P-value "S.D. Gender Male "22.0 Female "22.7 n.s. Treatment Elective "15.9 Emergency " Nicotine abuse "23.8 n.s. Alcohol abuse "18.1 n.s. ASA score* Class "12.0 Class "20.1 n.s. Class " Diabetes mellitus "17.2 n.s. Anaemia (Hb -120 mgydl) " Heart failure NYHA class 3 and "21.5 n.s. Hypertension "24.8 n.s. Renal dysfunction Serum creatinine G " Leucocytosis -9000yml " Elevated C-reactive protein )5 mgydl " CAD "21.9 n.s. NYHA, New York Heart Association; ASA, American Society of Anesthesiology physical status. *One-way ANOVA test. Mortality in patients with long-standing diabetes mellitus was 20%, compared with 7.1% in patients without diabetes (P-0.02, Fisher s exact test) (Table 3). The duration of the hospital stay was significantly influenced by the ASA score, emergency operation, the presence of renal dysfunction, a low haemoglobin level, leucocytosis and an elevated C-RP level. The median hospital stay was 15 days in elective patients (mean 19.5 "15.9 days), 29 days in emergency patients (mean 40.7 "30.3 days) (P-0.001). The duration of the hospital stay was not influenced by the age. Patients of group 1 had a mean duration of stay of 26.5 days, in group 2 and group 3 patients stayed 23.5 days. Multiple comparison of the patient groups (one-way ANOVA test) revealed a highly significant dependence between the perioperative ASA score and the duration of the hospital stay (P-0.001) (Table 4). 4. Discussion Overall mortality in elective patients was 2.3% in our study group, but increased to 26.4% in emergency procedures. On comparison of the literature data with our own results, it certainly has to be borne in mind that only 70% of patients in our study underwent elective surgery and 30% underwent emergency treatment. Previous studies reported a morbidity of 8 59% w2x and a mortality of 2 12% w3x in elective lung resections. However, these highly variable results from various American and European studies are only partially comparable, because patient selection, observation period, definitions of age and hospital mortality and also the reported operation figures (high- or lowvolume hospital) differ widely. Some previous studies emphasize the importance not only of nicotine abuse w4x, but also of impaired preoperative lung function w5x, cardiac co-morbidity and especially age w6x as risk factors. However, the data from our retrospective analysis did not show the age of the patients to be an independent risk factor. Crucial factors for the postoperative outcome are the number and severity of the comorbidities. And these do not correlate with age in our study population. We found evidence that the ASA classification had a significant influence on perioperative mortality. In 1999, Licker et al. w7x already reported ASA class 3 or 4 as an independent predictor of perioperative death in lung resection in non-small cell carcinoma. Beshay et al. (2007) also found that age alone was not an independent risk factor for perioperative complications w8x. Previous studies suggested that general health and disorders existing prior to surgery can crucially influence perioperative outcome w9x. And in the year 2000, Stéphan et al. likewise found that the ASA score, a prolonged operation and the need for prolonged postoperative ventilation were independent risk factors for postoperative pulmonary complications regardless of age w10x. Furthermore, if a patient already has diabetes mellitus as a single co-morbidity, this can significantly increase postoperative mortality. Patients with an elevated leucocyte count or C-RP value in the perioperative phase likewise showed an increased mortality risk. In our study perioperative renal failure was not a crucial risk factor and increased creatinine value did not significantly influence mortality. According to recent studies, the most frequent causes of death after lung resection are increasingly pneumonia and respiratory failure, whereas older studies generally reported bronchopleural fistula and empyema to be the most life-threatening complications w11x. We observed minor complications in 16.5% of cases and major complications in 12% (Table 1). In the literature, cardiac arrhythmia, PAL (prolonged air leak), respiratory failure, postoperative bleeding and pleural effusions are described as the most common postoperative complications following elective thoracic surgery w12x. The mean length of hospital stay in our patients was 25 days (median 16 days). Here, too, no significant difference was observed within the age groups. However, a significant difference was seen between emergency patient and elective patient, where the mean and median length of hospital stay was twice as long as in the elective group. Our work shows that the number of co-morbidities has a significant influence on the length of hospital stay. However, the prognostic influence of individual co-morbidities varies widely, and consequentially the diagnosis of coronary heart disease or rheumatoid arthritis cannot be compared with a case of renal failure or sepsis. Nevertheless, the total number of co-morbidities reflects the physiological status of the patient, and mortality and morbidity are directly correlated with the number of relevant secondary diagnoses. Accordingly, the ASA classification is again seen to have a crucial influence on the length of recovery. Patients with a high perioperative leucocyte count, an

5 416 S. Limmer et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) elevated C-RP value or a low Hb value had to remain in hospital significantly longer than the remainder of the patient population. In our opinion, these laboratory values are to be regarded as markers for the potential occurrence of perioperative complications. Irrespective of age, a preoperative risk evaluation to identify patients at risk is indispensable. This must take place through an interdisciplinary evaluation, because there is some dispute in recent literature as to whether a preoperative lung function test alone is suitable for reliably identifying high-risk patients w13x. Recent studies also suggest that patients with relevant co-morbidities could especially benefit from the advantages of a minimally invasive procedure with a faster recovery and a shorter hospital stay w14x. In our patient population, 15% of operations were already performed with minimal invasiveness. Our study clearly shows that calendar age alone is not an independent risk factor for postoperative morbidity and mortality following thoracic surgery, but that the biological age with corresponding co-morbidities is. The most important perioperative risk factors in our patient population are the number and severity of the secondary diagnoses. Furthermore, there was also found to be a marked difference in postoperative outcome between elective and emergency operations regardless of age. Acknowledgments The authors wish to thank Prof Dr M. Hüppe, MD, PhD, Department of Anaesthesiology, for his contributions in statistical analysis. References w1x Ginsberg RJ, Hill LD, Eagen 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: w2x Algar FJ, Alvarez A, Salvatierra A, Baamonde C, Aranda JL, López-Pujol FJ. Predicting pulmonary complications after pneumonectomy for lung cancer. Eur J Cardiothorac Surg 2003;24: w3x Romano PS, Mark DH. Patient and hospital characteristics related to in-hospital mortality after lung cancer resection. Chest 1992;101: w4x Harpole DH, Liptay MJ, DeCamp NM Jr, Mentzer SJ, Swanson SJ, Sugarbaker DJ. Prospective analysis of pneumonectomy: risk factors for major morbidity and cardiac dysrhythmias. Ann Thorac Surg 1996; 61: w5x Dales RE, Dionne G, Leech JA, Lunau M, Schweitzer I. Preoperative prediction of pulmonary complications following thoracic surgery. Chest 1993;104: w6x Wada H, Nakamura T, Nakamoto K, Maeda M, Watanabe Y. Thirty-day operative mortality for thoracotomy in lung cancer. General Thoracic Surgery 1998;115: w7x Licker M, de Perrot M, Höhn L, Tschopp J-M, Robert J, Frey J-G, Schweizer A, Spiliopoulos A. Perioperative mortality and major cardiopulmonary complications after lung surgery for non-small cell carcinoma. Eur J Cardio-thorac Surg 1999;15: w8x Beshay M, Dorn P, Ris HB, Schmid RA. Influence of comorbidity on outcome after pulmonary resection in the elderly. Asian Cardiovasc Thorac Ann 2007;15: w9x Smetana GW. Current concepts: preoperative pulmonary evaluation. N Engl J Med 1999 Mar 25;340: w10x Stéphan F, Boucheseiche S, Hollande J, Flahault A, Cheffi A, Bazelly B, Bonnet F. Pulmonary complications following lung resection. A comprehensive analysis of incidence and possible risk factors. Chest 2000; 118: w11x Watanabe S, Asamura H, Suzuki K, Tsuchiya R. Recent results of postoperative mortality for surgical resections in lung cancer. Ann Thorac Surg 2004;78: w12x Naunheim KS, Kesler KA, D Orazio SA, Fiore AC, Judd DR. Lung cancer surgery in the octogenerian. Eur J Cardio-thorac Surg 1994;8: w13x Pierce R. The role of respiratory function testing. Lung Cancer 1993; 9: w14x Koizumi K, Haraguchi S, Hirata T, Hirai K, Mikami I, Fukushima M, Kubokura H, Okada D, Akiyama H, Tanaka S. Video-assisted lobectomy in elderly lung cancer patients. Jpn J Thorac Cardiovasc Surg 2002; 50:15 22.