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© 2003 European Association of Cardio-Thoracic Surgery
Comparison of postoperative complications of 60- and 70-year-old patients after lung surgeryThird Department of Surgery, University Hospital Motol, V Uvalu 85, Prague 5, Czech Republic
* Corresponding author. Tel.: +420-2-2443-8001; fax: +420-2-2443-8020 Received March 11, 2003; received in revised form June 15, 2003; accepted August 12, 2003
This study investigated the association of age and postoperative complications in two different age groups undergoing thoracotomy and pulmonary resection. We retrospectively reviewed the medical records of all patients (  ) older than 60 years who underwent pulmonary operations between January 2000 and December 2001. Group A consisted of 91 patients at the age of 60–69 years. In group B, there were 59 patients older than 70 years. We recorded preoperative assessment, clinical parameters, pre- and postoperative complications. The incidence of postoperative complications were compared between the two age groups using univariate and multivariate analysis. The incidence of postoperative complications in group A was 30% compared to 35.6% in group B. The most frequent complications were: cardiac arrhythmias 9.9% in group A vs. 15.2% in group B, and prolonged air leak 8.8% in group A vs. 8.5% in group B. Thirty days mortality was 0 vs. 1.2%. We concluded that there was no significantly higher incidence of postoperative complications in these two age groups.
Key Words: Pulmonary resection; Age; Postoperative complications
Lung surgery with pulmonary resections remains the standard therapeutic option in most patients with early-stage non-small cell lung cancer (NSCLC) and benign pulmonary lesions. They are considered to be operations with higher risk of the postoperative complications. These complications may lead to increased mortality. Mortality ranges from 2 to 12% despite advances in surgical technique, anaesthesia and perioperative care [1,2]. There are several clinical studies which identified risk factors after lung resections, such as age, impaired preoperative pulmonary function tests, cardiovascular comorbidity and smoking status [1,3]. The objective of the present study was to compare two age groups after thoracotomy and lung surgery, compare the incidence of postoperative morbidity and mortality in these two groups, and identify age as a factor that may predispose the development of postoperative complications.
2.1. Patients Three hundred and fifteen patients who underwent thoracotomy for lung surgery between January 2000 and December 2001 in our institution were retrospectively reviewed. There were 150 patients older 60 years. Group A consisted of patients of age 60–69 years, and those patients older than 70 years belonged to group B. Preoperative evaluation included a detailed history and physical examination, complete blood cell count, serum electrolytes and renal profile, pulmonary function tests (PFTs), bronchoscopy, and computer tomography (CT). Operability was determined according to existing guidelines for pneumonectomy and lobectomy [4]. Emergency procedures were excluded from the analysis. All resections were performed with selective lung ventilation by a standard anterolateral thoracotomy approach. At the time of surgery, complete perihilar and mediastinal node dissection was performed in all patients for accurate pathologic staging. All patients were extubated in the operation room at the end of the operation. Postoperative pain was controlled by means of epidural analgesia as a primary choice, and than by systemic opioids. The chest tube was pulled out when there was no sign of pulmonary air leak, pneumothorax and less than 150 ml of serosanguineous liquid from pleural cavity per day. Patients had an active program of physiotherapy including deep-breathing exercises. We divided all tumors into central, located at the pulmonary hilus and peripheral, which had no connection to the pulmonary hilus. 2.2. Preoperative evaluation The following preoperative factors were abstracted from all charts: age, sex, body mass index (BMI), smoking history (current smokers, smokers with 1 month cessation – ex-smokers, never smoked – non-smokers), cardiovascular comorbidity (preexisting history of myocardial infarction, angina pectoris, hypertension, arrhythmia, stroke), preoperative function tests: forced expiratory volume per second (FEV1), presence or absence of lung malignancy, preoperative chemotherapy and type of pulmonary resection (Table 1).
2.3. Postoperative complications Postoperative complications were defined as those occurring within 30 days after surgery. We divided them into pulmonary (PPC), cardiovascular and technical complications. Death was analyzed as a separate complication (Table 2).
2.4. Pulmonary postoperative complications (PPC)
2.5. Other complications Cardiovascular complications were defined as follows: (1) symptomatic cardiac arrhythmia requiring treatment, (2) acute myocardial infarction (ECG, myocardial enzymes), (3) stroke. As technical complications we considered: (1) bleeding requiring reoperation, (2) wound infections, (3) excessive fluid in to the chest tube (more than150 ml and lasting longer than 5 days, with no PAL).2.6. Statistical analysis Data were computerized and analyzed using SPSS version 10.0 statistical packages. Categorical variables were compared using the 2 test or Fisher's Exact test, and Student's t-test was utilized to analyze continuous variables between the two age groups. Statistical significance was defined as  , highly significant as  .
Between January 1, 2000 and December 30, 2001, 150 patients older than 60 years underwent thoracotomy for lung surgery. In group A, there were 91 patients at the age of 60–69 years. Fifty-three of them (58%) had a cardiovascular comorbidity and preoperative FEV1 was 82.15±16.58% of predicted values. Lobectomy, the most common operation, was performed in 42 cases (47%), while 20 patients (23%) underwent pneumonectomy, 12 patients (13%) underwent wedge resection and 10 patients (9%) had explorative thoracotomy. Seventy-two patients (79%) had malignant neoplasms. Tumor type included squamous cell carcinoma in 38 patients (52%), adenocarcinoma in 23 patients (33%) and pulmonary metastases in six patients (8%). We recorded postoperative complications in 30 patients (30%). The most frequent one was arrhythmia, which was present in nine cases (9.9%) with the need of medical treatment. We observed the development of lobar atelectasis in eight patients (8.8%) with repeated bronchoscopies. The two of them proceeded to respiratory failure requiring intubations and being put on a ventilator. The first one was reintubated on the 5th day after lobectomy and taken off the ventilator on the 9th day with repeated bronchoscopy. The second one, who underwent right pneumonectomy, was intubated on the 2nd day and extubated on the 20th day with tracheostomy. Prolonged air leak PAL occurred in eight patients (8.8%), with chest tube suction for 9.22±2.04 days, and no reoperations were required for this complication. There were two reoperations in total. The first of these was for hemothorax after lower bilobectomy with bleeding from pericardial edge; therefore, we used simple stitches on the pericardium. In the second case, there was prolonged atelectasis of middle lobe, and bronchoscopy and physiotherapy was without success, so we conducted a middle lobectomy on the 6th postoperative day after upper lobectomy. There was no mortality in this group.
In group B, there were 59 patients older than 70 years. (39%). Thirty-six patients had cardiovascular comorbidity (61%); preoperative FEV1 was 86.61±19.37% of predicted values. BMI was 26.33±3.04. There were 46 operations (78%) for malignant tumors. We found no significant difference in preoperative evaluation. In group B there were five pneumonectomies, two bilobectomies, 32 lobectomies and eight explorations. There was a difference between performed pneumonectomies ( We also looked for differences in the postoperative complications after pneumonectomies between both groups. These results were also influenced by the fact that these groups are not equivalent concerning number of the patients and cannot be statistically compared. Clinically the difference in mortality was 0 in group A vs. 1 in group B (Table 3).
We were interested in the correlation of incidence of pneumonia before and after surgery. Preoperatively we found seven patients with a history of pneumonia in association with a tumor in group A versus three pneumonia patients in group B. None of those patients developed postoperative pneumonia. Another interesting finding is the correlation between preoperative stenosis or obstruction of bronchus and postoperative atelectasis. In group A five patients out of 36 with preoperatively diagnosed stenosis or obstruction developed postoperative atelectasis, while in group B just one patient of 16 developed this complication. In both groups, nine patients developed cardiac arrhythmia. We studied whether localization of the tumor, peripheral or central according to localization at the pulmonary hilus, can affect the incidence of postoperative arrhythmias. The incidence between postoperative arrhythmia and centrally localized tumor is nearly the same in both groups. Three patients with a central tumor developed cardiac arrhythmia in group A versus four patients in group B
Despite improvements in anesthesia, surgical technique and postoperative care, lung surgery is associated with pulmonary complications, which depend on various circumstances. Stephan et al. in their retrospective analysis document a 25% pulmonary complication/PPC rate, where PPCs increase mortality rate and surgical ward stay. PPCs continue to occur with incidence rates as high as 49% [2,3]. The most frequent PPCs in our series were prolonged air leak/PAL. Its incidences range from 4 to 26% [3,5]. Several studies tried to identify risk factors for PAL. In the study by Hazelrigg et al., an advanced age  years) and poor pulmonary function were identified as risk factors for development of PAL [6]. Izbicki et al. identified a radical systemic mediastinal lymphadenectomy as a risk factor for PAL [7]. Abolhoda et al. reported, that patients with severe obstructive airway disease (i.e. FEV1/forced vital capacity  ) are at a higher risk for development of troublesome parenchymal air leak [5]. Rice et al. in their study [8] present male gender, pneumothorax on postoperative chest radiograph (day 1), and lower FEV1/FVC as an independent predictive value in the development of PAL. In our study, we found no significant difference in PAL incidence, and all of them were conservatively treated on prolonged drainage and Heimlich valve placement for several days. The bronchopleural fistula rate is reported to be between 3.1 and 15%. It is one of the most difficult complications to manage following pneumonectomy and is associated with a high mortality rate [9]. Incidence of acute respiratory failure (ARF) is reported as between 2.4 and 17%, and a high mortality rate is associated with this complication. Our ARF incidence rate was 6% and was associated with 100% mortality in group B. The prognosis is closely related to the severity of the underlying pulmonary complication rather than to mechanical ventilation itself [5]. Mechanical ventilation is also associated with the risk of nosocomial pneumonia and bronchopleural fistula [9,13]. The most frequent extrapulmonary complications in our study were cardiovascular ones, particularly supraventricular arrhythmias with the incidence rate 9.9% in group A and 15.2% in group B. The reported incidence of this complication ranges between 10 and 28% [10,11]. In the study by Sekine et al. [12], 37% of patients experienced postoperative arrhythmias; in the chronic obstructive pulmonary disease (COPD) group the incidence was 58% while in the non-COPD group it was 27%, which was a significant difference. Based on the results of our retrospective analysis, there is no significant difference in postoperative complications between the two age groups. We do not consider age as an independent risk factor in itself for postoperative complications in patients who fulfill all surgical and preoperative criteria for pulmonary resection. doi:10.1016/S1569-9293(03)00179-8
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Abstract
1. Introduction
); however, this was due the fact that the patients in group B did not fulfill the criteria for pneumonectomy, and the age was not that criterion in itself. In group B there were 21 postoperative complications (35.6%). Arrhythmia was the most frequent complication, and was observed in nine patients (15.3%). PAL was present in five cases (8.5%). Acute respiratory failure and intubations occurred in two patients. The first of these was intubated on the 4th postoperative day after lobectomy for respiratory failure and died on the 24th day due to sepsis. The second patient was intubated on the 5th postoperative day after right pneumonectomy for respiratory failure and died on the 30th day also due to sepsis. 
