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Interact CardioVasc Thorac Surg 2009;8:412-416. doi:10.1510/icvts.2008.191346 © 2009 European Association of Cardio-Thoracic Surgery
Thoracic surgery in the elderly – co-morbidity is the limitDepartment of Surgery, University Hospital of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, D-23538 Luebeck, Germany Received 31 August 2008; received in revised form 16 November 2008; accepted 19 November 2008
*Corresponding author: Tel.: +49 (0) 451-500-6346; fax: +49 (0) 451-500-6350.
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 2007. 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 and/or prolonged hospital stay.
Key Words: Elderly patient; Thoracic surgery; Lung cancer; Operative mortality
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 [1]. 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.
From 1 January 2004 to 31 July 2007, 242 consecutive patients aged 65 years or older underwent 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 65–69 years (Group 1),  70–74 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 was performed using the impaired-samples t-test for mean values. The results are presented as mean values±S.D. unless otherwise stated. The 2-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.
A total of 242 patients were treated from January 2004 to July 2007. Of these patients, 143 (59%) were men and 99 (41%) were women with a mean age of 69.97 years (±5.5 S.D.) and 69.56 years (±4.9), respectively. The group of 65–69-year-olds (Group 1) was the largest group, accounting for 55% of the patient population (n=133/78 male, 55 female), while Groups 2 and 3 were almost identical in size at 23.1% (n=56/32 male, 24 female) and 21.9% (n=53/33 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 (n=170) were electively treated, and 30% (n=72) 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% (13/72). The overall mortality of all patients (n=242) was 9.5%. In patients who underwent elective surgery (n=170), mortality was 2.4%, while in emergency cases (n=72) the mortality increased to 26.4% (P<0.0001). 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 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 65–69-year-olds (Group 1) who underwent emergency surgery. In this group, a fatal outcome could be statistically expected in 3.8 patients, whereas in fact 11 patients died (P<0.0001) (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 2 7.1 and group 3 10.7. Patients with up to 12 secondary diagnoses (n=187) 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, R=0.54). 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 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 (n=196) was 4.6% compared with 30.4% for patients with more than 12 co-morbidities (n=46) (P=0.001, 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%).
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).
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% [2] and a mortality of 2–12% [3] 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 low-volume hospital) differ widely. Some previous studies emphasize the importance not only of nicotine abuse [4], but also of impaired preoperative lung function [5], cardiac co-morbidity and especially age [6] 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 co-morbidities. 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. [7] 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 [8]. Previous studies suggested that general health and disorders existing prior to surgery can crucially influence perioperative outcome [9]. 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 [10]. 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 [11]. 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 [12]. 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 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 [13]. 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 [14]. 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.
The authors wish to thank Prof Dr M. Hüppe, MD, PhD, Department of Anaesthesiology, for his contributions in statistical analysis.
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Abstract
1. Introduction
