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Ann Thorac Surg 1997;63:1405-1409
© 1997 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Improved Results in the Management of Surgical Candidates With Lung Cancer

Sections of Thoracic Surgery and Pulmonology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma

	Abstract

Top Footnotes Abstract Introduction Material and Methods Perioperative Management High-Risk Subgroup Pathology Results Comment Acknowledgments References

 
Background. Perioperative mortality and morbidity after lung resection for carcinoma are generally reported to be 3% to 6% and 15% to 30%, respectively, and higher in the elderly and those with limited cardiopulmonary reserve.

Methods. To minimize this risk and extend the surgical option to more high-risk patients, we adopted a protocol in 1991 that included preoperative digitalis, subcutaneous heparin and venoocclusive stockings, aggressive perioperative pulmonary toilet, and video-directed limited resections for many patients with limited pulmonary reserve. In October 1996, we reviewed our results with 173 consecutive patients (median age, 60 years; range, 17 to 89 years) undergoing operation for suspected lung carcinoma. Forty-one patients were 70 years old or older, and 70 patients were considered high risk on the basis of advanced age (70 years), poor cardiac or pulmonary reserve, or serious medical comorbidity. Procedures included pneumonectomy (n = 31), lobectomy (n = 83), bilobectomy (n = 12), and limited resection (n = 45). Two patients had unresectable disease.

Results. Hospital mortality was 1.6% (3/173) and morbidity was experienced by 15% (26/173). Among the high-risk subgroup mortality was 4.2% (3/70) and morbidity was 20% (14/70; p < 0.03). For the older patients these values were 4.8% (2/41) and 17.9% (7/41), respectively.

Conclusions. Morbidity and mortality from lung resections may be minimized with the perioperative management strategy outlined above. This would allow more high-risk patients to benefit from surgical resection, and do so with an acceptably low risk.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Perioperative Management High-Risk Subgroup Pathology Results Comment Acknowledgments References

 
See also page 1409.

Pulmonary resection is the most effective method of controlling the local disease in patients with bronchial carcinomas, and is the only treatment consistently associated with cure. Although current operative and anesthetic techniques have resulted in significantly improved outcome [1, 2], mortality and morbidity after lung resection for carcinoma are still high: 4% to 6% and 20% to 40%, respectively [1, 3–6], and higher in the elderly and other high-risk patients [3, 7]. Postoperative morbidity is mostly related to respiratory complications, pulmonary embolism, myocardial infarction, and arrhythmias [1, 4, 8].

In 1991 we adopted a management strategy that we hoped would minimize the causes of perioperative complications and allow us to extend the benefit of surgical resection to more patients with suspected lung carcinoma. In this article we review our results with this strategy.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Perioperative Management High-Risk Subgroup Pathology Results Comment Acknowledgments References

 
Patient Population
Between June 1991 and September 1996, 173 consecutive patients with proven lung cancer or indeterminate lung masses suspicious for lung cancer underwent pulmonary resection at the Oklahoma University Health Sciences Center. All operations were performed by or supervised by one of two surgeons (C.K.-C., n = 129; and since 1994, C.E.H., n = 44) who followed the same management philosophy. Many patients were second or third opinion referrals, having been previously considered inoperable on the basis on insufficient cardiopulmonary reserve. The median age of the patients was 60 years (range, 17 to 89 years). There were 132 male and 41 female patients. Sixty-five patients were veterans.

The operation reports, discharge summaries, and patient records were retrospectively reviewed and a data base established that included all complications experienced during the initial hospital stay or within 30 days of operation. Blood gas analyses, lung function tests, and split lung function tests were reviewed and recorded. Pathology reports were reviewed and used to stage the disease in patients with primary lung carcinoma. Dichotomous variables were compared using ², Fisher's exact test, or both, with a p value less than 0.05 considered significant.

Hospital mortality includes 30-day mortality and death prior to discharge. Morbidity includes all complications occurring during the initial hospitalization or within 30 days of operation. Morbidity was grouped as (1) reoperations for bleeding; (2) respiratory complications, including air leaks (>7 days), ventilation greater than 24 hours or need for reintubation, atelectasis requiring bronchoscopy, pulmonary and pleural space infections; (3) cardiac arrhythmias and infarction; (4) pulmonary embolism; (5) wound complications; and (6) anesthetic complications.

	Perioperative Management

Top Footnotes Abstract Introduction Material and Methods Perioperative Management High-Risk Subgroup Pathology Results Comment Acknowledgments References

 
The management plan adopted in May 1991 included (1) preoperative bronchodilators, subcutaneous heparin and venosupportive stockings, digitalization for patients with poor pulmonary reserve and those needing pneumonectomy, and pulse intravenous steroids for patients with obstructive lung disease and poor pulmonary reserve; (2) intraoperative rigid bronchoscopy and bronchial toilet before thoracotomy, muscle-sparing incisions when possible, video-directed limited incisions and limited resections (wedge resections or segmentectomies) in patients with poor cardiopulmonary reserve, supplemental intravenous nonsteroidal analgesics, long-acting intercostal nerve blockade, and limited intravenous fluid administration; and (3) postoperative early extubation, patient-controlled analgesia, aggressive bronchial toilet with fiberoptic bedside bronchoscopy and suctioning, early ambulation, and prolonged low-flow nasal oxygen supplementation.

In patients with poor pulmonary reserve and those in whom a limited resection was planned (wedge resection or segmentectomy), the thoracoscope was first inserted and the lesion identified. If the lesion could not be removed thoracoscopically, a limited counterincision was made directly over the pulmonary lesion, and the lesion was resected under direct vision with minimal spreading of the ribs.

	High-Risk Subgroup

Top Footnotes Abstract Introduction Material and Methods Perioperative Management High-Risk Subgroup Pathology Results Comment Acknowledgments References

 
Seventy patients (70/173; 40.4%) were considered to be at higher risk for mortality or morbidity either on the basis of age greater than 70 years (n = 41) or poor pulmonary reserve (n = 18: preoperative forced expiratory volume in 1 second [FEV₁] 1.5 L, or needing home oxygen or steroids preoperatively); 7 patients had decreased cardiac reserve (previous cardiac operation, preoperative percutaneous transluminal coronary angioplasty or coronary bypass grafting, congestive cardiac failure). Other "high-risk" patients include those with previous laryngectomy with or without esophagectomy (n = 6), previous high-dosage (>50 Gy) radiation therapy (n = 6), generalized debilitation and paraneoplastic syndromes (n = 4), or a combination of factors. Four patients were greater than 80 years old.

Certain patients posed unusual challenges: one 73-year-old man had a heavily calcified hemithorax, major hemoptysis, previous tuberculosis with empyema 38 years earlier, and a lung mass with sputum cytology suggestive of bronchial carcinoma (Fig 1). A sternal saw was required to resect a 10 x 4-cm rectangle of chest wall through which a pneumonectomy could be performed. Because the chest wall defect could not be closed, he was left with a permanent Eloessor flap.

View larger version (140K): [in this window] [in a new window]   Fig 1. . Preoperative chest roentgenogram of a 73-year-old high-risk patient needing a pneumonectomy. The heavily calcified chest wall needed to be opened with a sternal oscillating saw.

View larger version (89K): [in this window] [in a new window]   Fig 2. . (A) Preoperative computed tomographic scan in a 71-year-old woman with a preoperative forced expiratory volume in 1 second of 740 mL, receiving steroids and continuous home oxygen, with a squamous cell carcinoma of the right lower lobe, 5 years after left upper lobectomy for small cell carcinoma. (B) Immediate postoperative chest roentgenogram of the same patient showing complete collapse of contralateral lung, which occurred during attempted one-lung ventilation.

	Pathology

Top Footnotes Abstract Introduction Material and Methods Perioperative Management High-Risk Subgroup Pathology Results Comment Acknowledgments References

 
One hundred thirty patients had primary bronchial carcinoma (adenocarcinoma in 53, squamous in 58, large cell in 8, adenosquamous in 2, bronchoalveolar in 3, carcinoid in 3, and small cell in 3), 15 had metastatic lung carcinoma, and 28 had an inflammatory cause, for example, granulomas. Of the primary lung cancers 70 were stage I, 33 were stage II, 22 were stage IIIA, and 3 were stage IIIB.

Pneumonectomy was done in 31, bilobectomy in 12, lobectomy in 83, and limited resection in 45 patients. Included are 3 en-bloc chest wall resections, 2 sleeve resections, and 2 patients in whom lobectomies and additional wedge resections were performed for synchronous lesions. Two patients had unresectable disease at thoracotomy.

	Results

Top Footnotes Abstract Introduction Material and Methods Perioperative Management High-Risk Subgroup Pathology Results Comment Acknowledgments References

 
Hospital mortality was 1.7% (3/173). This was 3.2% (1/31) for pneumonectomy, 1.0% for lobectomy or bilobectomy (1/95), and 2.2% (1/45) for limited resection. For the high-risk subgroup mortality was 2.8% (2/70), and for those 70 years old or older this was 4.8% (2/41; p = not significant).

The first death occurred in a 62-year-old woman with an FEV₁ of 920 mL, vital capacity of 1.8 L, forced expiratory flow at 50% of forced vital capacity 21% of predicted, and maximum ventilatory volume 36% of predicted. She died suddenly of an acute myocardial infarction the night before her planned discharge on postoperative day 6. She was fully ambulant after right upper lobectomy, but had complained of vague chest pains postoperatively; these were associated with atrial tachyarrhythmias and were erroneously interpreted as "pericarditis" on the basis of electrocardiograms, echocardiogram, and cardiac output studies. The second death occurred intraoperatively when the main pulmonary artery was divided during a difficult left pneumonectomy for a large central carcinoma that had infiltrated the pericardium. The final death occurred 10 days postoperatively in a patient with poor pulmonary reserve (FEV₁ = 1.28 L) who underwent a limited resection for a carcinoid tumor of the lung. Dense pleural adhesions complicated the operation and resulted in a contained pleural hematoma; pneumonia and respiratory failure subsequently developed, and the patient died about 2 weeks later.

Morbidity occurred in 15.0% of patients (26/173):

This was 22.5% (7/31) for pneumonectomy, 15.7% (15/95) for lobectomy, and 8.9% (4/45) for limited resection. Among the high-risk subgroup, morbidity was 20.0% (14/70) versus 11.6% (12/103) for the rest (p = not significant). Almost half of the experienced complications were probably avoidable (12/26), these include 4 anesthetic complications, 5 reoperations for bleeding, and 3 bronchial stump dehiscences. The latter occurred early postoperatively in 3 pneumonectomy patients soon after the introduction of an unfamiliar bronchial stapler on which the staple height needed to be manually adjusted. All patients survived drainage and reclosure of the bronchus stump. Since we have changed staplers this complication has not recurred.

The anesthetic complications included radial artery thrombosis and hand ischemia after arterial line placement, inadvertent bilateral tension pneumothoraces after injudicious jet ventilation during a difficult intubation, and complete contralateral lung atelectasis immediately after one-lung anesthesia. The final anesthetic complication occurred in an 83-year-old patient in whom morphine epidural anesthesia resulted in postoperative ileus and aspiration pneumonia.

Cardiac arrhythmias occurred in 7 patients (4.0%; 7/173) and resulted in myocardial infarction and death in one. Pulmonary complications occurred in 8.0% (14/173) and included pulmonary embolism in 1, adult respiratory distress syndrome and ventilation in 3, pneumonia and atelectasis requiring bronchoscopy in 4, and prolonged air leak from the chest tubes in 6 patients.

	Comment

Top Footnotes Abstract Introduction Material and Methods Perioperative Management High-Risk Subgroup Pathology Results Comment Acknowledgments References

 
Surgical resection is the best treatment for lung carcinoma localized to the chest. Since the lung function criteria for pulmonary resection were published by Olsen and Block in 1973 [9], many authors have liberalized these selection criteria to allow more patients the benefit of resection. The value of clinical judgement in selecting patients has been emphasized [2], using the predicted postresection FEV₁ and forced vital capacity rather than the preoperative values has gained favor [1–4], and the diffusing capacity of carbon monoxide [10, 11] has been used to predict outcome and morbidity after resection, all with varying and contradictory significance. More recently, the cardiac right ventricular function at rest and with exercise has been used to predict morbidity [5, 12, 13].

Despite these preoperative assessments, the mortality and morbidity following major lung resections are still significant: 5% to 8% and 25% to 40% for pneumonectomy and 2% to 4% and 15% to 25% for lobectomy, respectively [1, 3–6], and 9% to 15% and 30% to 50% in the elderly and other high-risk patients [3, 7]. The causes of both morbidity and mortality relate to cardiac causes, respiratory complications, and pulmonary embolism [1, 4, 8, 14, 15]. Among the cardiac complications, arrhythmias are reported to occur in about 25% of patients and are associated with death in a quarter of those undergoing pneumonectomy [2, 8]. Factors associated with these arrhythmias are intrapericardial resection and administration of greater than 2.0 L of fluid during the operation.

Instead of attempting to minimize our complications through a more vigorous selection process, we elected to acknowledge the common causes of complications and introduce a management strategy designed to reduce these risks: preoperative digitalization, subcutaneous heparin, and venoocclusive stockings. Continuing this until the patient was fully mobilized and limiting intraoperative fluid administration would hopefully reduce the incidence of arrhythmias, other cardiac complications, and pulmonary emboli. The incidence of cardiac complications including arrhythmias in our patients was 4.0% (7/173), less than the 12% to 25% that we had anticipated from comparable series [4, 8]. For pneumonectomy patients this was 9.6% (3/31).

The only documented instance of pulmonary embolism occurred in a young man with metastatic pulmonary malignant melanoma who was receiving warfarin preoperatively for recurrent deep venous thrombosis. Despite our measures, postoperative thrombosis of the iliac veins and pulmonary embolism developed before therapeutic warfarin levels could be achieved postoperatively.

Preoperative antibiotics and bronchodilator breathing treatments, rigid bronchoscopy and bronchial toilet before insertion of the double-lumen tube, and aggressive postoperative care were designed to reduce postoperative pulmonary complications. The incidence of pulmonary complications was 10.4% (18/173), favorably comparable with other series. It is difficult to know to what degree this management strategy contributed to this very acceptable incidence.

Anesthetic complications and reoperations for bleeding may be considered "random" and unrelated to management protocols, and in many cases avoidable. Likewise the three bronchial dehiscences resulted from operator/equipment failure: these occurred within a short time interval and, once recognized and corrected with the help of the manufacturers, have not recurred. Early in our experience we observed that elderly patients seemed more prone to postoperative ileus if an epidural analgesia was used, and that this was very poorly tolerated in those with poor pulmonary reserve; in at least one instance this resulted in aspiration pneumonia. Therefore, in contrast to other recent reports [1, 2], we have not used epidural analgesia much, relying more on nonsteroidal analgesics, the administration of which we start intraoperatively, combined with long-acting intercostal nerve blockade and patient-controlled analgesic infusions. Pain scores are consistently less than or equal to 6/10 with this analgesic regimen, and respiratory efforts are very acceptable as judged by incentive spirometry. We have learned that minimal spreading of the ribs during thoracotomy, initiation of the nonsteroidal analgesia early in the operation (usually before opening the chest), and loosely approximating the periosteal ribs sutures are all important in minimizing postoperative pain.

In summary, with proactive anticipation of the common causes of perioperative morbidity and an attempt to minimize these risks through a concerted effort using the expertise of surgeon, anesthesiologist, pulmonologist, and respiratory therapist, surgical resection may be offered to a wider selection of patients with limited lung carcinoma with a lower expected mortality and morbidity than that which is usually encountered.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Perioperative Management High-Risk Subgroup Pathology Results Comment Acknowledgments References

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Perioperative Management High-Risk Subgroup Pathology Results Comment Acknowledgments References

 
Presented at the Forty-third Annual Meeting of the Southern Thoracic Surgical Association, Cancun, Mexico, Nov 7–9, 1996.

Address reprint requests to Dr Knott-Craig, Department of Thoracic Surgery, University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190.

This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals

	References

Top Footnotes Abstract Introduction Material and Methods Perioperative Management High-Risk Subgroup Pathology Results Comment Acknowledgments References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Christopher J. Knott-Craig C. Eric Howell Billy D. Parsons Ronald C. Elkins Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Knott-Craig, C. J. Articles by Elkins, R. C. Search for Related Content PubMed PubMed Citation Articles by Knott-Craig, C. J. Articles by Elkins, R. C. Related Collections Related Article