Mortality, complications and loss of pulmonary function after pneumonectomy vs. sleeve lobectomy in patients younger and older than 70 years

ARTICLE IN PRESS doi:10.1510/icvts.2008.182279 Interactive CardioVascular and Thoracic Surgery 7 (2008) 986–989 www.icvts.org Institutional report - Thoracic general Mortality, complications and loss of pulmonary function after pneumonectomy vs. sleeve lobectomy in patients younger and older than 70 years Division of Thoracic and Vascular Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland b Division of Pneumology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland c Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland d Department of Anaesthesiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland a Received 22 April 2008; received in revised form 12 June 2008; accepted 17 June 2008 Abstract Retrospective single institution analysis of all patients undergoing sleeve lobectomy or pneumonectomy between 2000 and 2005. Seventyeight patients underwent pneumonectomy (65 patients -70 years, 13 patients )70 years) and 69 sleeve lobectomy (50 patients -70 years, 19 patients )70 years). Pre-existing co-morbidity, surgical indication and induction therapy was similarly distributed between treatment by age-groups. In patients -70 years, pneumonectomy and sleeve lobectomy resulted in a 30-day mortality of 3% vs. 0 and an overall complication rate of 26% vs. 44%, respectively. In patients )70 years, pneumonectomy and sleeve lobectomy resulted in a 30-day mortality of 15% vs. 0 and an overall complication rate of 23% vs. 32%. In both age groups, pneumonectomy was associated with more airway complications (NS) and a significantly higher postoperative loss of FEV1 than sleeve lobectomy (P-0.0001, P-0.03). Age per se did not influence the loss of FEV1 and DLCO for a given type of resection. Sleeve lobectomy may have a therapeutic advantage over pneumonectomy in the postoperative course of elderly patients. 䊚 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Age; Pneumonectomy; Sleeve lobectomy; Pulmonary function; Morbidity; Mortality 1. Introduction A recently published meta-analysis has demonstrated no significant difference in postoperative morbidity, mortality, recurrence rate and survival after pneumonectomy and sleeve lobectomy in patients with NSCLC w1x. Since major resections are increasingly performed in elderly patients w2–5x, sleeve resections may be particularly useful in this age group in order to decrease the risk of postoperative mortality and complications while preserving lung function and quality of life. However, there are actually no data available which specifically compare the postoperative risk and loss of pulmonary function of pneumonectomy and sleeve lobectomy in different age populations. In this retrospective single institution study of patients treated between 2000 and 2005, we assessed postoperative mortality, complications and loss of pulmonary function after pneumonectomy vs. sleeve resection in patients less than and in patients more than 70 years old. 2. Patients and methods All patients qualifying for major pulmonary resection underwent preoperative pulmonary and cardiac evaluation *Corresponding author. Tel.: q41 21 314 24 08; fax: q41 21 314 23 58. E-mail address: (H.-B. Ris). 䊚 2008 Published by European Association for Cardio-Thoracic Surgery according to the algorithm of Bolliger w6x and Miller w7x, respectively. Patients with predicted FEV1 and DLCO of -80% underwent exercise testing and patients with VO2 max of -20 mlykgymin had split function testing by ventilationyperfusion scan; resection was performed if a postoperative predicted VO2 max of G10 mlykgymin was obtained. All patients )50 years and those with a history of heart disease underwent echocardiography and those with signs of ischemia myocardium scintigraphy or stress echocardiography. Resection was performed in the absence of signs of reversible ischaemia and preserved left ventricular function. Continuous peridural anaesthesia was offered to all patients in the absence of contraindications. Sleeve lobectomy was preferred to pneumonectomy whenever possible. If the extent of the disease required a pneumonectomy, resection was performed in the case of a postoperative predicted VO2 max of G10 mlykgymin and normal echocardiography. All patients had muscle flap coverage of the bronchial stump or airway anastomosis. All patients underwent postoperative avoidance of fluid overload, prevention of atelectasis by early mobilisation and chest physiotherapy, and routine s.c. thrombo-prophylaxis. Patients with pneumonectomy had postoperative oral anticoagulation for three months. Emanuel Melloula, Bernhard Eggerb, Thorsten Kruegera, Cai Chenga, Francois Mithieuxa, Christiane Ruffieuxc, Lennart Magnussond, Hans-Beat Risa,* ARTICLE IN PRESS E. Melloul et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) 986–989 987 Table 1 Patient characteristics according to the surgical procedure and the age at operation Pneumonectomy Co-morbidities (total) COPD Coronary artery disease Obesity Diabetes NSCLC1 Induction therapy Right-sided pneumonectomy P-value Sleeve lobectomy -70 years ns65 (%) )70 years ns13 (%) -70 years ns50 (%) )70 years ns19 (%) 35 26 8 6 8 75 25 49 62 46 15 0 15 85 8 15 40 32 12 4 6 79 12 – 58 26 32 16 11 79 21 – 0.2 0.5 0.06 0.3 0.6 0.7 0.2 0.03 Non-small cell lung cancer. 1 The charts of all patients undergoing sleeve lobectomy or pneumonectomy between 1 January 2000 and 30 June 2005 were revisited. Pre-existing co-morbidities, indications for surgery, induction therapy and side of pneumonectomy were noted for each patient as well as 30-day mortality and major postoperative morbidity including pneumonia, myocardial infarction, congestive heart failure, pulmonary embolism, cerebro-vascular accidents, airway dehiscence, broncho-pleural fistula, empyema or infections of the thoracotomy site. Minor complications were excluded such as atelectasis requiring -2 bronchoscopies, non-infected pleural effusion, residual air space, infections at the site of chest tubes and arrhythmias responding to medical therapy w8x. Postoperative pulmonary function testing (FEV1, DLCO) performed between 3 and 6 months after the operation were recorded and were compared to preoperative values. 2.2. Statistical analysis The x2 and Fisher’s exact-test were used to determine differences in proportions. The Wilcoxon test was used to test the differences in loss of FEV1 and DLCO. Two-sided P-values -0.05 were considered significant. 3. Results One hundred and forty-three patients underwent pneumonectomy or sleeve resection at our institution between 1 January 2000 and 30 June 2005. Seventy-eight patients underwent pneumonectomy, 65 patients were younger and 13 patients older than 70 years at the time of operation. Sixty-nine patients underwent sleeve lobectomy, 50 patients were younger and 19 older than 70 years. NSCL (...truncated)