HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) 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): Hisao Asamura Kenji Suzuki Ryosuke Tsuchiya Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Watanabe, S.-i. Articles by Tsuchiya, R. Search for Related Content PubMed PubMed Citation Articles by Watanabe, S.-i. Articles by Tsuchiya, R. Related Collections Lung - cancer Related Article

Ann Thorac Surg 2004;78:999-1002
© 2004 The Society of Thoracic Surgeons

---

Original article: general thoracic

Recent results of postoperative mortality for surgical resections in lung cancer

^a Division of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan

Accepted for publication April 1, 2004.

^* Address reprint requests to Dr Watanabe, Division of Thoracic Surgery, National Cancer Center Hospital, Tokyo 104-0045, Japan
syuwatan{at}ncc.go.jp

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
BACKGROUND: Changes in the postoperative mortality rates and causes of death for lung cancer surgery at the specialized hospital for cancer in Tokyo, Japan during the last 16 years were investigated.

METHODS: Data on 3,270 consecutive patients who underwent pulmonary resection for primary lung cancer between January 1987 and December 2002 at the National Cancer Center Hospital were retrospectively analyzed. The postoperative 30-day and in-hospital mortality rates and causes of death after pulmonary resection for lung cancer were investigated. Patients were divided into two period groups of almost equal number, the early (1,615 patients from 1987 to 1996) and the late (1,655 patients from 1997 to 2002) periods.

RESULTS: Fifty-eight operative and postoperative deaths occurred during the last 16 years. Thirty-day and in-hospital mortality were 0.6% (21/3,270) and 1.6% (58/3,270), respectively. During the last 6-year period, 30-day and in-hospital mortality were 0.5% (8/1,655) and 0.8% (21/1,655), respectively. The difference was significant between the 30-day/in-hospital mortality for pneumonectomy (3.1%/5.9%) and lobectomy (0.3%/1.3%) (p < 0.0001/p < 0.0001). The difference in mortality between lobectomy and segmentectomy or a lesser resection was not significant. The 58 deaths were caused by pneumonia/acute respiratory distress syndrome (ARDS) (36%, n = 21), bronchopleural fistula (BPF)/empyema (33%, n = 19), cerebrovascular accident (10%, n = 6), cardiac-related event (7%, n = 4), and others (14%, n = 8). The most frequent cause of death in the early period was BPF/empyema (18/45, 40%), while that in the late period was pneumonia/ARDS (6/13, 46%). Among the pneumonia/ARDS deaths in the late period (n = 6), 5 (83%) were due to acute deterioration of interstitial lung disease after lobectomy.

CONCLUSIONS: Recent postoperative mortality rates (30-day, 0.5%; in-hospital, 0.8%) in the treatment of lung cancer are quite acceptable. Special care must be taken for the patient after pneumonectomy, as reported by others. Furthermore, even after lobectomy, proper management of the patient with acute deterioration of interstitial lung disease will be required to improve the future outcome.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
A limited number of reports describe postoperative mortality rates in recent decades, and most reports have defined a postoperative death as one that occurs within 30 days after the procedure. However, with the recent developments in postoperative management, many complicated patients survive more than 30 days, and their deaths can be lost in such studies. This study analyzed the change in mortality rates, including both 30-day and in-hospital mortality, after pulmonary resection for lung cancer in the specialized institution for cancer in Tokyo, Japan during the last 16 years.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
A total of 3,270 pulmonary resections for lung cancer between January 1989 and December 2002 at the National Cancer Center Hospital, Tokyo, were studied. The postoperative mortality rates, including 30-day and in-hospital mortality, and causes of death were investigated. Thirty-day mortality was defined as a fatality that occurred within 30 days after pulmonary resection, and in-hospital mortality was defined as a fatality occurring at anytime in a postoperative hospital stay.

The 3,270 patients were divided into two period groups of almost equal number, the early (1,615 patients from 1987 to 1996) and the late (1,655 patients from 1997 to 2002) periods. A variety of analyses were performed to determine the changes in postoperative mortality in the last 16 years and to evaluate the risk factor for surgical resection for lung cancer. The result was compared with results from previous reports describing postoperative mortality in lung cancer surgery.

We normally perform the anatomic pulmonary resection for lung cancer through a standard posterolateral thoracotomy. In pneumonectomy cases, after closure of the main bronchial stump by suturing or stapling, we infold the stump with the membranous portion inside and oversew it with interrupted sutures, as we previously reported [1]. Then we prefer to cover the stump with a pericardial fat pad, especially for a right pneumonectomy. We have basically not used neoadjuvant preoperative therapy except for recent superior sulcus tumor cases.

Statistical analyses using the ² test was performed to evaluate the differences in mortality according to the type of resection.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Fifty-eight operative and postoperative deaths occurred during this period. Thirty-day and in-hospital mortality was 0.5% (21/3,270) and 1.6% (58/3,270), respectively. Among the recent 1,655 patients during the last 6-year period, 30-day and in-hospital mortality was 0.5% (n = 8) and 0.8% (n = 21), respectively (Table 1).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

A limited number of previous reports describe postoperative mortality rates in recent decades, and most reports have defined a postoperative death as one occurring within 30 days after the procedure, as shown in Table 5 [2–8]. However, with the development of postoperative management techniques, complicated patients tend to survive more than 30 days and their deaths can be lost in such studies. We addressed this point by collecting all postoperative in-hospital deaths beyond the 30-day limit.

We believe this may be due to following reasons:

• The detection of early stage cancer is increasing in Japan with the development of CT scanners;
  
• The percentage of pneumonectomy cases markedly decreased;
  
• Perioperative management, including anesthesia, surgical techniques, and cardio-respiratory management, has improved;
  
• Many of our outpatients with a smoking history undergo detailed pulmonary function tests to decide the proper treatment;
  
• A perfusion scan is performed to estimate postoperative pulmonary function in borderline cases;
  
• The preoperative evaluation, such as stress echocardiography, is shared with a medical cardiac consultant to reduce the cardiac complications; and
  
• Great care is taken for diabetic patients not to develop severe complications. The preoperative hospital stay of patients is normally 1 or 2 days; that of diabetic patients is 4 to 7 days, because we strictly control the diabetic status not only after surgery but also before surgery.
  

Others have noted the high operative risk of pneumonectomy. Ginsberg and the LCSG reported a high 30-day mortality of 6.2% for pneumonectomy [2]. We observed a 30-day mortality of 3.1% and an in-hospital mortality of 5.9% for pneumonectomy, which were also significantly higher than for lobectomy. As shown in Table 3, although the mortality of pneumonectomy has not changed, the percentage of pneumonectomy in our resected cases markedly decreased from 16.2% to 5.6%, which contributed to the improvement of our mortality rates. This resulted mainly because of the increasing detection of early stage lung cancer with the development of CT scanners and the aggressive employment of bronchoplasty to avoid pneumonectomy.

As shown in Table 4, the main cause of death shifted from BPF/empyema to pneumonia/ARDS. The decreased incidence of death because of BPF/empyema, which greatly contributed to the improvement of the mortality rate, was the result of two factors. First, as described above, the incidence of pneumonectomy cases is decreasing and consequently, the number of postpneumonectomy BPF has been reduced. Second, we have improved our treatment of BPF/empyema in the late period. We make a chest wall window immediately after BPF develops, even after lobectomy, in order to completely control the infection of the intrathoracic cavity, because massive bleeding from the great vessels due to empyema easily leads to a fatal situation.

Many previous reports have described respiratory complications as a leading cause of death after pulmonary resection [2–5, 9], although none of these have described the detail of the respiratory failure. Among the deaths due to pneumonia/ARDS in our study during the late period, 83% were due to acute deterioration of ILD. All patients who developed ILD exhibited a small interstitial change on preoperative chest CT; therefore, the surgeon should check a preoperative CT to see if the patient has interstitial change and if so, should present the potential risks of acute deterioration of ILD to the patient and his or her family, and special care must be taken on postoperative management. When acute deterioration of ILD develops in the patient, the high-dose administration of steroids may be effective, as reported by Murray and colleagues [10]. Although the effect of this pharmacologic therapy is still controversial [11], an early diagnosis of interstitial pneumonia and the initiation of steroid therapy with mechanical ventilation will be mandatory to ensure survival.

In summary, recent postoperative mortality rates (30-day, 0.5%; in-hospital, 0.8%) in the treatment of lung cancer are quite acceptable. Patients after pneumonectomy showed significant high mortality as previously reported by others. Furthermore, even after lobectomy, proper management of the patient developing acute deterioration of ILD is required to improve the future outcome.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Asamura H, Naruke T, Tsuchiya R, Goya T, Kondo H, Suemasu K. Bronchopleural fistulas associated with lung cancer operations. Univariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg. 1992;104:1456–1464[Abstract]
2. Ginsberg RJ, Hill LD, Eagan RT, et al. Modern thirty-day operative mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg. 1983;86:654–658[Abstract]
3. Deslauriers J, Ginsberg RJ, Piantadosi S, Fournier B. Prospective assessment of 30-day operative morbidity for surgical resections in lung cancer. Chest. 1994;106(6 Suppl):329S–330S[Abstract/Free Full Text]
4. Harpole DH Jr, DeCamp MM Jr, Daley J, et al. Prognostic models of thirty-day mortality and morbidity after major pulmonary resection. J Thorac Cardiovasc Surg. 1999;117:969–979[Abstract/Free Full Text]
5. Wada H, Nakamura T, Nakamoto K, Maeda M, Watanabe Y. Thirty-day operative mortality for thoracotomy in lung cancer. J Thorac Cardiovasc Surg. 1998;115:70–73[Abstract/Free Full Text]
6. Fryjordet A, Klevmark B. Bronchial carcinoma. Results of treatment in 515 patients. Scand J Thor Cardiovasc Surg. 1971;5:92–96[Medline]
7. Weiss W. Operative mortality and five-year survival rates in men with bronchogenic carcinoma. Chest. 1974;66:483–487[Abstract/Free Full Text]
8. Romano PS, Mark DH. Patient and hospital characteristics related to in-hospital mortality after lung cancer resection. Chest. 1992;101:1332–1337[Abstract/Free Full Text]
9. Nagasaki F, Flehinger BJ, Martini N. Complication of surgery in the treatment of carcinoma of the lung. Chest. 1982;82:25–29[Abstract/Free Full Text]
10. Murray JF, Matthay MA, Luce JM, Flick MR. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis. 1988;138:720–723[Medline]
11. Brun-Buisson C, Brochard L. Corticosteroid therapy in acute respiratory distress syndrome: better late than never? JAMA. 1998;280:182–183[Free Full Text]

This article has been cited by other articles:

				S. Limmer, L. Hauenschild, C. Eckmann, R. Czymek, H. Schmidt, H.-P. Bruch, and P. Kujath Thoracic surgery in the elderly - co-morbidity is the limit Interactive CardioVascular and Thoracic Surgery, April 1, 2009; 8(4): 412 - 416. [Abstract] [Full Text] [PDF]

				K. Shimizu, M. Nakata, Y. Hirami, A. Maeda, and K. Tanemoto Recent results regarding the clinical impact of smoking history on postoperative complications in lung cancer patients Interactive CardioVascular and Thoracic Surgery, December 1, 2008; 7(6): 1001 - 1006. [Abstract] [Full Text] [PDF]

				A. Tajima, M. Kohno, M. Watanabe, Y. Izumi, S. Tasaka, I. Maruyama, T. Miyasho, and K. Kobayashi Occult injury in the residual lung after pneumonectomy in mice Interactive CardioVascular and Thoracic Surgery, December 1, 2008; 7(6): 1114 - 1120. [Abstract] [Full Text] [PDF]

				M. Licker, J.-M. Tschopp, J. Robert, J.-G. Frey, J. Diaper, and C. Ellenberger Aerosolized Salbutamol Accelerates the Resolution of Pulmonary Edema After Lung Resection Chest, April 1, 2008; 133(4): 845 - 852. [Abstract] [Full Text] [PDF]

				T.-E. Strand, H. Rostad, R. A M Damhuis, and J. Norstein Risk factors for 30-day mortality after resection of lung cancer and prediction of their magnitude Thorax, November 1, 2007; 62(11): 991 - 997. [Abstract] [Full Text] [PDF]

				N. Alam, B. J. Park, A. Wilton, V. E. Seshan, M. S. Bains, R. J. Downey, R. M. Flores, N. Rizk, V. W. Rusch, and D. Amar Incidence and Risk Factors for Lung Injury After Lung Cancer Resection Ann. Thorac. Surg., October 1, 2007; 84(4): 1085 - 1091. [Abstract] [Full Text] [PDF]

				W. J. Scott, J. Howington, S. Feigenberg, B. Movsas, and K. Pisters Treatment of Non-small Cell Lung Cancer Stage I and Stage II: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition) Chest, September 1, 2007; 132(3_suppl): 234S - 242S. [Abstract] [Full Text] [PDF]

				S. G. Memtsoudis, M. C. Besculides, L. Zellos, N. Patil, and S. O. Rogers Trends in lung surgery: United States 1988 to 2002. Chest, November 1, 2006; 130(5): 1462 - 1470. [Abstract] [Full Text] [PDF]

				T. Maniwa, Y. Saito, H. Kaneda, and H. Imamura Bronchial stump reinforcement with the intercostal muscle flap without adverse effects. Eur. J. Cardiothorac. Surg., October 1, 2006; 30(4): 652 - 656. [Abstract] [Full Text] [PDF]

				T-E Strand, H Rostad, B Moller, and J Norstein Survival after resection for primary lung cancer: a population based study of 3211 resected patients Thorax, August 1, 2006; 61(8): 710 - 715. [Abstract] [Full Text] [PDF]

				D. Feller-Kopman, R. Bechara, R. Garland, A. Ernst, and S. Ashiku Use of a removable endobronchial valve for the treatment of bronchopleural fistula. Chest, July 1, 2006; 130(1): 273 - 275. [Abstract] [Full Text] [PDF]

				O. Schussler, M. Alifano, H. Dermine, S. Strano, A. Casetta, S. Sepulveda, A. Chafik, S. Coignard, A. Rabbat, and J.-F. Regnard Postoperative Pneumonia after Major Lung Resection Am. J. Respir. Crit. Care Med., May 15, 2006; 173(10): 1161 - 1169. [Abstract] [Full Text] [PDF]

				Y. Matsubara, S.-i. Takeda, and T. Mashimo Risk Stratification for Lung Cancer Surgery: Impact of Induction Therapy and Extended Resection Chest, November 1, 2005; 128(5): 3519 - 3525. [Abstract] [Full Text] [PDF]

				P. Lauwers, J. Hendriks, and P. Van Schil Lobectomy of the right lower lobe for lung cancer MMCTS, June 28, 2005; 2005(0628): 59. [Abstract] [Full Text] [PDF]

				J. Hendriks, P. Lauwers, and P. Van Schil Extrapericardial pneumonectomy MMCTS, June 28, 2005; 2005(0628): 83. [Abstract] [Full Text] [PDF]

				S.-i. Watanabe, H. Asamura, K. Suzuki, and R. Tsuchiya Problems in Diagnosis and Surgical Management of Clinical N1 Non-small Cell Lung Cancer Ann. Thorac. Surg., May 1, 2005; 79(5): 1682 - 1685. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) 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): Hisao Asamura Kenji Suzuki Ryosuke Tsuchiya Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Watanabe, S.-i. Articles by Tsuchiya, R. Search for Related Content PubMed PubMed Citation Articles by Watanabe, S.-i. Articles by Tsuchiya, R. Related Collections Lung - cancer Related Article