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. 2021 Apr;12(3):416-421.
doi: 10.1016/j.jgo.2020.09.016. Epub 2020 Sep 23.

Opportunities for quality improvement in the morbidity pattern of older adults undergoing pulmonary lobectomy for cancer

Luis E De León  1 , Matthew M Rochefort  2 , Carlos E Bravo-Iñiguez  2 , Sam W Fox  2 , Jeffrey N Tarascio  2 , Kristin Cardin  3 , Clark DuMontier  3 , Laura N Frain  3 , Michael T Jaklitsch  2
Affiliations

Opportunities for quality improvement in the morbidity pattern of older adults undergoing pulmonary lobectomy for cancer

Luis E De León et al. J Geriatr Oncol. 2021 Apr.

Abstract

Background: There is limited information on the frequency of complications among older adults after oncological thoracic surgery in the modern era. We hypothesized that morbidity and mortality in older adults with lung cancer undergoing lobectomy is low and different than that of younger patients undergoing thoracic surgery.

Methods: All patients undergoing lobectomy at a large volume academic center between May 2016 and May 2019 were included. Patients were prospectively monitored to grade postoperative morbidity by organ system, based on the Clavien-Dindo classification. Patients were divided into two groups: Group 1 included patients 65-91 years of age, and Group 2 included those <65 years.

Results: Of 680 lobectomies in 673 patients, 414(61%) were older than 65 years of age (group 1). Median age at surgery was 68 years (20-91). Median hospital stay was 4 days (1-38) and longer in older adults. Older adults experienced higher rates of grade II and IV complications, mostly driven by an increased incidence of delirium, atrial fibrillation, prolonged air leak, respiratory failure and urinary retention. In this modern cohort, there was only 1 stroke (0.1%), and delirium was reduced to 7%. Patients undergoing minimally invasive (MI) surgery had a lower rate of Grade IV life-threatening complications. Older adults were more likely to be discharged to a rehabilitation facility, however this difference also disappeared with MI surgical procedures.

Conclusions: Current morbidity of older adults undergoing lobectomy for cancer is low and is different than that of younger patients. Thoracotomy may be associated with postoperative complications in these patients. Our findings suggest the need to consider MI approaches and broad-based, geriatric-focused perioperative management of older adults undergoing lobectomy.

Keywords: Lobectomy; Minimally invasive surgery; Morbidity; Older adult; Oncology outcomes; Postoperative outcomes; Thoracic surgery.

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Conflict of interest statement

Declaration of Competing Interest Drs. De León, Bravo-Iñiguez, Fox, Tarascio, Cardin, Frain and Jaklitsch have nothing to disclose. Dr. DuMontier is supported by the Harvard Translational Research in Aging Training Program (National Institute on Aging of the National Institutes of Health: T32AG023480).

Figures

Fig. 1.
Fig. 1.
Morbidity stratified by age and surgical approach. Older adults who received minimally invasive surgery had lower rates of complications in comparison with older adults who underwent thoracotomies. The rate of complications of older adults undergoing minimally invasive surgery is comparable to that of patients younger than 65 years undergoing thoracotomy for lobectomy.
Fig. 2.
Fig. 2.
Morbidity stratified by age, surgical approach and grade of complication based on the Clavien-Dindo classification. Patients <65 years of age undergoing minimally invasive lobectomies had the lowest rate and severity of complications. The rate of Grade III and IV complications in patients ≥65 years of age undergoing lobectomies through a thoracotomy was 20% and 11%, respectively. These rates are over 3 times higher when compared to older adults undergoing lobectomy through a minimally invasive approach. Morbidity of older adults undergoing minimally invasive surgery, is comparable to younger patients undergoing thoracotomy.
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