Lung surgery in elderly patients: are we doing enough?

Predictors associated with Clavien-Dindo complications in lung cancer surgery: A retrospective cohort study

BACKGROUND

To highlight the risk assessment tool associated with postoperative cardiopulmonary complications of Clavien-Dindo (CD) ≥ II in elderly patients who underwent lung cancer surgery.

METHODS

In patients ≥ 60 years admitted during 2020-2023 and having undergone lung cancer surgery, postoperative cardiopulmonary complications were examined using the CD classification as groups (CD grade I versus ≥ II), and the risk factors were analyzed using logistic regression and receiver operating characteristic (ROC) curves.

RESULTS

Of the 239 elderly patients, 29.3% had postoperative complications (CD ≥ II). Subgroup analysis revealed that patients aged ≥70 years had a higher rate of postoperative complications compared to those aged 60-69 years, however, this relationship was not statistically significant in the multivariable model (OR: 2.03, 95% CI: 0.95-4.36, p = 0.068). The CD grade ≥ II group had longer surgical time (p = 0.002), greater postoperative pulmonary complications (p < 0.001), and longer length of hospital stay (p < 0.001); CD grade ≥ II was more likely in patients with older age (odds ratio [OR]: 1.08, 95% confidence interval [CI]: 1.02-1.15, p = 0.011), COPD (OR: 4.41, 95% CI: 1.55-13.44, p = 0.005) and smoking history (OR: 2.85, 95% CI: 1.12-7.24, p = 0.028), having undergone pneumonectomy (OR: 14.89, 95% CI: 1.71-334.9, p = 0.045), and who converted to open thoracotomy (OR: 16.33, 95% CI: 2.13-169.71, p = 0.007). The area under the ROC curve was 0.81.

CONCLUSIONS

Older age (≥70 years) is associated with higher rates of postoperative complications (CD classification ≥ II) but is not an independent predictor when adjusting for other factors. Comorbidities such as COPD and surgical factors, including pneumonectomy and conversion to thoracotomy, are significant contributors. These findings emphasize the need for comprehensive, multifactorial risk assessments to guide perioperative management and improve outcomes in elderly lung cancer patients.

Long-term Dependency in Older Adults After Surgery or Stereotactic Body Radiation Therapy for Stage I Non-Small Cell Lung Cancer

OBJECTIVE

To examine long-term healthcare dependency outcomes of stereotactic body radiation therapy (SBRT) to surgery for older adults with stage I non-small cell lung cancer (NSCLC).

BACKGROUND

SBRT is an emerging alternative to surgery in patients with early-stage lung cancer. There remains a paucity of prospective studies comparing these modalities, especially with respect to long-term dependency outcomes in older adults with lung cancer.

METHODS

Adults 70 years old and above with stage I NSCLC treated with surgery or SBRT from January 2010 to December 2017 were analyzed using 1:1 propensity score matching. Homecare use, days at home, and time spent alive and at home were compared. E-value methods assessed residual confounding.

RESULTS

A total of 1129 and 2570 patients underwent SBRT and surgery, respectively. In all, 1016 per group were matched. SBRT was associated with a higher overall risk of homecare utilization [hazard ratio (HR)=1.75, 95% confidence interval (CI): 1.37-2.23] than surgery up to 5 years following treatment. While the hazards of death or nursing home admission were lower in the first 3 months after SBRT (HR=0.55, 95% CI: 0.36-0.85), they became consistently higher beyond this period and remained high up to 5 years compared with surgery (HR=2.13; 95% CI: 1.85-2.45). The above findings persisted in stratified analyses for frail patients and those with no pretreatment homecare. E-values indicated it was unlikely that the observed estimates could be explained by unmeasured confounders.

CONCLUSIONS

Surgery offers robust long-term dependency outcomes compared with SBRT. These are important patient-centered endpoints which may be used for counseling and shared decision-making in older adults with stage I NSCLC.

Making a Painless Drain: Proof of Concept

Chest tubes account for a large proportion of postoperative pain after cardiothoracic operations. The objective of this study was to develop a novel, cost-effective, easy-to-use, lidocaine-eluting coating to reduce pain associated with postoperative chest tubes. A lidocaine-eluting hydrogel was developed by dispersing lidocaine-loaded nanoparticles in an aqueous solution containing gelatin (5%). Glutaraldehyde (1%) was added to crosslink the gelatin into a hydrogel. The hydrogel was dehydrated, resulting in a thin, stable polymer. Sterile lidocaine hydrogel-coated silicone discs and control discs were prepared and surgically implanted in the subcutaneous space of C57B6 mice. Using von Frey filaments, mice underwent preoperative baseline pain testing, followed by pain testing on post-procedure day 1 and 3. On post-procedure day 1, mice implanted with control discs demonstrated no change in pain tolerance compared to baseline, while mice implanted with 20 mg and 80 mg lidocaine-loaded discs demonstrated a 2.4-fold (P = 0.36) and 4.7-fold (P = 0.01) increase in pain tolerance, respectively. On post-procedure day 3, mice implanted with control discs demonstrated a 0.7-fold decrease in pain tolerance compared to baseline, while mice implanted with 20 mg and 80 mg lidocaine-loaded discs demonstrated a 1.8-fold (P = 0.88) and 8.4-fold (P = 0.02) increase in pain tolerance, respectively. Our results demonstrate successful development of a lidocaine-eluting chest tube with hydrogel coating, leading to improved pain tolerance in vivo. The concept of a drug-eluting drain coating has significant importance due to its potential universal application in a variety of drain types and insertion locations.

Pneumonectomy for lung cancer in the elderly: lessons learned from a multicenter study

Background

60% of patients diagnosed with lung cancer are older than 65 years and are at risk for substandard treatment due to a reluctance to recommend surgery. Pneumonectomy remains a high risk procedure especially in elderly patients. Nevertheless, the impact of age and neoadjuvant treatment on outcomes after pneumonectomy is still not well described.

Methods

We performed a multicentric retrospective study, analyzing outcomes of patients older than 70 years who underwent pneumonectomy for central primary lung malignancy between January 2009 and June 2019 in 7 thoracic surgery departments: Lucerne and Bern (Switzerland), Hamilton (Canada), Alicante (Spain), Monza (Italy), London (UK), Leuven (Belgium). Survival was estimated with Kaplan-Meier, and differences in survival were determined by log-rank analysis. We investigated pre- and post-operative prognostic factors using Cox proportional hazards regression model; multivariable analysis was performed only with variables, which were statistically significant at the invariable analysis.

Results

A total of 136 patients were included in the study. Mean age was 73.8 years (SD 3.6). 24 patients (17.6%) had an induction treatment (chemotherapy alone in 15 patients and chemo-radiation in 9). Mean length of stay (LOS) was 12.6 days (SD 10.39) and 74 patients (54.4%) had experienced a post-operative complication: 29 (21.3%) had a pulmonary complication, 33 (24.3%) had a cardiac complication and in 12 cases (8.8%) patients experienced both cardiac and pulmonary complications. 16 patients were readmitted [median LOS 13.7 days (range, 2–39 days)] and of those 14 (10.3%) required redo surgery. Median overall survival (OS) of the entire cohort was 38 months (95% CI: 29.9–46.1 months); in-hospital mortality was 1.5%, 30-day mortality rate was 3.7%, while 90-day mortality was 8.8% accounting for 5 and 12 patients respectively. Patients receiving neo-adjuvant therapy did not experience a higher incidence of postoperative complications (P=0.633), did not have a longer postoperative course (P=0.588), nor did they have an increased mortality rate (P=0.863).

Conclusions

Age should not be considered an absolute contraindication for pneumonectomy in elderly patients even after neoadjuvant treatment. It has become apparent that especially in these patients, a patient-tailored approach with a careful selection should be used to define the risk-benefit balance.