Enhanced recovery for thoracic surgery in the elderly

[Surgery of old people-Thoracic surgery]

Background

The incidence of a large number of diseases relevant to thoracic surgery increases with age; however, old age is still frequently considered a contraindication per se for curative interventions and extensive surgical procedures.

Objective

Overview of the current relevant literature, derivation of recommendations for patient selection as well as preoperative, perioperative and postoperative optimization.

Material and methods

Analysis of the current study situation.

Results

Recent data show that for most thoracic diseases, age alone is not a reason to withhold surgical treatment. Much more important for the selection are comorbidities, frailty, malnutrition and cognitive impairment. A lobectomy or segmentectomy for stage I non-small cell lung cancer (NSCLC) in carefully selected octogenarians can provide acceptable to even comparably good short-term and long-term results as in younger patients. Selected > 75-year-old patients with stages II-IIIA NSCLC even benefit from adjuvant chemotherapy. With appropriate selection high-risk interventions, such as pneumonectomy in > 70-year-old patients and pulmonary endarterectomy in > 80-year-old patients can be performed without an increase in mortality rates. Even lung transplantation can lead to good long-term results in carefully selected > 70-year-old patients. Minimally invasive surgical techniques and nonintubated anesthesia contribute to risk reduction in marginal patients.

Discussion

In thoracic surgery the biological age rather than the chronological age is decisive. In view of the increasingly older population, further studies are urgently needed to optimize patient selection, type of intervention, preoperative planning and postoperative treatment as well as the quality of life.

[Surgery of old people-Thoracic surgery]

BACKGROUND

The incidence of a large number of diseases relevant to thoracic surgery increases with age; however, old age is still frequently considered a contraindication per se for curative interventions and extensive surgical procedures.

OBJECTIVE

Overview of the current relevant literature, derivation of recommendations for patient selection as well as preoperative, perioperative and postoperative optimization.

MATERIAL AND METHODS

Analysis of the current study situation.

RESULTS

Recent data show that for most thoracic diseases, age alone is not a reason to withhold surgical treatment. Much more important for the selection are comorbidities, frailty, malnutrition and cognitive impairment. A lobectomy or segmentectomy for stage I non-small cell lung cancer (NSCLC) in carefully selected octogenarians can provide acceptable to even comparably good short-term and long-term results as in younger patients. Selected > 75-year-old patients with stages II-IIIA NSCLC even benefit from adjuvant chemotherapy. With appropriate selection high-risk interventions, such as pneumonectomy in > 70-year-old patients and pulmonary endarterectomy in > 80-year-old patients can be performed without an increase in mortality rates. Even lung transplantation can lead to good long-term results in carefully selected > 70-year-old patients. Minimally invasive surgical techniques and nonintubated anesthesia contribute to risk reduction in marginal patients.

DISCUSSION

In thoracic surgery the biological age rather than the chronological age is decisive. In view of the increasingly older population, further studies are urgently needed to optimize patient selection, type of intervention, preoperative planning and postoperative treatment as well as the quality of life.

As time goes by–developments in surgery for esophageal cancer in the new millennium

Background

In the last two decades, both treatment options and epidemiological features of cancer have changed. We studied the influence of related parameters on the outcome of patients undergoing resection for esophageal carcinoma.

Methods

We analyzed 499 consecutive patients who underwent esophagectomy for carcinoma since January 2000, comparing 2000–2010 with 2011–2021 and examining changes over time.

Results

The percentage of men (87.9 vs. 86.9%; p = 0.74) in the two groups was unchanged, whereas mean age increased significantly from 60.8 to 65.2 years (p = 0.000). There was a trend towards an increase of adenocarcinoma (gamma = 0.120, ASE = 0.055). Despite significantly increasing use of induction chemoradiotherapy (p = 0.000) from 7.14% in 2000 to 68.9% in 2021 the distribution of pT, pN stage, grading and the rate of positive lateral resection margins remained unchanged. When comparing the two periods, the overall 30-day mortality was 4.4 vs. 4.2% (p = 0.56), recurrence-free survival was 36.9 vs. 38% at 60 months and 33.9 vs. 36.4% at 120 months (p = 0.93). Tumor-associated survival was 41.1 vs. 45% at 60 months and 35.5 vs. 38.7% at 120 months (p = 0.78). None of the survival rates differed significantly. A multivariable analysis of year of surgery, age, sex, histological subtype, grading, pT, pN, lateral resection margin, and induction therapy showed that only higher pT (p = 0.01), positive pN (p = 0.000), positive lateral margin (p = 0.003), squamous cell carcinoma (p = 0.04) and higher grading (p = 0.026) had a statistically significant, independent, negative influence on prognosis.

Conclusion

Optimized noninvasive and invasive therapeutic modalities have produced only marginal improvement in the prognosis of esophageal cancer within the last two decades.

Roadmap to the Enhanced Thoracic Surgical Journey

The Enhanced Recovery Program (ERP) is a comprehensive, multidisciplinary approach that directly impacts the functional recovery and quality of life of patients after surgery. Initiated in 2013 at The University of Texas MD Anderson Cancer Center by the Liver Surgery group and expanded to numerous specialties, the Thoracic and Cardiovascular Surgery Department developed a version of Enhanced Recovery After Thoracic Surgery in 2014. The benefits gained thus far include (1) decreased postoperative complications, (2) reduced hospital length of stay, (3) decreased opioid usage, (4) decreased healthcare costs, and (5) improved patient satisfaction. This article aims to provide a brief description of the history of the enhanced recovery approach and to identify the critical elements of the program necessary for improved patient care. It is intended to serve as a practical guide for program implementation in thoracic surgery departments at other institutions.

Effectiveness of wound infusion of 0.2% ropivacaine by patient control analgesia pump after minithoracotomy aortic valve replacement: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Local anesthetic wound infusion has become an invaluable technique in multimodal analgesia. The effectiveness of wound infusion of 0.2% ropivacaine delivered by patient controlled analgesia (PCA) pump has not been evaluated in minimally invasive cardiac surgery. We tested the hypothesis that 0.2% ropivacaine wound infusion by PCA pump reduces the cumulative dose of opioid needed in the first 48 h after minithoracothomy aortic valve replacement (AVR).

METHODS

In this prospective, randomized, double-blind, placebo-controlled study, 70 adult patients (31 female and 39 male) were analyzed. Patients were randomized to receive 0.2% ropivacaine or 0.9% saline wound infusion by PCA pump for 48 h postoperatively. PCA pump was programmed at 5 ml h^- 1 continuously and 5 ml of bolus with 60 min lockout. Pain levels were assessed and recorded hourly by Numeric Rating Scale (NRS). If NRS score was higher than three the patient was administered 3 mg of opioid piritramide repeated and titrated as needed until pain relief was achieved. The primary outcome was the cumulative dose of the opioid piritramide in the first 48 h after surgery. Secondary outcomes were frequency of NRS scores higher than three, patient's satisfaction with pain relief, hospital length of stay, side effects related to the local anesthetic and complications related to the wound catheter.

RESULTS

The cumulative dose of the opioid piritramide in the first 48 h after minithoracotomy AVR was significantly lower (p < 0.001) in the ropivacaine (R) group median 3 mg (IQR 6 mg) vs. 9 mg (IQR 9 mg). The number of episodes of pain where NRS score was greater than three median 2 (IQR 2), vs 3 (IQR 3), (p = 0.002) in the first 48 h after surgery were significantly lower in the ropivacaine group, compared to control. Patient satisfaction with pain relief in our study was high. There were no wound infections and no side-effects from the local anesthetic.

CONCLUSIONS

Wound infusion of local anesthetic by PCA pump significantly reduced opioid dose needed and improves pain control postoperatively. We have also shown that it is a feasible method of analgesia and it should be considered in the multimodal pain control strategy following minimally invasive cardiac surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03079830 , date of registration: March 15, 2017. Retrospecitvely registered.

Elective Lung Resections in the Elderly: Where Do We Draw the Line?

INTRODUCTION

The increasing longevity of the Western population means patients with a more advanced age are being diagnosed with resectable disease. With improvements in imaging and diagnostic capabilities, this trend is likely to develop further. As a unit operating on a higher proportion of older patients and with limited literature regarding the population of older than 85 years, we retrospectively compared the outcomes of patients older than 85 years in our unit treated with elective lung resection for non-small cell lung cancer (NSCLC) with those between the age of 80 and 84 years inclusive.

METHODS

All patients who underwent elective lung cancer resection between the years 2012 and 2015 were identified from the National Thoracic Surgical Database.

RESULTS

A total of 701 elective lung resections were performed during this time frame; 76 patients between the ages of 80 and 84 years and 18 patients older than 85 years. The follow-up period was 3 to 7 years. There was a significant increase in the Thoracic Surgery Scoring System (2.04; 2.96%, p = 0.0015) and a significant reduction in the transfer factor (94.7; 69.5%, p = 0.0001) between the younger and older groups. There were three (3.9%) in-hospital deaths in the 80 to 84 years age group and no in-hospital deaths in the 85 years and older age group.

CONCLUSION

This study demonstrates that surgery for early NSCLC can be safely performed in 85 years and older population. This is a higher risk population and parenchymal-sparing procedures should be considered.

Enhanced Recovery After Surgery Protocols in Major Urologic Surgery

The purpose of the review

The analysis of the components of enhanced recovery after surgery (ERAS) protocols in urologic surgery.

Recent findings

ERAS protocols has been studied for over 20 years in different surgical procedures, mostly in colorectal surgery. The concept of improving patient care and reducing postoperative complications was also applied to major urologic surgery and especially procedure of radical cystectomy. This procedure is technically challenging, due to a major surgical resection and high postoperative complication rate that may reach 65%. Several clinical pathways were introduced to improve perioperative course and reduce the length of hospital stay. These protocols differ from ERAS modalities in other surgeries. The reasons for this are longer operative time, increased risk of perioperative transfusion and infection, and urinary diversion achieved using transposed intestinal segments. Previous studies in this area analyzed the need for mechanical bowel preparation, postoperative nasogastric tube decompression, as well as the duration of urinary drainage. Furthermore, the attention has also been drawn to perioperative fluid optimization, pain management, and bowel function.

Summary

Notwithstanding partial resemblance between the pathways in major urologic surgery and other pelvic surgeries, there are still scarce guidelines for ERAS protocols in urology, which is why further studies should assess the importance of preoperative medical optimization, implementation of thoracic epidural anesthesia and analgesia, and perioperative nutritional management.