252 Wellington and Lynn: Thoracic Surgery in the Elderly. Canad. Med. Ass. J. Aug. .... Nine patients underwent repair of a hiatus hernia and six with achalasia ...
252 Wellington
and
Lynn: Thoracic Surgery
Thoracic J.
L.
WELLINGTON, F.R.C.S. [C] and
Kingston,
blood replacement.
Retention of bronchial secretions
was
Canad. Med. Ass. J.
Elderly
Aug. 6, 1966, vol. 95
Surgery in the Elderly
With careful attention to details of preoperative, opera¬ tive and postoperative care, intrathoracic procedures can be carried out safely in the elderly patient. The authors describe such procedures in 111 patients over 60 years of age who presented with a wide variety of primary diseases. Bronchogenic carcinoma, present in 48 patients, was the commonest. One-third of the total group had significant associated disease, usually in the form of coronary artery or chronic respiratory disease. The overall mortality rate was 6.3%. Before surgery, all patients were prophylactically digitalized regardless of their cardiac status. Blood volume estimations were determined in those with excessive weight loss. At operation, measurement of central venous pressure was found to be the best guide
to
in the
the commonest can be
postoperative complication. This problem
minimized with intensive chest physiotherapy, adequate hydration, minimal doses of analgesic agents and, when indicated, early tracheostomy.
increasing life span has introduced ANproblems in all branches of surgery, particu¬ in thoracic diseases such
new
as larly surgery, since bronchogenic or esophageal cancer occur principally in older persons. Thus, patients in their 60's or 70's represent a significant percentage of the total number on any thoracic surgical service. General surgical experience has taught that pa¬ tients over 60 tolerate emergency surgery badly.13 In contrast to general surgical practice, most thoracic operations are not urgent, and older pa¬ tients withstand well-planned and well-executed intrathoracic procedures surprisingly well.4 Our experience with 111 elderly patients who under¬
R. B. Ont.
LYNN, F.R.C.S., F.A.C.S.,
A condition d'accorder une grande attention aux details des soins pre-ope>atoires, ope>atoires, et post-operatoires, on peut proceder sans danger a des interventions intrathoraciques sur les gens ages. Les auteurs decrivent ces interventions chez 111 patients de plus de 60 ans qui presentaient une grande variete de pathologies primaires. Le cancer bronchoge'nique, existant chez 48 patients, etait la pathologie la plus courante. Dans un tiers de l'ensemble des malades, on observait une pathologie secondaire, g^neralement sous forme d'affection des coronaires ou de pneumopathies chroniques. La mortalite globale a ete* de 6.3%. Avant d'6tre ope>es, tous les malades ont 6t6 digitalises, a titre prophylactique, quel qu'ait 6t6 leur etat cardiaque. On a calcule* le volume sanguin chez ceux qui avaient subi une perte de poids excessive. Au cours de l'operation, on a mesure la pression veineuse centrale qui etait consideree comme le meil¬ leur guide pour les transfusions. La complication post-operatoire la plus frequente ^tait la retention des s£cr£tions bronchiques. Cette difficulte peut etre surmontee au moyen de physiotherapie thoracique energique, d'une hydratation convenable, d'un recours minimum aux analgesiques et, le cas echeant, a une trache'otomie precoce. TABLE I..Sex and Age
Male. Female. Total.
of
111 Patients
Sex 87 24
111
Age (yr.) Range. Average.
60-84 66.4
The primary diseases present in these 111 pa¬ are shown in Table II. Forty-eight had lung tumours: 45 of these tumours were primary bron¬
went
tients
Material One hundred and eleven patients over 60 years of age have been operated upon within the past seven years; 87 were men and 24 women (Table I). These patients were drawn from the three local
from primary renal cell carcinomas, and one was a hamartoma. In 22, a variety of pulmonary infections were found, viz. tuberculosis in six, non-tubercu¬ lous granuloma in five, chronic lung abcess in four, chronic empyema in four, organizing pneu¬ monia in two and bronchiectasis in one. Many of these lesions were not recognized preoperatively but were identified and removed when thoracotomy was done to exclude malignancy. Twenty-five pa¬ tients had esophageal lesions: simple hiatus hernia in nine, hiatus hernia with esophageal stricture in
thoracic surgery leads us to believe that with careful attention to the details of preoperative, operative and postoperative care, the mortality rate is low and the overall results are most gratifying.
Kingston, Ontario, hospitals, namely Kingston General Hospital, Hotel Dieu Hospital and the Ongwanda Sanatorium. The attending surgeon in each case was Dr. R. B. Lynn, and the operations were performed by Dr. Lynn or by a member of the resident staff at these institutions, under his supervision. The patients ranged in age from 60 to
84 years; the average age
was
66.4.
Sub-Department of Cardiovascular and Thoracic Surgery, Queen's University, Kingston, Ontario. Presented at the 70th Annual Meeting of the Canadian Association of Clinical Surgeons, Kingston, December 1965. Address reprint requests to: Dr. R. B. Lynn, Etherington Hall, Queen's University, Kingston, Ontario. From the
chogenic carcinomas,
two
were
solitary metastases
TABLE II..Primary Disease for Which Intrathoracic Surgery was Undertaken Disease No. % of total
Lung tumours. Pulmonary infections. Esophageal lesions.
Cardiovascular disease. Other. Total.
43
48 20 22 23 25 11 12 4 3 111
100
Canad. Med. Ass. J. Aug. 6, 1966, vol. 95
two,
esophageal
Wellington carcinoma in
in six.
eight
and achalasia
Of the 12 patients who underwent cardiovascular surgery, six had complete heart block; two, rheu¬ matic heart disease; one, an atrial septal defect; one, an aortic arch syndrome; one, non-specific
myocarditis;
and one, portal hypertension. Of the remaining four patients, two had peri¬ cardial cysts, one had bullous emphysema and one a stomal ulcer. Associated Disease
Clinically significant associated disease was pres¬ patients (30%). Individuals with electrocardiographic abnormalities but no signs or symp¬
ent in 33
toms of heart disease
were
not
included.
TABLE III..Associated Diseases in 111 Patients Disease No. Emphysema. 16 Arteriosclerotic heart disease. 12
Duodenal ulcer. 1 tuberculosis. 1 Pulmonary Chronic renal disease. 1
Asthma. 1
Syphilis.
1
Total. 33 (30%)
Sixteen patients had pulmonary emphysema. Twelve had arteriosclerotic heart disease; this figure excludes those in whom heart disease was the primary disease for which surgery was per¬ formed. Duodenal ulcer, pulmonary tuberculosis, chronic pyelonephritis, asthma, and tertiary syphilis were each present in one patient. Operative Procedures Of the 48 patients with lung tumours, 16 were explored but found to be inoperable. Thirty-two had some form of pulmonary resection, viz. seg¬ mental resection in four, lobectomy in 14 and pneu¬ monectomy in 14. Of patients with pulmonary infections, 16 had some form of pulmonary resection. Four had a decortication; in two, this was combined with some
and
Lynn: Thoracic Surgery
in the
Elderly 253
type of resection. One patient with pulmonary tuberculosis had a thoracoplasty and one with Pott's disease had a transthoracic spinal fusion. Of the patients with esophageal lesions, 10 had an esophageal resection; among these were eight with carcinoma and two with a benign stricture. Nine patients underwent repair of a hiatus hernia and six with achalasia had a Heller procedure. Of the 12 patients with cardiovascular disease, six had a pacemaker inserted, and two had a mitral commissurotomy. Closure of an atrial septal defect, exploration of aortic arch, myocardial biopsy and portocaval shunt were performed in one pa¬ tient each. Of the remaining four, two had resection of a pericardial cyst; one, resection of an emphysema¬ tous bulla; and one, transthoracic vagotomy. At the end of the definitive procedure, prophy¬ lactic tracheostomy was performed in six instances. Postoperative Complications Postoperative complications, exclusive of those that caused death, occurred in about 20% of pa¬ tients and were usually readily correctable. Re¬ tention of bronchial secretions was the commonest complication. Two patients required a tracheostomy during the postoperative period on this basis. Other common
complications
were
urinary retention,
cardiac irregularities and mental confusion, the latter often making nursing care exceedingly dif¬ ficult and, on occasion, even hazardous. Mortality
Table V shows the overall mortality in the series. In this group of 111 patients, there were no deaths on the operating table. Seven patients (average age: 73 years) died after operation, a mortality rate of 6.3%. TABLE V..Mortality in 111 Intrathoracic Procedures No. of procedures. 111 No. of deaths. 7 Average age of those who died. 73 years
Mortality rate.
6.3%
The patients with lung cancer were the largest single group and warrant special consideration (Table VI). In this group three of 47 patients died, a mortality rate of 6.4%. No deaths followed thoracotomy alone. One patient died following seg¬ mental resection, and two following lobectomy. The most interesting highlight of our experience with TABLE VI..Lung Cancer Mortality Total Procedure number Deaths
Thoracotomy. 16 0 4 1 Segmental resection. Lobectomy. 13 2 Pneumonectomy. 14 0 Total.
ill
111
Total.
47
3
(6.4%)
254 Wellington
and
Lynn: Thoracic Surgery
this group is that the 14 patients who had a pneu¬ monectomy all survived and were discharged from
hospital.
Table VII gives a detailed analysis of those pa¬ tients who died. Death occurred from three days
to five weeks after operation. Of the seven deaths, six were in patients with cancer, and four had
clinically significant associated disease. As can be seen in Table VII, pulmonary em¬ bolism was the cause of death in two patients and was suspected in a third. Bronchopneumonia played a major role in the death of at least three patients. E.J., a 64-year-old woman, was the only patient in this series who was operated upon for a benign disease and died. She had a salvage resection for pulmonary tuberculosis and suffered marked re¬ duction in pulmonary function preoperatively. After operation she could not be weaned from the respirator and she died five weeks later from pul¬ monary insufficiency and cor pulmonale. Management of the Elderly Patient Since most intrathoracic surgery in elderly pa¬ tients is elective, time is well spent in thorough preoperative preparation. An optimistic attitude on the part of the staff is essential, so that the patient will approach surgery with a real will to recover. As mentioned earlier, concomitant cardiac and respiratory disease is common in these patients, and every effort must be made to improve cardiopulmonary function before surgery. Here the close co-operation of the surgeon and his medical col¬ leagues is all-important. Digitalis, diuretics and the judicious use of rest in patients with pre-existing heart disease will improve cardiac function. In addition, it is our policy to fully digitalize all pa¬
in the
Elderly
Canad. Med. Ass. J.
Aug. 6, 1966, vol. 95
tients over 60 years of age before operation, regard¬ less of their cardiac status. This prophylactic use of digitalis has led to no complications and, in our opinion, has helped to reduce the incidence of postoperative congestive failure and arrhythmias. Timed vital capacity and maximal breathing capacity are measured preoperatively in all pa¬ tients, and in selected cases where pneumonectomy is contemplated, bronchospirometry is also done. These tests not only serve as a guide to the limits of pulmonary resection in poor-risk patients but also indicate which patients may require prophy¬ lactic tracheostomy and postoperative ventilatory assistance.
preoperative physiotherapy to improve function will not only diminish the operative risk but will accustom the patient to it when it is started again in the immediate post¬ operative period to prevent atelectasis and pneu¬ monia. In patients with infected sputum, antibiotics are administered before operation on the basis of cul¬ ture and sensitivity test results. Bronchodilator Intensive
pulmonary
drugs are useful in cases with an element of bronchospasm. Patients with malignant disease and excessive weight loss often have a serious reduction in cir¬ culating blood volume which is not apparent on routine laboratory tests.5 If the deficit in circulating blood volume is undetected, the blood pressure of these patients will be unstable during and after operation to a degree that it is out of proportion to measured blood loss. By measuring total blood volume, this deficit may be rapidly and accurately estimated, and corrected by appropriate transfu¬ sions of whole blood or packed cells.
Canad. Med. Ass. J.
Aug. 6, 1966, vol. 95
Wellington
Patients with esophageal cancer are often malnourished and in negative nitrogen balance. In these cases supplementary high-caloric, high-protein feedings, often administered via a nasogastric tube, are indicated. Electrolyte disturbances should be sought for and corrected. In particular, potassium deficiency occurs commonly in patients on thiazide diuretics and is an important cause of prolonged ileus and mental confusion in the postoperative period. Finally, all patients must stop smoking com¬ pletely for at least five days before operation. Inhalation of cigarette smoke stimulates the pro¬ duction of excessive viscid mucus and also depresses ciliary activity. At operation minimal anesthesia and rapid bloodless surgery are important. The elderly thoracic surgery patient needs a well-executed operation that is speedily performed. Blood loss should be re¬ placed volume for volume, and the adequacy of transfusion should be monitored by measurement of central venous pressure. At the end of the pro¬
cedure a decision should be reached on the need for tracheostomy in each individual case. Postoperative analgesia should be given in small amounts but frequently. Small doses of meperidine (Demerol) (10-50 mg.), given frequently by the intravenous route, are preferable to longer-spaced but larger doses of this or any other narcotic. A small dose of analgesic just before chest physio¬ therapy often markedly improves a patient's per¬ formance. Intercostal block is useful to control incisional pain, but we have used this infrequently. Physiotherapy is reintroduced in the recovery room. Inhalations of sputum liquifiers such as the detergent, Alevaire, will often make it easier for the patient to raise viscid secretions. Elderly patients are notorious swallowers of air, and for this reason continuous gastric decompres¬ sion by Levin tube has been used almost routinely. Efficient gastric aspiration removes the risk of both gastric dilatation and aspiration pneumonia. In patients in whom prolonged gastric decompres¬ sion is anticipated (e.g. after esophagectomy), a
temporary gastrostomy or jejunostomy is frequently
useful. This does away with the problems asso¬ ciated with prolonged nasogastric intubation and is also useful for feeding at a later stage. Intra¬ venous fluid therapy must be carefully supervised to avoid both over- and under-hydration. Most problems arise from the overzealous use of saline, especially during the first 48 hours after operation! Conversely, dehydration results in inspissation of bronchial secretions and an increased tendency to pulmonary complications. The patient should be returned to oral intake as soon as possible. Urinary retention which recurs after catheterization should be treated with an indwelling catheter and regular antiseptic irrigations. This seems to carry less risk of infection than repeated catheterization.
and
Lynn: Thoracic Surgery
in the
Elderly 255
Early activity must be encouraged to prevent thromboembolic complications. The key word here is "activity". The sight of an elderly postoperative patient, sound asleep, slumped in a chair with hips and knees flexed, is all too common, while an ill patient being treated by "early ambulation" is often being dragged along the corridor by a battery of nurses. Elderly patients confined to bed must be encouraged to exercise their muscles frequently until they are well enough to be up and walking around. Mental confusion is a common problem and one which is often difficult to manage. Common causes such as abnormal states of hydration, hypoxia and potassium deficiency should be excluded. Emptying a distended bladder will often bring about dramatic improvement in an elderly, confused and restless patient. Simple measures such as leaving an overhead light on at night are often helpful in preventing disorientation. When drug therapy is indicated, small doses of perphenazine (Trilafon) given intravenously are useful and have little hypotensive effect.6 Running through the entire program must be an optimistic attitude by all attending the patient so that he feels his recovery is inevitable. An air of pessimism, albeit unconscious, all too often leads to mental depression. The patient must be en¬ couraged, kept interested and occupied, and to this end we usually put our elderly patients in twoor three-bed rooms with other patients. Discussion
Although the patients in this study were a selected group, they made up approximately 15% of the patients undergoing intrathoracic surgery at Queen's University and its associated hospitals in the last seven years. Not long ago most patients over the age of 60 were rejected for most forms of surgery on the basis of age alone. However, with more people living longer, the age barrier is failing and chronological age has become a less important guide to surgical acceptance. If one accepts the fact that these elderly patients have limited reserves and prepares them accordingly, the results are usually gratifying. Central preoperative prep¬ aration and enthusiastic, optimistic postoperative care will ensure the patient who has had a wellexecuted operation a good chance of cure or palliation. Since cardiac and respiratory systems are most likely to be deranged, these require spe¬ cial attention. Although most complications tend to be minor, such measures as elective tracheostomy may occasionally be life-saving in the older patient, who can be rapidly overwhelmed by retention of bronchial secretions and respiratory failure. It be¬ comes evident that the whole hospital course of the elderly patient requires close supervision, and the dedicated co-operation of nurse, physiotherapist, dietician, internist and surgeon.
256
UmN.Y T.CT Tuj,.io.jp1.
CONCLUSIONS A review of 111 intrathoracic surgical procedures carried out on patients 60 years of age and older shows that these patients, if well prepared for surgery and closely supervised after operation, will tolerate surgery surprisingly well. A mortality rate of 6.3% was recorded in this group of patients whose average age was 66.
Canad.6, 1966. Med. Ass. 3. Aug. vol. 95 REFERENCES
1. 2. 3. 4.
LIMBoscH, J.: A.M.A. Arch. Surg., 73: 124, 1956. BoscH, D. T. et al.: Ibid., 64: 269, 1952. COLE, W. H.: Ann. Surg., 138: 145, 1953. HAUG, C. A. AND DALE, W. A.: A.M.A. Arch. Surg., 64: 421, 1952.
5. BELING, C. A.,
BOSCH, D. T. AND CARTER, 0.
B., JR.:
Geriatrics, 7: 179, 1952. 6. BRADEN, D. H.: Personal communication.
The Natural History of Tumours of the Urinary Tract SIR ERIC RICHES, M.C., M.B., M.S., F.R.C.S.(Eng.),* London, England Experimental and epidemiological evidence has implicated environmental factors in the increasing incidence of bladder cancer. Papillary tumours are less malignant than solid. Of 36 patients with papillary growths in the renal pelvis, 20 lived five years but 11 of 15 with solid tumours died within one year. Social and geographical influences have affected the incidence of adenocarcinoma of the kidney. Experimentally it has been produced by hormones, carcinogem, viruses and irradiation. Clinically the most adverse factor was histological anaplasia; renal vein invasion was three times as common in high-grade tumours. The postoperative five-year survival was 30 out of 42 patients with low-grade lesions but 12 out of 42 with high-grade lesions. In the case of low malignancy tumours without adverse factors, 25 out of 29 patients survived for five years. This unpredictable behaviour is characteristic of urinary tract tumours.
Ii existe des preuves exp6rimentales et 6pid6miologiques qu'il faut incriminer des facteurs de milieu pour expliquer l'augmentation de la fr.quence du cancer v6sical. Les tumeurs papillaires sont moms malignes que les tumeurs solides. Vingt des 36 malades atteints de tumeurs papillaires dans le bassinet, ont surv6cu cinq ans, alors qu'une issue fatale dans l'ann6e suivant le diagnostic de tumeur solide est survenue chez 11 malades sur 15. Des facteurs sociaux et g6ographiques ont influenc6 la fr6quence de l'adenocarcmome du rein. Exp6rimentalement, on a pu le provoquer par des hormones, des substances carcinog.nes, des virus et de l'irradiation. Sur le plan clinique, le facteur le plus d6favorable a 6t6 l'anaplasie histologique; l'invasion par voie des veines r6nales a .td trois fois plus 6lev6e dans les tumeurs tr.s malignes. La survie de cinq ans a 6t6 de 30 sur 40 chez les malades dont la l6sion 6tait faiblement maligne, alors que la mortalit6 atteignait 12 sur 42 dans le cas des tumeurs . haute malignit6. Dans le cas des tumeurs faiblement malignes sans facteur d6favorable, 25 malades sur 29 ont surv&u cinq ans. Un comportement impr6visible caract6rise les tumeurs des voies urinaires.
1'HE endowment of an eponymous lecture is a sign of respect and admiration for the man whose name it commemorates; its establishment during his lifetime enhances the tribute and emphasizes the affection in which he is held by his colleagues. Dr. Donald Balfour graduated from this University in 1906. In 1908 he went to the Mayo Clinic, where he gained the reputation which made him famous throughout the world. The invitation to give this lecture named after him gives me great satisfaction and I wish to thank those to whom I owe it. Balfour always showed a great interest in current problems; I feel it is appropriate to discuss some aspects of malignant disease of the urinary tract in which there are many unsolved problems but about which knowledge is increasing. When I was a boy at school we had a Natural History Society which is still flourishing more than 50 years later. Its main object was to encourage an enquiring mind and observation into how things grow; the problem of why things grow remains as difficult now as it was then.
Nearly 200 years ago Gilbert White38 wrote in "The Natural History of Selborne": "When I was in town last month I partly engaged that I would some time do myself the honour to write to you on the subject of natural history, and I am the more ready to fulfil my promise, because I see you are a gentleman of great candour, and one that will make allowances; especially where the writer professes to be an out-door naturalist, one who takes his observations from the subject itself, and not from the writings of others." The evolution of the natural sciences and the extension of specialization make it impossible for one individual to keep abreast with the complexities of modern knowledge, and in considering the natural history of tumours of the urinary tract I have had to draw freely on the writings of others; and, knowing that you too are ladies and gentlemen of great candour, I trust that you also will make allowances.
*Emeritus Tjrological Surgeon, The Middlesex Hospital, London, England. The Donald Balfour Lecture, University of Toronto, 1966. Address reprint requests to: 22 Weymouth Street, London. W.1. England.
THE NATURAL DURATION OF DISEASE There are many gaps in our knowledge of the duration of a disease and this is particularly so in
