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J Thorac Cardiovasc Surg 1998;115:70-73
© 1998 Mosby, Inc.
GENERAL THORACIC SURGERY |
Editor of Journal of The Japanese Association for Chest Surgerya; Member of The Japanese Association for Chest Surgeryb; Chief of The Academic Committee of The Japanese Association for Chest Surgeryc; Fourteenth President of The Japanese Association for Chest Surgery.d
Received for publication June 13, 1997; revisions requested Sept. 2, 1997; revisions received Sept. 22, 1997; accepted for publication Sept. 22, 1997. Address for reprints: Hiromi Wada, MD, Department of Thoracic Surgery, Chest Disease Research Institute, Kyoto University, 53 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606, Japan.
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Abstract |
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 Top Abstract IntroductionPatients and methods.ResultsDiscussionReferences |
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Introduction |
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TopAbstractIntroductionPatients and methods.ResultsDiscussionReferences |
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The 30-day operative mortality in 2220 lung cancer cases in North America was reported in 1983
1 and, to date, has been referred to as the standard.
It has been more than 10 years, and the perioperative management has improved. From this, it may be natural to anticipate a more favorable operative outcome. Although several investigators have reported their operative mortalities in a population of several hundred cases, 2,3 in the aged groups, 2-7 or in cases with limited operative procedures, 8,9 and various stages, 10,11 no one has made a survey of the operative mortality of lung cancer in a large population comprised of several thousand cases, except for one. 12
This article reports on the Japanese Association for Chest Surgery 30-day study of operative deaths after thoracotomy in more than 7000 lung cancer cases in a 1-year period. The overall profile of Japanese lung cancer surgery is described, and a standard for comparing operative results in worldwide series is provided.
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Patients and methods. |
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TopAbstractIntroductionPatients and methods.ResultsDiscussionReferences |
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The number of operations, number of deaths, and mortalities were analyzed according to the operative procedure and age, and the causes of operative deaths were summarized. The operative procedures were divided into pneumonectomy, lobectomy, and less invasive operations (segmentectomy, partial resection, exploratory thoracotomy, and so on). Video-assisted thoracoscopic surgery was not included. Ages of the participants were divided into less than 60 years old, 60 to 69 years old, 70 to 79 years old, and 80 years and older. The operative mortality was defined as death within 30 days of operation.
Statistical analysis was performed by goodness test of fit for 
2 and 2 test for independence with a Stat View-J4.02 (Abacus Concepts, Berkeley, Calif.). A p value less than 0.05 was considered significant.
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Results |
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TopAbstractIntroductionPatients and methods.ResultsDiscussionReferences |
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Pneumonectomy was performed on 586 patients (8.3%), lobectomy on 5609 (79.0%), and less invasive operations on 904 (12.7%). Nineteen patients died after pneumonectomy (3.2%), 67 after lobectomy (1.2%), and 7 after a less invasive operation (0.8%). A significant difference in operative mortality was observed between pneumonectomy and lobectomy (p < 0.01) (Table I).
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Discussion |
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TopAbstractIntroductionPatients and methods.ResultsDiscussionReferences |
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The Lung Cancer Study Group (LCSG) published their detailed analysis on 30-day operative mortality for lung resections in a large population comprising 2220 lung cancer cases in North America in 1983. 1 In this report the 30-day operative mortalities were 3.7% in the overall population, 6.2% for pneumonectomy, 2.9% for lobectomy, and 7.1% for the patients 70 years of age or older. The data have been referred to as a standard for analysis of operative mortality in lung cancer.
Since then, there have been some reports on operative mortalities in groups with a relatively small number of cases, 2,3 aged patients, 2-7 limited operative procedures, 8,9 and selected clinical stage. 10,11 However, no study has been done on the operative mortality in lung cancer in a large population comprising as many as several thousand cases, except for one. 12 The operative mortality in this report, however, is based on discharge abstracts, not on the data directly collected from attending doctors. Furthermore, the observation periods are long in many of the previous reports. 2,6,7
This report was composed of more than 7000 cases, and the observation period was 1 year. Although several reports have pointed out that the operative outcome at selected institutions, such as university hospitals, would not reflect the level of general medical practice, 5,12 the institutions participating in our study ranged from national centers and university hospitals to institutions performing fewer cases. We report on one of the largest analyses made to date about the operative mortality in lung cancer and describe the present status of surgery in Japan.
Although the proportion of patients 70 years old or older, commonly with more complications, increased from 20.4% to 32.8%, the mortality in the whole series decreased greatly from 3.7% to 1.3% in our study compared with the LCSG report in 1983.
Such improvement may have resulted from the decreased proportion of pneumonectomy (from 25.6% to 8.3%), the increased proportion of lobectomy (from 67.9% to 79.0%), and the reduction in mortalities for pneumonectomy (from 6.2% to 3.2%), lobectomy (from 2.9% to 1.2%), the group 70 to 79 years old (from 7.0% to 2.0%), and the group 80 years old or older (from 8.1% to 2.2%), although the data in the elderly in the LCSG report were for lung resection.
The mortalities were 6.8% to 10.1% for pneumonectomy 2,3,12 and 3.4% to 4.0% for lobectomy 2,3,12 in the literature; in our study the mortalities were 3.2% for the former and 1.2% for the latter (Table IV).Compared with the mortalities of 4.9% to 17.0% for the patients 70 years old or older 2-5 and 3.0% to 15.0% for the patients 80 years old or older 6,7 in the literature (some data are for lung resection as indicated in Table V),our mortalities were 2.1% and 2.2%, respectively. Mortalities in our survey were obviously low.
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13; improvements in operative techniques, anesthesia, circulatory, and respiratory management; and control of postoperative infection. Downstaging by induction therapy also may have contributed to the reduced mortality. The pneumonectomy rate in this study was as low as 8.3%. The operative indications for lung cancer in Japan are as follows. Patients with non-small-cell lung cancer in clinical stage I to IIIA are generally operated on, some patients with non-small-cell lung cancer in clinical stage IIIB (T4) with preoperative tumor reduction by induction therapy are operated on. Some patients with small-cell lung cancer in clinical stage I are also operated on. The others are not treated surgically.
In Japan, operations for lung cancer in clinical stage I have increased and those for patients in clinical stage IIIA have decreased 13 because of the nationwide mass screening system. Moreover, surgeons generally try bronchoplasty or pulmonary arterioplasty to avoid pneumonectomy and conserve postoperative lung function. 14These are some of reasons for the low rate of pneumonectomy.
Compared with the data from the LCSG, 1 the causes of deaths have shifted from bronchopleural fistula and empyema to pneumonia and respiratory failure. As described above, operations for patients in the early stages have increased in Japan. This has brought the reduction of pneumonectomies and may have lessened bronchopleural fistula. Furthermore, although we do not have exact proof, the improvement of operative procedures and instruments or the appearance of drug-resistant pathogens may also account for this.
In conclusion, the results of our study on operative mortality in lung cancer in a large population exceeding 7000 cases could be used as a standard for discussing therapeutic outcome in patients with lung cancer. Thirty-day operative mortalities in our series were satisfactorily low: 1.3% in the overall population, 3.2% for pneumonectomy, 1.2% for lobectomy, and 2.1% for the patients 70 years old or older.
We are grateful to all the members of the Japanese Association for Chest Surgery for their contribution in collecting valuable data.
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Footnotes |
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References |
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TopAbstractIntroductionPatients and methods.ResultsDiscussionReferences |
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