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Thoracic Surgery in the Elderly

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Principles and Practice of Anesthesia for Thoracic Surgery

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Abstract

As the population ages, increasing numbers of elderly patients are presenting for thoracic surgery. Physiologic changes that occur with advanced age result in a decline of maximal reserves, affecting the patient’s ability to cope with the stress of surgery. Increased age is also associated with an increase in the number of comorbidities. Elderly patients with cancer may still stand to benefit from surgery, since survival rates for lung and esophageal cancer are very low without surgical resection. Perioperative morbidity and mortality is more closely associated with preoperative health status and tumor stage than chronological age. Minimally invasive surgical techniques such as video-assisted thoracoscopic surgery (VATS) have been shown to be an effective approach for surgical resection of cancer. Because better postoperative pulmonary function, less postoperative pain, and fewer complications were shown for patients who underwent VATS compared to those who underwent thoracotomy for lobectomy, VATS may be a good choice for patients of advanced age due to their decreased physiologic reserves. Careful preoperative assessment and postoperative care are essential in this surgical population due to their diminished ability to handle the stress of surgery.

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Author information

Authors and Affiliations

  1. Department of Anesthesiology, Mt. Sinai College of Medicine, New York, NY, USA

    Maria D. Castillo

  2. Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, New York, NY, USA

    Jeffrey Port

  3. Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA

    Paul M. Heerdt

Authors
  1. Maria D. Castillo
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  2. Jeffrey Port
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  3. Paul M. Heerdt
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Corresponding author

Correspondence to Paul M. Heerdt .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Clinical Case Discussion

Clinical Case Discussion

Case

An 84-year-old male presented with a left lung mass on a chest radiograph obtained during evaluation for right total knee replacement. Transthoracic biopsy was performed, and the mass was found to be non-small cell lung carcinoma (NSCLC). Imaging studies revealed hilar adenopathy, and lymph nodes obtained from the left chest by mediastinoscopy were positive for NSCLC leading to disease classification as stage IIIA. He subsequently underwent induction chemotherapy. Recent evaluation shows a decrease in size of the mass and regression of hilar adenopathy.

The patient is now scheduled for VATS resection of the left upper lung lobe. His medical history is otherwise notable for past smoking (none for 20 years), daily alcohol consumption (2–3 glasses of wine), hypertension (controlled), hypercholesterolemia, and severe osteoarthritis of the right knee (he had previously undergone left total replacement at age 78). Preoperative evaluation has been remarkable for anemia (hematocrit 33%), mild COPD, and a dobutamine stress echocardiogram negative for ischemia (mobility limited by knee pain and instability). On physical exam, he appears fit and vigorous but limited to a wheelchair when walking more than a block due to knee instability. He states that his plan is to proceed with knee replacement surgery following recovery from the lobectomy.

Questions

  1. 1.

    Is lung resection an acceptable approach for this patient from a physiological perspective?

  2. 2.

    Is left upper lobe lobectomy an acceptable procedure for this patient from an oncological standpoint?

  3. 3.

    What types of complications might this patient be at risk of developing?

  4. 4.

    What are some possible advantages of performing this procedure using video-assisted thoracoscopy?

Discussion

  1. 1.

    While this patient may appear to be fit and vigorous at baseline, all elderly patients have altered physiology as a consequence of aging. Thus, the stress of surgery may unmask these decreased functional reserves. For example, this patient may exhibit diminished maximum voluntary ventilation in response to the carbon dioxide load created by shivering, thus putting him at increased risk for hypercarbia in the postoperative period. Other alterations in respiratory function associated with aging, such as decreased PaO2, decreased DLCO, and increased ventilation–perfusion mismatch, may increase the patient’s risk of hypoxia.

Although this patient’s dobutamine stress echocardiogram was negative for ischemia, his advanced age suggests that he has some degree of LV hypertrophy and slower myocardial relaxation, which could negatively affect cardiac filling in the setting of tachycardia, for example.

These changes should be kept in mind during the perioperative period. However, a patient with good functional status, even an 84-year-old, can undergo this procedure safely.

  1. 2.

    Lung cancer is a fatal disease, with an estimated 5-year survival rate of 16% without surgical resection. Thus, a patient with good functional status stands to gain survival time if his stage I lung cancer is resected, even at an advanced age. This patient underwent induction chemotherapy for stage IIIA cancer, which caused regression of his adenopathy and decreased tumor size. Recent studies suggest that such patients stand to benefit from lung resection after chemotherapy, experiencing increased survival time.

  2. 3.

    Any patient undergoing lobectomy is at risk for cardiovascular and respiratory complications. Arrhythmias such as atrial fibrillation are among the most common complications, but myocardial ischemia and bleeding may also occur. Pneumonia and respiratory failure, prolonged air leak, bronchopleural fistula, and empyema are also possible risks in the setting of pulmonary surgery. However, preoperative health status, a history of COPD or smoking, and tumor stage all seem to contribute to outcome more than chronological age does.

  3. 4.

    VATS may result in better outcomes than thoracotomy. Recent data suggest that patients who underwent VATS as compared to patients who underwent thoracotomy experienced shorter hospital stays, less postoperative pain, less postoperative confusion, decreased time to return of preoperative activities, and higher satisfaction with the results of surgery. Several studies have reported decreased postoperative complication rates with the use of VATS rather than thoracotomy for lobectomy, which may be related to better preserved pulmonary function following minimally invasive surgery. Mortality rates were also significantly better for patients who underwent VATS, regardless of age.

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Castillo, M.D., Port, J., Heerdt, P.M. (2019). Thoracic Surgery in the Elderly. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_32

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