In recent years, specialty care for several medical diseases has been shown to improve patient outcome in terms of survival and quality of life [1,2]. Likewise, institutions with a high volume of thoracic procedures have lower perioperative complications compared with low-volume hospitals, suggesting that specialized care and high level of experience of the surgical team also contribute to better outcome after thoracic surgery [3–5].
Currently, thoracic surgery is mainly indicated to remove neoplastic or benign tumours, large emphysematous bullae and infectious cavities. Most of these cases are referred by chest physicians or general practitioners and the patients are operated upon either by general or thoracic surgeons. Instead of transferring these surgical patients to a large city-based hospital, another option exists to transfer a highly trained medical team – surgeons and anaesthesiologists – to a regional chest centre to which patients are referred, selected, evaluated and if necessary prepared for surgery. With this type of hospital management the medical costs can be reduced and patients remain in their local environment. In addition, scientific interactions between academic and community-based medical centres are created and high-quality medical care and teaching opportunities are provided.
In this study, outcome data were prospectively collected regarding all thoracic surgical procedures performed in a regional chest centre in collaboration with a university teaching hospital. The methods of perioperative management are described and specific risk factors for complications are determined. Mortality and morbidity rates are compared with other published series.
Hospital settings and patient management
The Chest Medical Centre in Montana (Switzerland) has 91 beds and is a referral centre in the canton of Valais (274 500 inhabitants). Two full-time chest physicians, assisted by one registrar and four residents, lead the care of 400–450 patients who are admitted annually for acute and chronic respiratory disorders as well as for postoperative rehabilitation. According to a joint agreement between the Health Ministries of the cantons of Valais and Geneva (Switzerland), cases of thoracic surgery are electively performed in Montana – one session per month – by two experienced thoracic surgeons and one anaesthesiologist from the University Hospital of Geneva (which is located 185 km from Montana). A few high-risk cases and those patients requiring lung transplantation are evaluated in Montana and then transferred to Geneva for further treatment.
Preoperative evaluation includes a complete history, physical examination, blood count, biochemical profile, chest radiography plus computed tomography scans, electrocardiography and pulmonary function testing. Patients with risk factors for coronary artery disease or with low functional capacity undergo further cardiological investigations including transthoracic echocardiography, stress testing (maximal exercise or thallium-dipyridamole myocardial scintigraphy) or coronary angiography according to the guidelines published by the American Heart Association and the American College of Cardiology . The chest physicians preselect the surgical candidates and the results of all preoperative investigations are sent to the surgeons and anaesthesiologists. All the patients are visited and examined by the attending anaesthesiologist on the day before surgery.
Before induction of anaesthesia, a thoracic epidural catheter is routinely inserted unless the patient refuses or there are contraindications such as coagulation disorders, acute neurological problems, local or systemic infection or else technical failure. Prophylactic antibiotics (cefuroxime 1.5 g 8 h−1, for 24 h) are routinely given and the operations are performed through a muscle-sparing anterior incision or a standard lateral thoracotomy. After anaesthesia has been induced (thiopental, 4–7 mg kg−1 with vecuronium 1 mg kg−1 for muscular relaxation), a double-lumen tracheal tube is inserted to allow one-lung ventilation. Anaesthesia is maintained with inhaled isoflurane whereas analgesia is maintained with repeated doses of intravenous (i.v.) opioid (fentanyl, 50–100 μg) or the epidural administration of a mixture of local anaesthetics and opioid (bupivacaine 0.25% and fentanyl 2 μg mL).
All patients are extubated in the operating room and monitored for at least 48 to 72 h in a high-dependency unit to provide adequate pain control, intensive nursing and respiratory care including diaphragmatic breathing, pulmonary drainage as well as early mobilization, ambulation and feeding. In the high-dependency unit, one nurse is usually in charge of two patients; this 0.5 nurse-to-patient ratio conforms to the criteria of the Intensive Care Society standards for intermediate care units . The analgesic regimen consists of the administration of i.v. morphine (through a patient-controlled analgesia pump) or an epidural mixture of bupivacaine (0.125%) and fentanyl (2 μg mL−1). The medical and nursing staff are well trained and regularly instructed about postoperative pain management and follow the instructions of the attending anaesthesiologist.
At the end of the surgical session, the nursing charts, chest radiographs, electrocardiograms and laboratory results are reviewed by the multidisciplinary medical team. When all physiological variables are stable or under control, one surgeon and the anaesthesiologist are permitted to return to Geneva whereas the second surgeon remains on call for the first 24 h in the vicinity of the Chest Medical Centre. In case of complications requiring intervention, the patient (or the medical team) can be urgently transferred by helicopter.
From January 1992 to December 1999 data were prospectively recorded for all patients scheduled to undergo thoracic surgery. Information was collected concerning several aspects of care including demographic, clinical, functional and surgical variables as well as perioperative complications and mortality.
Categorical data were obtained by identification of the presence or absence of potential preoperative risk factors: age ≥ 70 years, gender, body mass index (> 30 kg m−2 or < 18 kg m−2), smoking (past or current), American Society of Anesthesiologists’ grade of physical status, indication for surgery (cancer, other tumours, infection, emphysema), presence of arterial hypertension, diabetes mellitus, peripheral vascular disease, coronary artery disease (history of myocardial infarction, atypical angina, positive results of cardiac investigation) and bronchoemphysema (≥ 3 episodes of bronchitis per year or ≤ 60% FEV1). Potential intraoperative risk factors were also considered: the type of surgery (pneumonectomy, bi-lobectomy, lobectomy, minor resection, explorative thoracotomy), duration of surgery, and the type of analgesia (parenteral or epidural). Outcome data were apportioned into two periods, 1992–95 and 1996–99, for time-trend analysis. After surgery, all patients were followed up and a record was kept of complications occurring within 30 days or for a longer period if the patient remained in the hospital: death, respiratory failure (if mechanical ventilatory support was required), bronchopleural fistula, prolonged thoracic drainage (≥ 7 days), pneumonia (new infiltrate evident by chest radiography, combined with fever, leucocytosis), atelectasis (requiring bronchoscopy and/or intensive respiratory care), myocardial infarction, pulmonary embolism, dysrhythmias requiring medication and renal impairment (≥ 20% elevation of serum creatinine).
Data are presented as means ± SD, absolute numbers or percentages. In univariate analysis, the significance of each potential risk factor and time trend was evaluated using the χ2-test for categorical variables. Most of the variables were also tested by Spearman’s rank (non-parametric) correlation analysis to determine whether the potential risk factors were truly independent variables. Factors with an univariate significance level of P < 0.25 were initially included as independent variables and multivariate logistic regression analysis was performed. The dependent variable was the postoperative outcome (death or complications) and the independent variables were potential clinical and surgical risk predictors. Adjusted odds ratios (OR) with 95% confidence intervals (CI) were calculated by exponentiation of the logistic coefficient estimates.
The clinical characteristics of the 273 patients who underwent thoracic surgery are summarized in Table 1. The majority of patients was less than 70 years old (75%); they were past or current smokers (72%), classified as ASA I and II physical status (73%). Bronchoemphysema (in 17%) and cardiovascular disorders (in 24%) were the most frequently associated diseases.
The most common operation – lobectomy – was performed in 116 cases, whereas 52 patients underwent either pneumonectomy or bi-lobectomy (Figure 1 a). Surgery was mainly indicated for the removal of lung cancer (n =194; stage I and II, 133; stage IIIA, n =48; stage IIIB, n =9; stage IV=3) and more rarely for benign tumours (n =21), infectious cavities (n =16) and for emphysema (bullae, talc pleurodesis or volume reduction, n =14) (Figure 1 b).
The duration of surgery was 82 ± 26 min and an epidural catheter was inserted in 194 patients. Homologous red blood cells were administered in nine patients (3.3%). Overall, patients were discharged to their home 21 ± 4 days after surgery; the duration of hospital stay was longer for patients with respiratory complications (27 ± 7 days, compared with 18 ± 5 days for patients without respiratory complications).
Death occurred in six male patients (30-day mortality of 2.2%) and was related to sepsis in four cases and, haemorrhagic shock and pulmonary embolism in two cases (Table 2). Of note, haemorrhage due to rupture of the pulmonary artery developed within 6 h after the end of surgery while the surgical team was still present: immediate tracheal re-intubation with fluid resuscitation and chest re-opening were unsuccessful. Non-fatal postoperative complications developed in 74 of the 273 patients (Table 3). Cardiovascular complications occurred in 30 patients and consisted mainly of dysrhythmias. Pulmonary complications occurred in 27 patients of whom 17 had bronchopneumonia, 11 had atelectasis, four had bronchopleural fistula and one required mechanical ventilatory support. Three patients were transferred to the University Hospital in Geneva: one for the treatment of an acute lung injury and two for closure of persistent bronchopleural fistulae; all three fully recovered. Of the 13 patients who had ≥ 20% elevation of serum creatinine, none developed acute renal failure.
The incidence of most complications was low; therefore, individual complications were pooled into cardiovascular and respiratory complications. By univariate analysis, advanced age (≥ 70 years, history of smoking, body mass index, major lung resection (pneumonectomy and bi-lobectomy) and duration of surgery (≥ 2 h) were significantly associated with the occurrence of complications (Table 4). Respiratory complications occurred more frequently in smokers, in patients with a low body mass index and those requiring prolonged surgical time or major lung resection. Respiratory morbidity tended to decline during the second period – from 1996 to 1999 – compared with the period 1992–95. Dysrhythmias were the predominant cardiac complication and occurred in 19% patients undergoing pneumonectomy.
After multiple logistic regression, three independent risk factors for perioperative death or cardiovascular and respiratory complications were identified: smoking (OR=2.7, 95% CI from 1.5 to 4.2), prolonged surgical time (OR=2.4, 95% CI from 1.2 to 4.7) and major lung resection (OR=3.9, 95% CI from 2.3 to 9.7). There was no additive effect of advanced age, increasing ASA grade (III and IV), low expiratory volume (FEV1 ≤ 60% predicted value) or history of bronchoemphysema.
Given resource driven circumstances and speciality care policy, one may question what is in the best interest of patients selected to undergo thoracic surgical procedures? A transfer to a large teaching hospital or the availability of a mobile and specialized surgical team?
With regard to safety, it appears not optimal to perform thoracic surgery in hospitals where surgeons and anaesthesiologists are not on site. However, our prospective study including 273 low- to moderate-risk cases demonstrates that low rates of operative mortality (2.2%) and morbidity (28%) can be achieved if standardized protocols are applied and if the pulmonary physicians are well trained for the management of the postoperative period. Moreover, a previous cost-analysis study demonstrated that hospital costs (about €8950 ) were much lower than in larger hospitals (approximately €11 993) where standardized clinical care pathways are implemented .
The causes of the six perioperative deaths were clearly identified and we feel that additional therapy in an academic centre would have been worthless. Only three patients were transferred in stable conditions to the University Hospital because they required further surgical treatment and intensive care management.
Concerning lung cancer data, our perioperative mortality rate (2.6%) compares favourably with published data (Table 5) and was slightly lower than operative mortality achieved by the same team of surgeons and anaesthesiologists at the University Hospital of Geneva (4.0%) . The preoperative selection process probably accounted for these differences as higher risk patients were not accepted in Montana and were preferably admitted to the University Hospital.
Besides lung cancer, our study population also included benign tumours, chronic infection and emphysematous bullae. Postoperative cardiopulmonary complications occurred similarly among these different surgical indications and were strongly associated with a history of smoking, major lung resection and prolonged duration of surgery (> 120 min). Although advanced age is often associated with cardiopulmonary disorders and borderline organ function, it was not an independent predictor of mortality or major complications. These data lend support to the contention that the elderly should not be denied the option of curative surgery if comorbid diseases are under control and if a satisfactory quality of life can be anticipated . Of note are studies, involving large numbers of patients, that have shown that peripheral vascular diseases, insulin-dependent diabetes mellitus, a history of weight loss or lung infection, a low serum albumin concentration, low pulmonary diffusion capacity for carbon monoxide and ASA class III and IV, could all be associated with an increased risk of perioperative morbidity [12–18].
Our preoperative screening protocol included the assessment of maximal aerobic capacity because we demonstrated previously that it was predictive of postoperative cardiopulmonary complications . High-risk patients with poor or borderline exercise capacity, coronary artery disease or chronic obstructive pulmonary disorders were eventually selected to undergo lesser invasive procedures through a muscle-sparing anterior thoracotomy and they deserved additional investigations, intensive monitoring and prolonged pain therapy. Such strategy probably contributed to the low incidence of myocardial infarction and cardiac insufficiency (< 2%) in patients with cardiovascular risk factors and to the reduction of atelectasis and bronchopneumonia in patients with chronic obstructive pulmonary disease. Moreover, the use of thoracic epidural anaesthesia – applied in the majority of high-risk patients – has been shown to improve postoperative pulmonary outcome, by providing optimal pain relief without undue sedation and by reducing the inhibitory reflexes acting on the diaphragm .
Despite the high prevalence of preoperative cardiac risk factors, the incidence of cardiovascular complications (11%) was in the lower range of most published series (9–30%) [12–17]. Dysrhythmias were the most frequent cardiac complications – particularly after pneumonectomy – but they are usually benign as no negative impact on either short- or long-term mortality has been demonstrated . Pulmonary complications were implicated in three deaths and developed in 10% of survivors, mostly after major lung resection and prolonged surgical procedures; they were associated with a prolonged hospital stay (+50%) and tended to decline during the second study period.
Our Regional Chest Centre concentrates its resources towards all pulmonary disorders, including 30–40 thoracic surgical procedures annually. Not surprisingly, fewer complications have been reported in similar specialized hospitals or in general hospitals with a high volume (> 24) of specific operations [3,4]. A growing body of evidence suggests that, besides the complexity of surgical resection and patients’ associated diseases, successful operative outcome depends also on the skills, training and experience of the medical team. In other words, speciality care holds out the prospect of progress in medical treatment simply because ‘practice makes more perfect’. The recent emergence of cardiothoracic subspecialties in surgery and anaesthesiology has also contributed to increase patient safety and quality of care as well as to broaden our scientific knowledge . Hence, health authorities should encourage referral of thoracic surgical candidates in designated medical centres staffed by speciality trained physicians.
In conclusion, over the past 8 years, we have prospectively collected outcome data which demonstrate that various thoracic surgical procedures can be safely performed and at low cost, in a chest centre without resident thoracic surgeons and anaesthesiologists. Successful postoperative outcome can be achieved if several conditions are fulfilled: first, pulmonologists should be well trained in intensive care, acute pain control and management of postoperative complications; second, high-risk surgical cases are electively admitted and operated upon in the university based hospital; third, close contacts (telephone calls, visits) are maintained between the ‘on-site’ chest physicians and the ‘remote’ surgeon and anaesthesiologist; joint decisions are taken regarding patient selection, the planning of investigations and the treatment of postoperative complications.
This work was supported by a grant from the Lancardis Foundation in Sion, Switzerland.
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Keywords:© 2001 European Academy of Anaesthesiology
INTRAOPERATIVE COMPLICATIONS; POSTOPERATIVE COMPLICATIONS; RESPIRATORY SYSTEM, lung; SPECIALTIES, SURGICAL, surgery; VITAL STATISTICS, morbidity, mortality