Thirty-day mortality underestimates the risk of early death after major resections for thoracic malignancies

Our plain-English summary of Thirty-day mortality underestimates the risk of early death after major resections for thoracic malignancies, by R.R. McMillan, A. Berger, C.S. Sima, et al (The Annals of Thoracic Surgery, 2014).

The study

• Authors: R.R. McMillan, A. Berger, C.S. Sima, F. Lou, J. Dycoco, V. Rusch, N.P. Rizk, D.R. Jones, J. Huang
• Journal: The Annals of Thoracic Surgery
• Published: 2014;98(5):1769-74; discussion 1774-5
• Cited by: 69 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Operative mortality rates are of great interest to surgeons, patients, policy makers, and payers as a metric for quality assessment. Thirty-day mortality and discharge mortality have been presumed to capture procedure-related deaths. However, many patients die after the 30-day mark or are transferred to other facilities or to home and die there, leading to the underreporting of surgically related deaths. We hypothesized that a longer period of observation would address these concerns and provide a more accurate measure of operative mortality.

Methods: We retrospectively reviewed institutional databases of patients undergoing resection for lung cancer, esophageal cancer, and mesothelioma. Mortality rates at 30 and 90 days were calculated with 95% confidence intervals (CIs).

Results: From 1999 to 2012, 7,646 surgical resections were performed: 6,119 for lung cancer, 1,258 for esophageal cancer, and 269 for mesothelioma. Among the different cancers and across operations, the additional mortality from day 31 to 90 (1.4%; 95% CI, 1.2% to 1.8%; n=111) was similar to that by day 30 (1.2%; 95% CI, 1.0% to 1.5%; n=95), resulting in overall 90-day mortality (2.7%; 95% CI, 2.3% to 3.1%; n=206) that was more than double the 30-day mortality.

Conclusions: Among patients who have undergone operations for thoracic malignancies, mortality attributable to the operation occurs beyond the first 30 postsurgical days as well as after hospital discharge. Because cancer operations constitute a large portion of general thoracic surgery, we recommend national databases consider the inclusion of 90-day mortality in their data collection.

Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This study looked at deaths in the 90 days after chest cancer operations at Memorial Sloan Kettering Cancer Center, New York. The authors reviewed 7,646 operations from 1999 to 2012: 6,119 for lung cancer, 1,258 for esophageal cancer and 269 for mesothelioma. The study did not examine asbestos exposure. Across all operations, 95 patients (1.2%; 95% confidence interval 1.0% to 1.5%) died within 30 days. A further 111 of the 7,551 still alive at day 30 (1.4%; 1.2% to 1.8%) died between days 31 and 90, giving a 90-day death rate of 2.7% (2.3% to 3.1%). Extrapleural pneumonectomy for mesothelioma (154 patients) had the highest rates of any operation in days 31 to 90, 8.7% (4.7% to 14.4%), and by day 90, 11.0% (6.6% to 17.1%). By day 30, its rate was 2.6% (0.7% to 6.5%). Leading causes of death were respiratory failure, sepsis and heart problems. The authors concluded that deaths caused by the operation continue after 30 days and after hospital discharge. They recommended that national databases consider recording 90-day mortality. They noted the study was retrospective and single-institution.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of prospectively maintained surgical databases at one cancer center
• Who was studied: 7,646 patients aged 18 or older who had resections between January 1, 1999 and August 6, 2012 at Memorial Sloan Kettering Cancer Center, New York. These were 6,119 for lung cancer, 1,258 for esophageal cancer and 269 for mesothelioma (154 extrapleural pneumonectomy, 115 pleurectomy/decortication).
• Exposure: Surgical operations, not asbestos. Lung cancer: sublobar resection, lobectomy, pneumonectomy. Esophageal cancer: esophagectomy. Mesothelioma: extrapleural pneumonectomy and pleurectomy/decortication. Asbestos exposure was not studied.
• Main results:
  • All operations: 30-day mortality was 1.2% (95% CI 1.0% to 1.5%; 95 of 7,646). Additional mortality from day 31 to 90 was 1.4% (95% CI 1.2% to 1.8%; 111 of 7,551 alive at day 30).
  • All operations: 90-day mortality was 2.7% (95% CI 2.3% to 3.1%; 206 deaths)
  • Extrapleural pneumonectomy for mesothelioma had the highest mortality of any operation for days 31 to 90, at 8.7% (95% CI 4.7 to 14.4; 13 of 151). It was also highest by day 90, at 11.0% (95% CI 6.6 to 17.1; 17 of 154). Its 30-day mortality was 2.6% (95% CI 0.7 to 6.5; 4 of 154), slightly below esophagectomy's 2.8%.
  • Pleurectomy/decortication for mesothelioma: mortality was 0.9% by day 30 (1 of 115), 1.8% in days 31 to 90 (2 of 114), and 2.6% by day 90 (3 deaths)
  • The authors reported that in mesothelioma patients, 90-day mortality was four times the 30-day mortality
  • 83 of the 206 deaths (40%) would not have been counted by either 30-day or discharge mortality measures
  • Respiratory failure, sepsis and cardiac events were the leading causes of death. In 11 patients (5%), the cause was judged to be disease progression.
• The authors' conclusion: The authors concluded that deaths attributable to the operation occur after the first 30 days and after hospital discharge. They recommended that national databases consider collecting 90-day mortality.
• Limitations the authors state:
  • Retrospective study from a single institution
  • Loss to follow-up and difficulty obtaining accurate cause-of-death data. Cause of death was determined for 75% of patients who died.
  • Location of death was unknown for 50 patients who died after discharge
  • The analysis was limited to operations for thoracic cancers, and the results need replication for other operations
  • In the published discussion, the presenting author said the mortality figures were not adjusted for patients' other illnesses

Topics

Medical terms in this study, explained in our Lexicon: Lung Cancer, Esophageal Cancer, Mesothelioma, confidence interval, Surgical Resection, Thoracic Surgery.

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