Video−Assisted Thoracic Surgery in the Elderly

Video−Assisted Thoracic Surgery in the Elderly

Video-Assisted Thoracic Surgery in the Elderly* A Review of 307 Cases Michael T. Jaklitsch, MD; Malcolm M. DeCamp, Jr., MD; Michael J. Liptay, MD; D...

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Video-Assisted Thoracic Surgery in the


A Review of 307 Cases Michael T. Jaklitsch, MD; Malcolm M. DeCamp, Jr., MD; Michael J. Liptay, MD; David H. Harpole, Jr., MD; Scott J. Swanson, MD; Steven J. Mentzer, MD; and David J. Sugarbaker, MD was to investigate the impact of video-assisted thoracic Study objective: The objective of the studyand on (VATS) mortality for thoracic surgical procedures. morbidity age-related surgery consecutive VATS procedures from July 1991 to June Design: Prospective data were collected on 896collection thoracic surgical nurse and 1994. Daily in-hospital, postoperative data by a full-time done. were 1 6 weeks at and clinic in a thoracic surgery postdischarge follow-up Patients: On 296 patients aged 65 or older, 307 procedures were performed. One hundred nine on patients between 65 and 69 years, 110 on patients between 70 and performed procedures55were 75 and 79 years, and 33 on those between 80 and 90 years. between on 74 years, patients Measurements and results: The population was divided into four cohorts of 5-year age spans for analysis. Comparison was made with Fisher's Exact Test. Overall, 61% of the 307 procedures were for pulmonary disease. There were 32 anatomic lung resections (VATS lobectomies or segmentectomies), 156 extra-anatomic lung resections (thoracoscopic wedge or bullectomy), 78 procedures for 27 mediastinal dissections (9%), and 14 pericardial windows (5%). There was pleural disease a(25%), a trend toward lower mean FEVi with increasing age. There were 3 deaths; overall mortality was less than 1%. There were 4 conversions to open thoracotomy (1%). Complications occurred with 45 Twenty-two operations (7%) were associated with major complications proceduresthe(15% morbidity). of stay and 27 procedures (9%) had minor complications. Median length of stay adding to length after VATS was 4 days for patients aged 65 to 79 years and 5 days for those aged 80 to 90 years. Morbidity and mortality were unrelated to isage. Conclusions: The 30-day operative mortality superior to previous reports of standard thoracotomy. stay appears improved. VATS techniques may be safer than Morbidity is low andinlength of hospital open thoracotomy the aged. Age alone should not be a contraindication to operative interven¬


(CHEST 1996; 110:751-58)

Key words: elderly; thoracoscopy; video-assisted thoracic surgery Abbreviations: LCSG=Lung Cancer Study Group; UTI=urinary tract infection; VATS

HPhe US population is aging. The US Bureau of the -*- Census has that the average life expect¬ reported in is 75.6 years of age.1 Half 1995 of Americans ancy of all Americans currently alive can expect to reach the ninth decade of life. However, a significant number of them will suffer from diseases of the esophagus, lung, More than 1 million patients pleura,65or pericardium. or older aged years require major thoracic opera¬ tions each year.2 *From the Division of Thoracic Surgery, Brigham and Women's Cancer Institute, Boston (Drs. DeHospital, and Dana Farber Swanson, Mentzer, and Sugarbaker), and Liptay, Harpole, Camp, Division of Cardiothoracic Surgery, University of Minnesota,

Minneapolis (Dr. Jaklitsch).

Manuscript received January 18,1996; revision accepted March 13. Reprint requests: Dr. DeCamp, 75 Francis St, Roston, MA 02115


video-assisted thoracic surgery

One major source of intrathoracic disease in elderly patients is lung cancer. The American Cancer Society estimates that there will be 177,000 new cases of lung cancer diagnosed in the United States in 1996.3 Of these, 98,900 will be identified in men and 78,000 in women. At least half of these patients will require

surgery for staging, resection, or management of the from advanced cancer. Elderly patients complications are particularly vulnerable to lung cancer. The peak incidence of the disease occurs in the sixth and seventh decades of life; 27,394 men and 17,510 women aged 75 years or older are expected to die from lung cancer in 1996.3 The likelihood that a solitary pulmonary nodule, found in a smoker aged 70 years or greater, is an oc¬ cult lung cancer is nearly 70%.4 CHEST /110 / 3 / SEPTEMBER, 1996


reported to be associated with less pain, less pulmonary embarrassment, stronger cough, and less recovery time compared with open thoracotomy.9'10 We hypothe¬ sized that these clinical benefits might produce mea¬ surable reduction in operative risk for elderly patients. Materials and Methods From July 1, 1991, to June 15, 1994, 896 thoracoscopic and vid¬

cases were performed at the Brigham and Women's Hospital, Boston. Three hundred seven of these cases were in 296 patients aged 65 years or older. Potential advantages and disad¬ vantages of video-thoracoscopy vs open thoracotomy, as well as the potential to convert from video-assisted techniques to an open technique, were discussed with each patient prior to surgery, and informed consent was obtained. Specific operative details of the various types of procedures have been described elsewhere.11


Data Collection

Figure 1. Closed Axford et al12).

thoracoscopy (reprinted with permission from

Age is an independent risk factor for death after thoracotomy. Multiple single-institution studies5"' and one multi-institutional study8 have shown increased mortality after thoracotomy in patients aged 65 years or older. In the multi-institutional experience of the Lung Cancer Study Group (LCSG), mortality from increased in a linear fashion with pulmonary resection 1.3% for increasing age: patients younger than or equal to 59 of 4.1% for 60 to 69

years age, ages years, 7% for 70 to 79 and 8.1% for ages years, patients 80 years of

age or older.8 The elderly patient population, with increased mor¬ conventional surgery, may bidity andthemortality from to benefit most from minimally represent subgroup invasive surgery. Thoracoscopic surgery has been

Demographic, perioperative, and pathologic data were collected prospectively on all patients referred to the Division of Thoracic Surgery at Brigham and Women's Hospital and entered into a dioracic surgery, computerized database. A full-time, thoracic surgical nurse/data coordinator was responsible for the accurate completion of standardized data collection forms. Thoracoscopic and video-assisted cases were computer coded separately. Closed thoracoscopy was defined as surgical access of the thorax by a video-thoracoscope and endoscopic instruments through multiple chest wall incisions each less than or equal to 2 cm (Fig l).12 Video-assisted thoracic surgery (VATS) was defined as the use of the video-thoracoscope in combination with a utility musclesparing thoracotomy of 8 cm or less (Fig 2).13 Thoracotomy incisions larger than 8 cm or requiring the use of a rib spreader to enhance exposure were classified as open procedures. The operative surgeon classified each procedure as diagnostic, therapeutic, or both. The surgeon also recorded any reasons for abandoning video-assisted techniques and conversion to a formal thoracotomy. Daily in-hospital, postoperative data collection was performed ward visits by a surgical data manager. Postoperative length during of stay, final pathologic findings, and mortality were recorded. More than 100 potential complications were monitored, including causes of hemodynamic compromise, mental status changes, organ sub¬ system compromise, and the need for aggressive intervention be¬ yond the normal convalescent course. Complications were audited weekly during a meeting of the attending physicians, nursing, and house staffs. The coding of complications into the database from the previous week was reviewed and the source of complications discussed. To ensure complete capture of incident cases, the computerized database was checked against the operative log of the thoracic sur¬ gery residents-in-training. The log is a separate record maintained in the operating room for the board certification of each resident. Postoperative follow-up was performed in a thoracic surgery clinic at 1 and 6 weeks for all Patients with patients.


resections for neoplastic disease were followed up every 4 months

for 3 years.

Figure 2. VATS



(reprinted with permission from Sugarbaker and

Analysis and Statistics The elderly population was broken into four cohorts of 5- to 10year age spans (65 to 69 years, 70 to 74 years, 75 to 79 years, and 80 to 90 years of age) for overall analysis and comparisons between groups. Important outcomes included death, morbidity, conversion to open procedures, and length of stay. Mortality included all in-hospital deaths or those within 30 days of the procedure. Increasing age range was analyzed as a univariate predictor of out¬ come.

Comparison between groups was made with Fisher's Exact Clinical


Table 1.Procedures With Gender, Pulmonary Function, and Length of Stay as a Function of Age

Subject Age, yr Procedures on men (%) Procedures on women (%) Median FEVi

Range Lung resection

Lobe or segment




56 (51) 53 (49) 2.02 0.73-4.2

63 (57) 47 (43) 1.76 0.38-3.66

29 (53) 26 (47) 1.68 0.84-2.66

16 (48) 17 (52) 1.61 0.7-2.95

8 43 9 2 3 10 35 110

15 48 7 0 5 11 23 109

Wedge Bullectomy

Lung biopsy

Pericardial window Mediastinal dissection


Totals of 307 procedures Length of stay, d Median






Test. The length-of-stay curves were sufficiently skewed to suggest

nonnormal distribution and are described using the nonparamet¬ ric method of reporting quartiles. a



Results 1, 1991 and

June 15, 1994,


patients had 896 separate thoracoscopic procedures at the Brigham and Women's Hospital. performed Between 40 to 60 thoracoscopic operations were per¬ formed each month, representing 50% of the major thoracic operative caseload during that time period. This report focuses on the outcome of 307 separate on 296 patients between the procedures performed ages of 65 and 89 years. Of these, 164 operations were on 157 men and 143 operations on 139 performed women. Two hundred seventy-five cases were closed thoracoscopic procedures and 32 were8 cmvideo-assisted or less. One with a utilitythoracotomy procedures hundred ninety-two operations were classified as purely and 58 categorizedof as therapeutic, diagnostic,had57awere and combination diagnostic thera¬ patients One hundred interventions. peutic thoracoscopic the involved lung (61%), 78 eighty-eight operations were for pleural disease (25%), 27 were for mediasti¬ nal disease (9%), and 14 were pericardial windows (5%).

Table 1 summarizes the

procedures performed each the

variety of thoracoscopic

function of age. Within age group, percentage of procedures per¬ formed on male patients ranged between 48% and 57%. There was no significant difference in pulmonary function between the age groups, although there was a general trend toward a lower mean FEVi with increasing age from 2 L in patients aged 65 to 69 years to a mean of 1.6 L in the oldest patients. One hundred nine procedures were performed on patients between the ages of 65 and 69 years. One hundred ten proce¬ as a



3 21 1 0 0 2 6 33

6 21 3 1 6 4 14 55





dures were performed on patients between the ages of 70 and 74 years. Fifty-five procedures were performed on patients between the ages of 75 and 79 years and 33 operations were performed on patients between the ages of 80 and 90 years. In each subgroup, the lung resection and predominant procedures involved within each group, be¬ pleural evaluation; however, tween 9% and 20% of procedures were focused on more central structures such as the heart or mediasti¬ num. Median length of stay was 4 days for patients aged 65 to 79 years of age, and 5 days for patients aged 80 to 90 years of age. Table 2 summarizes the mortality, conversion, and rates as a function of age. There were 3 morbidity deaths in the entire elderly group (all between ages 70 and 74 years) for an overall mortality rate of less than 1%. One death was in a 70-year-old man with a underwent pleuros¬ malignant pleural effusion who died on the and talc poudrage, yetAnotherof his cancerwoman copy 73-year-old eighth postoperative day. had a pleuroscopic drainage of an empyema and sub¬ sequently developed acute renal failure and died on the 19th postoperative day. The third death was in a 73-year-old man with diffuse interstitial lung disease who underwent thoracoscopic lung biopsy, yet died of his primary disease process on the 24th postoperative

day.There were 4 conversions to

open thoracotomy, for

an overall conversion rate of 1%. Two conversions were tho¬ in men 65 and 70 due to decortication of a loculated empyema. A was in a of man due to the An man had a conversion due to intrathoracic but a VATS suffered no

(aged years) inadequate thoracoscopic mediastinal node biopsy abandoned 73-year-old inadequate atelectasis lung. 84-year-old during lobectomy bleeding, sequelae. racoscopic

CHEST /110 / 3 / SEPTEMBER, 1996


Table 2.Mortality, Conversion, and Morbidity as Functions of Age

Age, yr 65-69 No. of procedures

group) Conversion (% group) Death (%

Procedures associated with morbidity (% group) Procedures with major morbid events (%) No. of events Prolonged air leak

Respiratory failure/pneumonia Reoperation for bleeding

Other Procedures with minor morbid events (%) No. of events

109 0


15 (14)

4(4) 1 1 1 1

13 (12)





3(3) 2(2) 19 (17) 13 (12) 7

2 1 4





33 0

7(13) 4(7)

1(3) 4(12) 1(3)

3(<1) 4(1) 45 (15) 22(7)

2 2 0 0

0 1 0 0

10 6 2 5

0 0



Dysrhythmia Supraventricular

13 3

Ventricular Confusion Other

Forty-five of the 307 procedures were associated with a postoperative complication, for an overall mor¬ bidity rate of 15%. Twenty-two operations were asso¬ ciated with 23 major complications that added to the overall length of stay for a 7% major morbidity rate. The most common major complication was prolonged air leak defined as lasting greater than 10 days. This occurred in 10 (3%) of the procedures. Included with the category of other major morbid events were the following: one episode each of a myocardial infarction, acute renal failure, phrenic nerve palsy, postoperative colonic perforation, and anaphylaxis to IV medication. Twenty-seven procedures were associated with 31 minor setbacks that did not lengthen the time in the in a minor morbidity rate of 9%. The hospital, resultingminor most common complications were supraven¬ tricular tachyarrhythmias in 13 (4%) and confusion in 8 (3%) patients. Other minor morbidities included three ventricular dysrhythmias, three port wound infections, three urinary tract infections (UTIs), and one episode of postoperative hemoptysis. Table 3 analyzes mortality, conversion, and morbid¬ ity as a function of operative procedure. Anatomic lung resections were associated with a 28% overall morbid¬ ity but zero mortality in this series. The most common complication in this group was air leak lasting greater than 10 days postoperatively, occurring in 4 patients, 12% of the procedures. Minor morbidity for this class of cases included dysrhythmias in 3 patients (9%), postoperative confusion in 2 patients (6%), and one UTI (3%). Mediastinal dissections were also associated with a high overall morbidity (29%) and no mortality. Major morbid events in this group included 2 episodes of prolonged air leak (7%), 1 pneumonia (4%), 1 post¬ operative myocardial infarction, and 1 phrenic nerve 754

Minor events included 3 episodes of supraven¬ palsy. tricular tachycardia (an 11% incidence) and 2 wound infections (7%). Extra-anatomic lung resections, pleu¬ ral procedures, and pericardial windows had a low in¬ cidence of morbidity, as outlined in Table 3. Table 4 is a breakdown by quartiles of the length of stay as a function of surgical procedure. The longest stay was generally in patients having an anatomic lung resection, with a median stay of 7 days. Seventy-five percent of these patients were discharged from the hospital by the tenth day. Median stays for extra-ana¬ tomic lung resections and pleural procedures were 4 days, compared with 5 days for mediastinal dissections, and 6 days for pericardial windows. Discussion Thoracoscopy and VATS have proved to be useful tools in the management of intrathoracic disease in

elderly patients. The techniques are applicable to a wide variety of diseases of the lungs, pleura, pericar¬ dium, and mediastinum. This report demonstrates that operations can be performed safely with low morbid¬ ity and mortality in the high-risk, elderly population. Furthermore, most patients recover quickly with a short postoperative hospital length of stay. Our oldest patient treated to date was 90 years old; he had a tho¬ racoscopic wedge excision of his lung to remove a cancer. He returned home 3 days after surgery. The general spectrum of thoracoscopic procedures we describe is similar to previous reports. Extraanatomic wedge excisions of pulmonary disease have been the most frequently reported use of thoracosco¬ for 51% of our procedures in py91014"18 and accounted initial Our operative experience was elderly patients. with thoracoscopic pericardial windows and gained Clinical


Table 3.Mortality, Conversion, and Morbidity by Procedure Anatomic

No. of procedures Death (% group)


Lung Resection

Lung Resection

32 0




Pericardial Window



14 0 0

27 0



Procedures associated with morbidity

1(3) 9(28)


2(3) 2(3) 12 (15)

Procedures with major morbid events






1 3 1 1

0 0 0 0

2 1 0 2


(% group)

(% group)

(% group)

No. of events

Prolonged air leak

Respiratory failure/pneumonia Reoperation for bleeding

Other Procedures with minor morbid events

(% group)

4 0 0 2



3 2 1 0




1(4) 8(29)



No. of events

Dysrhythmia Supraventricular

Ventricular Confusion Other

thoracoscopic bullectomies. As experience increased, the indications for VATS were expanded. The large number of VATS lobectomies, mediastinal procedures, and pericardial windows in this series is similar to re¬ cent reports from other experienced thoracic surgical groups9,10,17,18 Qur cnoice 0f surgical procedure is based on the


disease process and not the age of the

The low operative mortality of this series is in sharp contrast to an increased mortality in the elderly patient population previously reported for open thoracotomy. The LCSG identified increasing age as an important risk for 30-day mortality in a retrospective multi-insti¬ tutional study of more than 2,000 patients undergoing pulmonary resection in 12 hospitals.8 This series included 569 pneumonectomies, 1,508 lobectomies, and 138 lesser resections. Mortality rates were 1.3% for patients younger than 60 years of age, 4.1% for ages 60 to 69 years, and 7.1% for patients 70 years of age or older. Our series included no pneumonectomies for comparison, but the lobectomy data are of particular interest. In the LCSG study, 27 of the 368 patients

aged 70 or older who had a 'lobectomy or less" died, rate of 7.3%. Three of the 27 demonstrating80a mortality or older who underwent lobec¬ patients aged years a tomy died, giving mortality rate of 11%. Other authors have reported the mortality for a lobectomy in patients aged 70 years or older to be between 14% and 16%.5"719 The best survival of a large series of elderly patients undergoing thoracotomy was the 3% operative mortality reported by Rush-Presbyterian-St. Luke's Medical Center in 218 patients aged 70 years or older over a 10-year period.20 This report was dominated by lobectomies, but included a wide variety of procedures for diseases of the pleura, lungs, mediastinum, and esophagus. Ina our series, none ofthe 32 elderly patients or segmentectomy died, and undergoing lobectomy 1 of 156 who only patients underwent lesser pulmonary resections died, giving our series a mortality within the resection subgroup of one half of 1%. The pulmonary low mortality associated with thoracoscopic proce¬ dures, as well as the observation that the cause of death was generally due to disease progression, has been substantiated by other gr0ups. '10'14"17'21"30

Table 4.Length of Stay as a Function of Procedure No. of procedures

Length of stay, d Minimum 25th percentile Median 75th percentile Maximum



Anatomic Lung Resection

Lung Resection

Pleural Disease

Pericardial Windows

Mediastinal Dissections






3 4

1 2 4 6

1 2 4 7 37

1 3 6 7 17

1 3 5 9 37


10 69


CHEST / 110 / 3 / SEPTEMBER, 1996


The 1% rate of conversion from thoracoscopic or VATS techniques to open thoracotomy in this elderly

patient population is similar to our previously reported conversion rate of 1.4% in 895 video-assisted proce¬ dures.18 This is a improvement over the 12% conversion rate the VATS Study The 7% major and 9% minor

significant reported by Group.17 morbidity morbidity rates within this heterogeneous group of thoracoscopic procedures in our series compares favorably to previ¬ ous reports of open thoracic procedures within this age group. The Rush-Presbyterian-St. Luke's Medical Cen¬ ter reported an overall 15% minor and 18% major morbidity rate, subdivided further into 18.9% minor and 22.3% major rate for pulmonary resections and a 2.3% minor and 18.6% major morbidity rate for other procedures in patients aged 70 years or older.20 Zapatero et al31 reported an overall morbidity rate of 20% in 100 patients aged 70 years or older undergoing a variety of thoracic procedures through standard inci¬ sions. Reclassifying their data by our subdivisions (major vs minor) produces a major morbidity rate of 11% and a minor morbidity rate of 13%.31 Furthermore, our morbidity rates compare favor¬ to previous retrospective reports of thoracoscopy ably in younger patients. Authors reviewing large hetero¬ geneous groups of patients undergoing various types of VATS have reported morbidity rates between 7.5% and 29%, with major morbidity reported as 16% and minor morbidity 13%.14"17'21 Self-reported complica¬ tions of the VATS Study Group included a 12% con¬ version, 9.3% major, and 5.1% minor morbidity rates. Also, our 28% (cumulative) morbidity for videoassisted anatomic lung resections is similar to the 15.8 to 22% morbidity previously reported.1''29 It is, how¬ ever, greater than the 5.7% morbidity in the prelimi¬ nary report by Kirby et al30 of VATS lobectomy. The other procedure-specific morbidities in Table 3 are Further¬ reports.15,17'25,27'28 comparable to previous in series was calculated this more, morbidity prospec¬ data by a trained nursemore daily ward roundsclassification tively on Such provides manager. prospective accurate morbidity estimates than retrospective chart review. The 4-day median length of stay (5 days in patients older than 80 years of age) is a marked improvement over the 12.4 days of expected hospitalization after a major thoracic operation (diagnosis-related group 75).32 Once again, the procedure-specific median of stay compare favorably to previous reports lengths of VATS or thoracoscopic procedures in younger pa¬ tients: 7 days for VATS lobectomies and segmentectomies, 4 days for extra-anatomic pulmonary resec¬ tions, 5 days for mediastinal dissections, and 6 days for pericardial windows compared with 4 to 6.3,1/'2930 2.4 to 4.4;25-28,33 g 23 anc[ 5

elderly subpopulation our entire cohort of 896 video-assisted procedures with a median length of stay of 3 days for thoracoscopic procedures and 5 days for VATS procedures.18 The reasons for this reduction in operative risk for elderly patients undergoing VATS are likely multifac¬ torial. The elderly patient is more vulnerable to stresses placed on respiratory muscles. Advanced age is asso¬ ciated with respiratory muscle atrophy, reduction in the force-generating capacity of residual muscle, and derangements in the mechanics of breathing.35 Tho¬ of stay in this more, the not dissimilar from that seen in


racoscopic port incisions are 2 cm or less and the util¬ ity incision of VATS is 8 cm or less. These limited in¬

cisions preserve the function of intercostal and

accessory respiratory muscles. They avoid rib fractures and chest wall splinting. Landreneau et al36 showed that VATS procedures were associated with less nar¬ cotic usage, reduced pain, less shoulder dysfunction, and less pulmonary impairment when compared with standard thoracotomy. The elderly patient greatly benefits from the reduction in pain and impairment of respiratory function. As a result, elderly patients require less narcotic analgesia, ambulate on the day of surgery, and enjoy a quicker return to full recovery. The 2.6% incidence of postoperative confusion is particularly noteworthy in this series, and may reflect the reduced severity of physiologic stress brought on by VATS compared with standard thoracotomy. A pro¬ spective study of acute postoperative confusion in elective noncardiac surgery is ongoing at our institu¬ tion.37"39 Based on the data obtained from more than 1,300 procedures, an age of 70 years or older and noncardiac thoracic surgical procedures were identi¬ fied as independent correlates of delirium.38 If these two risk factors are combined (ie, patients older than 69 years undergoing noncardiac thoracic surgery), the incidence of postoperative confusion is expected to be between 13% and 19%. The lower incidence of observed postoperative confusion in this elderly cohort undergoing video-assisted procedures may be due to less physiologic stress of the new surgical techniques, less narcotic analgesia, or a quicker return to the pa¬ tient's home environment. Postoperative confusion in elderly patients has been associated previously with a 7-fold increase in major complications, a 13-fold increase in mortality, and a 3-fold increase in the rate of hospital discharge to long-term care or rehabilitation facilities.38 Our decrease in delirium is interrelated with the low mortality, morbidity, and short length of stay previously noted for VATS. This is a phase 2 descriptive study of the application of VATS to the higher-risk elderly population. As such, we cannot make valid, direct comparisons to standard thoracotomy procedures. Such a comparison would Clinical Investigations

require a prospective phase 3 trial randomizing pa¬

tients with thoracic disease to either video-assisted


standard open thoracic surgery techniques. Such ef¬ forts are currently underway within discreet disease groups, such as patients with malignant pleural effu¬ sions or metastatic disease to the lungs. These trials are not limited to elderly patients, but include all patients with these diseases. The encouraging results reported herein are partly due to a standardized approach to thoracoscopic sur¬ gery that has been developed through a large clinical experience. The approach involves experienced sur¬ geons and anesthetists, the expertise of several nursing staffs and support personnel, and the application of new surgical technology. Although the actual morbid¬ ity and mortality rates may differ in smaller commu¬ thora¬ nity-based programs, we believe our data show in and are VATS versatile and safe selected coscopy

elderly patients.


The literature suggests that elderly patients are at higher riskarefor adverse outcomes when conventional incisions used to approach thoracic disease. Tho¬ racoscopic (only small port incisions) and VATS (in¬ cludes a utility incision of 8 cm or less) can be used safely to perform a wide variety of surgical procedures in selected elderly patients with an expected mortality of less than 1%. Furthermore, this can be accom¬ with an acceptable morbidity and a short length plished of hospital stay. Age alone, therefore, should not be a contraindication to thoracic surgical intervention when video thoracoscopy is thoughtfully applied.

Elayne DiBiccaro, RN, for data collection and retrieval and Mary Sullivan Visciano for

ACKNOWLEDGMENTS: We wish to thank

editorial assistance.

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{1996} WORLD


If surgery issues interest you, consider attending CHEST 1996.where surgery is one of the study tracks offered. Hundreds of scientific sessions, many focusing on surgery, will be presented at this extraordinary 5-day meeting. Make plans now to attend... October 27-31, 1996 . San Francisco, California For more information, contact ACCP Product and Registration Services at 800-343-2227, or check our web site at:


Clinical Investigations