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Evidence-Based Preoperative Evaluation of Candidates for Thoracotomy^*

^* From the Division of Pulmonary and Critical Care, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA

Correspondence to: John J. Reilly, Jr, MD, FCCP, Associate Professor of Medicine, Harvard Medical School, Brigham and Women’s Hospital, 7S Francis Street, Boston, MA 02115.

	Abstract

TOP Abstract Introduction What Predicts Short-Term Risk? Factors That Identify "Low... Proposed Factors That Identify... Predicting Postoperative... Indications for Quantitative... Evidence Supporting the Ability... References

 
1. All patients considered for thoracotomy should have preoperative spirometry. 2. Patients meeting the criteria outlined below should also have quantitative radionuclide perfusion scanning. 3. Patients felt to be at high risk on the basis of predicted postoperative FEV₁ should be considered for exercise assessment. 4. If exercise assessment is performed, an MO₂ of < 10–15 mL/kg/min or a predicted postoperative MO₂ < 10 mL/kg/min identifies a patient at very high risk for complications and mortality. 5. Limited available data support the use of preoperative risk indices to identify patients at high risk (See Table 4 ). 6. Lung volume reduction surgery may provide new approaches in selected patients with significant obstructive lung disease and concomitant lung cancer.

	Introduction

TOP Abstract Introduction What Predicts Short-Term Risk? Factors That Identify "Low... Proposed Factors That Identify... Predicting Postoperative... Indications for Quantitative... Evidence Supporting the Ability... References

Gass and Olsen, Chest 1986; 89:127–135

The assessment of patients with known or suspected lung cancer is a common clinical situation for pulmonologists and internists. Almost all patients with lung cancer have a history of cigarette smoking, which puts them at risk for other conditions that may potentially affect operative risk, including chronic obstructive pulmonary disease and coronary artery disease. Patients with symptomatic chronic obstructive pulmonary disease have an increased risk for lung cancer relative to smokers without lung disease. Thus, clinicians are frequently called upon to evaluate the risks and feasibility of thoracotomy in patients with comorbid conditions.

In addition to defining the clinical stage of the known or possible lung cancer, preoperative evaluation has the goal of estimating the risk of the planned surgery. The risks associated with thoracotomy can be divided into two categories: immediate or short-term risk, which refers to perioperative morbidity and mortality, and long-term risk, which primarily indicates activity limitation resulting from lung resection.

Much of clinical practice concerning preoperative evaluation of candidates for thoracotomy is based upon clinical experience. Few prospective trials critically examined the various criteria used in preoperative assessment. Rather, clinical guidelines have been adopted that have subsequently identified patients who tolerate thoracotomy with "acceptable" risk.¹ There are far fewer data about the converse, that is patients who have clearly unacceptable risk. Indeed, there are many reports in the literature documenting the ability of certain patients with one or more contraindications to thoracotomy who tolerated the procedure without adverse consequences.

There are two components in the assessment of patients considering thoracotomy. The first is an assessment of operative risk that any patient contemplating a major surgical procedure must undergo, including an assessment of cardiac risk.² A consideration unique to the evaluation of patients considered for thoracotomy is the effect of pulmonary parenchymal resection on postoperative pulmonary function and, consequently, exercise capacity.^{3 4 5}

	What Predicts Short-Term Risk?

TOP Abstract Introduction What Predicts Short-Term Risk? Factors That Identify "Low... Proposed Factors That Identify... Predicting Postoperative... Indications for Quantitative... Evidence Supporting the Ability... References

 
There is agreement in the literature that, in the absence of significant nonpulmonary comorbid conditions, certain characteristics identify populations of patients who are at low risk or high risk for morbidity, mortality, and long-term disability after pulmonary parenchymal resection.

	Factors That Identify "Low Risk" Patients:

TOP Abstract Introduction What Predicts Short-Term Risk? Factors That Identify "Low... Proposed Factors That Identify... Predicting Postoperative... Indications for Quantitative... Evidence Supporting the Ability... References

 
• FEV₁ > 2 L

• MVV > 50% predicted

• Predicted postoperative FEV₁ > 0.8 L and 40% predicted

• absence of cardiac disease

	Proposed Factors That Identify "High Risk" Patients

TOP Abstract Introduction What Predicts Short-Term Risk? Factors That Identify "Low... Proposed Factors That Identify... Predicting Postoperative... Indications for Quantitative... Evidence Supporting the Ability... References

 
• PCO₂ > 45

• PO₂ < 50

• Predicted Postoperative FEV₁ < 0.7 L and/or 40% predicted

• Age > 70

• Poor exercise performance

	Predicting Postoperative Pulmonary Function

TOP Abstract Introduction What Predicts Short-Term Risk? Factors That Identify "Low... Proposed Factors That Identify... Predicting Postoperative... Indications for Quantitative... Evidence Supporting the Ability... References

 
A number of tests have been used over the years predict postoperative pulmonary function. For most patients, a simple calculation based on the preoperative FEV₁ and the amount of parenchymal resection contemplated (assuming 5.2% per segment) provide a reasonable estimate of postoperative function and tend to underestimate, rather than overestimate, postoperative function.

Certain patients require additional testing to accurately predict postoperative function. These tests include bronchospirometry, lateral position testing, pulmonary lobar artery occlusion, and quantitative radionuclide scanning. It has been clearly established that a quantitative analysis of a radionuclide pulmonary perfusion scan provides enough information to allow accurate prediction of postoperative function.^{6 7} This is most clearly established with respect to FEV₁ (reviewed in reference 4).

	Indications for Quantitative Radionuclide Scanning

TOP Abstract Introduction What Predicts Short-Term Risk? Factors That Identify "Low... Proposed Factors That Identify... Predicting Postoperative... Indications for Quantitative... Evidence Supporting the Ability... References

 
• Significant obstructive lung disease (FEV₁ < 60% predicted)

• Known or suspected endobronchial obstruction

• Significant hilar disease (mass/adenopathy)

• Significant pleural disease

• Selected patients who have had prior resections

	Evidence Supporting the Ability to Identify High Risk Patients

TOP Abstract Introduction What Predicts Short-Term Risk? Factors That Identify "Low... Proposed Factors That Identify... Predicting Postoperative... Indications for Quantitative... Evidence Supporting the Ability... References

 
Evidence about several factors that identify patients at high risk for complications from thoracotomy, outlined above, is controversial. Age is not clearly an independent risk factor for complications, although it may interact with other risk factors.^{8 9} There is little convincing modern evidence supporting the contention that hypercarbia alone is a risk factor for complications. Its use in the preoperative evaluation is based on experience of > 45 years ago in the evaluation of patients being considered for parenchymal resection in the setting of tuberculosis.

There is evidence, including our own experience, that patients with a lower ppo FEV₁ are at higher risk for complications and death, although the risk is still considered by many to be "acceptable."⁵ A number of reports exist establishing the ability to operate on selected patients with low pulmonary function.^{5 10 11} The most recent examples include the combination of lung volume reduction surgery with resection of lung cancer, in which the patient may recover with pulmonary function that is improved over that measured preoperatively.¹²

Given that the two largest categories of complications after thoracotomy are pulmonary and cardiac, it makes sense to identify patients at risk by assessing both of these systems. This is most easily accomplished by preoperative testing that involves the function of both systems and is best determined by some form of exercise. The available options for such an assessment include self-reporting by patients of activity capability, a timed walking test (6- or 12-min walk), stair climbing, and integrative cardiopulmonary exercise testing with expired gas analysis. The latter allows determination of maximal oxygen uptake (expressed as mL/min, mL/min/kg, or as % predicted). Of these approaches, the bulk of published data concerns the latter two approaches and is summarized in Tables 1 and 2. These data suggest that, in selected patients, exercise assessment may play a useful role in identifying patients at unacceptably high risk for surgery. More recently, this has been extended to calculate predicted postoperative maximal oxygen consumption and to assess candidate suitability for surgery.¹³

	Footnotes

	References

TOP Abstract Introduction What Predicts Short-Term Risk? Factors That Identify "Low... Proposed Factors That Identify... Predicting Postoperative... Indications for Quantitative... Evidence Supporting the Ability... References

 

1. Zibrak, JD, O’Donnell, CR, Marton, K (1990) Indications for pulmonary function testing. Ann Intern Med 112,763-771
2. Goldman, L, Caldera, DL, Nussbaum, SR, et al (1977) Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 297,845-850[Abstract]
3. Reilly, JJ, Jr, Mentzer, SJ, Sugarbaker, DJ (1993) Preoperative assessment of patients undergoing pulmonary resection. Chest (Suppl) 103,342S-345S
4. Reilly, JJ, Jr (1995) Benefits of aggressive perioperative management in patients undergoing thoracotomy. Chest (Suppl) 107,312S-315S[Medline]
5. Kearney, DJ, Lee, TH, Reilly, JJ, et al (1994) Assessment of operative risk in patients undergoing lung resection: importance of predicted pulmonary function. Chest 105,753-759[Abstract/Free Full Text]
6. Wagner, HN (1976) The use of radioisotope techniques for the evaluation of patients with pulmonary disease. Am Rev Resp Dis 113,203-218[ISI][Medline]
7. Kristersson, S, Lindell, S, Svanberg, L (1972) Prediction of pulmonary function loss due to pneumonectomy using 113 Xe-radiospirometry. Chest 62,694-698[Abstract/Free Full Text]
8. Ebner, H, Sudkamp, N, Wex, P, et al (1985) Selection and preoperative treatment of over-seventy-year-old patients undergoing thoracotomy. Thorac Cardiovasc Surg 33,268-271[ISI][Medline]
9. Dales, RE, Dionne, G, Leech, JA, et al (1993) Preoperative prediction of pulmonary complications following thoracic surgery. Chest 104,155-159[Abstract/Free Full Text]
10. Miller, JI, Hatcher, CR (1987) Limited resection of bronchogenic carcinoma in the patient with marked impairment of pulmonary function. Ann Thorac Surg 44,340-343[Abstract]
11. Pate, P, Tenholder, MF, Griffin, JP, et al (1996) Preoperative assessment of the high-risk patient for lung resection. Ann Thorac Surg 61,1494-1500[Abstract/Free Full Text]
12. McKenna, RJ, Jr, Fischel, RJ, Brenner, M, et al (1996) Combined operations for lung volume reduction surgery and lung cancer. Chest 110,885-888[Abstract/Free Full Text]
13. Bolliger, CT, Wyser, C, Roser, H, et al (1995) Lung scanning and exercise testing for the prediction of postoperative performance in lung resection candidates at increased risk for complications. Chest 108,341-348[Abstract/Free Full Text]
14. Richter Larsen, K, Svendsen, UG, Milman, N, et al (1997) Exercise testing in the preoperative evaluation of patients with bronchogenic carcinoma. Eur Respir J 10,1559-1565[Abstract]
15. Smith, TP, Kinasewitz, GT, Tucker, WY, et al (1984) Exercise capacity as a predictor of post-thoracotomy morbidity. Am Rev Resp Dis 129,730-734[ISI][Medline]
16. Bechard, D, Wetstein, L (1987) Assessment of exercise oxygen consumption as preoperative criterion for lung resection. Ann Thorac Surg 44,344-349[Abstract]
17. Epstein, SK, Faling, LJ, Daly, BD, et al (1993) Predicting complications after pulmonary resection. preoperative exercise testing vs a multifactorial cardiopulmonary risk index. Chest 104(3),694-700[Abstract/Free Full Text]
18. Morice, RC, Peters, EJ, Ryan, MB, et al (1992) Exercise testing in the evaluation of patients at high risk for complications from lung resection. Chest 101,356-361[Abstract/Free Full Text]
19. Olsen, GN, Bolton, JW, Weiman, DS, et al (1991) Stair climbing as an exercise test to predict the postoperative complications of lung resection. Two years’ experience. Chest 99,587-590[Abstract/Free Full Text]
20. Holden, DA, Rice, TW, Stelmach, K, et al (1992) Exercise testing, 6-min walk, and stair climb in the evaluation of patients at high risk for pulmonary resection. Chest 102,1774-1779[Abstract/Free Full Text]
21. Van Nostrand, D, Kjelsberg, MO, Humphrey, EW (1968) Preresectional evaluation of risk from pneumonectomy. Surg Gynecol Obstet 127,306-312[ISI][Medline]
22. Prause, G, Offner, A, Ratzenhofer-Komenda, B, et al (1997) Comparison of two preoperative indices to predict perioperative mortality in non-cardiac thoracic surgery. Eur J Cardiothorac Surg 11(4),670-675[Abstract]

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