PREOPERATIVE ASSESSMENT OF THE THORACIC SURGICAL PATIENT
Preoperative evaluation of patients who are
candidates for thoracic surgery is a complex process
that is essential in fulfilling a variety of objectives.
The surgeon requires such assessment lo plan the
operative approach, anticipate potential operative and
postoperative complications, decide on the necessary
level of postoperative care, and determine what
resources might be required to support the patient
until full recovery takes place. The patient requires
such assessment so that he or she can ask relevant
questions about the recommended procedure, gain an
understanding of the short- and long-term
consequences of having surgery, and make an
informed decision about whether to proceed.
The preoperative evaluation of candidates for
thoracic surgery is an art as much as it is a science.
Despite the plethora of noninvasive and invasive tests
that is available for assessing operative risks and
predicting outcomes, the final decision ultimately is
based on the surgeon's impression of the likelihood of
success of the planned operation. Success can be
identified in a number of ways, such as absence of
complications, survival until hospital discharge,
correction of an underlying disorder, cure of a cancer,
or improved long-term quality of life (QOL). This
chapter focuses on the physiologic evaluation of
patients and on the associations among surgery and
perioperative complications, operative mortality,
long-term survival, and postoperative QOL.
GENERAL STATUS
Age
Given the continued growth of the advanced age
sector of the population, is it no surprise that surgeons
are being referred a higher percentage of elderly
patients for consideration for surgery. Seventy-five
years was once considered a prohibitive age for
aggressive intervention for intrathoracic problems, but
it is now commonplace to recommend major surgery
to such patients. In 1975, the average U.S. white male
barely lived into his early 70s; in 2005, the life expec-
tancy of a 75-year-old U.S. white male was more than
10 years. The realization that the aging population
needs and desires continued aggressive surgical care
for selected problems has resulted in a substantial
increase in the percentage of elderly patients in an
overall surgical practice. For example, in 2001, the
percentage of patients older than 70 years of age
undergoing major lung resection was in excess of
43%,' a 25% increase over the percentage of elderly in
such a cohort only 2 decades earlier.2
In the 1970s and 1980s, advanced age was
associated with a substantial increase in morbidity and
mortality from thoracic surgery.2 In most reports, age
continues to be an important and independent
determinant of operative mortality and morbidity for
lung resection, although the relative increased risk of
surgery-related death associated with advanced age
has substantially decreased owing to improvements in
patient selection and surgical and postoperative
management (Berrisford et al, 2005; Ferguson et al,
1995}.3,4 In fact, some reports suggest that age is no
longer an independent determinant of operative
mortality.5,6 In contrast, advanced age universally
remains an independent and strong factor associated
with increased risk of mortality and morbidity after
esophagectomy (Atkins et al, 2004).7-9
Advanced age by itself is not an absolute
contraindication to major thoracic surgery. For
example, disease-specific survival is unrelated to the
patient's age at the time of resection for lung cancer.10
However, a patient's age must be considered carefully
in deciding on major surgical intervention,
particularly in light of other comorbid conditions. Age
interacts with other factors to increase the risk of
operative morbidity and mortality. For example,
diffusing capacity and age have been shown to be
independent predictors of morbidity and mortality
after major lung resection.3 Whereas the presence of a
high risk value for only one parameter moderately
increases operative risk, mortality increases
exponentially if both parameters are in the high risk
zone. Similarly, combined increased risk values for
age and renal function, or for age and cardiovascular
function, substantially elevate the risk of post-
operative morbidity and mortality.11 For this reason,
never consider such values independently; rather,
evaluate them collectively in the overall context of a
patient's medical condition.
Performance Status
Performance status is a general measure of a patient's
overall ability to participate in activities of daily life.
It is useful to routinely assess performance status as
part of the overview of a patient's physiologic and
psychological condition. Several scales have been
developed for scoring performance status that are easy
to use and are reproducible. The most commonly used
scales are the Karnofsky score and the Zubrod
(Eastern Cooperative Oncology Group [ECOG]] scale
(Table 2-1). In the absence of specific risk factors,
patients with an ECOG score of 0 to 1 or a Karnofsky
score of 80% to 100% have a normal risk of
complications and mortality after major thoracic
surgery. Progressively worse performance status
levels are associated with incremental operative
risk.Performance status has been shown in a few
studies to be an independent determinant of operative
outcomes. For example, mortality after
esophagectomy has been shown to be predicted by
age and performance status.7 Similarly, poor
performance status is associated with an increase in
the risk of operative mortality after resection for lung
cancer in elderly patients.12 However, most studies
assessing operative risk associated with thoracic
surgery have not specifically evaluated performance
status as a potential risk factor. In addition, specific
risk factors that contribute to poor performance status
are more likely to be statistically linked to adverse
outcomes than is performance status itself.
PULMONARY FUNCTION
A general assessment of pulmonary function is
appropriate in every patient undergoing thoracic
surgery. The risk of pulmonary complications after
major thoracic surgery is as high as 25%, and
preoperative pulmonary function is an important
predictor of such complications. Many patients who
are candidates for thoracic surgery have had extensive
exposure to tobacco smoke, putting them at high risk
for emphysema and other forms of chronic obstructive
lung disease. Assess the patient's smoking status
during the initial evaluation, and provide smoking
cessation advice as part of the initial encounter. It is
often appropriate to remind patients of the substantial
increase in risk of pulmonary complications for those
patients who are unable or unwilling to stop smoking
before major thoracic surgery.
Initial screening consists of taking a history
focused on the patient's respiratory status, including
symptoms such as shortness of breath, dyspnea on
exertion, the presence of a cough, whether the cough
is productive, hemoptysis, and limitations in exercise
capacity related to breathlessness. Additional informal
evaluation in an outpatient clinic setting might include
measurement of oxygen saturation during exercise,
such as walking for a measured distance on flat
ground or climbing a specified number of stairs.
Failure to maintain adequate oxygen saturation during
such maneuvers may indicate the need for more
formal testing of pulmonary function.'3,14
Formal pulmonary function testing is appropriate in
patients undergoing certain types of thoracic surgery
in whom surgical recommendations would be altered
based on the results of such testing. The finding of
poor spirometry values may not influence the decision
to perform limited wedge resection for diagnosis of
diffuse pulmonary disease or thoracoscopic excision
of a small, peripheral lung nodule. In contrast, elec-
tive major lung resection should virtually always be
preceded by a formal assessment of pulmonary
function to help determine operative risks and enable
the surgeon to hold an informed discussion with the
patient. Assessment of pulmonary function is also
appropriate in many instances for preoperative
evaluation before nonpulmonary surgery. For
example, the risk of pulmonary complications is
predicted by spirometry in patients undergoing
esophagectomy,15"17 and operative mortality after
esophagectomy may similarly be related to
preoperative pulmonary disease.18
Risk Factors
Specific risk factors for major thoracic surgery related
to pulmonary function include chronic pulmonary
disease (emphysema, chronic bronchitis, asthma} and
any condition that limits lung volume, including a
large pleural effusion, a large diaphragmatic hernia,
and prior major lung resection. Interstitial lung
disease that interferes with gas exchange may be
associated with hypoxia. Induction chemotherapy and
radiotherapy result in measurable decrements in lung
function. Similarly, distant prior radiotherapy to the
lung or mediastinum can cause considerable
impairment of pulmonary function as well as
decreasing chest wall mobility and limiting
mediastinal motion. In addition to these conditions,
many of which cause chronic changes in lung
function, performance of a thoracotomy has acute
detrimental effects on spirometry that persist for up to
8 to 12 weeks postoperatively. Functional residual
capacity drops by 35% on the first postoperative day.
Sixty percent decreases in forced vital capacity (FVC)
and forced expiratory volume in 1 second (FEVi) also
occur during this period.19,20
The addition of a major lung resection substantially
further decreases spirometric values and gas exchange
parameters to an extent directly correlated with the
amount of functional lung tissue that is resected.
Furthermore, these reductions persist because of
permanent loss of lung volume and are sometimes
associated with impaired exercise capacity, par-
ticularly in patients who have undergone
pneumonectomy. At 6 to 12 months postoperatively,
patients who have undergone lobectomy have a 5% to
15% reduction in FVC and a 10% to 25% reduction in
FEV|. Corresponding values for pneumonectomy are a
35% to 40% reduction in FVC and a 35% to 50%
decrease in FEVi.21,22 Interestingly, in highly selected
patients with severe heterogeneous emphysema who
undergo major lung resection, it is possible to
demonstrate an improvement in spirometric function-
that is similar to that seen in patients undergoing lung
volume reduction surgery (LVRS) (Baldi et al,
2005).23"25 Standard calculation of expected
postoperative function in such patients may sub-
stantially underestimate their actual postoperative
function.
In order to properly select patients who can be
shepherded through the acute recovery period after
major lung resection and some other types of thoracic
surgery, a careful preoperative assessment of lung
function and estimation of expected postoperative
function is essential in the evaluation of the lung
resection candidate.
Spirometry
Spirometry has been used to assess operative risk in
Section 1 Introduction
lung resection candidates for more than 5 decades.
FVC was initially used to assess risk, and
subsequently FEV] was considered the optimal
parameter for assessing the likelihood of
postoperative respiratory complications (Table 2-2).
Calculation of a predicted postoperative value for
FEVi (ppoFEVi) has proved to be very useful in
estimating a patient's postoperative risk.26 Patients
with normal risk have a ppoFEVi of 800 to 1000 mL
or greater. Maximum voluntary ventilation (MVV)
has also been used as a measure of risk associated
with major lung resection; patients with an MW less
than 50% of predicted are at increased risk for
postoperative complications after major lung
resection. However, this parameter is strongly
dependent on patient effort and therefore is subject to
tremendous variability.
Traditional cutoff values for FVC and FEV! that
are used to differentiate between low and high risk for
major pulmonary resection are relatively inaccurate at
the extremes of the body mass spectrum. In
consideration of this fact, spirometric values
expressed as a percentage of the predicted value based
on age, gender, and height have more commonly been
used to assess operative risk.13,26,27 In general, patients
with a preoperative FEV| of at least 60% of predicted
have a normal risk profile for major lung resection
excluding pneumonectomy. Further refinement has
included calculation of a ppoFEVi; values of 40% or
greater are generally thought to indicate normal
operative risk for major lung resection.
The calculation of predicted postoperative values is
sometimes challenging. In patients with normal lung
function (who do not often need major lung
resection), the simplest method is to multiply the
preoperative spirometric value by the fraction of
functional lung segments expected to remain postop-
eratively. For example, assuming 19 functional lung
segments, a patient who is undergoing right upper
lobectomy (losing 3 segments) would be expected to
retain 16/19 of original lung function. Another simple
method of estimation is to subtract 5% from original
lung function for each functioning segment that is to
be removed.
The calculation becomes more important in
patients with marginal lung function, especially those
who have areas of functional heterogeneity, and in
patients who have undergone prior lung resection.
Lung segments that are obstructed are eliminated
from calculations in order to more accurately assess
predicted postoperative lung function. Lobes that are
affected by emphysema to a greater extent than the
remaining lung are not considered fully functional for
purposes of calculating estimated postoperative
function. Several techniques are available that enable
refinement of the calculation of estimated
postoperative function. Quantitative pulmonary
scintigraphy, using the perfusion phase of the
examination as the best estimate of regional function,
effectively estimates regional lung function assessed
per quadrant or per lung. A newer method,
quantitative computed tomography (CT], provides
similar or greater accuracy through measurement of
relative lung density as an estimate of pulmonary
vasculature (Bolliger et al, 2002).28 By using one or
more of these techniques for estimating regional lung
function, and thus the amount of functional lung
expected to remain after major lung resection, one can
calculate a ppoFEVj that closely parallels the
measured postoperative function.
In addition to the utility of spirometry in estimating
postoperative risk after major lung resection, it is also
effective in predicting the risk of pulmonary
complications after esophagectomy.17,29,30 Pulmonary
complications are more than four times more likely to
occur in patients with abnormal spirometry results
than in those with normal spirometry.31 These findings
do not suggest that spirometry be performed in all
patients undergoing esophagectomy. Rather,
spirometry may be appropriate to perform in patients
who have clinical evidence of underlying lung
dysfunction as a means to estimate the risk of
postoperative pulmonary complications. If that risk is
high, interventions such as preoperative
cardiopulmonary rehabilitation may be appropriate,
and a more accurate informed discussion can take
place with the patient.
Diffusing Capacity
Until the late 1980s, the only reliable method of
assessing lung function as a means for predicting
complications in patients undergoing thoracic surgery
was spirometry. The measured and postoperative
estimated values failed to predict most pulmonary
complications and postoperative mortality,
particularly in patients undergoing major lung
resection. Subsequent studies identified diffusing
capacity as an independent and important predictor of
incremental risk of postoperative pulmonary
morbidity and overall mortality after major lung
resection.32"3,1 The highest risk group initially was
identified as having a preoperative carbon monoxide
diffusing capacity (DLCO) of less than 60% of
predicted. The identification of high-risk patients is
more accurately achieved by calculating the ppoDLCO
based on the amount of lung to be resected; the
highest risk group includes those patients with
ppoDLCO less than 40% of predicted.3 In addition to
predicting perioperative complications, DLCO also
predicts long-term outcomes after major lung
resection. Patients with a preoperative DLCO less than
50% of predicted who underwent lobectomy or less
than 60% of predicted who underwent
pneumonectomy had a worse QOL, an increased need
for supplemental oxygen, and a greater frequency of
hospital readmission during the first postoperative
year after resection, compared to patients with normal
DLCO.35
DLCO is also an important predictor of outcomes in
patients undergoing LVRS for emphysema. DLCO is
one of the components that helps identify patients
who belong to the so-called prohibitive risk category
for LVRS, which is characterized by an FEV! of less
than 20% of predicted and either a diffusing capacity
less than 20% of predicted or homogenous
distribution of emphysema.36 DLCO also predicts the
likelihood of pulmonary morbidity after LVRS in the
lower-risk groups.37
The data are sufficiently compelling that diffusing
capacity be measured routinely in candidates for
major lung resection or LVRS. In the absence of
severe pulmonary dysfunction, DLCO assessment in
patients undergoing lesser lung operations is of
questionable value; DLCO measurement in patients
with severely compromised lung function may assist
the physician in having an informed discussion with
the patient about potential risks and outcomes.
In addition to its utility in assessing risk related to
major lung resection and LVRS, the DLCO predicts
the incremental risk of pulmonary complications in
patients undergoing esophagectomy. In the predictive
model that was developed from this analysis, patients
with a DLCO less than 80% of predicted had a 1.7-fold
increased risk of pulmonary complications, compared
to patients with a DLCO of 100% of predicted or
better/8 The predictive capacity of this value, although
strong, is probably overshadowed by several other
physiologic predictors in candidates for
esophagectomy. Therefore, routine measurement of
DLCO is not generally indicated in this patient
population.
Exercise Capacity and Oxygen
Consumption
Another method of assessing operative risk for major
lung resection is measurement of exercise capacity.
This is accomplished with simple techniques such as
the 6-minute walk distance, stair climbing ability, and
assessment of arterial oxygen saturation (Pa0 2) during
walking on flat ground or during stair climbing.39''10
Patients with a very limited ability to exercise and
those who experience a substantial drop in Pa02
during exercise are considered to be at high risk for
postoperative complications.41 These techniques are
inexpensive and are reasonably reliable for estimating
whether a patient's risk is normal or substantially
increased. However, incremental risk is difficult to
establish using these semiquantitative methods.
It is often appropriate to further evaluate patients
who are deemed to be at substantially increased risk
for complications after major lung resection by
measuring maximum oxygen consumption (Vo2max)
during exercise. This technique is expensive and labor
intensive, and its accuracy depends to some extent on
the patient's willingness to exercise to capacity and on
the ability of the physician who is supervising the;
test to determine when the point of maximum
exercise has been achieved. With these caveats in
mind, the objective data that result from this test
provide estimates of risk that are similar or greater in
accuracy to those provided by more standard
measurements such as spirometry and DLCO.42 The
limiting value of Vb2max for prohibitive risk is
10mL/kg/ min; values in excess of 15 to 20
mL/kg/min are indicative of normal risk. Values
between 10 and 15 mL/kg/min must be interpreted
clinically because the risk level associated with this
range of oxygen consumption is variable and often is
not prohibitive. Efforts have been made to correlate
risk with V02max expressed as a percentage of the
predicted value; the results suggest that values less
than 50% to 60% of predicted are indicative of much
higher than average risk, although the accuracy of
such predictions is poor at the extremes of the
functional spectrum [Win et al, 2005).43'46
An algorithm for the stepwise pulmonary
assessment of candidates for major lung resection is
presented in Figure 2-1.
Lung Function and Long-Term Outcomes
In addition to the immediate postoperative risk of
morbidity and mortality after major thoracic surgery,
long-term QOL and overall survival must be
considered when making surgical recommendations to
patients. The influence of pulmonary function on
long-term outcomes has been best defined for patients
undergoing major lung resection and often reflects
processes that are characteristic of a general
population. Impaired short- and intermediate-term
QOL is related to reduced DLCO after major lung
resection (Hardy et al, 2002).47,4S Spirometric values
do not appear to have an important influence on QOL
in this time frame.
It has been known for centuries that life expectancy
in the general population is inversely related to FVC,
and insurance companies have recently begun to use
spirometry as part of their actuarial analyses in setting
life insurance rates. Similarly, long-term survival in
patients with lung cancer is related to the severity of
chronic obstructive pulmonary disease (Lopez-
Encuentra et al, 2005).49 In patients who undergo
major lung resection, long-term survival is inversely
related to FEV1( with incremental mortality occurring
as a result of intercurrent disease rather than recurrent
cancer.50'53 In patients with severely impaired
spirometry results, give careful consideration to the
impact of major lung resection on QOL and long-term
survival. Weight this factor against the relative risk of
death from recurrent cancer based on the type of lung
resection performed.
CARDIOVASCULAR STATUS
Patients who have disease requiring major thoracic
surgery frequently have risk factors for pulmonary
disease, as described earlier, and many of those risk
factors are also associated with cardiovascular
disease. As part of the initial evaluation of such
patients, a careful history and a thorough physical
examination are vitally important in identifying
problems that portend an increased risk of
postoperative cardiovascular complications, including
stroke, myocardial infarction, and arrhythmia. It is
estimated that between one quarter and one third of
patients undergoing general anesthesia have known
Section 1 Introduction
cardiac disease or known risk factors (Box 2-1) and
that almost 5% of all patients will experience a
postoperative cardiac complication.54 The risk of
possible neurovascular and peripheral vascular
complications is also substantial. In general, the risk
of cardiovascular complications is much higher in
patients undergoing major thoracic surgery than in
those undergoing less stressful types of general
surgical procedures.
Coronary Artery Disease
Risk factors for postoperative coronary artery
complications include ischemic heart disease,
congestive heart failure, diabetes mellitus, renal
insufficiency, and poor overall functional status
(Fleisher and Eagle, 2001}.54 In the absence of any
such risk factors, patients proceed directly to surgery
without any specific evaluation of their coronary
arterial anatomy. Patients who have unstable angina
or recent myocardial infarction must undergo a
thorough evaluation, and any elective surgery is
postponed until such conditions are stabilized. An
algorithm for managing patients with one or more
risk factors is outlined in Figure 2-2. Specific testing
is performed when the clinical situation indicates that
changes in management would occur if the test
returned positive, suggesting that the algorithm is
cost-effective. Further testing is not performed if the
results would not influence a patient's overall
management strategy.
The likelihood of perioperative complications in
patients with these risk factors may be reduced
through revascularization for coronary artery disease,
including use of such techniques as angioplasty,
stenting, and coronary artery bypass grafting
(CABG). Stenting requires administration of anti-
platelet agents, including aspirin and clopidogrel, for
a period of at least 4 to 12 weeks after stent placement
and aspirin indefinitely afterward. Performance of
major surgery before the end of the 4- to 1 2-week
period leads to unacceptable risks of bleeding if
antithrombotic agents are not discontinued or to
myocardial infarction in those patients in whom
antithrombotic agents are stopped preoperatively.
Some newer drug-eluting stents require intensive
antithrombotic therapy for even longer periods before
the risk of stent thrombosis is sufficiently small to
permit discontinuation of these medications
preoperatively. Both aspirin and clopidogrel must be
discontinued for 5 to 7 days before major surgical
intervention to reduce the risk of surgical bleeding.
CABG before thoracic surgical intervention is
appropriate in patients in whom important coronary
artery disease is not amenable to percutaneous
revascularization techniques. There is no specified
interval that must be observed between successful
coronary artery surgery and subsequent major thoracic
surgery. The surgeon's clinical judgment about the
patient's condition and ability to withstand further
major surgery is the best means for determining
suitable timing. It remains to be seen whether the
routine use of minimally invasive approaches to off-
pump coronary artery bypass surgery can
meaningfully decrease the necessary time interval
between operations. Of note, there is rarely an
imperative to perform a major thoracic procedure
under the same anesthesia used for CABG. Extensive
operations for lung resection are usually performed
less thoroughly through a median sternotomy than
they are through a transthoracic approach, which may
potentially compromise the therapeutic efficacy of
interventions for oncologic problems. In addition,
manipulations of tumor tissue before or during
periods when patients are on cardiopulmonary bypass
theoretically increase the risk of bloodborne distant
metastatic disease. Finally, the use of anticoagulation,
which is frequently necessary for performing coronary
artery bypass, increases the risk of bleeding from the
thoracic surgical sites, and these sites may not be easy
to identify or control if such bleeding occurs.
Additional medical management suitable for most
patients with at least one risk factor includes
administration of |3-blockers in the perioperative
period. The medication is begun 2 to 7 days
preoperatively and is continued for at least 1 week
postoperatively. The dose is titrated to reduce resting
heart rate to about 60 beats per minute. Patients with
risk factors for coronary artery disease treated within
these guidelines experience a reduction of up to 90%
in the incidence of myocardial infarction or cardiac
death after major noncardiac surgery.55 ^-Blockers
must be administered carefully in patients with
important lung disease such as reactive airways
disease or emphysema; however, use of highly
selective P-blockers is appropriate in most patients in
this group.
Risk Factors for Postoperative
Arrhythmias
Cardiac arrhythmias, particularly supraventricular
arrhythmias, occur commonly after major thoracic
surgery. Often they are transient, but frequently they
are persistent and difficult to manage. In efforts to
prevent such complications, which develop most
frequently after pneumonectomy and esophagectomy,
prophylactic regimens are sometimes recommended
for patients at increased risk. Elevated risk is associ-
ated with advanced age, greater extent of lung
resection, mediastinal surgery (thymus, mediastinal
tumor, esophagectomy), and possibly a low DLCO
(Vaporciyan et al, 2004).56,57 One regimen used after
major lung resection that has been shown to reduce
the risk of supraventricular arrhythmias (including
atrial fibrillation) by 50% is diltiazem given intra-
venously (IV) on arrival in the postanesthetic care unit
and continued thereafter IV or orally for a period of 2
weeks.58
Systemic
Anticoagulation in the
Perioperative Period
Conditions requiring preoperative anticoagulation are
not uncommon among thoracic surgical patients.
Anticoagulation is necessitated most commonly by
acute conditions, including venous thrombosis and
pulmonary embolism, and by chronic conditions such
as recurrent venous thrombosis, a mechanical heart
valve, or atrial fibrillation. In the setting of chronic
conditions such as prior venous thrombosis, atrial
fibrillation, or distant prior pulmonary embolism,
anticoagulation is usually safely discontinued 1 week
preoperatively and is resumed after the risk of
postoperative bleeding is normal. In contrast, patients
with mechanical artificial valves or more acute
thrombotic problems require anticoagulation until the
day of the operation. This is most easily achieved by
using either IV heparin in an inpatient setting or
enoxaparin injections until 8 to 12 hours before the
planned incision time. Anticoagulation therapy is
resumed as soon as the risk of bleeding is
substantially reduced, typically not until the day after
surgery.
PREOPERATIVE EVALUATION
OF OTHER SYSTEMS
Patients undergoing major thoracic surgery who have
underlying diabetes mellitus are at increased risk for a
variety of complications, including myocardial
infarction (see earlier discussion), wound infection,
bronchial stump leak, and a variety of other wound
healing complications.59,60 In patients undergoing
cardiac surgery, assiduous control of blood glucose
levels perioperatively appears to improve overall
outcomes.61,152 Similar benefits may occur in general
thoracic surgical patients, although this has not yet
been established. In any case, assessment of the
increased risks associated with diabetes enables the
surgeon to have an informed discussion
. with the patient regarding surgical outcomes and to
prepare necessary resources to permit optimal
perioperative management.
Impaired renal function poses important challenges
during the preoperative evaluation of thoracic surgical
patients. Use of contrast material as part of staging
studies is often contra-indicated, reducing the
accuracy of such studies and adding potential
uncertainty to the outcome of any operation.
Perioperative management in such patients requires a
careful review of medications to be used, with
appropriate dose reduction or altered dose scheduling
based on the degree of functional renal impairment.
For patients who are undergoing hemodialysis,
arrangements must be made for this to be performed
on the day before surgery, so that dialysis on the day
of surgery is avoided, reducing the risk of bleeding
associated with heparin needed for hemodialysis.
Patients who are receiving peritoneal dialysis and who
require a laparotomy must be converted for the short
term to hemodialysis, usually through a temporary
venous catheter rather than a shunt or fistula. The
presence of renal failure is associated with poorer
outcomes for most important general thoracic
procedures, including major lung resection,63,6'' and it
is appropriate that this be discussed as part of the
informed consent process.
Hepatic insufficiency presents considerable
challenges for performing thoracic surgery, including
increased risks of bleeding from coagulopathy,
hemorrhage from esophageal varices, hepatic
encephalopathy, and uncontrollable ascites. Patients
with suspected cirrhosis are evaluated according to
standard systems such as the Child classification,
which requires assessment of serum bilirubin and
albumin, prothrombin time, degree of encephalopathy,
and amount of ascites. Carefully selected patients in
Child's group A or possibly group B may be
candidates for major lung resection or
esophagectomy, with the anticipation that their risks
of operative complications are considerably
increased.65 The finding of cirrhosis also portends a
reduced long-term survival after potentially curative
oncologic thoracic surgery because of the increased
risk of death from intercurrent causes.
General physical limitations sometimes become
important in the preoperative evaluation of the
thoracic surgery patient. Patients with lower extremity
amputations (e.g., for sarcoma] sometimes develop a
need for thoracotomy or sternotomy, often for
resection of pulmonary metastases. Patients who
cannot ambulate independently using a limb
prosthesis must be assessed with regard to their ability
to ambulate as part of their recovery from surgery.
This may not be an important issue if a muscle-
sparing thoracotomy is performed because this
procedure preserves shoulder girdle musculature and
function and does not affect the use of walking aids.
However, it may be a complicating factor if a
sternotomy or transverse sternothoracotomy is
performed because ambulation using a walker or
crutches places unusual stresses on the reapproxi-
mated sternum, possibly leading to dehiscence and
infection or simple malunion.
Airway issues affect any patient who requires lung
isolation as part of a thoracic surgical procedure. Lung
and esophageal cancers share common risk factors
with head and neck cancer, and it is not uncommon
for a patient to require surgery for more than one of
these conditions over time. Patients who have
undergone laryngectomy for head and neck cancer
present unique challenges for obtaining lung isolation.
This must be considered before major thoracic surgery
is recommended.
The collective effect of comorbidities has an
important influence on both short-term and long-term
outcomes after thoracic surgery. Higher comorbidity
scores are associated with an increased risk of
postoperative complications after major lung
resection.66,67 In addition, elevated comorbidity scores
are linked to increased long-term mortality after lung
cancer resection.68,69
RISK ASSESSMENT
An important focus of clinical research is the
development of organized methods of assessing
preoperative risks for surgical procedures. Risk
assessment tools in thoracic surgery are in their
Section 1 Introduction
infancy, compared with the robust tools available for
risk assessment in adult cardiac surgery. The use of
such algorithms is potentially important in informing
individual patients about risk levels, in determining
the potential utility of preoperative interventions for
lowering risk, and in assessing the need for enhanced
resources during the postoperative care of such
patients.
Various scoring systems have been used to provide
a reasonably accurate quantitative estimate of risk for
patient populations undergoing major lung resection
and other operations. These systems include the
Physiological and Operative Severity Score for the
Enumeration of Mortality and Morbidity (POSSUM),
the Cardiopulmonary Risk Index (CPRI), the
Predictive Respiratory Quotient (PRQ), the Predicted
Postoperative Product (PPP), APACHE II (adapted
from a trauma scoring system), the Estimation of
Physiologic Ability and Surgical Stress (E-PASS), and
evaluation of the three most important predictors of
outcomes (expiratory volume, age, and diffusing
capacity: EVAD).70"75 Unfortunately, such systems
have not been adequately assessed with regard to their
utility in estimating risk for individual patients. They
are currently most useful for estimating outcomes in
populations undergoing major lung resection that are
stratified according to standard risk profiles.
DECISION MARKING PROCESS
After completing the preoperative evaluation of
candidates for thoracic surgery, the surgeon offers
recommendations regarding possible operative
intervention. In making such recommendations, the
goals of the surgeon and of the patient must be
explicitly expressed and assessed; they are not always
similar, and in many cases they are quite disparate.
Patients tend to follow their self-interest by seeking
procedures and outcomes that minimize discomfort
and optimize QOL; death as an outcome of surgery
does not pose nearly as great a concern as does
permanent postoperative disability (Cykert et al,
2000).'6 Surgeons, serving in part their own self-inter-
est, tend to focus on minimizing postoperative
complications and maximizing long-term survival,
especially for oncologic conditions.
Most risk factors described in this chapter are well
understood and are indelibly etched into the minds of
surgeons who deal with these patients on a daily
basis. The scoring systems mentioned assess only
short-term risk for groups of patients; none purports
to assess risk for an individual patient. Potential
methods to do this include the use of artificial intel-
ligence software to train a neural network based on
actual outcomes.77,78 As large quantities of data are
entered, the neural network identifies risk patterns
and modifies these patterns as new outcomes are
included in the database. After sufficient learning and
validation have taken place, the accuracy of neural
network prediction of complications can exceed 95%.
However, at present, a trained neural network is site
specific, making its use feasible only in high-volume
centers in which infrastructure is available to manage
the network.
No current scoring or artificial learning systems can
provide insight into long-term outcomes, including
QOL and long-term survival. In fact, the necessary
tools to measure QOL in the specific context of
thoracic surgical procedures have not yet been devised
or validated. Generic QOL tools have been applied to
outcomes for lung resection, esophagectomy, and
LVRS. Examples of tools that assess overall QOL
include the Short-Form 36 (SF-36] derived from the
Medical Outcomes Study, the Health Related Quality
of Life Measure (HRQOL-14) of the Centers for
Disease Control and Prevention, the Sickness Impact
Profile, and the Nottingham Health Profile.79 There
are numerous QOL measures for chronic lung disease,
including those that measure baseline function,
function during exercise, general fatigue, and
responsiveness to interventions.80 No measure to date
has sought to incorporate issues such as QOL during
the postoperative recovery period, postoperative and
chronic incisional pain, swallowing impairment after
esophageal surgery, maintenance of normal body
weight, or the impact of surgery on specific vocational
and avocational activities. Until such measures are
developed, surgeons and their patients will not have
the ability to make truly informed decisions about the
utility of surgery.
Decision analysis models are being developed as
methods to appropriately weigh risks and benefits for
patients undergoing thoracic surgery. Some issues
that have been assessed include the utility of various
treatments (surgical and nonsurgical) for achalasia,
whether to perform routine mediastinoscopy for
staging of surgical candidates for lung cancer
resection, and the choice between sleeve lobectomy
or pneumonectomy for centrally located lung
cancers.sl"83 Future possibilities for similar models
include the selection of optimal therapy for medically
marginal candidates for lung resection and
esophagectomy. Such models, using data relevant to
individual patients, may prove very useful in
providing patient-specific risk estimates and
guidelines for recommendations.
Despite the promising work that is being done on
risk analysis and decision-making algorithms, the
evaluation of potential thoracic surgical patients
currently remains an art that ultimately is dependent
on the experience and judgment of the surgeon. The
assessments outlined in this chapter provide useful
algorithms for consideration of risks and outcomes in
patient populations and in individual patients. Use of
these algorithms must be tempered by the surgeon's
knowledge of an individual patient's risks, needs, and
desires. It is unlikely that this vital judgment function
will ever be completely subsumed by technological
advances.
COMMENTS AND CONTROVERSIES
As pointed out by Doctor Ferguson, the preoperative evaluation
of potential candidates for major thoracic procedures is a
complex but important process that must be done for every
patient. One must try to establish a reliable patient profile (low have been prevented if the problem had been identified
risk, high risk, prohibitive risk) to ensure that no individual is preoperatively.
denied surgery while minimizing postoperative morbidity. Most J. D.
importantly, the appreciation of such considerations allows the
surgeon and other members of the team (anesthetist,
intensivlst) to use a number of prophylactic measures intended
to decrease morbidity in high-risk patients. Where indicated,
pulmonary rehabilitation, smoking cessation, optimization of
medical treatment of chronic obstructive pulmonary disease,
and treatment of cardiac disease decrease the risks associated
with pulmonary or esophageal resection. Although scoring
systems are available to predict operative risk, numbers do not
tell everything, and nothing replaces good clinical judgment.
Moreover, none of those systems has been validated with large
numbers of patients, and none provides insight into long-term
outcomes such as QOL and cardiorespiratory function 5 years
after surgery.
In this excellent chapter by Doctor Ferguson, a number of
risk factors for operative morbidity and mortality are analyzed.
In general, advanced age (70 years or older) and comorbidities
are intimately related and act as dependent variables in
increasing the risk of postoperative events, especially In
patients undergoing pneumonectomy or esophagectomy.
Indeed, older patients are more likely to lose their ability to
cooperate postoperatively (increased risk of delirium), a feature
that may add significantly to the operative risk.
No patient should have pulmonary surgery, no matter how
limited, without preoperative pulmonary function testing. In
many cases, a simple spirometric test provides enough
information to determine that the pulmonary function is normal
and that the patient can tolerate pneumonectomy if necessary.
Exercise testing (measurements of Vo2max, Pao2, and Paco2,
both at rest and during exercise) measures the ability of the
whole organism to perform well because it assesses the
interaction of pulmonary function, hemodynamic performance,
and peripheral tissue oxygen use. A Paco2 that rises on
minimal exercise, for example, is a strong indicator of
inadequate reserve, and such patients must be looked at very
carefully before surgery. Indeed, several authors have shown
that exercise testing is the only objective measurement of
cardiopulmonary reserve to demonstrate a statistically
significant difference between patients with benign
postoperative courses and those with cardiorespiratory
complications.
For most patients undergoing thoracotomy, the greatest
cardiac risk arises from the presence of coronary artery
disease. Operations performed within 3 months after a
myocardial infarction, for instance, result in a 27% incidence of
recurrent infarction. This incidence decreases to about 15% if
the infarction occurred 4 to 6 months previously and to 6% if
the operation is delayed for 6 months or longer. Similar risks
have been identified for patients with angina. For these
reasons, an accurate cardiac history and evaluation are of
utmost importance. A screening exercise test is recommended
for all patients who are smokers and older than 45 years of
age, and for those with significant other risk factors for
coronary artery disease.
Overall, it is important to remember that, in the practice of
thoracic surgery, technical misadventures do occur but seldom
account for significant postoperative morbidity. On the other
hand, the majority of postoperative complications and deaths
are related to cardiopulmonary events, most of which could