All patients being considered for lung resection should have pulmonary function tests including spirometry and a DLCO (diffusing capacity of the lung for carbon monoxide) test, from which the predicted postoperative values are calculated. If the results are unfavorable, a measure of exercise capacity or peak oxygen consumption should be obtained.
Cardiac evaluation of the thoracic surgical patient should include surgeons, anesthesiologists, and cardiologists. Higher levels of perioperative risk may be acceptable because of the potential curative benefit of surgery for non-small-cell lung cancer.
A thorough history of cancer therapy that considers chemotherapy, radiation, and an evaluation of the paraneoplastic effects of the cancer identifies other potential perioperative vulnerabilities.
A 69-year-old man is scheduled for a left pneumonectomy. A CT-guided biopsy 6 days ago revealed adenocarcinoma. He is obese and has hypertension, type 2 diabetes mellitus, osteoarthritis, and a 55 pack-year smoking history. When a mass was seen on his chest x-ray 2 weeks ago, he quit smoking. Pulmonary function tests show a moderately obstructive ventilatory defect with an FEV1 of 63% of predicted. He blames limited exercise tolerance on his "bad knees" and has never been evaluated by a cardiologist. How should this case be managed? Are there any other tests that would be helpful for stratifying his perioperative risk?
Thoracic surgery can have profound effects on cardiopulmonary function in the operating room, in the immediate postoperative setting, and in the long-term. The scope of thoracic surgery ranges from a thoracoscopic sympathectomy for a healthy 20-year-old patient to an extrapleural pneumonectomy for an 80-year-old with coronary disease and emphysema. Ever since the first pneumonectomy was described in 1933,1 physicians have been looking for a simple, effective way to evaluate patients to optimize outcomes. This chapter focuses primarily on the preoperative evaluation of patients who need pulmonary resection, but the principles apply for other thoracic surgeries as well. Esophageal surgery, for example, does not involve resection of lung tissue, but because esophageal pathology is associated with smoking, patients frequently have concurrent pulmonary disease. Several other considerations are noteworthy for esophageal surgery including the frequent presence of reflux and aspiration, poor nutritional status, and preoperative chemotherapy or radiation.
Understanding the surgical approach is critical to preparing for thoracic surgery. For example, if a patient has had coronary bypass surgery with an internal mammary artery, he is at high risk for myocardial ischemia during an ipsilateral extrapleural pneumonectomy. The unique physiology and pathophysiology of pulmonary resection necessitates several other considerations.
Pulmonary resection is generally performed on patients with lung cancer, which accounts for 160,000 deaths per year in the United States.2 Five-year survival—only 15% for all lung cancers—is 49% for patients with surgically resectable, localized disease. It is likely that surgery is responsible for most of the long-term survivors. Lung cancers double in size within 30 to 500 days,3 and faster growing tumors are associated with poorer prognosis.4 Because of the aggressive ...