Stair climbing test predicts cardiopulmonary complications after lung resection

Handheld Office-Based Spirometry versus Laboratory Spirometry in Low-Risk Patients Undergoing Lung Resection

Objective

To compare handheld office spirometry with laboratory spirometry in evaluation of low-risk patients undergoing pulmonary resection.

Methods

Low-risk patients evaluated for lung resection were enrolled in a prospective study and underwent office and laboratory spirometry. Standard laboratory spirometry values were considered the gold standard. Values of forced expiratory volume in 1 second (FEV1) <1.5 L or FEV1% <60% were determined in advance to signal high risk.

Results

Thirty patients with mean age 64 ± 12 years and median Karnofsky performance status 100 (80–100) were evaluated. The mean FEV1-office spirometry and mean FEV1-laboratory spirometry were comparable (2.14 L vs 2.36 L) as were the mean FEV1%-office spirometry and FEV1%-laboratory spirometry (78% vs 85%). The differences were within limits established a priori. Laboratory spirometry identified 3 of 30 (10%) patients as high risk and office spirometry identified 5 of 30 (16%) patients as high risk, including the 3 patients identified by laboratory spirometry. The sensitivity of office spirometry for detecting high risk was 100% (3/3) and specificity was 93% (25/27). The negative predictive value of office spirometry was 100% (25/25). Office spirometry added a median of 1 minute to the office visit, whereas laboratory spirometry added 42 minutes. Eventually, 25 of 30 (83%) patients underwent lung resection. There were 12 lobar and 13 sublobar resections. One patient developed postoperative respiratory morbidity. This patient was high risk by office spirometry but not by laboratory spirometry. This patient was discharged on home oxygen.

Conclusions

Office spirometry FEV1 and FEV1% are clinically comparable to formal laboratory spirometry values. Office Spirometry saves time and possibly expense in the preoperative workup of patients evaluated for lung resection.

The 6-min walk test: is it an effective method for evaluating heart failure therapies?

The 6-min walk (6MW) is a self-paced test for measuring functional capacity. Lower 6MW distances have been associated with adverse outcomes in patients with heart failure. The purpose of this article is to describe the history of the 6MW test and to evaluate its reliability, validity, and predictive value as well as the responsiveness of the test to therapies. In the literature we reviewed, reliability was affected by several factors including learning effects and protocol deviations. The 6MW distance was moderately correlated with peak oxygen consumption derived from cardiopulmonary exercise stress testing. In some studies the 6MW distance was predictive of hospitalization and mortality. In pharmacological and cardiac resynchronization trials the 6MW distance did not consistently detect clinical improvements. Despite limitations, the 6MW test is a viable alternative to stress testing for objectively evaluating functional capacity in some settings. We provide recommendations for using the 6MW test in future studies.

[Preoperative evaluation and risk estimation in thoracic surgery]

Preoperative evaluation of patients undergoing lung resection remains an interdisciplinary challenge. Despite substantial progress in anesthesiology, intensive care medicine and surgery, mortality of patients undergoing pneumonectomy remains high at 5-9%. Guidelines were developed to identify patients with an increased perioperative risk for morbidity and mortality. These guidelines are focused around the forced expiratory capacity (FEV) measured by spirometry, following further investigations in patients with limited FEV(1). Extended testing includes measurement of the diffusion capacity, calculation of postoperative predicted values of lung function and spiroergometry to determine maximal oxygen uptake. In this article the methods to measure parameters of lung function and gas exchange are described and evaluated in the context of the current guidelines.

Accuracy of six minute walk test, stair test and spirometry using maximal oxygen uptake as gold standard

PURPOSE: To assess the accuracy of the variables stair climbing time (SCt), stair climbing power (SCP), six-minute walk test distance (6MWT), and forced expiratory volume in 1 second (FEV1) using maximal oxygen uptake on exercise (VO2max) as the gold standard. METHODS: Tests were performed in 51 patients. FEV1 was measured by spirometry and 6MWT was performed in a flat 120-m corridor. Stair climbing test was performed on a 6-flight stairway to obtain SCt and SCP. VO2max was measured by ergospirometry, using the Balke protocol. Pearson's linear correlation and p values were calculated between VO2max and the other variables tested. For accuracy calculations, variable cutoff points were obtained through receiver operating characteristic (ROC) curves, dividing individuals into normal or unhealthy. Kappa statistic was used to calculate concordance. RESULTS: Accuracy was: SCt - 86%, 6MWT - 80%, SCP - 71%, FEV1(L) - 67%, FEV1(%) - 63%. SCt and 6MWT showed 93.5% sensitivity when combined in parallel, and 96.4% specificity in series. CONCLUSION: SCt presented the best accuracy. SCt and 6MWT combined showed nearly 100% sensitivity or specificity. Thus, these simple exercise tests should be more routinely used, especially when an ergospirometer is not available to measure VO2max.

Paced-walk and step tests to assess exertional dyspnea in COPD

This study reports on the development and test-retest reproducibility of a modified shuttle walking and step testing protocols to assess exertional dyspnea in patients with COPD. Patients with COPD randomly performed four externally paced 3-min bouts of shuttle walking at 1.5, 2.5, 4.0 and 6.0 km x h(- 1) or stepping at constant rate of 18, 22, 26 and 32 steps x min(- 1). Walking and stepping procedures were repeated once, on a separate occasion. Ventilation, heart rate, gas exchange parameters and dyspnea Borg scores were obtained at the end of each exercise bout. Most patients completed walking or stepping at the slow and middle speed cadences but only 33% completed walking at 6.0 km x h(- 1) and 40% completed stepping at 32 steps x min(- 1). Walking and stepping at progressively faster pace caused a progressive increase in ventilation and dyspnea. Test-retest Pearson correlation coefficients for ventilation, heart rate, gas exchange parameters and dyspnea scores over the four exercise bouts, all exceeded 0.80. Intra-class correlation coefficients were at least as strong as Pearson coefficients. Bland & Altman representation showed that for repeated Borg scores, 92 and 96% of points lied within 2 SD of the mean difference between test-retest values for walking and stepping. The majority of moderate and severe COPD patients completed the 3-min shuttle waking testing at 1.5 to 4.0 km x h(- 1) and the 3-min of step testing at rates between 18 and 26 steps x min(- 1). Both field tests were highly reproducible in patients with COPD.

Multidisciplinary Evaluation of Patients With Suspected Lung Cancer

Lung cancer diagnosis and treatment has evolved to require the input and expertise of multiple diverse medical and surgical specialties. The approach to lung cancer patients requires the adherence to a few principles that include thorough use of staging modalities to assure the proper treatment for each patient, and an understanding of the limitations and advantages of each of these modalities. Evidence is continuing to emerge that supports the notion that diagnostic workup and treatment of lung cancer patients is best done within the context of a multidisciplinary team devoted to this purpose.

Preoperative evaluation for thoracic surgery

The goal of the preoperative evaluation for thoracic surgery is to assess and implement measures to decrease perioperative complications and prepare high-risk patients for surgery. Major respiratory complications, such as atelectasis, pneumonia, and respiratory failure, occur in 15% to 20% of patients and account for most of the 3% to 4% mortality rate. Development of pulmonary complications has been associated with higher postoperative mortality rates. Strategies aimed at preventing postoperative difficulties have the potential to reduce morbidity and mortality, decrease hospital stay, and improve resource use. One lung ventilation leads to a significant derangement of gas exchange, and hypoxemia can develop due to increased intrapulmonary shunting. Recent advances in anesthetic management, monitoring devices, improved lung isolation techniques, and improved critical care management have increased the number of patients who were previously considered inoperable. In addition, there is a growing tendency to offer surgery to patients with significant lung function impairment; hence a higher incidence of intraoperative gas-exchange abnormalities can be expected. The anesthesiologist must also consider the risks of denying or postponing a potentially curative operation in patients with lung cancer. Detailed consideration of the information provided by preoperative testing is essential to successful outcomes following thoracic surgery.

Performance at symptom-limited stair-climbing test is associated with increased cardiopulmonary complications, mortality, and costs after major lung resection

BACKGROUND

Exercise tests are increasingly used during preoperative evaluation before lung resection. This study assessed the association between performance at the symptom-limited stair-climbing test and postoperative cardiopulmonary morbidity, mortality, and costs after major lung resections.

METHODS

As part of their routine preoperative evaluation, 640 patients who had lobectomy (n = 533) or pneumonectomy (n = 107) for lung cancer from January 2000 through April 2007 performed a preoperative symptom-limited stair-climbing test. Sensitivity/specificity analysis was used to identify the best cutoff values of altitude climbed (number of steps x height of the step in m) associated with outcome. Univariate and multivariate regression analyses (validated by bootstrap) were used to test associations between preoperative and operative factors and postoperative cardiopulmonary complications, mortality, and postoperative costs.

RESULTS

The altitude reached at the stair-climbing test was reliably associated with increased cardiopulmonary complications (p = 0.04), mortality (p = 0.02), and costs (p < 0.0001). In patients who climbed less than 12 m, cardiopulmonary complications, mortality, and costs were 2-fold (p < 0.0001), 13-fold (p < 0.0001), and 2.5-fold higher, respectively, than in patients who climbed more than 22 m.

CONCLUSIONS

Performance at a maximal stair-climbing test was reliably associated with postoperative morbidity and mortality. We recommend the use of this simple and economic test in all lung resection candidates. Patients who perform poorly at the stair-climbing test should undergo a formal cardiopulmonary exercise test with measurement of oxygen consumption to optimize their perioperative management.

Future trends in preoperative evaluation

Preoperative evaluation before lung resection has been frequently addressed in modern medical literature. Actual or predicted pulmonary volumes are considered relevant to predict the risk of surgery. Nevertheless, ppoFEV1 underestimates the real functional loss in the immediate postoperative period when most of the complications occur. Not all patients, however, have comparable functional changes after lobectomy. Minimal impairment or even improvements have been demonstrated in COPD cases after lobectomy. Efforts should be directed to an accurate prediction of the immediate postoperative pulmonary volumes for a better evaluation of high-risk patients caused by respiratory impairment. Future developments are needed on the role of measuring preoperative DLCO and how to evaluate a patient's general cardiorespiratory status. Evidence underlines the relevance of routine evaluation of preoperative DLCO at rest or, better, during exercise for a thorough assessment of patient's capability to adapt to a stressful situation (Fig. 3). Only by improving knowledge about the general condition of the patient, can one assess the physiologic response to surgery. Widespread use of sophisticated or simple exercise tests and measurements or daily activity using motion detectors can identify high-risk patients with otherwise acceptable pulmonary volumes. Another suggested investigation issue is to develop different relevant outcome parameters, not only from the surgeon's point of view but also from the patient's perspective, such as postoperative QOL-related variables or delayed outcomes. Finally, multidisciplinary investigation teams, including experts in mathematical modeling, are essential to improve the quality and validity of the developed models. Although knowledge about perioperative physiologic changes has increased, clinicians are still far from finding a way to put all this knowledge down and make it applicable for an individual patient. Multicentric cooperation and evaluation of large prospectively recorded databases are essential to develop evidence-based clinical guidelines on preoperative evaluation.

Stair climbing in the functional assessment of lung resection candidates

BACKGROUND

Algorithms for the pre-operative evaluation of lung resection candidates with impaired lung function invariably include maximum oxygen uptake (VO(2)MAX) as a critical parameter of functional reserves, with a VO(2)MAX >or=20 ml/kg/min generally considered sufficient for pneumonectomy. Stair climbing is a low-cost alternative to assess exercise capacity.

OBJECTIVES

As stair climbing is not standardised, we aimed to compare the altitude reached and the speed of ascent with VO(2)MAX measured by cycle ergometry.

METHODS

We prospectively enrolled 44 pulmonary resection candidates (mean age: 47.6 +/- 12.5 years) with an FEV(1) <80%. Patients were asked to climb as high and as fast as they could, to a maximum elevation of 20 m. The altitude reached and the average speed of ascent were compared to VO(2)MAX.

RESULTS

Forty-three patients reached a 20-metre elevation. Thirteen of them, as well as the patient who did not reach this height, had a VO(2)MAX <20 ml/kg/min. There was a linear correlation between speed of ascent and VO(2)MAX/kg (R(2) = 0.67), but not between altitude and VO(2)MAX/kg. All 24 patients with a speed >or=15 m/min had a VO(2)MAX >or=20 ml/kg/min. Thirty-nine of 40 patients with a speed >or=12 m/min had a VO(2)MAX >or=15 ml/kg/min.

CONCLUSIONS

The average speed of ascent during stair climbing was an accurate semiquantitative predictor of VO(2)MAX/kg, whereas altitude was not. We were able to identify potential cut-off values for lobectomy or pneumonectomy. Pending validation with clinical endpoints, stair climbing may replace formal exercise testing at much lower costs in a large proportion of lung resection candidates.

Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition)

BACKGROUND

This section of the guidelines is intended to provide an evidence-based approach to the preoperative physiologic assessment of a patient being considered for surgical resection of lung cancer.

METHODS

Current guidelines and medical literature applicable to this issue were identified by computerized search and evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee.

RESULTS

The preoperative physiologic assessment should begin with a cardiovascular evaluation and spirometry to measure the FEV(1). If diffuse parenchymal lung disease is evident on radiographic studies or if there is dyspnea on exertion that is clinically out of proportion to the FEV(1), the diffusing capacity of the lung for carbon monoxide (Dlco) should also be measured. In patients with either an FEV(1) or Dlco < 80% predicted, the likely postoperative pulmonary reserve should be estimated by either the perfusion scan method for pneumonectomy or the anatomic method, based on counting the number of segments to be removed, for lobectomy. An estimated postoperative FEV(1) or Dlco < 40% predicted indicates an increased risk for perioperative complications, including death, from a standard lung cancer resection (lobectomy or greater removal of lung tissue). Cardiopulmonary exercise testing (CPET) to measure maximal oxygen consumption (Vo(2)max) should be performed to further define the perioperative risk of surgery; a Vo(2)max of < 15 mL/kg/min indicates an increased risk of perioperative complications. Alternative types of exercise testing, such as stair climbing, the shuttle walk, and the 6-min walk, should be considered if CPET is not available. Although often not performed in a standardized manner, patients who cannot climb one flight of stairs are expected to have a Vo(2)max of < 10 mL/kg/min. Data on the shuttle walk and 6-min walk are limited, but patients who cannot complete 25 shuttles on two occasions will likely have a Vo(2)max of < 10 mL/kg/min. Desaturation during an exercise test has not clearly been associated with an increased risk for perioperative complications. Lung volume reduction surgery (LVRS) improves survival in selected patients with severe emphysema. Accumulating experience suggests that patients with extremely poor lung function who are deemed inoperable by conventional criteria might tolerate combined LVRS and curative-intent resection of lung cancer with an acceptable mortality rate and good postoperative outcomes. Combining LVRS and lung cancer resection should be considered in patients with a cancer in an area of upper lobe emphysema, an FEV(1) of > 20% predicted, and a Dlco of > 20% predicted.

CONCLUSIONS

A careful preoperative physiologic assessment will be useful to identify those patients who are at increased risk with standard lung cancer resection and to enable an informed decision by the patient about the appropriate therapeutic approach to treating their lung cancer. This preoperative risk assessment must be placed in the context that surgery for early-stage lung cancer is the most effective currently available treatment for this disease.

Preoperative maximal exercise oxygen consumption test predicts postoperative pulmonary morbidity following major lung resection

BACKGROUND AND OBJECTIVE

Pulmonary resection carries a significant morbidity and mortality. The utility of maximal oxygen uptake test (VO(2)max) to predict cardiopulmonary complications following major pulmonary resection was evaluated.

METHODS

Following standard preoperative work-up and VO(2)max testing, 55 patients (49 male; mean age 59 years, range 20-74) underwent major pulmonary surgery: lobectomy (n = 31), bilobectomy (n = 6) and pneumonectomy (n = 18). An investigator blinded to the preoperative assessment prospectively collected data on postoperative cardiopulmonary complications. Patients were divided into two groups according to preoperative VO(2)max and also according to FEV(1). The frequency of postoperative complications in the groups was compared.

RESULTS

Complications were observed in 19 (34.5%) patients, 11 of which were pulmonary (20%). There were two deaths (3.6%), both due to respiratory failure. Preoperative FEV(1) failed to predict postoperative respiratory complications. Five of 36 patients with a preoperative FEV(1) > 2 L suffered pulmonary complications, compared with six of 19 patients with FEV(1) < 2 L. Cardiopulmonary complications were not observed in patients with VO(2)max > 15 mL/kg/min (n = 27); however, 11 patients with VO(2)max < 15 mL/kg/min (n = 28) suffered cardiopulmonary complications (P < 0.05).

CONCLUSION

VO(2)max predicts postoperative pulmonary complications following major lung resection, and the risk of complications increases significantly when the preoperative VO(2)max is less than 15 mL/kg/min.

Influence of preoperative exercise capacity on length of stay after thoracic cancer surgery

BACKGROUND

Stress testing is frequently used to assess cardiac risk before thoracic surgery. However, the relationship between treadmill exercise capacity and length of stay (LOS) has not been investigated. We hypothesized that exercise capacity, a strong predictor of long-term prognosis, can also predict LOS after thoracic cancer surgery.

METHODS

Accordingly, 191 consecutive patients who had exercise stress testing before major thoracic cancer surgery were retrospectively grouped by poor (<4 metabolic equivalents [METs], n = 31), fair (4 to 7 METs, n = 107), good (7 to 10 METs, n = 30), and excellent (>10 METs, n = 23) exercise capacity. The relationship between exercise capacity and LOS was then determined.

RESULTS

Average LOS was inversely related to exercise capacity, with a nearly twofold increase in LOS between the excellent and poor exercise groups (4.8 versus 9.2 days). This relationship remained significant even after controlling for operation type, history of dyspnea, sex, and smoking history in analysis of covariance. Prolonged hospital stay (10 days or more) was strongly predicted by exercise capacity. Failure to exceed 4 METs was associated with a high risk of prolonged stay (9 of 31, 39%), whereas none of the 23 patients who exceeded 10 METs had a prolonged stay.

CONCLUSIONS

Treadmill exercise capacity has independent predictive value for LOS and risk of prolonged stay after thoracic cancer surgery. These findings have important implications for risk assessment and cost, suggesting that preoperative programs designed to improve exercise capacity may favorably influence LOS and associated costs.

Complications of lung resection and exercise capacity: a meta-analysis

RATIONALE

While exercise capacity, expressed as maximal oxygen consumption (VO2max), has been proposed to be the best predictor of postoperative cardiopulmonary complications after surgical resection in lung cancer patients, the literature remains controversial. The purpose of this study was to use the meta-analytic approach to determine if VO2max, expressed as either ml kg(-1) min(-1) or as a percentage of predicted, differed between patients who develop postoperative cardiopulmonary complications versus those that do not.

METHODS

Studies were retrieved via (1) computerized literature searches, (2) cross referencing from retrieved articles, and (3) expert review of our reference list. Trials were included if they reported preoperative VO2max values (ml kg(-1) min(-1) or percentage of predicted) and had patients in which postoperative cardiopulmonary complications occurred.

RESULTS

Fourteen studies representing a total of 955 men and women met our criteria for inclusion. Across all designs and categories, random-effects modeling demonstrated that patients without postoperative pulmonary complications had significantly higher levels of VO2max in ml kg(-1) min(-1) (mean difference=3.0, 95% confidence interval (CI), 1.9-4.0) as well as VO2max as a percentage of predicted (mean difference=8, 95% CI, 3.3-12.8).

CONCLUSION

After a systematic review of the literature, we found that exercise capacity, expressed as VO2max, is lower in patients that develop clinically relevant complications after curative lung resection. These results are important for the practicing clinician because they answer the literature controversy on the usefulness of measuring preoperative exercise capacity and reinforce the current guidelines on decision making for lung resection.

Acurácia do teste de escada utilizando o consumo máximo de oxigênio como padrão-ouro

OBJETIVO: Determinar a acurácia dos atributos do teste de escada (TE) de altura definida utilizando como padrão-ouro o consumo máximo de oxigênio (VO2 máx). MÉTODOS: O TE foi realizado com incentivo, em escada (6 lances; 72 degraus; 12,16 m de altura total), em 51 pacientes. O 'tempo' de subida foi cronometrado e o 'trabalho' e a 'potência' calculados. O VO2 máx foi obtido por ergoespirometria, utilizando-se o protocolo de Balke. Foram calculados a correlação linear de Pearson (r) e os valores de p entre as variáveis do TE e o VO2 máx. Para o cálculo da acurácia, o ponto de corte do VO2 máx foi estabelecido em 25 mL/kg/min, estratificando os indivíduos em normais ou alterados. Os pontos de corte para os atributos do TE foram obtidos através da curva receiver operating characteristic. A estatística Kappa (k) foi utilizada para estudo da concordância. RESULTADOS: Obtiveram-se os seguintes valores para a variável 'tempo': ponto de corte = 40 s; x= 41 ± 15,5 s; r = -0,707; p < 0,005; especificidade = 89%; sensibilidade = 83%; acurácia = 86% e k = 0,724. Para a variável 'potência', obteve-se ponto de corte = 200 w; x= 222,3 ± 95,2 w; r = 0,515; p < 0,005; especificidade = 67%; sensibilidade = 75%; acurácia = 71% e k = 0,414. A correlação de 'trabalho' com o VO2 máx não foi significativa, sendo esse atributo descartado. CONCLUSÃO: Dos atributos testados do TE, tendo como padrão-ouro o VO2 máx, a variável 'tempo' foi a que apresentou a melhor acurácia.

Genetics of postoperative complications following thoracic surgery

The field of complex trait-gene interaction research has expanded exponentially in recent years, and new insights into the ways patients respond to surgical stimuli have arisen from this body of work. From a physiological systems perspective, thoracic surgical procedures (thoracotomy in particular) represent a massive input stimulus, and it is, therefore, not surprising that approximately 30% of these patients experience an adverse postoperative event. The best risk prediction models have typically explained about 60% to 70% of the risk, leaving a large residual component unaccounted for. It is quite possible that there is a genetic (heritable) component to this residual risk. This article explores some of the concepts underlying gene-disease interactions, the preliminary work that has been done to date in this area, and finally discusses some of the more important methodological issues involved in complex trait association study design.

Prise en charge anesthésique de l'œsophagectomie: avancées et perspectives

Oesophagectomy is still characterized by a high postoperative mortality and respiratory morbidity. Nevertheless, epidemiological, medical and surgical advances have improved the management of this surgical procedure. The anaesthesiologist influence is present at each level, from the preoperative evaluation to the management of postoperative complications. The preoperative period is improved by the use of assessment scores, the better knowing of respiratory risk factors and of the neoadjuvant therapy adverse effects. The main objective of the operative period is to ensure a rapid weaning procedure and stability of the respiratory and haemodynamic functions, warranting the anastomotic healing. The interest of the association between respiratory rehabilitation and thoracic epidural analgesia is highlighted in the postoperative period. The management of postoperative complications, mainly represented by respiratory failure and anastomotic leakages, requires a multidisciplinary analysis. The potential interest of non-invasive ventilation and of the modulation of postoperative inflammatory response needs further investigation.

Evaluation of Expiratory Volume, Diffusion Capacity, and Exercise Tolerance Following Major Lung Resection

BACKGROUND

Lung resections determine a variable functional reduction depending on the extent of the resection and the time elapsed from the operation. The objectives of this study were to prospectively investigate the postoperative changes in FEV(1), carbon monoxide lung diffusion capacity (Dlco), and exercise tolerance after major lung resection at repeated evaluation times.

METHODS

FEV(1), Dlco, and peak oxygen consumption (Vo(2)peak) calculated using the stair climbing test were measured in 200 patients preoperatively, at discharge, and 1 month and 3 months after lobectomy or pneumonectomy. Preoperative and repeated postoperative measures were compared, and a time-series, cross-sectional regression analysis was performed to identify factors associated with postoperative Vo(2)peak.

RESULTS

One month after lobectomy, FEV(1), Dlco, and Vo(2)peak values were 79.5%, 81.5%, and 96% of preoperative values and recovered up to 84%, 88.5%, and 97% after 3 months, respectively. One month after pneumonectomy, FEV(1) percentage of predicted, Dlco percentage of predicted, and Vo(2)peak values were 65%, 75%, and 87% of preoperative values, and were 66%, 80%, and 89% after 3 months, respectively. Three months after lobectomy, 27% of patients with COPD had improved FEV(1), 34% had improved Dlco, and 43% had improved Vo(2)peak compared to preoperative values. The time-series, cross-sectional regression analysis showed that postoperative Vo(2)peak values were directly associated with preoperative values of Vo(2)peak, and postoperative values of FEV(1) and Dlco, and were inversely associated with age and body mass index.

CONCLUSIONS

Our findings may be used during preoperative counseling and for deciding eligibility for operation along with other more traditional measures of outcome.

Gemcitabine-Cisplatin Chemotherapy Before Lung Resection: A Case-Matched Analysis of Early Outcome

BACKGROUND

The objective of the present study was to assess whether neoadjuvant chemotherapy with gemcitabine and cisplatin was associated with an increased incidence of morbidity and mortality after major lung resection for lung cancer.

METHODS

We analyzed 570 patients who underwent lobectomy or pneumonectomy for nonsmall-cell lung cancer at our institution from January 2000 through June 2005. Of these, 70 patients underwent three cycles of gemcitabine-cisplatin chemotherapy before operation for locally advanced disease. Propensity scores were constructed to match those patients undergoing neoadjuvant chemotherapy and lung resection with those undergoing surgery alone. The propensity score analysis yielded two groups of 70 well-matched pairs that were compared in terms of baseline characteristics and early outcome (morbidity, mortality, length of postoperative stay, intensive care unit admission).

RESULTS

The two case-matched groups had similar morbidity (p = 0.8), mortality (p = 0.4), perioperative blood transfusions (p = 0.8) and intensive care unit admission rates (p = 0.8). Likewise, the length of postoperative stay did not differ between the groups (p = 0.9).

CONCLUSIONS

Gemcitabin-cisplatin neoadjuvant chemotherapy appears to be safe before major lung resection. This finding warrants its use for efficacy studies of locally advanced and even early-stage lung cancer.

Prognostic factors in non-small cell lung cancer surgery

AIMS

Complete surgical resection of primary tumours remains the treatment with the greatest likelihood for survival in early-stage non-small cell lung cancer (NSCLC). Although TNM stage is the most important prognostic parameter in NSCLC, additional parameters are required to explain the large variability in postoperative outcome. The present review aims at providing an overview of the currently known prognostic markers for postoperative outcome.

METHODS

We performed an electronic literature search on the MEDLINE database to identify relevant studies describing the risk factors in NSCLC surgery. The references reported in all the identified studies were used for completion of the literature search.

RESULTS

Poor pulmonary function, cardiovascular disease, male gender, advanced age, TNM stage, non-squamous cell histology, pneumonectomy, low hospital volume and little experience of the surgeon were identified as risk factors for postoperative outcome. However, with the exception of TNM stage and extent of resection, the literature demonstrates conflicting results on the prognostic power of most factors. The role of molecular biological factors, neoadjuvant treatment and adjuvant treatment is not well investigated yet.

CONCLUSIONS

The advantage of knowing about the existence of comorbidity and prognostic risk factors may provide the clinician with the ability to identify poor prognostic patients and establish the most appropriate treatment strategy. The assessment of prognostic factors remains an area of active investigation and a promising field of research in optimising therapy of NSCLC patients.

Comparison of shuttle walk with measured peak oxygen consumption in patients with operable lung cancer

BACKGROUND

The relationship between the shuttle walk test and peak oxygen consumption in patients with lung cancer has not previously been reported. A study was undertaken to examine this relationship in patients referred for lung cancer surgery to test the hypothesis that the shuttle walk test would be useful in this clinical setting.

METHODS

125 consecutive patients with potentially operable lung cancer were prospectively recruited. Each performed same day shuttle walking and treadmill walking tests.

RESULTS

Shuttle walk distances ranged from 104 m to 1020 m and peak oxygen consumption ranged from 9 to 35 ml/kg/min. The shuttle walk distance significantly correlated with peak oxygen consumption (r = 0.67, p<0.001). All 55 patients who achieved more than 400 m on the shuttle test had a peak oxygen consumption of at least 15 ml/kg/min. Seventy of 125 patients failed to achieve 400 m on the shuttle walk test; in 22 of these the peak oxygen consumption was less than 15 ml/kg/min. Nine of 17 patients who achieved less than 250 m had a peak oxygen consumption of more than 15 ml/kg/min.

CONCLUSION

The shuttle walk is a useful exercise test to assess potentially operable lung cancer patients with borderline lung function. However, it tends to underestimate exercise capacity at the lower range compared with peak oxygen consumption. Our data suggest that patients achieving 400 m on the shuttle walk test do not require formal measurement of oxygen consumption. In patients failing to achieve this distance we recommend assessment of peak oxygen consumption, particularly in those unable to walk 250 m, because a considerable proportion would still qualify for surgery as they had an acceptable peak oxygen consumption.

Preoperative pulmonary evaluation of the thoracic surgical patient

Fig. 2 is an algorithm for the preoperative pulmonary evaluation of the lung resection candidate. Patients should undergo routine spirometry and diffusion capacity testing. If the FEV1 and DLCO are greater than 80% predicted, no further study is needed. When these parameters are less than 80%, some estimation of postoperative function is likely needed, taking into account the proposed resection. Patients with ppoFEV1 or ppoDLCO less than 40% are at increased risk of perioperative complications or death and should undergo formal exercise testing. A VO2max or ppoVO2max less than 10 mL/kg/min is associated with prohibitive risk for anatomic lung resection, and alternative treatment modalities should be considered.

Escalas de risco de Torrington e Henderson e de Epstein: aplicabilidade e efetividade nas ressecções pulmonares

OBJETIVO: Comparar a incidência de complicações pulmonares e cardiopulmonares estimadas, respectivamente, pelas escalas de Torrington e Henderson e de Epstein, em amostra populacional submetida à ressecção pulmonar para tratamento de câncer de pulmão. MÉTODOS: Dados de doentes submetidos à ressecção de um lobo pulmonar ou mais foram retirados de dois bancos de dados montados de forma prospectiva, oriundos de dois hospitais terciários. As medidas de desfecho analisadas foram complicações pulmonares, cardíacas e óbito. Teste exato de Fisher foi usado para avaliar a concordância das taxas de complicações obtidas com as estimadas previamente. RESULTADOS: A escala de Torrington e Henderson foi aplicada em 50 doentes (12 apresentaram risco leve, 32 moderado e 6 grave) e subestimou a taxa de complicações pulmonares nas categorias leve e moderado (p = 0,0003 e p = 0,0006, respectivamente), porém foi capaz de reconhecer os pacientes com alto risco de desenvolver complicações. A escala de Epstein foi aplicada em 38 doentes (4 apresentaram risco alto e 34 baixo) e também subestimou a taxa de complicações cardiopulmonares pós-operatórias da categoria de risco leve, que continha a maioria dos doentes (p < 0,0001), mas reconheceu, também, os pacientes com chance alta de complicar. CONCLUSÃO: As duas escalas não foram adequadas para estimar ocorrência de complicações pulmonares e cardiopulmonares na maioria dos doentes.

Preoperative assessment for lung cancer surgery

PURPOSE OF REVIEW

Pulmonary resection remains the only curative treatment option for lung cancer surgery. This review summarizes recent advances in the preoperative functional evaluation of the patient with lung cancer.

RECENT FINDINGS

The workup of patients with bronchogenic carcinoma covers three areas: tumor type, tumor extent, and patient cardiopulmonary reserves. Significant advances have been made in the latter two areas. Traditionally lobectomy was regarded as the minimum resection for lung cancer; new studies are challenging this view and suggesting that segmentectomy is acceptable for stage Ia cancers < or =20 mm. An important change relating to cardiopulmonary reserves of the patient is the shift in emphasis toward early exercise testing and, in particular, the use of stair climbing as a surrogate marker of maximal oxygen consumption. New studies confirm the benefit of combined lung volume reduction surgery and lung cancer surgery in certain patients who might otherwise be excluded from surgery because of poor lung function.

SUMMARY

Advances in the preoperative workup of lung cancer patients and in surgical techniques are permitting resections in previously inoperable patients. A new, simplified algorithm for the preoperative workup of lung cancer patients assessing the value of stair climbing as a surrogate marker of maximal oxygen consumption is proposed.

Relationship between the inability to climb two flights of stairs and outcome after major non-cardiac surgery: implications for the pre-operative assessment of functional capacity

Functional capacity is an integral component of the pre-operative evaluation of the cardiac patient for non-cardiac surgery. Stair climbing capacity has peri-operative prognostic importance. It may predict survival after lung resection and complications after major non-cardiac surgery. However, stair climbing cannot determine the aerobic metabolic capacity necessary to survive the peri-operative stress response. The potential benefits and current limitations of cardiopulmonary exercise testing to determine peri-operative aerobic capacity are discussed. Principles for the selection of an appropriate screening test of aerobic function are put forward.

Lung cancer: Preoperative pulmonary evaluation of the lung resection candidate

Lung resection provides the best chance of cure for individuals with early stage non-small cell lung cancer. Naturally, lung resection will lead to a decrease in lung function. The population that develops lung cancer often has concomitant lung disease and a reduced ability to tolerate further losses in lung function. The goal of the preoperative pulmonary assessment of individuals with resectable lung cancer is to identify those individuals whose short- and long-term morbidity and mortality would be unacceptably high if surgical resection were to occur. Pulmonary function measures such as the forced expiratory volume in 1 second and the diffusing capacity for carbon monoxide are useful predictors of postoperative outcome. In situations in which lung function is not normal, the prediction of postoperative lung function from preoperative results and the assessment of exercise capacity can be performed to further clarify risks. Published guidelines help to direct the order of testing, permitting us to offer resection to as many patients as possible.

Optimization of lung function before pulmonary resection: pulmonologists' perspectives

Many risk factors for morbidity and mortality with lung resection have been identified. Factors such as age, gender, and cancer stage cannot be altered, but lung function can be optimized by treating COPD or asthma with bronchodilators, corticosteroids, or antibiotics (when indicated) and by inspiratory muscle training. Although smoking cessation 2 months in advance of surgery may not be feasible, cessation nevertheless should be encouraged because it may decrease postoperative inflammation and in the long-term may decrease the risk of recurrence. In addition, morbidity and mortality can be minimized by careful patient selection using lung scanning or CT to determine predicted postoperative functions (FEV1% and DLco%) and some form of exercise testing, such as cardiopulmonary exercise testing or simple stair climbing. When the risk of surgery is high, any benefit from possible cure must be weighed against the risk of long-term disability or death. Although much data are available to guide clinicians in these decisions, there still is no one test that provides the answer in individual cases. The art and science of medicine must merge at this point.

Surgical lung cancer

STUDY OBJECTIVE

To identify those variables that are associated with operative morbidity or mortality in cases of thoracotomy in lung cancer.

SETTING

Third level university hospital.

PATIENTS

Consecutive patients with thoracotomy due to lung cancer operated on between 1994 and 1997 (n = 115).

METHODS

Pre- and postoperative variables potentially associated with operative morbidity or mortality were retrieved prospectively as follows: demographic and clinical characteristics of the patients, cardiopulmonary function characteristics, tumour characteristics, and treatment characteristics. A bivariate analysis of all variables under evaluation was carried out in order to identify those variables associated with operative morbidity and mortality. A multivariable analysis of the selected variables was then conducted using a logistic model.

RESULTS

The predicted postoperative product (predicted FEV1 x predicting diffusing capacity of carbon monoxide), the carbon monoxide diffusion coefficient (Kco) and the contralateral pulmonary perfusion are variables that relate to the overall morbidity or mortality (number of events 63, 55%) (-2 log likelihood chi2 = 22.9; R2 = 0.27). For variables associated with postoperative morbidity, the best associative model combines functional variables (diffusion, predicted FEV1), endoscopic variables (obstructed segments to be resected), clinical variables (comorbidity) and an important postoperative variable, the pathological tumoural staging (pN) (number of events 49, 43%) (-2 log likelihood chi2 = 32.9; R2 = 0.36).

CONCLUSION

The numerous variables under analysis are poorly associated with morbidity or mortality after thoracotomy in lung cancer. With regard to postoperative morbidity, the best associative models combine information that is known pre- and postoperatively and which is provided by both the patient and the tumour.

Stair climbing test as a predictor of cardiopulmonary complications after pulmonary lobectomy in the elderly

BACKGROUND

The objective of this study was to assess the role of a symptom-limited stair climbing test in predicting postoperative cardiopulmonary complications in elderly candidates for lung resection.

METHODS

A consecutive series of 109 patients more than 70 years of age who underwent pulmonary lobectomy for lung carcinoma from January 2000 through May 2003 formed the prospective database of this study. All patients in the analysis performed a preoperative symptom-limited stair climbing test. Univariate and multivariate analyses were performed to identify predictors of postoperative cardiopulmonary complications.

RESULTS

At univariate analysis, the patients with complications had a lower forced expiratory capacity percentage of predicted (p = 0.048), predicted postoperative forced expiratory volume in 1 second percentage of predicted (p = 0.049), climbed a lower height at preoperative stair climbing test (p = 0.0004), and presented a greater proportion of cardiac comorbiditiy with respect to the patients without complications (p = 0.02). After logistic regression analysis, significant predictors of postoperative complications resulted in the presence of a concomitant cardiac disease (p = 0.04) and a low height climbed preoperatively (p = 0.0015).

CONCLUSIONS

A symptom-limited stair climbing test was a safe and simple instrument capable of predicting cardiopulmonary complications in the elderly after lung resection.

Evaluation of operability before lung resection

Lung resection remains the treatment of choice in the curative approach to nonsmall cell lung cancer. Because most lung cancer patients are current or former smokers, they are at increased risk of chronic obstructive pulmonary disease and coronary artery disease, conditions associated with increased surgical morbidity and mortality. Careful preoperative assessment of the cardiopulmonary reserves is therefore of great importance. Various single and combined parameters for the functional assessment before surgery have been proposed. Currently the emphasis is on the determination of forced expiratory volume in the first second, the diffusing capacity for carbon monoxide, and exercise testing with the measurement of maximal oxygen uptake. Adherence to established algorithms for this preoperative evaluation, advances in operative technique (video-assisted thoracoscopic surgery and combined operations of lung cancer surgery with lung volume reduction surgery), and perioperative care permit resections in patients who until recently would have been considered functionally inoperable.