Prospective evaluation of an algorithm for the functional assessment of lung resection candidates

Percent predicted peak oxygen uptake is superior to weight-indexed peak oxygen uptake in risk stratification before lung cancer lobectomy

OBJECTIVE

To improve preoperative risk stratification in lung cancer lobectomy by identifying and comparing optimal thresholds for peak oxygen uptake (VO2peak) presented as weight-indexed and percent of predicted values, respectively.

METHODS

This was a longitudinal cohort study including national registry data on patients scheduled for cancer lobectomy that used available data from preoperative cardiopulmonary exercise testing. The measured VO2peak was indexed by body mass (mL/kg/min) and also compared with 2 established reference equations (Wasserman-Hansen and Study of Health in Pomerania, respectively). By receiver operating characteristic analysis, a lower 90% specificity and an upper 90% sensitivity threshold were determined for each measure, in relation to the outcome of any major complication or death. For each measure and based on these thresholds, patients were categorized as low risk, intermediate risk, or high risk. The frequency of complications was compared between groups using χ2.

RESULTS

The frequency of complications differed significantly between the proposed low-, intermediate-, and high-risk groups when using % predicted Study of Health in Pomerania (5%, 21%, 35%, P = .007) or % predicted Wasserman-Hansen (5%, 25%, 35%, P = .002) but not when using the weight-indexed VO2peak groups (7%, 23%, 15%, P = .08). Nonsignificant differences were found using the threshold <15 mL/kg/min (P = .34).

CONCLUSIONS

This study showed that weight-indexed VO2peak was of less use as a marker of risk at the lower range of exercise capacity, whereas % predicted VO2peak was associated with a continuously increasing risk of major complications, also at the lower end of exercise capacity. As identifying subjects at high risk of complications is important, % predicted VO2peak is therefore preferable.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

INTRODUCTION

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.

METHODS

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.

RESULTS

Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).

CONCLUSIONS

These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Simple Anatomical Calculations Possibly As Accurate As Three-Dimensional Lobar Quantification with SPECT-CT in Predicting Lung Function after Pulmonary Resection

The estimation of predicted postoperative (PPO) lung function is important in lung resection candidates. We utilized simple anatomical calculations and single-photon emission computed tomography combined with computed tomography (SPECT-CT) to calculate PPO in 24 consecutive patients with impaired pulmonary function who underwent lung resection. PPO values calculated by anatomical calculations and three-dimensional lobar SPECT-CT quantification both correlated well with the postoperative forced expiratory volume in 1 s, with r = 0.825, p < 0.001 and r = 0.796, p < 0.001, respectively. Both techniques fared well at predicting postoperative lung function, but our observations unexpectedly suggested that simple anatomical calculations might be equivalent to three-dimensional SPECT-CT lobar quantification.

Routine intensive monitoring but not routine intensive care unit-based management is necessary in video-assisted thoracoscopic surgery lobectomy for lung cancer

Background

Evidence for immediate postoperative intensive care unit (ICU) care is still lacking in the era of minimally invasive video-assisted thoracic surgery (VATS). We evaluated the safety and feasibility of general ward (GW) care after VATS lobectomy for lung cancer.

Methods

A total of 451 patients who underwent VATS lobectomy for lung cancer between June 2012 and August 2017 were retrospectively studied. The patients were divided into two groups (ICU 344 vs. GW 107). We compared the postoperative complications and mortality between the two groups after propensity score matching. Furthermore, we evaluated the clinical factors associated with complications, and stratified patients according to the risk for complications.

Results

Immediate complications (within 24 hours after surgery) occurred in 0.4%. Non-immediate complications occurred in 18.8%. There were no differences in the incidence of complications and mortality between the two groups, after propensity matching. However, the length of postoperative stay (12.6±10.0 vs. 10.3±4.1 days, P=0.041) was significantly higher in the ICU group than in the GW group. Multivariate regression analyses revealed that chronic obstructive pulmonary disease (COPD) [odds ratio (OR) =3.00, 95% confidence interval (CI): 1.51-5.97, P=0.002], non-stage I cancer (OR =2.54, 95% CI: 1.39-4.62, P=0.002), multi-port surgery (OR =3.75, 95% CI: 2.18-6.44, P<0.001), and age ≥60 years (OR =2.12, 95% CI: 1.03-4.37, P=0.042) were associated with complications. Immediate postoperative care in GW had no influence on complications.

Conclusions

Immediate postoperative care after VATS lobectomy for lung cancer in GW was safe and feasible without poor outcomes. Therefore, selective intensive monitoring for high risk groups may offer cost-saving and efficient use of ICU resources.

Prediction of postoperative lung function after major lung resection for lung cancer using volumetric computed tomography

OBJECTIVES

The study objectives were to assess the accuracy of volumetric computed tomography to predict postoperative lung function in patients with lung cancer in relation to anatomic segments counting and perfusion scintigraphy, to generate specific predictive equations for each functional parameter, and to evaluate accuracy and precision of these in a validation cohort.

METHODS

We assessed pulmonary functions preoperatively and 3 to 4 months postoperatively after lung resection for lung cancer (n = 114). Absolute and relative lung volumes (total and upper/middle/lower) were determined using volumetric software analysis for staging thoracic computed tomography scans. Predicted postoperative function was calculated by segments counting, scintigraphy, and volumetric computed tomography.

RESULTS

Volumetric computed tomography achieves a higher correlation and precision with measured postoperative lung function than segments counting or scintigraphy (correlation and intraclass correlation coefficients, 0.779-0.969 and 0.776-0.969; 0.573-0.887 and 0.552-0.882; and 0.578-0.834 and 0.532-0.815, respectively), as well as greater accuracy, determined by narrower agreement coefficients for forced vital capacity, forced expiratory volume in 1 second, lung diffusing capacity, and peak oxygen uptake. After validation in an independent cohort (n = 43), adjusted linear regression including volumetric estimation of decreased postoperative ventilation for postoperative lung function parameters explains 98% to 99% of variance.

CONCLUSIONS

Volumetric computed tomography is a reliable and accurate method to predict postoperative lung function in patients undergoing lung resection that provides better accuracy than conventional procedures. Because lung computed tomography is systematically performed in the staging of patients with suspected lung cancer, this volumetric analysis might simultaneously provide the information necessary to evaluate operability.

The five commandments of efficient and effective care in the initial evaluation of lung cancer

PURPOSE OF REVIEW

Multiple recent studies have found an astounding lack of concordance with national guidelines in the workup of lung cancer in both community and academic settings. The resultant increase in complications and delays may potentially contribute to the overall dismal outcomes, as well as cost. This article aims to increase awareness among clinicians about the scope of this problem, and provides a simplified primer on the core concepts of how to perform an efficient and effective workup that is in-line with national guidelines.

RECENT FINDINGS

Although the basic principles underlying lung cancer evaluation have not changed in the last decade, there are new areas of debate which are outlined and discussed in this article. These include: the value of brain and bone imaging in asymptomatic patients, the best initial site to biopsy in the era of genomics, and the use of biomarkers with low-dose chest tomography screening.

SUMMARY

Given the huge stakes in lung cancer, the current national quality gap in initial evaluation is unacceptable. However, physician re-education can change this. This article provides a quick review of how to properly evaluate a patient with potential lung cancer, as well as an update on new and continuing controversies in the field.

All grades of severity of postoperative adverse events are associated with prolonged length of stay after lung cancer resection

OBJECTIVE

To determine whether all grades of severity of postoperative adverse events are associated with prolonged length of stay in patients undergoing pulmonary cancer resection.

METHODS

This was a retrospective cohort study of all patients who underwent pulmonary resection with curative intent for malignancy at The Ottawa Hospital, Division of Thoracic Surgery (January 2008 to July 2015). Postoperative adverse events were collected prospectively with the Thoracic Morbidity & Mortality System, based on the Clavien-Dindo severity classification. Patient demographics, comorbidities, preoperative investigations, cardiopulmonary assessment, pathologic staging, operative characteristics, and length of stay were retrospectively reviewed. Prolonged hospital stay was defined as >75th percentile for each procedure performed (wedge resection 6 days, segmentectomy 6 days, lobectomy 7 days, extended lobectomy 8 days, pneumonectomy 10 days). Univariable and multivariable logistic regression analyses were conducted to identify factors associated with prolonged hospital stay.

RESULTS

Of 1041 patients, 579 (55.6%) were female, 610 (58.1%) were >65 years old, 232 (22.3%) experienced prolonged hospital stay, and 416 (40.0%) patients had ≥1 postoperative adverse event. Multivariable analyses identified significant (P < .05) factors associated with prolonged hospital stay to be (odds ratio; 95% confidence interval): lower diffusion capacity of the lung for carbon monoxide (0.99; 0.98-0.99), surgical approach: open thoracotomy (1.8; 1.3-2.5), and presence of any postoperative adverse event: Grade I (5.8; 3.3-10.2), Grade II (6.0; 4.0-8.9), Grade III (11.4; 7.0-18.7), and Grade IV (19.40; 7.1-55.18).

CONCLUSIONS

Lower diffusion capacity of the lung for carbon monoxide, open thoracotomy approach, and the development of any postoperative adverse event, including minor events that required no additional therapy, were factors associated with prolonged hospital stay.

Quantitative computed tomography to predict postoperative FEV1 after lung cancer surgery

BACKGROUND

Predicted postoperative FEV1 (ppoFEV1) must be estimated preoperatively prior to surgery for non-small cell lung cancer (NSCLC). We evaluated a lung volumetry approach based on chest computed tomography (CT).

METHODS

A prospective study was conducted over a period of one year in eligible lung cancer patients to evaluate the difference between ppoFEV1 and the 3-month postoperative FEV1 (poFEV1). Patients in whom CT was performed in another hospital and those with factors influencing poFEV1, such as atelectasis, pleural effusion, pneumothorax, or pneumonia, were excluded. A total of 23 patients were included and ppoFEV1 was calculated according to 4 usual Methods: Nakahara formula, Juhl and Frost formula, ventilation scintigraphy, perfusion scintigraphy, and a fifth method based on quantitative CT. Lung volume was calculated twice and separately by 2 radiologists. Tumor volume, and emphysema defined by a -950 HU limit were subtracted from the total lung volume in order to estimate ppoFEV1.

RESULTS

We compared 5 methods of ppoFEV1 estimation and calculated the mean volume difference between ppoFEV1 and poFEV1. A better correlation was observed for quantitative CT than for Nakahara formula, Juhl and Frost formula, perfusion scintigraphy and ventilation scintigraphy with respectively: R²=0.79 vs. 0.75, 0.75, 0.67 and 0.64 with a mean volume difference of 266±229 mL (P<0.01) vs. 320±262 mL (P<0.01), 332±251 mL (P<0.01), 304±295 mL (P<0.01) and 312±303 mL (P<0.01).

CONCLUSIONS

Quantitative CT appears to be a satisfactory method to evaluate ppoFEV1 evaluation method, and appears to be more reliable than other approaches. Estimation of ppoFEV1, as part of the preoperative assessment, does not involve additional morphologic examinations, particularly scintigraphy. This method may become the reference method for ppoFEV1 evaluation.

Is age a predisposing factor of postoperative complications after lung resection for primary pulmonary neoplasms?

INTRODUCTION

Age has been classically considered as a determining factor for the development of postoperative complications related to lung resection for bronchogenic carcinoma. The Postoperative Complications Study Group of the Spanish Society of Thoracic Surgery has promoted a registry to analyze this factor.

METHODS

A total of 3,307 patients who underwent any type of surgical resection for bronchogenic carcinoma have been systematically and prospectively recorded in any of the 24 units that are part of the group. Several variables related to comorbidity and age, as well as postoperative complications, were analyzed.

RESULTS

The mean age of patients was 65,44. Men were significantly more common than female. The most frequent complication was prolonged air leak, which was observed in more than one third of patients. In a univariant analysis, air leak presence and postsurgical atelectasis showed statistical association with patient age, when stratified in age groups. In a multivariate analysis, age was recognized as an independent prognostic factor in relation to air leak onset. However, this could not be confirmed for postoperative atelectasis.

CONCLUSION

Age is a predisposing factor for the development of postoperative complications after lung resection. Other associated factors also influence the occurrence of these complications.

Evaluation of postoperative lung volume and perfusion changes by dual-energy computed tomography in patients with lung cancer

PURPOSE

The aim of our study was to retrospectively evaluate postoperative physiologic changes in lung cancer patients using dual-energy CT (DECT), and develop modified methods reflecting postoperative change for predicting pulmonary function.

METHODS AND MATERIALS

88 patients (M:F=64:24; mean age, 63.5 years) with lung cancer who underwent DECT and pulmonary function tests before and after operation were included. Volume and iodine values for perfusion of each lobe were quantified. The predicted postoperative FEV1 using the current method was calculated by multiplying the preoperative FEV1 by the fractional contribution of perfusion of the remaining lung. The modified method reflecting postoperative volume change was compared to the current method.

RESULTS

Postoperative lung volume showed compensatory increases in the contralateral and remaining ipsilateral lobes, with a significantly greater increase in the ipsilateral lobe than contralateral lobe (21.8%±46.2% vs. 10.0%±20.8%, P=0.031). Perfusion analysis showed blood volume increases in both ipsilateral and contralateral lobes without statistical differences (blood volume ratio difference, 29.2%±26.7 vs. 24.6%±16.5, P=0.368). The performance of the modified method considering postoperative lung volume change was comparable to that of the current method in the development and validation datasets (95% CI, -24.5% to 37.1% vs. -33.3% to 22.2% and -23.6% to 32.0% vs. -31.9% to 16.0%, respectively).

CONCLUSIONS

Postoperative compensatory increases in lung volume and perfusion occur in different ways. Our modified method incorporating postoperative lung volume changes can be considered a comparable method for prediction of postoperative lung function.

Surgical risk evaluation of lung cancer in COPD patients - A cohort observational study

Coexistence between pulmonary cancer and chronic obstructive pulmonary disease (COPD) is frequent and is anticipated to be lead to high worldwide mortality in the next decades. The most powerful therapeutic approach for non-small cell lung carcinoma is lung surgical resection. However, in COPD patients, this approach bears a higher mortality and morbidity risk, thus requiring an accurate pre-operatory evaluation of the surgical risk comprising a clinical and functional assessment at rest, as well as a cardiopulmonary exercise test. In this observational study, factors associated with cardiopulmonary complications within 30 days after tumor resection surgery were investigated in a cohort of patients with COPD and lung cancer assigned to perform a cardiopulmonary exercise test. This study included 50 patients (46 men, 92.0%) with a mean age of 64.7 years old (standard deviation 7.9), forced expiratory volume in the first second (FEV1) of 61.8% (SD 19.0%) and carbon monoxide diffusing capacity (DLCO) of 46.0% (SD 14.8%). Complications were observed in eighteen patients (36.0%) including 2 deaths (4.0%). Peak oxygen uptake (VO2peak) expressed in percentage of the predicted value was the only parameter showing a statistically significant difference between the groups with and without complications (p=0.027). The best value of VO2peak to discriminate complications occurrence was 61.0%. This study highlights the relevance of the cardiopulmonary exercise test in the risk assessment of pulmonary resection surgery in patients with COPD. The VO2peak (percentage of predicted value) is shown to be associated with complications within 30 days after surgery.

Morbidity, mortality, and categorization of the risk of perioperative complications in lung cancer patients

OBJECTIVE

To determine morbidity and mortality rates by risk category in accordance with the American College of Chest Physicians guidelines, to determine what role pulmonary function tests play in this categorization process, and to identify risk factors for perioperative complications (PCs).

METHODS

This was a historical cohort study based on preoperative and postoperative data collected for cases of lung cancer diagnosed or suspected between 2001 and 2010.

RESULTS

Of the 239 patients evaluated, only 13 (5.4%) were classified as being at high risk of PCs. Predicted postoperative FEV1 (FEV1ppo) was sufficient to define the risk level in 156 patients (65.3%); however, cardiopulmonary exercise testing (CPET) was necessary for identifying those at high risk. Lung resection was performed in 145 patients. Overall morbidity and mortality rates were similar to those reported in other studies. However, morbidity and mortality rates for patients at an acceptable risk of PCs were 31.6% and 4.3%, respectively, whereas those for patients at high risk were 83.3% and 33.3%. Advanced age, COPD, lobe resection, and lower FEV1ppo were correlated with PCs.

CONCLUSIONS

Although spirometry was sufficient for risk assessment in the majority of the population studied, CPET played a key role in the identification of high-risk patients, among whom the mortality rate was seven times higher than was that observed for those at an acceptable risk of PCs. The risk factors related to PCs coincided with those reported in previous studies.

Preoperative Maximal Oxygen Uptake and Exercise-induced Changes in Pulse Oximetry Predict Early Postoperative Respiratory Complications in Lung Cancer Patients

BACKGROUND

Postoperative respiratory complications often arise in lung cancer patients after lung resection, although these are often difficult to predict. We sought to identify reliable predictors of early-onset postoperative respiratory complications in lung cancer patients who had moderate-to-severe preoperative respiratory impairment.

METHODS

This was a prospective observational study that included 107 consecutive lung cancer patients with forced expiratory volume in 1 s <60% of predicted who were scheduled for thoracotomy and lung resection. Preoperative functional assessments included pulmonary function testing by spirometry, single breath diffusion capacity of lung for carbon monoxide, and cardiopulmonary exercise testing. Risk factors for early-onset postoperative respiratory complications that occurred within 30 days postoperatively were sought from among these pulmonary function testing and cardiopulmonary exercise testing results.

RESULTS

By multivariable logistic regression, peak oxygen uptake (V'O_2max%; p < 0.001) and the transcutaneous pulse oxygen saturation difference during load exercise (ΔSPO₂%; p < 0.001) were independent predictors of postoperative respiratory complications. A receiver operating characteristic curve had an area under the curve of 0.846 for the combination of V'O_2max% and ΔSPO₂%, while the area under the curve with V'O_2max% only was 0.726. From this, the probability of postoperative respiratory complications was [Formula: see text]. P_complication ≥ 0.202 for postoperative respiratory complications had a sensitivity of 80.8% and a specificity of 81.5%.

CONCLUSIONS

For lung cancer patients with forced expiratory volume in 1 s <60% of predicted, in addition to common preoperative tests, V'O_2max% and ΔSPO₂% may be an aid for predicting early-onset postoperative respiratory complications.

Preoperative evaluation of the patient with pulmonary disease

BACKGROUND AND OBJECTIVES

In daily clinical practice, pulmonary complications related to surgical procedure are common, increasing the morbidity and mortality of patients. Assessment of the risk of pulmonary complications is an important step in the preoperative evaluation. Thus, we review the most relevant aspects of preoperative assessment of the patient with lung disease.

CONTENT

Pulmonary risk stratification depends on clinical symptoms and patient's physical status. Age, preexisting respiratory diseases, nutritional status, and continued medical treatment are usually more important than additional tests. Pulmonary function tests are of great relevance when high abdominal or thoracic procedures are scheduled, particularly when lung resection are considered.

CONCLUSION

Understanding the perioperative evaluation of the potential risk for developing pulmonary complication allows the medical team to choose the adequate anesthetic technique and surgical and clinical care required by each patient, thereby reducing adverse respiratory outcomes.

Response to exercise in patients with liver cirrhosis: implications for liver transplantation

End-stage liver cirrhosis is a systemic disease carrying a short-term desperate prognosis without liver transplantation. Given the discrepancy between the growing number of candidates and the limited available liver grafts, the pre-transplantation screening process has become a challenging task. Cardiopulmonary exercise testing, by measuring maximal oxygen consumption at peak exercise, provides a global integrative approach of the health status of an individual. In the setting of liver cirrhosis, decreased oxygen consumption at peak exercise may result from a combination of multiple extra-hepatic complications, including deconditioning, malnutrition-associated muscle weakness, anaemia, cirrhotic cardiomyopathy, and hepato-pulmonary syndrome for instance. In addition, oxygen consumption at peak exercise not only correlated with the severity of the liver disease, but it is also independently associated with survival following liver transplantation. The present article aims to review the numerous determinants of impaired aerobic capacity in patients with severe liver disease, and to discuss how useful is cardiopulmonary exercise testing as a critical tool in the pre-transplantation assessment of these patients.

Physiology and clinical applications of cardiopulmonary exercise testing in lung cancer surgery

Cardiopulmonary exercise testing (CPET) permits measurement of oxygen uptake (Vo2), an indicator of overall cardiopulmonary fitness and a useful measurement in the assessment of operative risk for lung cancer patients. The evidence supporting the use of CPET in pre-operative assessment of the lung cancer surgery patient is examined. CPET methodology and limitations, as well as alternatives to CPET for risk assessment are discussed.

Surgical treatment of non-small-cell lung cancer in octogenarians

Reluctance to recommend lung cancer surgery for octogenarians is partly based on the expectation that the rate of complications and mortality is higher in this group of patients, and on the impression that the life expectancy of an octogenarian with lung cancer is limited by death from natural causes. Moreover, the belief that radiation therapy and observation yield similar results to surgery in early-stage disease have influenced low resection rates in this population. Nevertheless, advances in surgical techniques, anaesthesia and postoperative care have made surgical lung resection a safer procedure than it was in the past. Judging from the more recent findings, surgery should not be withheld because of postoperative mortality, but suboptimal or palliative treatment may be necessary in patients with poor physical or mental function. To enable informed decision-making, both patients and clinicians need information on the risks of surgical treatment. In this review, available information from the literature was collected in an effort to understand the real benefit of surgical treatment in octogenarians with non-small-cell lung cancer, and to determine what should be done or avoided during the selection course.

Risk factors for impaired lung function after pulmonary metastasectomy: a prospective observational study of 117 cases

OBJECTIVES

The prediction of postoperative preserved pulmonary function is essential for ascertaining the functional operability of pulmonary metastasectomy candidates. Formulae to predict pulmonary function after metastasectomy have not yet been described. This study was undertaken to provide data about the functional loss after a pulmonary metastasectomy, which often includes non-anatomical resections or combinations with anatomical resections.

METHODS

Pulmonary function tests were performed preoperatively, postoperatively and 3 months after a pulmonary metastasectomy, and the factors potentially influencing the functional outcome were prospectively collected in a database. The functional loss was calculated as the difference in the values between the follow-up visit and the preoperative values, and the influencing factors were tested using the Mann-Whitney test.

RESULTS

A total of 162 patients were prospectively included in the study and 117 completed the study protocol with a follow-up evaluation after a mean of 3.4 months. Of these, 33 patients had bilateral resections, 30 interventions were repeated resections and adhesions were removed in 46. The greatest lung resection performed was a lobectomy in 13, with segmentectomy in 27 and wedge resection in 77 patients. The mean overall functional loss was: forced vital capacity -9.2%, total lung capacity -8.8%, forced expiratory volume in 1 s -10.8% and diffusion capacity for carbon monoxide (DLCO) -9.7%, whereas the diffusion coefficient (KCO) and pO(2) remained unchanged after 3 months. This functional loss was significant (P < 0.001) for all the parameters mentioned. The two factors were inversely found to influence the functional outcome: bilateral resection reduced spirometry values (P < 0.01), postoperative chemotherapy reduced DLCO (P = 0.011) and KCO (P = 0.029).

CONCLUSIONS

A pulmonary metastasectomy leads to a significant loss of pulmonary function after 3 months in an average patient collective. The most important factors for deteriorating lung function are a bilateral operation and postoperative chemotherapy.

Techniques of Bronchial Sleeve Resection

A bronchial sleeve resection can be considered for lesions arising from a lobar bronchus so as to preclude a standard lobectomy, yet without enough distal involvement as to warrant a pneumonectomy. Limited bronchial resection allows maximal conservation of pulmonary function in patients with benign or malignant disease, without compromising oncologic outcome. This article defines the indications and preoperative management of candidate patients and discusses key anesthetic considerations and surgical techniques for this complex airway reconstruction. The essential component of a successful operation is a tension-free bronchial anastomosis. Open communication and careful discussion of airway management between anesthesiologist and surgeon will help ensure a good outcome.

Delay between the initial symptoms, the diagnosis and the onset of specific treatment in elderly patients with lung cancer

INTRODUCTION

The proportion of elderly patients with lung cancer is increasing. The objectives of this study were to describe the initial symptoms in elderly patients (≥ 70 years) with lung cancer and to describe the diagnostic and treatment delays.

PATIENTS AND METHODS

We reviewed all consecutive patients with lung cancer that were diagnosed between 2006 and 2008 in our department. The initial symptoms and delays in the diagnosis and treatment in elderly patients were compared with those of younger patients.

RESULTS

One hundred ninety-three patients were included (26 small-cell cancers and 167 non-small-cell lung cancers [NSCLCs]). Ninety-two patients (47.7%) were ≥ 70 years old. No statistical differences were identified between the 2 groups concerning initial symptoms. In elderly patients, the delay between the initial symptoms and the first visit with a thoracic oncologist (median 1.6 months [IQR 23 days-3.3 months]), the delay between the first visit and the specific treatment (median 1.1 months [IQR 18 days-1.8 months]), and the delay between initial symptoms and the specific treatment (median 3 months [IQR 2-5.7 months]) were similar to those in the younger patients (P = .101, P = .084, and P = .671, respectively). Eighty-four percent of the elderly patients were actively treated vs. 98% of the younger patients (P = .001).

CONCLUSION

We identified no differences regarding the initial symptoms in elderly patients with lung cancer compared with those in younger patients. The delays in diagnosis and treatment were similar between the 2 groups.

Functional evaluation before lung resection

Lung cancer is the leading cause of cancer-related death worldwide, and lung resection remains the only curative approach. In the Western world, lung cancer is one of the main indications for lung resection, despite only 15% to 25% of all lung cancers being operable at the time of presentation. In most cases of operable lung cancer, a substantial part of functional lung tissue has to be resected, leading to a permanent loss of pulmonary function. Resection in patients with insufficient pulmonary reserves can result in permanent respiratory disability. This article reviews the current standards of preoperative assessment.

Immediate Postoperative Care in the General Thoracic Ward Is Safe for Low-risk Patients after Lobectomy for Lung Cancer

Background

Following major lung resection, patients have routinely been monitored in the intensive care unit (ICU). Recently, however, patients are increasingly being placed in a general thoracic ward (GTW). We investigated the safety and efficacy of the GTW care after lobectomy for lung cancer.

Materials and Methods

316 patients who had undergone lobectomy for lung cancer were reviewed. These patients were divided into two groups: 275 patients were cared for in the ICU while 41 patients were care for in the GTW immediately post-operation. After propensity score matching, postoperative complications and hospital costs were analyzed. Risk factors for early complications were analyzed with the whole cohort.

Results

Early complications (until the end of the first postoperative day) occurred in 11 (3.5%) patients. Late complications occurred in 42 patients (13.3%). After propensity score matching, the incidence of early complications, late complications, and mortality were not different between the two groups. The mean expense was higher in the ICU group. Risk factors for early complications were cardiac comorbidities and low expected forced expiratory volume in one second. The location of postoperative care had no influence on outcome.

Conclusion

Immediate postoperative care after lobectomy for lung cancer in a GTW was safe and cost-effective without compromising outcomes in low-risk patients.

Oxygen Pulse as a Predictor of Cardiopulmonary Events in Lung Resection

Traditional algorithms suggest a stepwise approach to the functional evaluation of candidates for lung resection. A cardiopulmonary exercise test is incorporated as a supplementary test for patients with borderline pulmonary predicted values, and sometimes as a first screening test for cardiac risk evaluation. To assess the predictive weight of exercise tests in noncardiac thoracic surgery, we retrospectively analyzed 99 patients (80 males) aged 67.8 ± 8.1 years who underwent lung resection after a cardiopulmonary exercise test. During basal spirometry, the mean predicted forced expiratory volume in the first second was 69.9% ± 18.6%, and predicted carbon monoxide diffusing capacity was 71.6% ± 20.5%. Peak oxygen consumption was 11.1 ± 3.2 mL·kg−1·min−1, oxygen pulse was 9 ± 2.8 mL·beat−1, and minute ventilation/CO2 output was 45.2 ± 7.7. Mean hospital stay was 10.4 days, and intensive care unit stay was 0.3 days. Postoperative complications occurred in 20 (20%) patients. On multivariate analysis, body mass index, a high level of exercise achieved during the cardiopulmonary exercise test, lower heart rate at peak exercise, and oxygen pulse correlated significantly with better postoperative outcome. Cardiopulmonary exercise tests are helpful for stratifying patients undergoing thoracic surgery. Perioperative complications seem to be strongly related to left ventricular function and physical performance.

Oxygen consumption, shuttle walking test and the evaluation of lung resection

BACKGROUND

Assessment of peak oxygen uptake (VO(2)) is recommended in the evaluation of patients with borderline pulmonary function as VO(2) is the strongest independent predictor of postoperative pulmonary complications. However, the measurement of VO(2) requires expensive equipment not available in many medical facilities. The shuttle walking test (SWT) has been proposed to be used as a screening tool prior to performing a cardiopulmonary exercise test. Although an association exists between SWT distance and VO(2), only one small study directly measured VO(2) during the SWT.

OBJECTIVES

The aim of this study was to further validate the VO(2)-SWT association by directly measuring VO(2) during SWT in a larger cohort of patients with stable chronic obstructive pulmonary disease (COPD).

METHODS

Fifty stable COPD patients with mild/severe disease were studied. Each patient performed an SWT while wearing a validated portable metabolic monitor.

RESULTS

Mean VO(2) (ml/kg/min) measured after each finalized minute of the SWT was (95% confidence interval): 6 (5-7), 9 (8-10), 11 (10-12), 13 (11-14), 15 (14-16), 18 (16-20) and 21 (18-26) for minutes 1-7, respectively. Patients that completed the British Thoracic Society-recommended 25 shuttles (5 min or 250 m) in the SWT had a mean VO(2) of 15 (14-16). The positive predictive value for walking 25 shuttles (predicting a VO(2) of >or=15ml/kg/min) was 90% and the negative predictive value was 90%.

CONCLUSIONS

Our findings validate the association between VO(2) and SWT distance and facilitate the interpretation of the test in general practice, particularly when deciding the candidacy of a patient for surgical resection.

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.