Patients meeting the criteriaoutlined below should also have quantitative radionuclide perfusionscanning.
3.
Patients felt to be at high risk on thebasis of predicted postoperative FEV1 should be consideredfor exercise assessment.
4.
If exercise assessment isperformed, an MO2 of < 10–15 mL/kg/min or apredicted postoperative MO2 < 10 mL/kg/minidentifies a patient at very high risk for complications andmortality.
5.
Limited available data support the use ofpreoperative risk indices to identify patients at high risk (See Table 4).
ASA > III: high risk, CRI not additive information
6.
Lung volume reduction surgery may provide newapproaches in selected patients with significant obstructive lungdisease and concomitant lungcancer.
Section snippets
What Predicts Short-Term Risk?
There is agreement in the literature that, in the absence of significant nonpulmonary comorbid conditions, certain characteristics identify populations of patients who are at low risk or high risk for morbidity, mortality, and long-term disability after pulmonary parenchymal resection.
Factors That Identify “Low Risk” Patients:
• FEV1 > 2 L
• MVV > 50% predicted
• Predicted postoperative FEV1 > 0.8 L and 40% predicted
• absence of cardiac disease
Proposed Factors That Identify “High Risk” Patients
• pco2 > 45
• po2 < 50
• Predicted Postoperative FEV1 < 0.7 L and/or 40% predicted
• Age > 70
• Poor exercise performance
Predicting Postoperative Pulmonary Function
A number of tests have been used over the years predict postoperative pulmonary function. For most patients, a simple calculation based on the preoperative FEV1 and the amount of parenchymal resection contemplated (assuming 5.2% per segment) provide a reasonable estimate of postoperative function and tend to underestimate, rather than overestimate, postoperative function.
Certain patients require additional testing to accurately predict postoperative function. These tests include
Indications for Quantitative Radionuclide Scanning
Evidence Supporting the Ability to Identify High Risk Patients
Evidence about several factors that identify patients at high risk for complications from thoracotomy, outlined above, is controversial. Age is not clearly an independent risk factor for complications, although it may interact with other risk factors.8, 9 There is little convincing modern evidence supporting the contention that hypercarbia alone is a risk factor for complications. Its use in the preoperative evaluation is based on experience of > 45 years ago in the evaluation of patients being
Patients with missing data at discharge were excluded from the analysis. Patient selection criteria were consistent throughout the study period and were based on the preoperative functional assessment guidelines in place at the time of the intervention12–15. The patients were operated on by 5 expert surgeons.
Failure to rescue (FTR), defined as the mortality rate among patients suffering from postoperative complications, is considered an indicator of the quality of surgical care. The aim of this study was to investigate the risk factors associated with FTR after anatomical lung resections.
Patients undergoing anatomical lung resection at our center between 1994 and 2018 were included in the study. Postoperative complications were classified as minor (grade I and II) and major (grade IIIA to V), according to the standardized classification of postoperative morbidity. Patients who died after a major complication were considered FTR. A stepwise logistic regression model was created to identify FTR predictors. Independent variables included in the multivariate analysis were age, body mass index, cardiac, renal, and cerebrovascular comorbidity, ppoFEV1%, VATS approach, extended resection, pneumonectomy, and reintervention. A non-parametric ROC curve was constructed to estimate the predictive capacity of the model.
A total of 2.569 patients were included, of which 223 (8.9%) had major complications and 49 (22%) could not be rescued. Variables associated with FTR were: age (OR: 1.07), history of cerebrovascular accident (OR: 3.53), pneumonectomy (OR: 6.67), and reintervention (OR: 12.26). The area under the ROC curve was 0.82 (95% CI: 0.77–0.88).
Overall, 22% of patients with major complications following anatomical lung resection in this series did not survive until discharge. Pneumonectomy and reintervention are the most significant risk factors for FTR.
El fallo en el rescate (FTR) definido como la tasa de fallecimientos entre los pacientes que sufren una complicación postoperatoria, es considerado un indicador de la calidad de los cuidados quirúrgicos. El objetivo de este estudio es investigar los factores de riesgo asociados al FTR después de resecciones pulmonares anatómicas.
Se incluyeron en el estudio pacientes sometidos a resección pulmonar anatómica en nuestro centro entre 1994 y 2018. Las complicaciones postoperatorias se clasificaron en menores (grados I y II) y mayores (grados IIIa a V) según la clasificación estandarizada de morbilidad postoperatoria. Los casos que fallecieron tras una complicación mayor fueron considerados FTR. Se creó un modelo de regresión logística por pasos para identificar los factores predictores de FTR. Se consideraron variables independientes en el análisis multivariante la edad, índice de masa corporal, comorbilidad cardiaca, renal, cerebrovascular, VEF1ppo%, abordaje VATS, resección extendida, neumonectomía y reintervención. Se construyó una curva ROC no paramétrica para estimar la capacidad predictiva del modelo.
Se analizaron 2.569 pacientes. En total, 223 casos (8,9%) tuvieron complicaciones mayores y 49 (22%) no pudieron ser rescatados. Las variables asociadas con FTR fueron: edad (OR: 1,07), antecedente de ACV (OR: 3,53), neumonectomía (OR: 6,67) y reintervención (OR: 12,26). El área bajo la curva de la curva ROC fue 0,82 (IC 95%: 0,77–0,88).
22% de los pacientes que presentan complicaciones mayores tras la resección pulmonar anatómica en esta serie no sobreviven al alta. La neumonectomía y la reintervención son los factores de riesgo más potentes para FTR.
In case 3, a pulmonary function test was not conducted due to hemoptysis. Surgery is indicated for patients with a predicted postoperative forced vital capacity (FVC) of >800 ml/m2, a forced expiratory volume in one second (FEV1) of >600 ml/m2 and a FEV1 >40% [10,11]. The data were collected retrospectively for all patients and included a detailed history, age, sex, clinical staging, pathological staging, histology, treatment modalities and the surgical details.
Patients with advanced non-small cell lung cancer (NSCLC) continue to have a poor prognosis. The majority of patients are not indicated for surgery for a radical cure, and systemic chemotherapy is the mainstay of treatment. However, long-term survival is rare due to the resistance to therapy. On the other hand, surgery is performed only under certain conditions for colon cancer and esophageal cancer. Few reports are available about salvage thoracic surgery in patients with primary lung cancer. The purpose of this study was to show the outcomes of salvage surgery for lung cancer, and we discuss possible future treatment strategies based on our findings.
Three hundred and fifty-two patients with primary lung cancer underwent surgical resection, and we evaluated those who underwent salvage operations. We also examined the relationships between the performance of a salvage operation and the clinicopathological characteristics of the patients. The clinical outcomes of salvage surgery for lung cancer were assessed.
Salvage thoracic operations were performed in eight (2.3%) of the 352 patients. The surgical procedures were lobectomy in four patients, segmentectomy in two, and pneumonectomy and wedge resection were each performed in one patient. There was no postoperative mortality. All patients were alive at the time of the analysis. The mean follow-up period for the salvage operation cases was 14.0 months. No significant correlation was identified between the incidence of salvage surgery and the age, gender, histology, postoperative stay or hospital stay. The incidence of advanced stage disease was higher in the salvage cases than in the overall cases.
Salvage thoracic surgery was possible, and moderately improved the prognosis, without prolongation of the postoperative stay or hospital stay. A salvage operation might be considered a reasonable and proper treatment for carefully selected patients.
2013, Best Practice and Research: Clinical Anaesthesiology
Citation Excerpt :
Therefore, the stratification of preoperative cardiovascular risk should be at least at the same level as that of patients undergoing major abdominal surgery [12,13]. Additional assessment of pulmonary reserve is necessary for patients undergoing HITHOC [14,15]. Coagulation disorders and renal failure have been reported after HIPEC.
Recent advances in cancer therapy have seen increased combinations of different treatment modalities as well as novel approaches that affect anaesthetic care. Increasingly, surgery is being combined with chemotherapy and radiation therapy. Moreover, minimally invasive procedures are gaining popularity and more targeted therapies are being used. These events have created a demand for new anaesthetic techniques from anaesthesiologists in order to provide safe patient care. This article will discuss anaesthetic considerations for proton therapy, hyperthermic intracavitary chemotherapy, limb perfusion, radiosurgery, robotic surgery and intra-operative radiation therapy and high-dose brachytherapy.
Recommendations were developed by the writing committee, graded by a standardized method (see the article by Lewis et al,1 “Methodology for Guidelines for Lung Cancer,” in the ACCP Lung Cancer Guidelines), and were reviewed by all members of the Lung Cancer Panel and the Thoracic Oncology Network prior to approval by the Guidelines Oversight Committee and the Board of Regents of the ACCP. Although numerous reviews have been published on the preoperative risk assessment of patients with lung cancer being considered for curative-intent surgical resection,4–9 most available guidelines on the management of non-small cell lung cancer do not address the preoperative evaluation process.10–16 The British Thoracic Society,17 the ACCP,3 and the European Respiratory Society (ERS) jointly with the European Society of Thoracic Surgeons (ESTS)18 have provided two guidelines with specific recommendations on the steps needed to evaluate preoperative risk.
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.
The current guidelines and medical literature applicable to this issue were identified by computerized search and were evaluated using standardized methods. Recommendations were framed using the approach described by the Guidelines Oversight Committee.
The preoperative physiologic assessment should begin with a cardiovascular evaluation and spirometry to measure the FEV1 and the diffusing capacity for carbon monoxide (Dlco). Predicted postoperative (PPO) lung functions should be calculated. If the % PPO FEV1 and % PPO Dlco values are both > 60%, the patient is considered at low risk of anatomic lung resection, and no further tests are indicated. If either the % PPO FEV1 or % PPO Dlco are within 60% and 30% predicted, a low technology exercise test should be performed as a screening test. If performance on the low technology exercise test is satisfactory (stair climbing altitude > 22 m or shuttle walk distance > 400 m), patients are regarded as at low risk of anatomic resection. A cardiopulmonary exercise test is indicated when the PPO FEV1 or PPO Dlco (or both) are < 30% or when the performance of the stair-climbing test or the shuttle walk test is not satisfactory. A peak oxygen consumption (o2peak) < 10 mL/kg/min or 35% predicted indicates a high risk of mortality and long-term disability for major anatomic resection. Conversely, a o2peak > 20 mL/kg/min or 75% predicted indicates a low risk.
A careful preoperative physiologic assessment is useful for identifying those patients at increased risk with standard lung cancer resection and for enabling an informed decision by the patient about the appropriate therapeutic approach to treating his or her 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 of this disease.
