Review Article
“Fit for Surgery? What's New in Preoperative Assessment of the High-Risk Patient Undergoing Pulmonary Resection”

https://doi.org/10.1053/j.jvca.2020.11.025Get rights and content

Advances in perioperative assessment and diagnostics, together with developments in anesthetic and surgical techniques, have considerably expanded the pool of patients who may be suitable for pulmonary resection. Thoracic surgical patients frequently are perceived to be at high perioperative risk due to advanced age, level of comorbidity, and the risks associated with pulmonary resection, which predispose them to a significantly increased risk of perioperative complications, increased healthcare resource use, and costs. The definition of what is considered “fit for surgery” in thoracic surgery continually is being challenged. However, no internationally standardized definition of prohibitive risk exists. Perioperative assessment traditionally concentrates on the “three-legged stool” of pulmonary mechanical function, parenchymal function, and cardiopulmonary reserve. However, no single criterion should exclude a patient from surgery, and there are other perioperative factors in addition to the tripartite assessment that need to be considered in order to more accurately assess functional capacity and predict individual perioperative risk.

In this review, the authors aim to address some of the more erudite concepts that are important in preoperative risk assessment of the patient at potentially prohibitive risk undergoing pulmonary resection for malignancy.

Section snippets

Does Minimally Invasive Surgery Provide a Better Alternative for Patients Who Present a Potentially Unacceptable Perioperative Risk?

Lung cancer screening programs have advanced the early diagnosis of potentially curable lung cancer. However, uncertainty exists regarding the upper age limit for screening, and the risk-benefit in those with significant comorbidity and functional limitation.5 Up to 40% of patients with anatomically resectable lung cancer may be considered inoperable on the basis of severe pulmonary dysfunction alone.6 Parenchymal- sparing surgery, minimally invasive thoracoscopic surgery, and improvements in

Risk Stratification Increasingly is Challenging

The use of a global risk score is recommended to stratify risk and calculate risk-adjusted perioperative morbidity and mortality in patients undergoing pulmonary resection for lung cancer. Risk scores do not predict the future and their main purpose is not to select patients for surgery. Rather, their value lies in screening and stratification of risk to decide if further functional testing is necessary to make a more informed clinical decision. Risk stratification is, however, increasingly

Predicted Postoperative Pulmonary Function – Are Traditional Thresholds Accurate Measurements of Perioperative Risk?

Preoperative assessment for patients undergoing pulmonary resection traditionally focuses on an inter-related triad derived from a confluence of international recommendations: mechanical respiratory function, parenchymal lung function, and cardiopulmonary reserve, also known as the “three-legged stool” of pulmonary assessment.31

The most useful spirometry parameters in assessing risk of postoperative morbidity, pulmonary complications, and mortality are the forced expiratory volume in one second

Cardiac Risk Assessment: A Key Discriminator

Cardiac complications occur in up to 30% of thoracic surgical patients, with atrial fibrillation being the most common. The reported incidence of myocardial infarction is low at 5%, but is associated with up to 40% mortality.2 Right ventricle systolic (RV) dysfunction often is seen as the rate-limiting step in determining suitability in patients with extremely poor lung function. RV function also has been shown to deteriorate in the immediate postoperative period. The degree of dysfunction is

Functional Capacity Assessment: CPET Versus Low-Technology Exercise Tests

In lung malignancy, functional capacity is a strong independent predictor of survival, with many factors contributing to impaired cardiorespiratory fitness.65,66 Exercise tests are used preoperatively to quantify functional capacity, diagnose the etiology of exercise limitation, evaluate cardiac risk, predict perioperative outcomes, and monitor response to prehabilitation. CPET remains the gold standard, but there is an apparent lack of consensus regarding the spirometry thresholds that should

Pulmonary Hypertension: Not Necessarily a Contraindication to Pulmonary Resection

Many studies have explored the relationship between PH and perioperative outcomes in noncardiac surgery.85 However, high-quality large-scale data regarding the effect of PH on lung cancer patients undergoing pulmonary resection do not exist. Perioperative mortality ranges from 7% to 24%, with death usually occurring secondary to right heart or respiratory failure. Recent data suggest that the overall mortality in major noncardiac surgery is approximately 3%, with 30% of patients experiencing at

Risk of Postoperative Atrial Fibrillation

POAF occurs in up to 44% of patients, and is usually self-limiting within the first 48 hours. Nevertheless, its incidence increases hospital length of stay, morbidity, including 30-day risk of stroke, and mortality. Risk factors in patients undergoing pulmonary resection include surgical factors, such as bilobectomy or pneumonectomy, in addition to multiple patient factors. These comprise age >65, male gender, preoperative tachycardia, neoadjuvant chemotherapy, chronic lung disease, ischemic

Frailty Assessment – An Underutilized Tool to Improve Risk Stratification in Pulmonary Resection

Frailty is a dynamic, multidimensional, and potentially reversible syndrome of reduced physiologic reserve. It is distinct from comorbidity and disability, although they may coexist. It involves a decline in multiple inter-related physiologic systems, dysregulation of normal homeostatic mechanisms, and an increased vulnerability to impaired resolution of baseline reserve after an acute stressor.108 To date, frailty assessment has not been performed routinely in patients undergoing pulmonary

The Role of Prehabilitation

More important than just identifying frailty and reduced functional capacity is how to intervene and optimize preoperatively to a more robust and less frail state. The recent enhanced recovery after surgery guidelines highlight the emerging importance of prehabilitation in patients undergoing pulmonary resection for lung cancer.138,139 It is arguably one of the most important interventions in moving a patient from physiologically inoperable to the operable category. It can result in improved

Intensive Care Unit Versus Postanesthesia Care Unit for the High-risk Patient?

Despite advances in perioperative care, patients undergoing pulmonary resection may require unplanned postoperative intensive care unit (ICU) admission. Although a recent audit in the United Kingdom in this area found an incidence of 2.3%, it ranges from 6.3% to 18.0% in the general literature, depending on the criteria used.160 It is associated with a high in-hospital mortality between 16.6% and 46%.161 ICU readmission after initial recovery also remains a problem and is associated with

Summary

Although the “three-legged stool” approach remains the cornerstone of preoperative assessment in thoracic surgery, the parameters that determine fitness for pulmonary resection have expanded and are being continually tested. The spirometry and CPET risk thresholds recommended in the referenced international guidelines pertain to thoracotomy and major pulmonary resection. They do not necessarily apply to the patient undergoing minimally invasive surgery ± limited surgical resection and should be

Conflict of Interest

Dr. Peter Slinger is an Associate Editor at the Journal of Cardiothoracic and Vascular Anesthesia.

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