BACKGROUND: There is controversy surrounding the value of the predicted postoperative diffusing capacity of lung for carbon monoxide (DLCOppo) in comparison to the forced expired volume in 1 s for prediction of pulmonary complications (PCs) after thoracic surgery.

METHODS: Using a prospective database, we performed an analysis of 956 patients who had resection for lung cancer at a single institution. PC was defined as the occurrence of any of the following: atelectasis, pneumonia, pulmonary embolism, respiratory failure, and need for supplemental oxygen at hospital discharge.

RESULTS: PCs occurred in 121 of 956 patients (12.7%). Preoperative chemotherapy (odds ratio 1.64, 95% confidence interval 1.06–2.55, P = 0.02, point score 2) and a lower DLCOppo (odds ratio per each 5% decrement 1.13, 95% confidence interval 1.06–1.19, P < 0.0001, point score 1 per each 5% decrement of DLCOppo less than 100%) were independent risk factors for PCs. We defined 3 overall risk categories for PCs: low <=10 points, 39 of 448 patients (9%); intermediate 11–13 points, 37 of 256 patients (14%); and high >=14 points, 42 of 159 patients (26%). The median (range) length of hospital stay was significantly greater for patients who developed PCs than for those who did not: 12 (3–113) days vs 6 (2–39) days, P < 0.0001, respectively. Similarly, 30-day mortality was significantly more frequent for patients who developed PCs than for those who did not: 16 of 121 (13.2%) vs 6 of 835 (0.7%), P < 0.0001.

CONCLUSIONS: These data show that PCs after thoracic surgery for lung cancer can be predicted with moderate accuracy based on DLCOppo and whether patients had chemotherapy. Forced expired volume in 1 s was not a predictor of PCs.

Objective: FEV1 measured on the first postoperative day has shown to be a better predictor of complications than traditional ppoFEV1. Therefore, its estimation before operation may enhance risk stratification. The objective of this study was to develop and validate a model to predict FEV1 on the first postoperative day after major lung resection. Methods: FEV1 was prospectively measured on the first postoperative day in 272 patients submitted for lobectomy or pneumonectomy at two centers. A random sample of 136 patients was used to develop a model estimating the first day FEV1 by using multiple regression analysis including several preoperative and operative factors. The model was then validated by bootstrap analysis and tested on the other sample of 136 patients. Results: Factors reliably associated with postoperative first day FEV1 were age (p=0.002), preoperative FEV1 (p<0.0001), the presence of epidural analgesia (p<0.0001), and the percentage of non-obstructed segments removed during operation (p=0.001). The following model estimating the first day postoperative FEV1 was derived: -2.648+0.295xage+0.371xFEV1+8.216xepidural analgesia-0.338xpercentage of non-obstructed segments removed during operation. In the validation set, the mean predicted first day postoperative FEV1 value did not differ from the observed one (42.6 vs 42.0, respectively; p=0.3) and the plot of the observed versus the predicted first day FEV1 showed a satisfactory calibration. Conclusions: We developed a model predicting the first day postoperative FEV1. If future analyses will prove its role in stratifying the early postoperative risk, it may be integrated in preoperative evaluation algorithms to refine risk stratification.

Background: Diffusing capacity (Dlco), an independent predictor of morbidity after major lung resection, is not used routinely in preoperative evaluation because of a perceived lack of value in patients with normal spirometry. We evaluated the potential utility of measuring Dlco for assessment of operative risk in lung resection patients with normal spirometry. Methods: A retrospective review was conducted for patients undergoing lung resection from 1980 through 2006 to identify predictors of postoperative morbidity. Patients were divided into groups with or without chronic obstructive lung disease (COPD), defined as a ratio of forced expiratory volume in the first second to forced vital capacity of less than 0.7 or a ratio of 0.7 or greater, respectively. Analyses for each group identified covariates for three outcomes: operative mortality, pulmonary morbidity, and overall morbidity. Results: Of 1,046 patients in the database, 1,008 (545 men; mean age, 61.8 +/- 0.35 years) had data permitting determination of COPD status: 450 (45%) with COPD, 558 (55%) without COPD. Operations included lobectomy (752; 75%), bilobectomy (83; 8%), and pneumonectomy (173; 17%). Overall mortality, pulmonary morbidity, and overall morbidity incidences were 59 (5.8%), 140 (14.0%), and 311 (31.4%), respectively. Pulmonary morbidity and operative mortality were related to postoperative predicted Dlco, age, and performance status in patients with and without COPD. The postoperative predicted Dlco was the single strongest predictor of pulmonary morbidity and operative mortality in both patient groups. Overall complications were related to postoperative predicted Dlco only in the COPD group. Conclusions: Diffusing capacity is an important predictor of postoperative morbidity after lung resection even in patients with normal spirometry. Routine measurement of Dlco, regardless of spirometric findings, can help predict risk in candidates for major lung resection.

Spaggiari, Lorenzoa; Scanagatta, Paoloa. Curr Opinion Oncol. Volume 19(2), March 2007, p 84–91
Purpose of review: The aim of this review is to analyze recent evidence for optimal treatment of elderly patients with non-small cell lung cancer, focusing on surgery, and possibly to foresee the future strategies to apply in these patients.

Recent findings: Surgery in elderly patients affected by non-small cell lung cancer is safe and feasible when careful preoperative respiratory and cardiac studies have been carried out and the disease has been properly staged. The surgical treatment is not to be denied in elderly patients due to age per se, but when a major contraindication to surgery has been recognized. Long term survival for elderly patients with early stage lung cancer treated by anatomical pulmonary resection is comparable to the survival rate of younger patients. Pneumonectomy, extended surgical procedure or preoperative induction chemotherapy are major risk factors for an increased postoperative morbidity and mortality rate. When co-morbidities are present or a patient is 80 years or older, there is evidence that a non-anatomical resection can be performed without affecting long-term results.

Summary: Due to the aging of the general population, elderly patients will become a large percentage of the cases of non-small cell lung cancer to be treated. Implementing preoperative cardiologic studies and redefining selective respiratory criteria specifically could dramatically improve results.

Authors
Dyszkiewicz W. Pawlak K. Gasiorowski L.
Institution
Department of Thoracic Surgery, K. Marcinkowski University of Medical Sciences, Ul. Szamarzewskiego 62, Poznan, Poland.
Title
Early post-pneumonectomy complications in the elderly.
Source
European Journal of Cardio-Thoracic Surgery. 17(3):246-50, 2000 Mar.
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Abstract
OBJECTIVE: The surgical treatment of non-small cell lung cancer (NSCLC) in elderly patients presents a serious challenge to thoracic surgeons. As there is considerable divergence of opinion about both the mortality and morbidity rates, it is important to set guidelines for proper patient selection. METHODS: Early post-operative complications in 42 patients aged over 70 years who had undergone pneumonectomy because of NSCLC (Group I) were analyzed. The control group (Group II) consisted of 48 patients, also aged over 70 years, but who had undergone lobectomy or wedge resections. In both groups, the pre-operative conditions and 30-day morbidity and mortality were evaluated. RESULTS: Postoperative complications occurred significantly more frequently in pneumonectomy patients (78.5%) than in Group II (58%). Transient or long-standing arrhythmias were noted in 20 patients (47.6%) from Group I and in 17 (35.4%) from Group II. Pulmonary complications occurred in 17 patients (40.4%)!
from Group I and 16 (33.3%) from Group II. The most important factors contributing to post-operative complications in pneumonectomy patients were performance status (WHO), chronic obstructive pulmonary disease (COPD) and elevated level of blood urea nitrogen (BUN). The highest impact on early mortality in pneumonectomy patients was exerted by COPD, arterial hypertension, formation of broncho-pleural fistula (BPF), the need for re-thoracotomy and high level of BUN. CONCLUSIONS: (1) Pneumonectomy in patients over the age of 70 carries a considerable risk of severe post-operative complications and death, when compared to patients with less extensive pulmonary resections. (2) Elderly patients with impaired Performance Status (WHO 2 or more) and co-existing arterial hypertension, COPD and elevated level of BUN should be considered for pneumonectomy very carefully and cautiously.

Peter D. Slinger, MD, FRCPC,
Associate Professor of Anesthesia , University of Toronto,
and The University Health Network

Michael R. Johnston, MD, FRCSC,
Associate Professor of Surgery, University of Toronto,
and The University Health Network
Key Words: Anesthesia, Thoracic. Preoperative assessment. Pulmonary function. Respiratory function. Surgery, Thoracic.

Preoperative anesthetic assessment prior to chest surgery is a continually evolving science and art. Recent advances in anesthetic management, surgical techniques and perioperative care have expanded the envelope of patients now considered to be “operable” (see Fig.1)1. This article is an update on pre-anesthetic assessment for pulmonary resection surgery in cancer patients. Continue Reading »