estimate of complication in thoracic surgery

ESTIMATE OF COMPLICATION IN THORACIC SURGERY

11-15 APRIL 2012TURKISH THORACIC SOCİETY 15. ANNUAL CONGRESSANTALYA/SİDE

PROF. DR. TAHİR ŞEVVAL EREN DICLE UNIVERSITY MEDICAL SCHOOL DEPRT. THORACİC SURGERY

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THERE IS NO CONFLICT OF INTEREST

PLAN PRESENTATION

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GENERAL INFORMATION RISK FACTORS

Patient relatedOperation related

PREOPERATIVE RISK ASSESSMENT RISK MODELS AND RISK SCORES

PULMONARY FUNCTION TESTS and DLco TESTS TO EVALUATE PULMONARY CAPACITY• Simple exercise tests• Complex exercise tests

ESTIMATE OF POSTOPERATIVE PULMONARY FUNCTION• ALGORITHM• CONCLUSION

4

We have to define the benefits and risks of any procedure before the treatment.

Low risk No stres

High risk High stres

5

Regarding resections and pulmonary complications in thoracic surgery;

Mortality 1-14 %

Morbidity 7-70 %

Surgical procedure and general anesthesia lead pulmonary complications through several mechanisms.

Smetana GW. Evaluation of preoperative pulmonary risk, 2012 UptoDate.Keoogh BF, et al. Anaesthesia and Intensive Care Medicine 2011.Bapoje SR, et al. Chest 2007.Bernstein WK, Semin Cardiothorac Vasc Anesth 2008.

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New surgical techniques and VATS have decreased postoperative complications due to diminished lung functions.

In addition, morbidity and mortality related to lobectomy and pneumonectomy have been even challenging.

Colice GL, et al. ACCP evidenced based clinical practice guidelines (2nd Edition) Chest 2007

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The main cardiopulmonary complications: Atelectasis Bronchitis Pneumonia Pulmonary edema Pulmonary emboli Respiratory failure Myokard infarction Rythim disorder Hypotension/schock Mechanic ventilatory need > 48 hours Hypercapnia Death

Bapoje SR, et al. Chest 2007

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Respiratory functions are affected by thoracotomy together lung resection regarding the extent of removal.

Within lobectomy 10-20 %, Within pneumonectomy 40-50 % loss .

Ali KM, et al. Chest 1980 Wynne R et al. AJCC 2004.

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Preoperative Risk Assesment

1.To evaluate postoperative mortality and morbidity.

2.To calculate postoperative respiratory functions.

3.To choose the surgical procedure and to define the risks.

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RISK FACTORS

PATIENT RELATED

Smetana GW. Evaluation of preoperative pulmonary risk, 2012 UptoDate.

BTS/SCTS guidelines , Thorax 2001, update2010

PREOPERATIVE RISK ASSESSMENT

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HISTORY, PHYSICAL EXAMINATIONCHEST X-RAYCARDIAC EVALUATIONRISK MODELS AND RISK SKORSRESPIRATORY FUNCTION TESTSREVERSIBILITY TESTARTERIAL BLOOD GASESPULMONARY ARTER Y OCCLUSION PRESSURE

(PNEUMONECTOMY)CARDIOPULMONARY EXERCISE TESTSVENTILATION PERFUSION SCREENING (RESECTION)

PREOPERATIVE RISK EVALUATION

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HISTORY & PHYSICAL EXAMINATIONInadequate exercise capacity (estimate of

complication)

At least ability to walk 500 meters

Copious secretion and purulent sputum increase postoperative problems.


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HISTORYDyspnoea on light exertion

MI within the last 3 months

Angina Pectoris, Hypertension, valve disease and conduction disorders


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PHYSICAL EXAMINATION

Decrease in breathing soundsIncrease in expirationWheezingRale ve ronchiBarrel chestCyanosisFlapping tremorRespiratory rate

RISK


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Ability to cough effectively be controlledCoughing exercises must makeDeep respiratory exercisesIncentive spirometryBlowing baloon

CHEST X-RAY

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Complication risk was repeorted 22% in those with preoperative pathological x-ray

as 7% in patients with normal x-ray.

Doyle RL. et al. Chest 1999. Smetana GW. Evaluation of preoperative pulmonary risk, 2012 UptoDate

CARDIAC ASSESSMENT

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Changed by ACC (American College of Cardiology and AHA (American Heart Assocciation) .

Focusing on the surgical procedure instead of general cardiac evaluation.

ACC/AHA guidelines 2007

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ACC/AHA Guidelines classify thoracic surgery as an intermediate risk procedure with a cardiac risk of 1%- 5%.

Risk of perioperative MI is 0.13% in patients with no prior cardiac history versus 2.8% to 17% in patients with a prior history of MI.

CARDIAC ASSESSMENT

ACC/AHA guidelines 2002/2006.Ferguson MK. Preoperative evaluation Thoracic Surgery Patients 2010.

CARDIAC ASSESSMENT

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Family history Smoking historyHypercholesterolemiDMHBPPrevious cardiac disorder

CARDIAC ASSESSMENT

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Functional statusPhysical examinationECGActive cardiac conditions must be identifiedCardiac murmur or unexpected dyspnea

ECHO

ACC/AHA 2007 guidelines

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In patients without active cardiac conditions, a revised cardiac index may be applied.

Patients with good cardiac functional capacity (such as the ability to walk up two flights of stairs without stopping) and two risk factors or fewer may proceed to surgery without further cardiac assessment.

CARDIAC ASSESSMENT

BTS/SCTS guidelines 2010

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Patients with poor cardiac functional capacity or three or more risk factors or with severe active cardiac conditions require further cardiology investigation and review.

CARDIAC ASSESSMENT


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Patients who have suffered myocardial infarction within the previous 6 months require cardiology assessment, and in recent infarction, should wait at least 30 days before surgery for lung resection.

CARDIAC ASSESSMENT


CARDIAC ASSESSMENT

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CABG within the last 5 years and followed by without any symptom or

No major risk after within 2 years of cardiac cardiac evaluation and normal findings on physical examination

No need for further cardiac assessment.


CARDIAC ASSESSMENT

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High Risk: Unstable coronary syndrome MI within 30 days Unstable or severe coronary

angina Decompansting heart failure Severe valve disease High level atrioventricular

block Ventricular arrythmia Uncontrolled supraventricular

arrythmias with ventricular response

ACC/AHA guidelines 2007.

Moderate Risk: Moderate Angina Story of MI or finding of MI

on ECG Compensated heart failure DM Renal failure

Low Risk: Older age Abnormal ECG Low functional capasity Stroke history Uncontrolled HBP

CARDIAC ASSESSMENT

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To postpone the surgery in the high risk group unless emergency.

To consider the medical treatment followed by coronary angiography in these patients.


28

More recent data indicate that commonly used regimens of perioperative beta-blockers increase the risk of stroke and overall mortality.

Threfore, the institution of a beta-blocker therapy is not recommended in heart ischemic disease patients who are not already taking them.

CARDIAC ASSESSMENT

Devereaux PJ, et al. POISE trial, Lancet 2008.

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RISK MODELS AND RISK SCORES


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Several logistic models and scoring have been developed, tested and issued.

Surgical risks were studied to define for morbidity and mortality preoperatively in population based researches .

Brunelli A, et al. Ann Thorac Surg 1999.

Birim O, et al. Eur J Cardiothorac Surg 2003.

Ferguson MK, et al. Eur J Cardiothorac Surg 2003.

Berrisford R, et al. Eur J Cardiothorac Surg 2005.

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European Society Objective Score (ESOS)Thoracoscore (The Thoracic Surgery Scoring System) Canet risk indexPOSSUM (Physiologic and operative severity score for the

enumeration of mortality and mortalityCardiopulmonary risk index (Epstein-CPRI)EVAD (Expiratory volume, age, diffusing capacity)Charlson indexPRQ (Predictive respiratory quotient)PPP (Predicted postoperative product)E-PASS (Estimation of physiologic ability and surgical stress)Kaplan-Feinstein indexASAECOGArozullah multifactorial risk index


Berrisford R., et al. Eur J Cardiothorac Surg, 2005. Canet J, et al. Anesthesiology, 2010.Brunelli A, et al. (ESOS) Eur J Cardiothorac Surg, 2008 Arozullah AM, et al. Ann Surg 2000. Falcoz PE. Et al. J Thorac Cardiovas Surg, 2007. Epstein SK, et al. Chest 1993.


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ESOS, developed from the lung resection group of 3400 patients (ESTS database version 1). (ERS/ESTS).

Developed to estimate hospital mortality .

Composed of 2 specific objective predictors : age and ppoFEV1

Used in thoracic surgical units in Europe. Berrisford R. Eur J Cardiothorac Surg 28, 2005Brunelli A. Eur J Cardiothorac Surg 33, 2008


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Thoracoscore was developed by France multiinstutional database (Epithor) .

Has included more than 15.000 patients undergone different procedures.

Used to guess for hospital mortality and has 9 factors.

BTS reccommends (2010), Thoracoscore, the last one (Global risk model).

Falcoz PE. J Thorac Cardiovas Surg 133, 2007. Lim E, et al. Guidlines on the radical management of patients with lung cancer. British Thoracic Society and the for Cardiothoracic Surgery in Great Britain and Ireland. Thorax 2010.

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RISK MODELS and RISK SCORES

Falcoz PE, et al. J Thorac Cardiovasc Surg 2007


35

These scoring systems do not need in the routine assessment of patients undergoing lung surgery today.

This scoring systems can be used for risk classification and comparison among surgical candidates (for mortality and mortality).

Brunelli A, et al, ERS/ESTS clinical guidlines . Eur Respir J 34:17-41, 2009.Lim E, et al. Guidlines on the radical management of patients with lung cancer. British Thoracic Society and the for Cardiothoracic Surgery in Great Britain and Ireland. Thorax 2010.

PULMONARY FUNCTION TESTS

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PULMONARY FUNCTION TESTS

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Indications1. Smoking history or active smoker2. Symptoms of respiratory systems (cough,

dyspneoa)3. Abnormal finding on physical examination4. COPD history5. Morbid obesity6. Older age7. Debility and malnutrition8. Those for lung resection

Delisser HM, et al. In:Fishman’s Pulmonary diseases and disordersMcGraw Hill 1998.

Zibrak JD, et al. Clin Chest Med 1993

PFT-II

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Cheap and available everywhere.

In recent studies,RFT has not been proper solely to define postoperative morbidity and mortality.

Smetana GW. N Engl J Med . 1999.Lim E,et al. Thorax 2010 (BTS /SCTS

guidlines)

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Preoperative PFT does not always correlate with postoperative complications.

Preoperative normal RFT may not indicate postoperative complication risk to be low.

Smetana GW. N Engl J Med . 1999. Falcoz PE, et al. J Thorac Cardiovasc Surg 2007.

Lim E,et al. Thorax 2010 (BTS guidlines)

PFT-III

PFT-IV

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FEV1 and (Forced expiratory volume in one second) DLco (Carbon monoxide diffusing capacity) tests are more important for the assessment of postoperative morbidity and mortality risks.

BTS guidelines. Thorax 2001.

Brunelli A,et al. ERS/ESTES clinical guidelines. 2009.

Colice GL, et al. ACCP guidelines. Chest 2007.

PFT-V

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At the same timeUsed for calculation of predicted

postoperative FEV1 (ppo FEV1) and predicted postoperative DLco (ppo DLco).

Ppo:Predicted postoperative

BTS guidelines. Thorax 2001.American Thoracic society,

standardization of spirometry, 1994.European Respiratory Society, lung volumes and forced

ventilatory flows, Eur Respir J 1993

PFT-VI

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First, and especially FEV1, FVC and FEV1/FVC rate is checked.

PFT-VII

43 American Thoracic society,

standardization of spirometry, 1994. European Respiratory Society, lung volumes and forced


FEV1: Forced expiratory volume in one second

Normal healthy people can exhale 80% of their vital capasity within first second, all within 3 seconds.

So, the amount out in the first second is evaulated as a distinctive parameter and stated in litres or %predicted.

FEV1 is decreased in obstructive lung diseases.

PFT-VIII

44 American Thoracic society,

standardization of spirometry, 1994.European Respiratory Society, lung volumes and forced


FVC : Forced vital capacity The amount of the air exhaled following

forced inspiration.

Expressed as litre or % predicted .

It is decreased in restrictive lung diseases.

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FEV1/FVC rate

Important criteria for differentation of restrictive and obstructive lung diseases.

Both FEV1 and FVC together decrease so they remain normal in restrictive diseases.

FEV1 significantly decreases in obstructive diseases and this rate becomes low.

American Thoracic society, standardization of spirometry, 1994. European Respiratory Society, lung volumes and forced ventilatory flows, Eur Respir J 1993.

REVERSIBILITY TESTING-I

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Ruppel GL, Manuel of pulmonary function testing, 7th edt. Mosby-year Book, 1998. American Thoracic society, standardization of spirometry, 1994. European Respiratory Society, lung volumes and forced ventilatory flows, Eur Respir J 1993.

It is proper in COPD.

The procedure is repeated after 15-20 minutes of bronchodilatation following basal FEV1 measurement.

An increase of 15 % or more than 200 ml in FEV1 or FVC shows ‘meaningful reversibility’ .

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REVERSIBILITY TESTING-II

Ruppel GL, Manuel of pulmonary function testing, 7th edt. Mosby-year Book, 1998. American Thoracic society, standardization of spirometry, 1994. European Respiratory Society, lung volumes and forced ventilatory flows, Eur Respir J 1993.

Generally, both FEV1 and FVC increases and FEV1/FVC rate is not changed .

FEV1/FVC rate is not to be used for evaluation of the response to bronchodilatators.

Reversibility test (+) patients undertake preoperatively bronchodilator theraphy and corticosteroids .

Respiratory functions are improved and complication risks are decreased.

DLco (Carbon monoxide diffusing capacity) calculation-I

48 Ruppel GL, Manuel of pulmonary function testing, 7th edt. Mosby-year Book, 1998. Aubrey WR. Anesthesia and Intensive Care Medicine 2011.

The most valuable test showing alvealar gas exchange in patients undergoing lung resections.

It is also expressed as TLco (Carbon monoxide transfer factor) .

Shown as Mmol/Kpa/min .

indicates alveolar membran sufficiency.

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Considered as an independent predictor in the assessment of postoperative morbidity and mortality in resection surgery.

Publications have increased in recent years, indicating that it has a highly determinative role in resection surgery.

DLco calculation-II

Brunelli A. Semin Thoracic Surg 2010.

FEV1 and DLco

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BTS/SCTS guidelines 2010 ERS/ESTS guidelines 2009 ACCP guidelines 2007

All the guidelines in the world recommend measurements of FEV1 ve DLCO as the baseline for assessment of perioperative morbidity amortality risks.

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Studies now suggest that DLco is an important predictor of postoperative morbidity despite normal spirometry.

Guideline Development Committee (GDC) therefore chose to the recommended the measurument of TLco in all patients.

FEV1 and DLco

Brunelli A, et al. Ann Thorac Surg 2007.Ferguson MK, et al. Ann Thorac Surg 2008.Bolliger CT, et al. Eur Respir J. 1996.BTS/SCTS guidelines. Thorax 2010

ARTERIAL BLOOD GASES- I

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PaO2 and PaCO2 may show complication risk perioperatively.

The risk was known to increase in the cases of PaCO2 > 45 mmHg previously.

Recent papers have indicated that hypercapnia was not important in the assessment of complication risks.

The risk has been increased in the cases with desaturation more than 4% on exercise when SaO2 < %90 at rest.

Marshall MC. Clin Chest Med

1993 Bernstein WK, Semin Cardiothorac Vasc Anesth 2008;

Keogh BF. Anaesthesi and Intensive care Medicine 2011.

ARTERIAL BLOOD GASES- - III

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Mainly, elevated PaCO2 and lowered PaO2 likely increase major morbidity ve mortality after major lung resections.

They can be neglected in life threatening conditions.

PaO2 > 60 mmHg Low Risk

PaCo2 < 45 mmHg

However, it is uncertain that which parameters are necessary for a safe surgery.Marshall MC. Clin Chest Med 1993

Keogh BF. Anaesthesi and Intensive care Medicine 2011.

PULMONARY ARTERIAL OCCLUSION PRESSURE

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Can be done for candidates of pneumonectomy.

Pulmonary arterial occlusion pressure <35 mmHg is suitable for pneumonectomy.

If mean PAP>35 mmHg and PaO2 < 45 mmHg , there will be high risk for postoperative complication and mortality.

Marshall MC, et al. Clin Chest Med 1993

EXECISE TESTING TO EVALUATE THE FUNCTIONAL CAPACITY

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57

The first measurements carried out FEV1 ve/veya DLco < %80 pred

orPpo FEV1 ve/veya Ppo DLco < %40

EXERCISE TESTING SHOULD BE DONE

BTS /SCTS 2010 ERS/ESTS 2009 ACCP 2007


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In patients with upper lobe emphysema and cancer in the same region, preoperative

FEV1> 20 (pred) LVRS and resection can be done together

DLco > %20 (pred)

National Emphysema treatment trial research group, N Engl J Med 2001.

AN EXCEPTION CONDITION

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Degree of dyspnea O2 saturation

Stair climbing test Shuttle walk test6-min walk test


STAIR CLIMBING TEST-I

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Used to calculate performance and functional reserve. Half objective but practical.

Used for all the times.

3 floors / 54 stairs for lobectomy

5 floors /90 stairs for pneumonectomy ability show that the patients sufficient

reserve . Brunelli A. Ann Thorac Surg 2004 Olsen GN. Chest 1991

61

This approach was found to corralate with lung function;

Climbing three flights indicates an FEV1 of > 1.7 L

Climbing five flight indicates an FEV1 of > 2 L.

STAIR CLIMBING TEST -II

Bolton JWR, et al. Chest 1987

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Several studies showed that patients were under low risk postoperatively following lobectomy even with ppoFEV1 or ppoDLco <40% provided that they could climbing 3 floors.

In a prospective study , a significant difference was found indicating in cardiopulmonary complications and mortality between those climbing 12 stairs and those climbing 22 stairs.

STAIR CLIMBING TEST-III

Brunelli A, et al. Ann Thorac Surg 2008. Brunelli A, et al. Chest 2002. Olsen GN, et al. Chest 1991.

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It could be used as a preferred method of screening test stated in ERS/ESTS guidelines (2009)

The patients who are able climbing more than 22 stairs, do not need cardiopulnonary exercise test for decision to operation.

Those not climbing 2 flights are at high risk.

STAIR CLIMBING TEST-IV

Brunelli A, et al. ERS/ESTS task force, 2009.Keogh BF, et al. Anaesthesia and Intensive Care Medicine 2011.

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Patients with > 4% exercise oxigen desaturasyon (mesured by pulse oximetry) during stair climbing may have an increased rate of complications and mortality.

They need, to be further assessed with CPE testing.

STAIR CLIMBING TEST-V

Brunelli A, et al.ERS/ESTS task force guidelines 2009.

6-MİN WALK TEST

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The simple test and not need equipment except portable pulse oximetry.

Patients walks with their steps in a particular place along the 6-minute.

Heart rate and oxygen saturation measured at baseline and at regular intervals .

ERS, Clinical exercise testing. Eur Respir J, 1997. Wasserman JE, et al. Principles of exercise testing and interpretation 1999. Brunelli A, et al.ERS/ESTS task force guidelines 2009.

66

Decrease in oxygen saturation of more than 4% indicates a respiratory problem.

Without a decrease in oxygen saturation, have more heart rate indicates the patient dose not fit or has a cardiac problem.

However, this test not sufficient alone to eliminate patients from surgery.

6-MİN WALK TEST-II

ERS, Clinical exercise

testing. Eur Respir J, 1997. Wasserman JE, et al. Principles of exercise testing and interpretation 1999. Brunelli A, et al.ERS/ESTS task force guidelines 2009.

SHUTTLE WALK TEST-I

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The shuttle walk test is a standardized, externally paced walk test between cones 10 m apart at an increasing pace.

25 shuttles indicate a VO2max (maximal oxigen consumption) of 10 mL/kg/min.

The patients who walked > 400 m at shuttle walk test had a VO2max > 15 mL/kg/min (BTS 2001). Singh SJ, et al. Eur

Respir J 1994. Lim E, et al. BTS guidelines,

Thorax 2010. Keogh BF, et al. Anaesthesia and Intensive Care Medicine 2011.

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Indicated that it should not be used alone to exclude patients from operation.

SHUTTLE WALK TEST-II

Win T, et al. Thorax 2006.Win T, et al. Eur Cardiothorac Surg 2004

ADVANCED (COMPLEX) CARDIOPULMONARY EXERCISE TESTS (CPET)

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70

Some tests have been used to calculate cardiopulmonary reserve with analyzing gases exhaled by expirium in recent years.

Maximal exercise capasity and maximal oxygen consumption velocity (VO2max)

Treadmill or bicycle ergometri

CARDIOPULMONARY EXERCISE TESTS EVALUATING FUNCTIONAL CAPACITY(CPET)

CARDIOPULMONARY EXERCISE TESTS-VO2 max

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VO2max (maximal oxigen consumption-mL/kg/min):

Maximal oxygen amount consumed per minute by an individual at the highest workpower.

Ribas J, et al. Eur Respir J 1998

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This system analyses air flow, oxygen and CO2 concentration.


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Aerobic exercise capasity is very well evaluated with this test.

Bicycle ergometry is more practical and advantageous in terms of application compared to treadmill.

Decreased exercise VO2 max response shows the reduction in oxygen providing to heart, lung, systemic and pulmonary circulation and O2 compsumption of muscles.

ERS, Clinical exercise testing. Eur Respir J, 1997. Wasserman JE, et al. Principles of exercise testing and interpretation 1999.


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Eugene et al. wrote that mortality was 75% by bicycle ergometry with VO2 max < 10 ml/kg/minute .

No mortality withVO2 max > 10 ml/kg/minute .

Those with VO2 max < 10 ml/kg/minute bear a distinctive risk in perioperative morbidity and mortality even with a suitable spirometric measurements.Eugene H, et al. Surgery

forum 1982.Brunelli A, et al. Chest

2009.


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PREDICTION OF POSTOPERATIVE (Ppo) LUNG FUNCTION

PREDICTION OF POSTOPERATIVE LUNG FUNCTIONS

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If FEV1 and DLco are less than 60% of the predicted at the first evaluation and

the patient undergoes resection

Respiratory function after the resection should be calculated.

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Calculation of postoperative remaining lung capacity is a significant definition in operative risks.

Preoperative values and number of segments are required for calculations.

BTS/SCTS guidelines 2010. ERS/ESTS guidelines 2009. ACCP guidelines 2007.

PREDICTION OF POSTOPERATVE LUNG FUNCTIONS

PREDICTION OF POSTOPERATIVE LUNG FUNCTION

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TESTS USED FOR THIS PURPOSEVentilation ScanPerfusion scanQuantitative CTSPECTPerfusion MRAnatomic estimation

Radionucleid perfusion scan , the most common method of choice .

ACCP guidelines 2007

Ppo LUNG FUNCTION

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Using together quantitative CT scan has a potential advantage.

This is also used for staging routinely.

It eliminates the need of other tests (perfusion scan ).

Wu MT, et al. AJR Am J Roentgenol 2002.

Bolliger CT, et al. Respiration 2002.

Ueda K, et al. Chest 2005.

ACCP guidelines 2007

80

•DLco is more suitable in COPD patients especially instead of FEV1.

• If preoperative DLco ≥ 60%,Ppo DLco %40 ≥ in COPD patients

SAFE RESECTIONBTS/SCTS 2010ERS/ESTS 2009ACCP 2007

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• Quantitative lung sintigraphy (ventilation-perfusion) and Kristersson formula are used commonly and practically.

• There is no added benefit to use together 2 methods.

• Ppo FEV1 and DLco are calculated

• Quantitative perfusion sintigraphy is easy so used commonly.

Ppo LUNG FUNCTION-V

Kristersson S, et al. Chest 1972.

Win T, et al. AJR Am J Roentgenol 2006

82Florian von Groote-Bidlingmaier, Clin Chest Med 32 (2011)

Radionucleotide perfusion ventilation scan. An example of a radionucleotide ventilation perfusion scanperformed on a patient with almost completely destroyed left lung and only 13% of total perfusion left on that side. Quantification is performed according to zones and evaluation of anterior and posterior views. (Courtesyof Prof J. Warwick, Medical Imaging and Clinical Oncology, Stellenbosch University and Tygerberg Hospital,Cape Town, South Africa.)

84

Pulmonary quantitative CT scan. Functional lung volume of a representative slice is shown on a quantitative CT map. Lung parenchyma is outlined from mediastinum and chest wall with tumor (Tu) being excluded. Then 3 segments in the lung parenchyma are generated. The white area, less than 910 HU, denotes emphysema (E); the black area, more than 500 HU, denotes infiltration and atelectasis; and the gray area, between 500 and 910 HU, denotes functional lung volume (FLV). Ht, heart.(Reproduced from Wu MT, Pan HB, Chiang AA, et al.Prediction of postoperative lung function in patients with lung cancer: comparison of quantitative CT with perfusion scintigraphy. AJR Am J Roentgenol 2002;178(3):668; with permission.)

FG-Bidlingmaier, Clin Chest Med 32 (2011)

85

Dynamic perfusion MRI. A dynamic perfusion MRI of a patient with a left upper lobe adenocarcinoma. Theimages show heterogeneous, but well-enhanced, pulmonary parenchyma at 5 and 13 seconds in portions of lungsnot affected by the cancer (arrows). The adenocarcinoma also is enhanced after 13 seconds. (Reproduced fromOhno Y, Koyama H, Nogami M, et al. Postoperative lung function in lung cancer patients: comparative analysisof predictive capability of MRI, CT, and SPECT. AJR Am J Roentgenol 2007;189(2):404; with permission.)

Florian von Groote-Bidlingmaier, Clin Chest Med 32 (2011).

Kristersson Formula

86

Postpneumonectomic FEV1= Preop. FEV1x % function of the remaining lung (perfusion)

Postlobectomic FEV1= Preoop. FEV1x (1- % function of the diseased lung.X number of removed segments)

Total number of segments

Kristersson S. Chest 1972.

Ppo FEV1

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Ppo FEV1 postpneumonectomic: preoperative FEV1 x (1- total perfusion fraction of the lung to be resected)

anatomic method for lobectomy:Ppo FEV1 postlobectomy: preoperative FEV1 x (1-a/b)

a: number of unobstructive segments to be resectedb:total number of unobstructive segments

ACCP 2007 Guidelines

ERS/ESTS 2009 Guidelines

88

Ppo-DLco lobectomy: preoperative DLco x (1-a/b)

Ppo-DLco pneumonectomy: preop DLco x (1- total perfusion fraction of the lung to be resected)

Ppo-VO2 lobectomy:preop VO2max x (1-a/b)Ppo-VO2 pneumonectomy: preop VO2max x (1-

total perfusion fraction of the lung to be resected)

a: number of unobstructive segments to be resectedb:total number of unobstructive segments

PpoDLco, PpoVO2max

ERS/ESTS Guidelines 2009.

89

Ppo values = (preop value/T) x R

T: total number of functioning segments before operation (19-number of obstructed segments, estimated by image tecniques and/or bronchoscopy).

R: residuel number of functioning segments after the operation

PpoFEV1, PpoDLco, PpoVO2max

Ferguson MK, et al. J Thorac Cardiovasc Surg 1995.

Bolliger CT, et al. Respiration 2002.ERS/ESTS guidelines 2009

90

Ppo VO2max has been used as postoperative risk estimation recently.

VO2max > 15-20 ml/kd/dk negligible risk Ppo

Eğer PpoVO2max < 10 ml/kg/dk or HIGH

RISK PpoVO2max < %35 (pred.)

MORTALITY IS HIGH

Brunelli A, et al. Ann

Thorac Surg 2007.

PREDICTION OF POSTOPERATIVE RISK-VO2max

ALGORITHMS IN ORDER TO ASSESS THE PATIENTS PREOPERATIVELY

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ERS/ESTS 2007ACCP 2007BTS/SCTS 2010

92

AlgorithmaPreoperative physiologic assessment of perioperative risk. ACCP Guidelines 2007

93 Colice GL,et al. ACCP evidenced based clinical practice guidelines.Chest 2007.

94

Revised algorithm for the assessment of cardiorespiratoryreserve and operability before pulmonaryresection. Reproduced from Brunelli A, Charloux A,Bolliger CT, et al. ERS/ESTS clinical guidelines onfitness for radical therapy in lung cancer patients(surgery and chemo-radiotherapy). Eur Respir J2009;34(1):22; with permission.)

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Ferguson MK. Preoperative evaluation of Thoracic Surgery Patients. 2010

EXAMPLE

100

PpoFEV1: 40 X (1-45/100): 40 X 0.55: 22%

PpoDLco: 59 X (1-45/100): 59 X 0.55: 32.4%

HIGH RISK- CARDIOPULMONARY EXERCISE TEST

STAIR CLIMBING TEST

104

PATIENT CLIMBED SMOOTLY 6 FLIGHTS OF STAIRS.

SaO2= %97, DESATURATION 0%PNEUMONECTOMY WAS PERFORMED.POSTOP. PATIENT WITHOUT PROBLEM

Postoperative dyspnoea and quality of life.

105

Offer surgical resection to patients at moderate to high risk of postoperative dyspnoea if they are aware of and accept the risk of dyspnoea and associated complications


Old words

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The ingenuity is to discharge the patient healthy not only to operate.

Let the patient get out alive from operation theatre.

A good surgeon who knows not to operate which patient..

Former teachers

CONCLUSION

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PRECAUTIONS MUST BE TAKEN IN ORDER TO DEFINE AND PREVENT POSTOPERATIVE RISKS OF COMPLICATIONS WITH PREOPERATIVE EVALUATION.

EVALUATION OF MULTIDISCIPLINARY APPROACH FOR HIGH RISK PATIENTS SHOULD DECREASE POSTOPERATIVE MORBIDITY AND MORTALITY CONSIDERABLY.

THANKS FOR YOUR PATIENCE

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estimate of complication in thoracic surgery

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