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Pre operative evaluation for pulmonary surgery

Pre operative evaluation for pulmonary surgery. Chananya Karunasumetta , MD . Division of Cardiothoracic S urgery Department of Surgery Queen Sirikit Heart Center of the Northeast Srinagarind Hospital, Khonkaen University. Common procedure. Pneumonectomy Lobectomy Wedge Resection

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Pre operative evaluation for pulmonary surgery

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  1. Pre operative evaluation for pulmonary surgery ChananyaKarunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart Center of the Northeast Srinagarind Hospital, Khonkaen University

  2. Common procedure • Pneumonectomy • Lobectomy • Wedge Resection • Segmentectomy

  3. MortalityRates • Pneumonectomy: 6.8% • Bi-lobectomy: 4.4 % • Lobectomy: 3.9 % • LesserResection: 1.4 % (Damhuisetal., EurRespir J 1996 ; 9:7-10)

  4. Patient Disease Preopertative evaluation for lung resection Operation

  5. PART I: FITNESS FOR SURGERY Preopertative evaluation • Age • Pulmonary function • Cardiovascular fitness • Weight loss, performance status and nutrition PART II: OPERABILITY • Diagnosis and staging • Operability and adjuvant therapy • Operations available • Locally advanced disease

  6. PART I: FITNESS FOR SURGERY Age Pulmonary function Cardiovascular fitness Weight loss, performance status and nutrition

  7. PART I: FITNESS FOR SURGERY Age Pulmonary function Cardiovascular fitness Weight loss, performance status and nutrition

  8. PART I: FITNESS FOR SURGERY Age • Advancing age increase risk • Surgery for clinically stage I and II in patients over 70 years = younger patients • Age over 80 alone is not a contraindication to lobectomy or wedge resection • Pneumonectomy is associated with a higher mortality risk in the elderly

  9. PART I: FITNESS FOR SURGERY Age Pulmonary function Cardiovascular fitness Weight loss, performance status and nutrition

  10. PART I: FITNESS FOR SURGERY • Step I :Preop lung function • Arterial Blood Gas • Spirometry Analysis • DLCO • Step II :Postop lung function • PPO FEV1,PPO DLCO • Quantitative Ventilation-Perfusion Scan • Quantitative CT Scan • Step III: Cardiopulmonary exercise test • Shuttle walk • Exercise Testing: Oxygen Uptake (VO2 Max) Pulmonary function

  11. PCO2 >50 mm Hg - traditional contraindication to lung resection • PO2 < 90% STEP 1 : PRE OP ASSESSMENT ABG • FEV1 > 0.6Lforsegmentectomy • FEV1> 1.5 Lfor a lobectomy • FEV1 > 2Lfor a pneumonectomy Spriro-meter • DLCO < 60% predicted associated with ↑ mortality DLCO

  12. STEP 2 POST OP ASSESSMENT • PPO FEV1 >40%, PPO DLCO >40% and SaO2 >90% on air: average risk • PPO FEV1 <40%, PPO DLCO <40% : high risk. PPO FEV1= pre op FEV1 x (19- seg. To be remove) 19 PPO FEV1= pre op FEV1 x (19- A)-B 19-A

  13. STEP 2 POST OP ASSESSMENT • Quantitative Ventilation-Perfusion Scan • Highly accurate • Inhaled 133Xe or IV 99Tc • Normally: 19 Segments (10 R & 9 L) • Right Lung (3/2/5): 55 % & Left Lung(3/2/4): 45% PPO FEV1= Preope.FEV1X % of radioactivity contributed by nonoperated lung

  14. STEP 2 POST OP ASSESSMENT • Using 133Xe Inhalation: • PPO FEV1 of < 1 L . (Kristersson S et al.Chest 1972; 62:696–698) • Using 99Tc Macroaggregate of Albumin Perfusion: • PPO FEV1 of < 0.8 L is indicative of surgical inoperability. (Olsen GN et al. Chest 1974; 66:13–16)

  15. Shuttle walk • A best distance on two shuttle walk tests of <25 shuttles (250 m) • desaturation during the test of more than 4% SaO2 STEP 3 CARDIOPULMONARY EXERCISE TEST Stair Climbing and Walking Tests • climb three flights of stairs lobectomy. • five flights of stairs Pneumonectomy. VO2peak (Maximal oxygen consumption) • <15 ml/kg/min indicates that a patient is a high risk for surgery

  16. PART I: FITNESS FOR SURGERY Age Pulmonary function Cardiovascular fitness Weight loss, performance status and nutrition

  17. PART I: FITNESS FOR SURGERY • ECG • Murmur echo • MI  Sx 6 wk Cardiovascular fitness

  18. Cardiac risk factor

  19. PART I: FITNESS FOR SURGERY • Major risk • Formal cardiologist assessment • CABG prior lung resection • Intermediate risk • Functional good : no further Ix • Poor function : ECG, exercise test, echo • Minor risk • ≥ 1 cardiovascular risk • Hx TIA, CVA Cardiovascular fitness

  20. PART I: FITNESS FOR SURGERY Age Pulmonary function Cardiovascular fitness Weight loss, performance status and nutrition

  21. performance status

  22. PART II: OPERABILITY • Diagnosis and staging • Operability and adjuvant therapy • Operations available

  23. Diagnosis and staging • H&P • CXR • CT chest (including upper abdomen and adrenals) • CBC, platelets • Chemistry profile • Smoking cessation • Pulmonary function test, bronchoscope

  24. CA LUNG STAGING

  25. Diagnosis and staging

  26. Diagnosis and staging

  27. Recommend • PFT, bronchoscope , CT scan : all • Mediastinoscope : all except T1 a,b peripheral lesion • MRI brain : stage IIb (T3 invasion, No)

  28. Gene L. Colice, Chest 2007

  29. Average risk

  30. Srinivas R. Bapoje, Chest 2007

  31. Conclusion • HX & PE • Part 1 : Fitness • Age • PFT • Step 1 : Pre op assessment • Step 2 : Predict post op function • Step 3 : Cardiopulmonary exercise test • Cardiac status • Performance status • Part 2 : Operability • Diagnosis and staging • PFT, bronchoscope, CT scan • Mediastinoscope • MRI brain • Bone scan

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