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About Thoracic Surgery

Dr. Pierre – Emmanuel Falcoz and the Thoracoscore

The ‘thoracoscore’ is a scoring system created to predict the risk of in-hospital death after thoracic surgery.  This model was first created and tested by Dr. Pierre – Emmanuel Falcoz.  Dr. Falcoz is a thoracic surgeon at the Hospital Civil in Strasbourg, France*.

The thoracoscore uses nine variables to predict patient surgical mortality and has been tested and validated in several large studies. The variables are age, gender, ASA (anesthesia classification), performance status class, dyspnea score, priority of surgery, procedure class, diagnosis group and co-morbidity score.)

Definitions of Variables:

Age of patient has been divided into three groups; under 55 years of age, 55 – 64 years old, and 65 years and older.

ASA classification – this is the scoring used and devised by the American Society of anesthesiologists in 1963.   These are:

  1. A normal healthy patient.
  2. A patient with mild systemic disease.
  3. A patient with severe systemic disease.
  4. A patient with severe systemic disease that is a constant threat to life.
  5. A moribund patient who is not expected to survive without the operation.
  6. A declared brain-dead patient whose organs are being removed for donor purposes.

Performance Status:

World Health Organization Performance status

Grade Explanation   of activity
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours
3 Capable of only limited self-care, confined to bed or chair more than 50% of waking   hours
4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair
5 Dead

Dyspnea Score: the dyspnea scale by the medical research council.

mMRC Breathlessness Scale

Grade

Degree of dyspnea

0

no dyspnea except with strenuous exercise

1

dyspnea when walking up an incline or hurrying on the level

2

walks slower than most on the level, or stops after 15 minutes of walking on the level

3

stops after a few minutes of walking on the level

4

with minimal activity such as getting dressed, too dyspneic to leave the house

Priority of Surgery:  Urgent/emergent versus elective.

Procedure class:  pneumonectomy or other lung procedure

Diagnosis group:  benign versus malignant

Co-morbidity score: number of significant co-morbid conditions (smoking, history of cancer, chronic obstructive pulmonary disease, diabetes mellitus,  arterial hypertension, peripheral vascular disease, obesity and alcoholism).

Scoring:

Using specific calculations assigned to each category score  – each calculation is summed together to determine the patient’s risk group.  Estimated mortality is assigned by risk group.  (See table 5 in original article to compare predicted mortality to actual mortality in Falcoz et. al. 2007).

Several of the surgeons interviewed previously report that they use this scoring system routinely, as part of their pre-operative assessments.  While several of the variables are intuitive (ie. urgency of surgery[1] increases mortality), this scoring system also validates previous surgical observations.

One of the strengths of the thoracoscore is the use of scales to measure everyday performance (ie. performance status, breathlessness) versus clinical indicators such as pulmonary function tests, pet scans and other more costly/ time-consuming diagnostic devices.  (During initial data collection Falcoz et. al collected these measures [PFTs etc.] but during analysis, these criteria were not shown to be statistically significant).

References

The Thoracoscore on-line calculator: includes risk category definitions

Thoracoscore app for iTunes – in french

Chamogeorgakis TP, Connery CP, Bhora F, Nabong A, Toumpoulis IK. (2007). Thoracoscore predicts midterm mortality in patients undergoing thoracic surgery. J Thorac Cardiovasc Surg. 2007 Oct;134(4):883-7.

Chamogeorgakis TP, Connery CP, Bhora F, Nabong A, Toumpoulis IK.  (2009).  External validation of the modified Thoracoscore in a new thoracic surgery program: prediction of in-hospital mortality.  Interact Cardiovasc Thorac Surg. 2009 Sep;9(3):463-6.

Falcoz, et. al. (2007).  The thoracic surgery scoring system: Risk model for in-hospital death in 15, 183 patients requiring thoracic surgery.  J. Thorac Cardiovasc Surg 2007; 133 (2) 325-32.

Falcoz PE, Dahan M; French Society of Thoracic and Cardiovascular Surgery; Epithor Group (2008).  Focus on the thoracoscore. J Thorac Cardiovasc Surg. 2008 Jul;136(1):242-3.


[1] This is classified as ‘priority of surgery’ on the thoracoscore.

* Attempted to contact Dr. Falcoz while working on this article, but was unable to do so.

About K Eckland

World of Thoracic Surgery is a blog about the work, research, and practices of thoracic surgeons around the world. It includes case studies, [sometimes] dry research, interviews with thoracic surgeons along with patient perspectives, and feedback.

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