Recommended reading: Advances in Lung Cancer

this 2012 article by Hannon & Yendamuri explains the newest methods and modalities of treating nonsmall cell lung cancer (NCLC) as well as the importance of accurate staging for diagnosis and evidence-based treatment.

A layperson’s guide to “Advances in Lung Cancer,” by Hannon & Yendamuri

In addition to providing links to the full article text, we have also provided a highlighted pdf version  – with additional notes, links and information contained in this post.

What is staging?

Staging is the diagnostic process of determining how much/ how far cancer has spread.  Staging usually involves several tests and procedures such as PET/CT scans, mediastinoscopy or bronchoscopy (with endobronchial biopsy).  Some of these tests may have been done at the time of initial diagnosis.  Others will be done as part of the work-up after doctors suspect or have diagnosed lung cancer.

More about mediastinoscopy:

Mediastinoscopy as explained by Dr. Carlos Ochoa

WebMd article on mediastinoscopy

when mediastinoscopy is done with a camera, it is called video-assisted mediastinoscopic lymphadenectomy (VAMLA)

Transcervical extended mediastinal lymphadenectomy: is an extended version of a traditional mediastinoscopy, allowing for more extensive lymph node dissection.

article at CTSnet

The jury is still out on whether the newer technologies are superior to traditional mediastinoscopy. The most important thing is for a patient to have a mediastinoscopy-type procedure for accurate tissue diagnosis.  The more lymph nodes sampled – the more accurate the staging.

This procedure may be combined with other procedures like bronchoscopies with needle biopsy (EBUS) to be able to sample more nodes from more locations in the mediastinum.  (Each procedure samples a different area of the mediastinum.)

Why is staging important?

Staging provides doctors and patients with information about the extent of cancer present.  Is the cancer in a small area of the lung alone?  Has it spread to the lymph nodes?  Is there distant metastasis to other organs?

Knowing the answers to these questions will determine the course of treatment (surgery versus chemotherapy alone, surgery plus chemotherapy/ radiation).  Staging also gives us information about anticipated or expected survival – which is important for patients to know when deciding on treatment options.

Lung cancer 101 – article on staging of lung cancer, small and non-small at

Non-small cell lung cancer staging – National Cancer Institute. Also have information about the diagnostic testing used for accurate staging.

Staging is done, now what?

Once the cancer has been staged accurately, doctors can begin to discuss treatment options.  Treatment options can include surgery, chemotherapy and radiation.  Surgery is usually the most effective for early stage cancers (IA to IIIB in most cases).  More advanced cancers may require chemotherapy regimens or palliation alone.

Treatment Modalities discussed in Hannon & Yendamuri:

Brachytherapy – this is a type of radiation treatment that is implanted into the patient at the time of surgery.

American Brachytherapy Society (ABS)

Radiation therapy – has a section on brachytherapy

Single port thoracic surgery – archives for related posts on single port thoracic surgery

Robotic surgery – posts on robot surgery and the DaVinci surgical system.

Dr. Buitrago and robotic surgery – with short YouTube clip

Dr. Mark Dylewski – master of robotic surgery

Dr. Weksler – robotic surgery

The Davinci Robot

Awake thoracic surgery with Dr. Mauricio Velaquez

Palliation – including treatment for malignant pleural effusions

What is palliative care?

Reference article:

Hennon, M. W., & Yendamuri, S. (2012). Advances in lung cancer.  Journal of Carcinogenesis 2012, 11:21.

Dr. Mark Hennon and Dr. Sai Yendamuri  are board-certified thoracic surgeons, and assistant professors of thoracic surgery at the State University of New York – Buffalo.  They currently practice at the Roswell Park Cancer Institute in Buffalo, New York.

Post operative pain after thoracic surgery

What kind of pain should patients expect after thoracic surgery, and how long will it last? Also, is this normal? When should I call my doctor?

Like all posts here at Cirugia de Torax, this should serve as a guide for talking to your healthcare provider, and is not a substitute for medical advice.

Quite a few people have written in with questions about post-operative pain after thoracic surgery procedures so we will try to address those questions here.

1.  What is a normal amount of pain after these procedures?

While no two people will experience pain the same, there are some general guidelines to consider.  But to talk about this issue – we will need to refer to a basic pain scale which rates pain from 0 (no pain) to 10 – (excruciating, writhing pain, worst possible imaginable).

Unfortunately, for the majority of people who have thoracic surgery, there will be some pain and discomfort.

Pain depends on the procedure

In general, the intensity and duration of pain after thoracic procedures is related to the surgical approach – or the type of surgical incision used.

open thoracotomy,empyema, advanced with extensive purulence
This open incision (with rib spreading) will hurt more..
Photo: advanced empyema requiring open thoracotomy for decortication
Pain will be much less with a single incision VATS surgery (now with chest tube) and specimen removed (photo courtesy of Dr. Chen)
Pain will be much less with a single incision VATS surgery (now with chest tube) and specimen removed (photo courtesy of Dr. Chen)

Patients with larger incisions like a sternotomy, thoracotomy or clamshell incision will have more pain, for a longer period of time than patients that have minimally invasive procedures like VATS because there is more trauma to the surrounding tissues.  People with larger incisions (from ‘open surgeries’) are also more likely to develop neuralgia symptoms as they recover.

.  (I will post pictures of the various incisions once I return home to my collection of surgical images).

Many patients will require narcotics or strong analgesics for the first few days but most surgeons will try to transition patients to anti-inflammatories after surgery.

Post-operative surgical pain is often related to inflammation and surgical manipulation of the chest wall, particularly in procedures such as pleurodesis, decortication or pleurectomy.  For many patients this pain will diminish gradually over time – but lasts about 4 to 6 weeks.


This pain is often better managed with over the counter medications such as ibuprofen than with stronger narcotics.  That’s because the medication helps to relieve the inflammation in addition to relieving pain.  Anti-inflammatory medications also avoid the risks of oversedation, drowsiness and severe constipation that often comes with narcotics.

Use with caution

However, even though these medications are available without a prescription be sure to talk to your local pharmacist about dosing because these medications can damage the kidneys.  Also, be sure to keep hydrated while taking this medications.

People with high blood pressure should be particularly cautious when taking over the counter anti-inflammatories because many of these medications have drug interactions with blood pressure medications.

2.  “I had surgery three weeks ago, and I recently developed a burning sensation near the incision”

Neuralgias after surgery

For many patients, the development of a neuralgia is a temporary effect and is part of the healing process.  However, it can be quite disturbing if patients are unprepared.  Neuralgic pain is often described as a burning or stinging sensation that extends across the chest wall from the initial incision area.  Patients also describe it as a ‘pins and needles’ sensation or “like when your foot falls asleep”.  This usually develops a few weeks after surgery as the nerves heal from the surgery itself.

It the discomfort is unmanageable, or persists beyond a few weeks, a return visit to your surgeon is warranted.  He/She can prescribe medications like gabapentin which will soothe the irritated nerves and lessen the sensations.  However, these medications may take some time to reach full effect.

Range of motion and exercise after surgery

Exercise limitations are related to the type of incision.

Sternotomy incisions/ sternotomy precautions

If you have a sternotomy incision – (an incision through the breast bone at the center of your chest), this incision requires strict precautions to prevent re-injury to the area.  Since the sternal bone was cut, patients are usually restricted from lifting anything greater than 10 pounds for 6 to 12 weeks, and to avoid pushing, pulling or placing stress on the incision.  Patients are also restricted from driving until bone healing is well underway.  (Be sure to attend a rehab program or physical therapy program to learn the proper way to exercise during this time period).

Patients will also need to take care to prevent a surgical skin infection or something more serious like mediastinitis.  The includes prohibitions against tub bathing/ soaking, swimming or over- aggressive cleaning of the incision with harsh abrasives like hydrogen peroxide or anti-bacterial soaps.  These chemicals actually do more harm than good in most cases by destroying the newly healing tissue.  A good rule of thumb to remember (unless your doctor says otherwise): No creams or lotions to your incisions until the scabs fall off.

Post-thoracotomy incisions

With a large thoracotomy incision, most patients will be restricted from lifting any items greater than 10 pounds on the surgery side for around two weeks.  However, unlike sternotomy patients – we want you to use and exercise that arm daily – otherwise patients have a risk of developing a ‘disuse’ syndrome.  One of the common exercises after a thoracotomy is called the spider crawl. This exercise helps the muscles to heal and prevent long-term disability or problems.  The physiotherapist at your local hospital should have a list of several others that they can teach you to practice at home.

The spider crawl

In this example, the patient had a left thoracotomy:

1. Stand with your surgical side within arm’s length of the wall.

start with your hand at waist level
start with your hand at waist level

Now, use your hand to “walk” up the wall, similar to a spider crawling.

'walking' the hand up the wall
‘walking’ the hand up the wall

Continue to walk your hand up the wall until your arm is fully extended.

continue until arm fully extended
continue until arm fully extended

Perform this exercise (or similar ones) for several minutes 5-6 times a day.  As you can see – it is fast and easy to do.


For patients with minimally invasive procedures – there are very few exercise restrictions, except no heavy lifting for 2 to 3 weeks (this is not the time to help your neighbor move his television.)

General incision care guidelines are similar to that for sternotomy patients – no soaking or bathing (showering is usually okay), no creams or lotions and no anti-bacterial soaps/ hydrogen peroxide/ harsh cleaners.

Whats NOT normal – when it’s time to call your surgeon

– dramatic increase in pain not associated with activity (i.e. lifting or reaching).  If your pain has been a “4” for several days and suddenly increases to an “8”

– If the quality of the pain changes – ie. if it was a dull ache and becomes a stabbing pain.

– any breathlessness, shortness of breath or difficulty breathing

– Any increase in redness, or swelling around your incisions.  Incisions may be pink and swollen for the first 2-3 days, but any increase after that warrants a ‘wound check’ by your surgeon

– Any fresh bleeding – bright red blood.  A small amount of drainage (from chest tube sites) that is light pink, clear or yellow in nature may be normal for the first few days.

– Drainage from the other sites (not chest tube sites) such as your primary incision is not normal and may be a sign of a developing infection.

– Fever, particularly fever greater than 101.5 – may be a sign of an infection.

– If you are diabetic, and your blood sugars become elevated at home, this may also be a sign of infection. (Elevation in the first few days is normal, and is often treated with insulin – particularly if you are in the hospital.

– Pain that persists beyond 3 months may be a sign of nerve damage (and you will need additional medications / therapies).

Mediastinitis: a potentially lethal infection

Exploring the causes of mediastinitis in non-cardiac surgery patients with review of recent cases in the literature.

Mediastinitis is a serious, and potentially life-threatening infection of the mid-chest area (or mediastinum.) While it most commonly occurs after cardiac surgery* (and is a dreaded complication of), it can also occur after large thoracic procedures or blunt trauma. 

Sternotomy incisions, along with clamshell/ hemi-clamshell incisions may be utilized for large anterior mediastinal tumor resections, which places patients at the same risk of mediastinitis as traditional cardiac surgery procedures.

Blunt trauma can include injuries such as an esophageal tear that allows bacterial/ food/ fluids to seep from the torn esophagus into the chest.   In rare cases, it can occur due to the spread of an infection affecting the head /neck.  Recently, there have been several case reports of mediastinitis resulting from necrotizing fascitis which is particularly devastating, with cases originating as dental infections.

If untreated, mediastinitis can rapidly progress to sepsis (a systemic bloodstream infection causing numerous serious sequelae) and death.  Mortality related to the development of mediastinitis ranges from 21 – 60% (depending on sources).

Additional Risk Factors for the development of mediastinitis

Any condition that delays or impedes healing can promote the development of mediastinitis – particularly in post-surgical patients.  This includes diabetes, patients taking immunosuppressive therapies (such as Rheumatoid arthritis treatments, COPD and other patients on prednisone (and other steroids), transplant recipients and cancer patients receiving chemotherapy.)  This is why care of sternotomy or large chest incisions should be taken very seriously. 

Prevention of mediastinitis in patients with sternotomy incisions:  (s/p thymectomies, mediastinal mass resections etc.)

Patients should be sure to follow all lifting or movement restrictions (sternotomy precautions) and report any drainage from their incisions.  Patients should also contact their surgeons if they develop any wound dehiscence (wound edges come apart) or development fluctuance or swelling around the surgical site.  Fever following discharge from the hospital should be reported to the surgical service, particularly if it accompanies any signs of wound breakdown.

Patients with diabetes or elevated serum blood glucose need to be aggressive in the treatment of hyperglycemia.  Even patients who were previously well controlled on oral agents may require basal or correction insulins post-operatively to prevent elevated glucose, and increased risk of infection. 

Large breasted female patients, or obese males should wear a support bra to keep gravity from pulling breast tissue apart, and placing stress on the healing incision.  This is one of the most common reasons for poor wound healing of sternotomies.  (This will also significantly reduce post-operative pain.)

Post-thoracic surgery patients receiving radiation early in the course of their surgical recovery are also at risk, even from smaller procedures such as mediastinoscopies and Chamberlain procedures.  Aggressive surveillence and regular inspection of all wounds may help detect early signs of superficial infection/ wound breakdown to prevent the development of more serious complications.

Do not apply creams, lotions or ointments to incisions without speaking to your surgeon.  Avoid overly harsh anti-bacterial soaps and scrubs.  These products may actually damage the delicate tissues and promote infection.

Diagnosis may require CT scans of the chest to detect the development of a fluid collection within the chest.

Treatment of Acute Mediastinitis

Early treatment and surgical debridement of infected material (dead tissue, pus, etc) are essential for optimal results.  Intravenous antibiotics are a crucial part of this treatment to help prevent / and treat possible sepsis.  In patients presenting with more advanced infection – fluid resuscitation and treatment of underlying sepsis and sepsis related complications (organ failure) may be required along with other supportive measures.  Urgent evacuation of mediastinal space should remain a priority, even in the critically ill and unstable patient to prevent further spread of infection, particularly if necrotizing organisms are suspected.

* Sternotomy or the surgical division of the sternum was actually first adopted by a thoracic surgeon to access the anterior chest and mediastinum almost fifty years prior to its use in cardiac surgery.  Sternotomy remains one the primary ways (along with clamshell and hemi-clamshell incisions) that surgeons can access the anterior mediastinum for large tumor resections.

Additional References and Information about Mediastinitis

New York Times article on mediastinitis

Banazadeh M.  (2011).  Successful management of acute necrotizing mediastinitis with trans-cervical drainage.  Ann Thorac Cardiovasc Surg. 2011 Oct 25;17(5):498-500. Epub  2011 Jul 13. 

Dajer-Fadel, et al (2012).  Thoracic necrotizing fasciitis due to snake ointment that progressed to a mediastinitis. Interact Cardiovasc Thorac Surg. 2012 Jan;14(1):94-5. Epub  2011 Nov 18.  Story of fatal case of mediastinitis in Mexico City, Mexico.  Please note: photos are fairly graphic.

Kim, et. al. (2011).  Application of radiographic images in diagnosis and treatment of deep neck infections with necrotizing fasciitis: a case report.  Imaging Sci Dent. 2011 Dec;41(4):189-93. Epub  2011 Dec 19.  Discussion of case of serious, necrotizing infection originating from a dental infection- with CT images showing close proximity of infection to thoracic cavity. [Patient in case report did not develop mediastinitis.]

Mahmodlou (2011).  Aggressive surgical treatment in late-diagnosed esophageal perforation: a report of 11 cases.  ISRN Surg. 2011;2011:868356. Epub  2011 Jun 22.  Iran case reports of mediastinitis after esophageal injury.

Saha et. al (2011).  Perils of prolonged impaction of oesophageal foreign bodies.  ISRN Surg. 2011;2011:621682. Epub  2011 Jun 13.  2 Cases (with color photos and CT scans) of mediastinitis after foreign body ingestion.

Blebs, Bullae and Spontaneous Pneumothorax

Overview of spontaneus pneumothorax and treatment modalities.

There are multiple classifications of pneumothoraces – primary, secondary, iatrogenic, traumatic, tension etc.  This article is a limited overview of the most common type(s) of pneumothorax, and methods of treatment.

What are blebs? 

The lung is made up of lung tissue itself (consisting of alveoli, bronchi and bronchioles) and a thin, membranous covering called the pleura.  This covering serves to prevent inhaled air from travelling from the lung to the area inside the thoracic cavity.  ‘Blebs’ are blister-like air pockets that form on the surface of the lung.  Bulla (or Bullae for pleural) is the term used for air-filled cavities within the lung tissue.

Who gets/ who has blebs and/or bullae?

Blebs and bullae may be related to an underlying disease process such as emphysema / chronic obstructive pulmonary disease, but they (blebs in particular) may also be found in young, healthy people with no other medical issues.  Indeed, the ‘classic’ scenario for a primary spontaneous pneumothorax is a young adult male (18 – 20’s), tall and thin in appearance and no other known medical history who presents with complaints of shortness of breath or dyspnea.

Smoking, and smoking cannabis have been implicated in the development of spontaneous pneumothorax in young (otherwise healthy) patients.

Bullae, or air pockets within the lung tissue are more commonly associated with chronic disease processes such as chronic obstructive pulmonary disease (emphysema).  It can be also part of the clinical picture in cystic fibrosis and other lung diseases.

How do blebs cause a pneumothorax?

When these blebs rupture or ‘pop’ inhaled air is able to travel from the airways to the thoracic cavity, creating a pneumothorax or lung collapse.

The symptoms of a pneumothorax depend on the amount of lung collapse and the baseline respiratory status of the patient.   In young, otherwise healthy patients, the symptoms may be more subtle even with a large pneumothorax.  In patients with limited reserve (chronic smokers, COPD, pulmonary fibrosis, sarcoidosis) patients may experience shortness of breath, dyspnea/ difficulty breathing, chest and chest wall pain.  With large pneumothoraces or complete collapse of a lung, patients may become cyanotic, or develop respiratory distress.

In cases of pneumothorax caused by external puncture of the lung, or other traumatic circumstances, a patient may develop a life-threatening condition from a tension pneumothorax.  This can happen with a simple, primary lung collapse from bleb rupture, but it is uncommon. 

How is this treated?

Simple (or first-time) pneumothorax

Oxygen therapy – traditional treatment for small pneumothorax in asymptomatic or minimally symptomatic patients was oxygen via a face mask or non-rebreather.  Much of the more recent literature has discredited this as an effective treatment.

Tube thoracostomy  (aka chest tube placement) – a chest tube is placed to evacuate air from the thoracic cavity, to allow the lung to re-expand.  The chest tube is initially placed to suction until the lung surface heals, and the lung is fully expanded.  After a waterseal trial, the chest tube is removed.

Recurrent pneumothorax / other circumstances;

Blebectomy via:

  1. VATS (video-assisted thoracoscopy)
  2. Open thoracotomy or mini-thoracotomy

As we have discussed previously, the VATS procedure / open thoracotomy and mini-thoracotomy are not really stand alone procedures but are the surgical approaches or techniques used to gain entry into the chest.  Using a VATS technique involves the creation of one or more ‘ports’ or opening for the use of thoracoscopic surgical tools, and a thoracoscope (or camera.)  There are rigid and flexible scopes available; but most thoracic surgeons prefer the rigid scopes for better visibility and control of tissue during the operation[1].

blebs seen during VATS procedure

Open thoracotomy or mini-thoracotomy incisions may be used to gain access to the lung, particularly for resection of bullae (lung volume reduction) surgeries for the treatment of chronic disease.

During this procedure, fibrin sealants may be used.  Investigational use of both radio-frequency and other ablative therapies have also been used (Linchevskyy, Makarov & Getman, 2010, Funai, Suzuki, Shimizu & Shiiya 2011**).

Treatment Guidelines

British Thoracic Surgeons 2010 treatment guidelines

American College of Chest Physicians – a bit dated (2001)

Linchevskyy, Makarov & Getman, 2010.  Lung sealing using the tissue-welding technology in spontaneous pneumothorax.  Eur J Cardiothorac Surg (2010) 37(5): 1126-1128.

Funai, Suzuki, Shimizu & Shiiya (2011).  Ablation of weak emphysematous visceral pleura by an ultrasonically activated device for spontaneous pneumothorax. Interact CardioVasc Thorac Surg (2011) 12(6): 908-911. 

Pleurodesis may also be used – in combination with either tube thoracostomy or surgical resection.  Pleurodesis can be performed either mechanically, chemically or both.  Mechanical pleurodesis is accomplished by irritated the pleura by physical means (such as scratching or rubbing the pleura with the bovie scratch pad or surgical brushes.  A chest tube also produces a small amount of mechanical pleurodesis as the tube rubs on the chest wall during patient movement.

Chemical pleurodesis is the instillation of either sterile talc or erythromycin to produce irritation or inflammation of the pleura.  With bedside pleurodesis or tube thoracostomy pleurodesis, sterile talc is mixed with lidocaine and sterile water to create a talc slurry.  (If you like your patient, carry it in your pocket for 10 – 20 minutes to allow the solution to warm to at least room temperature.  This will help reduce the discomfort during instillation.)  The mixture should be in a 60cc syringe or similar delivery device – shake briskly before use.  The mixture is then instilled via the existing thoracostomy tube.  The chest tube is clamped for 30 – 60 minutes (dwell time) and the patient is re-positioned every 10 to 20 minutes. Despite the lidocaine, the talc will produce a burning sensation, so pre-medication is desirable.  This procedure has largely fallen out of fashion in many facilities.  Post-pleurodesis, pleural inflammation may cause a brief temperature elevation.  This is best treated with incentive spirometry, and pulmonary toileting.

Chemical pleurodesis can also be performed in the operating room.  Loose sterile talc can be insufflated, or instilled using multiple delivery devices including aerosolized talc.  As discussed in previous articles, pleurodesis can also be used for the treatment of pleural effusions.

Sepehripour, Nasir and Shah (2011).  Does mechanical pleurodesis result in better outcomes than chemical pleurodesis for recurrent primary spontaneous pneumothorax?  Interact CardioVasc Thorac Surg ivr094 first published online December 18, 2011 doi:10.1093/icvts/ivr094

Alayouty, Hasan,  Alhadad Omar Barabba (2011).  Mechanical versus chemical pleurodesis for management of primary spontaneous pneumothorax evaluated with thoracic echography.                     Interact CardioVasc Thorac Surg (2011) 13(5): 475-479 

Special conditions and circumstances related to Pneumothorax:

Catamenial pneumothorax – this a pneumothorax that occurs in menstruating women.  It usually occurs on the right-side and is associated with endometriosis, and defects in the diaphragm. A related case study can be viewed here.  Several recent studies suggest catamenial pneumothorax may be more common that previously believed and should be suspected in all women presenting with right-sided pneumothorax, particularly if pneumothorax occurs within 48 – 72 hours of menstrual cycle.  This may be the first indication of underlying endometrial disease.

Additional References

For more reference citations and articles about the less common causes  – see More Blebs, Bullae and Spontaneous Pneumothorax

Pneumothorax: an update – gives a nice overview of the different types of pneumothorax, and causes of each.

Medscape overview of pneumothorax – this is a good article with radiographs with basic information about pneumothoraces.

More on the difference between blebs and bullae – from learning

Lung resection for bullous emphysema

Japanese study suggesting Fibulin-5 protein deficiency in young people with pneumothoraces.

VATS versus tube thoracostomy for spontaneous pneumothorax

What’s worse than a spontaneous pneumothorax?  Bilateral pneumothoraces – a case report.

Early article suggesting VATS for treatment of spontaneous pneumothorax (1997)

Blebs, Pneumothorax and chest drains

[1] Flexible scopes are usually preferred for GI procedures such as colonoscopy, where the camera is inserted into a soft tissue orifice.  By comparison, the thoracic cavity with the bony rib cage is more easily navigated with the use of a firm instrument.

** I have contacted the primary authors on both of these papers for more information.

Like all materials presented on this site, this paper is presented for information only.  It should not be considered medical advice or treatment.  Also, all information provided is generalized information and (outside of clinical case presentations) is not intended to treat of diagnose any disease or condition.  If you have questions about the content, please contact us.  If you have medical questions, please consult your thoracic surgeon or pulmonologist.

Surgery for pleural infection: Empyema

second in a series of articles questioning whether thoracic surgery remains a relevant treatment for pleural diseases – as discussed in an article by Davies et. al.

In a previous post, we presented an article by Australian pulmonologists that challenged several of the current surgical treatments utilized in thoracic surgery for different pleural conditions.  In today’s post we will discuss Davies, Rosenstengel & Lee’s contention that fibrinolytics and thoracostomy drainage are superior versus surgical decortication and evacuation for treatment of empyema.  (An empyema is a collection of purulent material or pus from a lung infection that collects in the pleural space.  Additional references and information on this condition are listed below.)

Unfortunately, Davies are operating on a faulty premise – that all empyemas are currently managed with surgery or that current treatment theories support the use of surgery for uncomplicated empyemas.  For the most part, in early, and uncomplicated empyemas (stage I) – thoracostomy (chest tube placement) and antibiotics are the most common first line treatment. In fact, Na, Dikensoy & Light at Vanderbilt (2008) attributed the high mortality rates in this condition to the failure to pursue more aggressive( surgical) treatment after early evidence of treatment failure (with antibiotics, and thoracentesis.)  They, along with most of the thoracic surgery community, advocate surgery as treatment once initial conservative measures fail (as discussed in this article by Barbetakis  et. al(2011).

Davies also contends that thoracentesis is an effective measure noting that thoracostomy catheter size is not an issue, stating “Empyema fails to drain most commonly because of multiple septations, a hurdle which large drains will not overcome; increasing numbers of studies now show that larger drain size does not increase efficacy, even in empyema” as an argument against surgery – however – it is this very condition (septations) that is best served by surgery, where surgeons can physically break up and remove these pocketed areas of infectious material.


Photo courtesy of CTSnet – CT scan showing loculatations

While the Austrailian authors argue that the use of antibiotics has changed the treatment regimen of empyema in recent times, a look back at a previous article by our guest commentator shows this too, to be a dated approach.

Surgery is usually reserved for advanced empyemas, with patients presenting in septic conditions, or failure of conservative measures (antibiotics & chest tube treatment) or residual trapped lung following attempted drainage. (However, multiple authors content that the problem with the treatment of empyema is that surgery is not utilized early enough).

As commonly reported in the literature, advanced empyema (stage II or III) or empyema with septic presentation is a serious condition with patient mortality approaching or exceeding THIRTY percent.  In these cases, it can easily be argued that more aggressive (and rapid) treatment of these critically ill patients is warranted.  Many of these patients have already failed multiple rounds of antibiotics. Evacuation of the infected fluid is key to survival in these patients – and VATS decortication is the most effective way to remove the fibrinous material (that causes loculations and trapped lung.)  In these patients – treatment failures lead to rapid reaccumulation of purulent material (pus), and worsening of patient condition.

Another factor to be considered – is that many of these patients initially present to hospitals with later stage empyemas due to delayed diagnosis in outpatient settings.  These patients have loculations and evidence of trapped lung on initial CT evaluation.  Given the gravity of this condition, and the relative ease (and safety) of modern-day surgery by VATS – surgical intervention at this time is not unreasonable.   If we take practical issues into consideration – the risk of hemorrhage and bleeding with fibrinolytics not withstanding – VATS allows for direct visualization and manipulation within the pleural space.

Surgeons can physically and manually remove purulent material and necrotic tissue, and free compressed lung.  (in comparison – fibrinolytics such as t-Pa are injected blindly into the pleural space in an attempt to chemically dissolve fibrous tissue.)  These medications (which are also known as ‘clot busters’) can cause severe bleeding – particularly in these patients which often have very friable (or delicate) pleural tissue due to the extensive infection.

Conclusion: A review of existing literature and available studies shows mixed results – making Davies’s conclusions premature at best – and potentially harmful to this fragile subset of patients. For patients with advanced empyema, or empyema complicated by sepsis – surgical intervention remains the best course of treatment to reduce morbidity and mortality.

Additional references: (limited selection of more recent literature)

Overview and explanation of pleural abscess and empyema on Medscape.

Guidelines for surgical treatment of Empyema and Related Pleural Diseases (note these are pediatric guidelines but the article is clear, concise and well-written.)

Tuberk Toraks. 2008;56(1):113-20.  New trends in the diagnosis and treatment in parapneumonic effusion and empyema.  Na MJ, Dikensoy O, Light RW

Rahman et. al (2011) reported modest results in their double-blind randominzed study using fibrolytics versus placebo in “Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection,” with use of a combination of agents showing modest decrease in hospital stays and surgical referrals.  No benefit was seen with a single agent alone versus placebo.  There was no difference in the incidence of adverse outcomes in the treatment group versus placebo.  

Curr Opin Pulm Med. 2011 Jul;17(4):255-9.  Comparison of video-assisted thoracoscopic surgery and open surgery in the management of primary empyema.   Zahid I, Nagendran M, Routledge T, Scarci M.  (no free full text available.)   In comparison to Davies et. al,  Zahid et. al, contend that current evidence supports the use of early VATS decortication rather than conservative measures in this article, published in the same issue of Current Opinions in Pulmonary Medicine.

Clin Med Insights Circ Respir Pulm Med. 2010 Jun 17;4:1-8.  Empyema thoracis.  Ahmed AE, Yacoub TE.  While the authors cite fibrinolytics and thoracostomy for first line treatment in children (who rarely have underlying co-morbidities) – the authors readily concede that VATS decortication is the treatment of choice in adults.

Monaldi Arch Chest Dis. 2010 Sep;73(3):124-9.  Practical management of pleural empyema.  Tassi GF, Marchetti GP, Pinelli V, Chiari S.  (No free full text available).  The authors in this review of the literature acknowledge the effectiveness of VATS decortication for the treatment of empyema but recommend additional consideration of medical manangement particularly in more fragile patients.

Prilozi. 2010 Dec;31(2):61-70.  Indications for VATS or open decortication in the surgical treatment of fibrino-purulent stage of parapneumonic pleural empyema.  Colanceski R, Spirovski Z, Kondov G, Jovev S, Antevski B, Cvetanovski M V.  Article linked in text above, recommending early surgical treatment for better patient outcomes.  However, this study did not compare surgical treatments to medical therapies.

Asian Cardiovasc Thorac Ann 2010;18:337–43. Thoracic empyema in high-risk patients: conservative management or surgery?   Bar I, Stav D, Fink G, Peer A, Lazarovitch T, Papiashvilli M.  Limited study of 119 patients showing benefit in both groups of patients with surgery used as primary management strategy in clinically unstable patients.  (Increased mortality in this limited study of surgical interventions versus medical management can be easily attributed to the fact that surgery was used as a last resort in the sicker, more debilitated patients by the authors descriptions).

older references on VATS decortication:

J Thorac Cardiovasc Surg 1999;117:234-8. Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome.  Cassina PC et al.  Authors discuss the results of VATS decortication in 45 patients after failed medical treatment and attempted thoracostomy drainage.  Several patients required open thoracotomy due to late organized infectious process.

Ann Thorac Surg 2006;81:309-313.  Video-Assisted Thoracic Surgery for Pleural Empyema.  Wurnig, S. S.,Wittmer, V., Pridun, N., & Hollaus, P. H. (2006).  Linked in text above. Austrian study of 130 patients.

Article Re-post: Pre-operative evaluation for lung resection

by special request – a re-post of an article by Dr. Mazzonone, “Pre-operative evaluation of the lung Cancer Resection Candidate.”

I’ve had a lot of interest on this topic lately, so I would like to re-post an article,”Preoperative Evaluation of the Lung Cancer Resection Candidate” by Peter J Mazzone which was originally published in 2010.  Some of this has been covered before at Cirugia de Torax, but Dr. Mazzone does a particularly nice, comprehensive overview for readers. This article has been re-posted from in it’s entirety for all of my readers without journal access.

Peter J Mazzone, MD, MPH, FRCPC, FCCP
Respiratory Institute, The Cleveland Clinic, Cleveland, OH 44195, USA Tel.: +1 216 445 4812 Fax: +1 216 445 8160

From Expert Review of Respiratory Medicine

Preoperative Evaluation of the Lung Cancer Resection Candidate

Peter J Mazzone

Abstract and Introduction


Anatomical lung resection offers the best chance of cure for patients with localized lung cancer. Many people who have lung cancer have additional comorbidities, including other lung problems. Lung resection will affect our patient’s pulmonary function. When evaluating patients for lung resection we use measures of pulmonary function, predictions of postoperative lung function and measures of exercise capacity to determine their short- and long-term risks from resection. This article attempts to relate the evidence that is available regarding the physiologic evaluation of lung-resection candidates to guidelines that have been developed to help us coordinate our assessment. Testing algorithms are provided from these guidelines. In addition, perioperative considerations and alternative surgical approaches are discussed.


Surgical resection has the greatest chance of curing patients with localized lung cancer. Unfortunately, only 20–30% of individuals with lung cancer are found to be candidates for lung resection, owing to the stage of their disease or associated comorbidities.[1,2] Many patients with lung cancer are elderly and have a history of cigarette use. Thus, those being evaluated for lung resection frequently have comorbidities. A report demonstrated that 37% of individuals who present with anatomically resectable disease are deemed not to be surgical candidates based on poor lung function alone.[3] Understanding the prognosis without surgery, the expected early morbidity from lung resection and the potential loss of lung function related to the resection helps us to understand the importance of the preoperative pulmonary evaluation of lung resection candidates.

Poor Prognosis Without Lung Resection

Many series have described very poor outcomes in those who are unable or unwilling to have a curative intent lung resection for early-stage lung cancer. Without surgical treatment:

  • Patients who had been screen-detected stage I had a median survival of 25 months without surgical treatment. Symptom-detected stage I patients had a median survival of 13 months in one report;[4]
  • Screen-detected stage I patients had 5- and 10-year survival rates of 16.6 and 7.4%, respectively;[5]
  • Individuals with squamous cell carcinoma on sputum cytology with negative chest imaging had 5- and 10-year lung cancer survival rates of 53.2 and 33.5%, respectively;[6]
  • A total of 57 patients with resectable cancer had a median survival of 15.6 months, compared with 30.9 months in 346 patients who completed resection.[7]

Surgical Morbidity & Mortality

In the past decade, several large series have described modern operative mortality and early complications of lung resection. Others have attempted to identify factors that are associated with immediate postoperative complications:

  • A survey conducted in 2001 from 729 hospitals in the USA[2] reported on 11,668 surgically treated patients. The cohort was representative of the group that develops lung cancer. A total of 47% were aged 70 years or more and 76% had comorbidities. Perioperative mortality was 5.2%;
  • A report from 63 large institutions described 1023 lung cancer patients undergoing resection as part of a randomized trial (lymph node sampling vs lymph node dissection).[8] The median age of the group was 68 years. The operative mortality in this group was 1.3%, with complications reported in 38% of the patients;
  • A report of 46,951 lung cancer resections, with data obtained from the Nationwide Inpatient Sample data set from 1998 to 2004, reported an in-hospital mortality of 3.5%. The mean age of the patients was 66.3 years;[9]
  • A report of 512,758 lung resections performed from 1988 to 2002, with data obtained from the national Hospital Discharge Survey, reported an in-hospital mortality of 4.8% over that time. Over time, there were increases in the average age (63.2 years), the proportion of women (49.6%) and the proportion of lobectomies. There was a decrease in the hospital length of stay (9.1 days) and in listed complications (21.8%);[10]
  • A total of 9033 pulmonary resections for primary lung cancer were analyzed using information recorded in the Society of Thoracic Surgeons General Thoracic Surgeons database from 1999 to 2006. There were equal portions of men and women, with a median age of 67 years. Comorbidities were present in 79% of the group. Median length of stay was 5 days, operative mortality was 2.5% and postoperative complications occurred in 32% of the patients;[11]
  • A total of 4979 patients from the Society of Thoracic Surgeons General Thoracic Surgery database were reviewed to develop a risk-adjustment model for outcomes after lobectomy. Prolonged length of stay (>14 days) was found to be a surrogate of postoperative events and, thus, was used to develop the model. Predictors of a prolonged length of stay included age, Zubrod score, being male, the American Society of Anesthesiology score, insulin-dependent diabetes mellitus, renal dysfunction, induction therapy, percentage predicted forced expiratory volume in 1 s (FEV1) and smoking;[12]
  • A prospective evaluation of 168 patients undergoing lung resection demonstrated that up to 25% develop postoperative pneumonia. This increases to 48% if the airways are colonized at the time of surgery. Other predictors included the presence of chronic obstructive pulmonary disease (COPD), being male and the extent of resection. Standard measures of outcome, including mortality, are increased if pneumonia develops;[13]
  • Active smoking, dyspnea, age, the extent of surgery, vascular disease, diabetes mellitus and dysrhythmias have been variably associated with an increased risk of complications and/or mortality.[1,14–16]

Impact on Pulmonary Function of Standard Resection

It is important to consider the impact of resection on lung function and quality of life after operative recovery. Reports of the expected loss of lung function and exercise capacity are available. Variables that have been considered in some of the reports include the time postresection that loss of function is being assessed, the extent of the resection (lobe vs pneumonectomy), the presence of COPD at baseline (or the impact of the preoperative lung function) and the area of the lung being removed. The following points illustrate the available literature:

  • Unselected series have recorded postoperative FEV1 values of 81–91% of preoperative values when measured up to 6 months after lobectomy, and 64–66% after pneumonectomy;[17–20]
  • Unselected series have recorded postoperative diffusing capacity for carbon monoxide (DLCO) values of 82–89% of preoperative values when measured up to 6 months after lobectomy and 80% after pneumonectomy;[19,20]
  • Unselected series have recorded maximal oxygen consumption (VO2 max) values of 87–100% of preoperative values when measured up to 6 months after lobectomy, and 72–89% after pneumonectomy.[17–20] One study assessed VO2 max in pneumonectomy patients 3 years after resection. Values were 70% of baseline;[21]
  • Series that included only COPD patients, or compared patients with COPD with those without, described a smaller decline in FEV1 in those with COPD who had a lobectomy (0–8%) compared with those without COPD (16–20%).[22,23,20] The fall in DLCO and VO2 max was more variable (3–20% for DLCO; 0–21% for VO2 max);[23,20]
  • Measures of pulmonary function and exercise capacity increased from the time of surgery through at least 6 months in those who underwent lobectomy. Significant improvements were not seen beyond 3 months postpneumonectomy;[17,18,20]
  • The location of the resection can influence the degree of loss of lung function;[20]
  • The quality of life of individuals with resectable lung cancer tends to be lower than the general population. Physical measures have been shown to decline at the 1-month postoperative time but return to baseline by 3 months postoperatively. Mental measures may not decline throughout. Quality-of-life measures have a poor correlation with measures of pulmonary function or other high-risk patient features.[24]

The aforementioned studies demonstrate a poor prognosis for lung cancer when surgery is not an option, a reasonable morbidity and mortality related to standard resection despite an ill population, and a modest decline in lung function and exercise capacity from resection. In the remainder of this article, the author reviews the evidence that supports various means of assessing an individual’s pulmonary fitness, considerations related to preparing them for resection and opportunities for resection when standard criteria are not met. The evidence in each area is related to two recent guidelines published by the American College of Chest Physicians (ACCP)[25] and the European Respiratory Society (ERS) with the European Society of Thoracic Surgery (ESTS).[26]



Age is an identified as an independent predictor of complications from lung resection. Elderly age influences decisions related to resection.[27] A large study reported surgical rates of 14% in those aged over 70 years and 26% in those under 70 years of age. Pneumonectomy rates were 27% in those aged over 70 years and 37% in those under 70 years of age.[1]

There are many series describing outcomes of lung resection in the elderly.[28–41] These series span a long period of time, including different populations of patients. Outcomes reported and the period of follow-up have varied. The general concerns raised by the literature include a higher operative mortality in the elderly, relatively high operative risks for pneumonectomy and an increased risk of postoperative complications. The presence of comorbidities are more predictive of outcome than age alone.[40–41] Those who are elderly and are able to tolerate resection, survive longer than those who cannot undergo surgery (Table 1).

Table 1. Lung resection in the elderly.

Author (year) Age (years) Operative mortality (%) Survival (%), years Ref.
Evans (1973) 65–74
48, 4 L
31, 4 P
Kirsh et al. (1976) >70 14 30, 5 O
0, 5 P
Breyer et al. (1981) >70 3 42, 5 L
13, 5 P
Nagasaki et al. (1982) >70 [30]
Ginsberg et al. (1983) 60–79
Sherman et al. (1987) >70 9.4 36, 5 [32]
Ishida et al. (1990) >70 3 48, 5 [33]
Shirakusa et al. (1989) >80 12 55, 5 [34]
Roxburgh et al. (1991) >70 4.7 – L
9.1 – P
73, 2
67, 4
Riquet et al. (1994) >75 12.1 16, 5 [36]
Massard et al. (1996) >70 6.6 –L
10 – P
33, 5 [37]
Pagni et al. (1997) >80 3.7 86, 1
43, 5
Port et al. (2004) >80 1.6 38, 5
82, 5 IA
Birim et al. (2003) >70 3.2 37, 5 [41]
Brock et al. (2004) >80 8.8 73, 1
34, 5

IA: Stage IA; L: Lobectomy; O: Overall; P: Pneumonectomy.


The ACCP guidelines recommended that patients with lung cancer are not denied lung resection surgery on the grounds of age alone.

Standard Lung Function Testing

Many measures of pulmonary function have been studied as predictors of risk for lung resection. The following section describes the guidelines and evidence surrounding the use of the two most commonly applied tests, FEV1 and DLCO.


FEV1 is able to help predict the risk for postoperative complications including death. Absolute values and percent predicted values have been used.[42] It has been difficult to identify an absolute cut-off value, capable of consistently predicting surgical and long-term risks. An older series reported that 40% of patients with an FEV1 under 2.0 l and age over 60 years did poorly.[43] Preoperative values of 2 l for pneumonectomy and 1.5 l for lobectomy have been suggested as cut offs to allow surgery to occur without the need for additional testing. Other series have confirmed that individuals whose FEV1 is above these thresholds have a low risk of mortality.[43–45] Absolute FEV1 values represent a range of lung function based on an individual’s age, sex and height. Thus, FEV1 values expressed as percentages of normal have been used. In one report, those with a preoperative FEV1 under 60% predicted had an odds ratio of 2.7 for respirator complications and 1.9 for 30-day mortality.[42] Another group reported a mean FEV1 of 75% predicted in uncomplicated resections and 66% in complicated resections.[7] A value of 80% predicted or higher has been suggested in a reported algorithm as a cut off, which if met would permit resection without the need for additional testing.[46]

DLCO is a predictor of postoperative complications including death, length of hospital stay and hospital costs.[47–49] As mentioned previously, absolute cut offs are not clearly established in the literature. Individuals with a preoperative DLCO less than 60% predicted had a higher risk of respiratory complications, a higher risk of hospitalizations for respiratory compromise and lower median dyspnea scores in one report.[50] In another report, the mean DLCO was 77% predicted in those without complications and 67% in those with.[7] The FEV1 and DLCO have only a modest correlation with each other. A report found that 43% of patients with a FEV1 over 80% predicted had a DLCO under 80% predicted.[51]


The ACCP guidelines state that in patients being considered for lung cancer resection, spirometry is recommended. If the FEV1 is over 80% predicted or over 2 l and there is no evidence of either undue dyspnea on exertion or interstitial lung disease, the patient is suitable for resection including pneumonectomy without further physiologic evaluation. If the FEV1 is over 1.5 l and there is no evidence of either undue dyspnea on exertion or interstitial lung disease, the patient is suitable for a lobectomy without further physiologic evaluation.

The ACCP guidelines also state that in patients being considered for lung cancer resection, if there is evidence of either undue dyspnea on exertion or interstitial lung disease, even though the FEV1 might be adequate, measuring DLCO is recommended.

The ERS/ESTS guidelines state that DLCO should be routinely measured during preoperative evaluation of lung resection candidates, regardless of whether the spirometric evaluation is abnormal.

Predicted Postoperative Lung Function


Three strategies have been used to predict pulmonary function after lung-resection surgery.

Segment Methods When using a segment method, postoperative pulmonary function is predicted by calculating the portion of all bronchopulmonary segments that will remain after resection, then multiplying this portion by the preoperative lung function value. In a study that used 19 total segments as the starting value (ten on the right and nine on the left), the predicted postoperative lung function was found to have a good correlation with actual lung function for those undergoing lobectomy (r = 0.867), and a fair correlation (r = 0.677) for those undergoing pneumonectomy.[52] The actual lung function was consistently underestimated (by 250 ml for lobectomy and 500 ml for pneumonectomy). A second segment method based calculations on the total number of subsegments (42) then corrected for those that were obstructed by tumor preoperatively.[53] When a regression equation relating the predicted and measured lung function was applied, a good correlation between predicted and actual lung function was found (r = 0.821).

Radionuclide Scanning Techniques When using radionuclide scanning techniques, the relative function of the portion of lung to be resected is estimated by quantifying either the perfusion or ventilation to that area. Postoperative lung function is then calculated as the product of the preoperative function and the portion of lung function that will remain after resection as estimated by the scan. Studies using radionuclide scanning techniques have shown a fair-to-good correlation of the predicted and actual postoperative FEV1 (r = 0.63–0.88).[54–57] The correlation of predicted postoperative and actual DLCO has been as low as 0.68.[57]

Some studies have suggested the predictive capabilities of radionuclide scanning are less than ideal. One study found that only 41 out of 159 predicted postoperative values were within 5% of actual values.[58] Another found values of imprecision of 18–21%, despite showing reasonable correlation.[59] The estimates of postoperative lung function were better for lobectomy in the right lung than in the left. As with the segment methods, FEV1 was consistently underestimated, particularly if the starting value was lower.

Quantitative Computed Tomography When using quantitative computed tomography (CT) scanning, the volume of lung with attenuation between -500 and -910 Hounsfield units makes up the estimated functional lung volume. The functional lung volume in the area to be resected is calculated as a portion of the total functional lung volume. Using this technique, predicted postoperative lung function has correlated as well as or better than that calculated by radionuclide quantitative perfusion imaging in some studies.[60,61] As with the other techniques, predictions of postoperative lung function often underestimate actual lung function in those with COPD.[62] One study used quantitative CT scanning to develop a regression equation to estimate the predicted postoperative oxygen saturation, which has correlated with postoperative recovery time and cardiopulmonary complications.[63]

Comparison A study of 44 subjects compared predictions of postoperative lung function (FEV1, forced vital capacity [FVC], DLCO and VO2 max) based on five methods (radionuclide perfusion scan, quantitative CT and three segment methods – a standard segment method, functional segment method and subsegment method) with actual values obtained at 6 months post-resection. Perfusion imaging outperformed other methods for all measures regardless of the extent of resection or degree of obstruction. All other methods performed well in those who had a lobectomy. Segment methods did not perform well in those who had a pneumonectomy.[19] This finding was confirmed in a study of 32 patients who underwent pneumonectomy. Perfusion imaging prediction outperformed the segment method at the 3-year postresection time point.[21]


The ACCP guidelines state that in patients being considered for lung cancer resection, if either the FEV1 or DLCO are under 80% predicted, it is recommended that postoperative lung function be predicted through additional testing.

The ERS/ESTS guidelines state that the predictive postoperative (ppo)FEV1 should not be used alone to select patients with lung cancer for lung resection, particularly patients with moderate-to-severe COPD. It tends to underestimate the functional loss in the early postoperative phase and does not appear to be a reliable predictor of complications in COPD patients.

The ERS/ESTS guidelines also state that the first estimate of residual lung function should be calculated based on segment counting. Only segments not totally obstructed should be taken into account: the patency of bronchus (bronchoscopy) and segment structure (CT scan) should be preserved.

Furthermore the ERS/ESTS guidelines state that patients with borderline function should need imaging-based calculation of residual lung function: ventilation or perfusion scintigraphy before pneumonectomy, or quantitative CT scan before lobectomy or pneumonectomy.


The ppoFEV1 is an independent predictor of complications, including mortality in some reported series.[64–66] Absolute values for ppoFEV1 that would permit resection have been difficult to find. Examples from the literature include:

  • The mean ppoFEV1 in individuals who developed respiratory failure after surgery was 37.6% predicted normal and 42.3% in those who died. All individuals with a ppoFEV1 of less than 30% predicted normal developed respiratory failure or died;[67]
  • A total of 70% of individuals with a ppoFEV1 less than 35% predicted normal experience complications;[68]
  • Individuals with a ppoFEV1 greater than 34% predicted or greater than 58% of the preoperative value have a decreased postoperative mortality;[69,70]
  • A ppoFEV1 greater than 40% predicted normal was found to identify those at risk for mortality, with no deaths in those greater than 40%, and a 50% mortality rate in those less than 40%.[47]

The ppoFEV1 has been used to permit individuals to have resection who may have been denied on the basis of their absolute FEV1 value alone. Examples from the literature include:

  • Individuals with an FEV1 less than 2 l to undergo pneumonectomy if their ppoFEV1 was over 800 cc.[71] The operative mortality in these patients was 15%;
  • A study using the same criteria reported 61% survival at 1 year, 34% at 2 years and 5% at 5 years;[72]
  • Another group allowed resection if the ppoFEV1 was greater than 1 l. An operative mortality of 6.7% was found in those who had pneumonectomy. A total of 22 individuals who had preoperative FEV1 values less than 2 l, and 40 with FEV1 values less than 1.5 l would have been denied pneumonectomy and lobectomy, respectively, if not for the ppoFEV1 value. There were no postoperative deaths in these individuals;[44]

One study found the ppoDLCO to be a predictor of mortality, while others determined it to be an independent predictor of pulmonary complications, morbidity and death.[66,73–75] A ppoDLCO under 40% was reported to be a predictor of postoperative complications in patients with a normal FEV1.[51] A combined value, termed the predicted postoperative product (PPP), has been studied as a risk predictor. The PPP is the product of the ppoFEV1 and ppoDLCO. It was found to be the best predictor of surgical mortality in one study.[76] A PPP less than 1650 was found in 75% of those who died and 11% of those who survived surgery.


The ACCP guidlelines state that in patients with lung cancer who are being considered for surgery, either a product of % ppoFEV1 and % ppoDLCO of under 1650% ppo or an FEV1 of under 30% ppo indicates an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. It is recommended that these patients should be counseled about nonstandard surgery and nonoperative treatment options for their lung cancer.

The ERS/ESTS guidelines state that a ppoFEV1 value of 30% predicted is suggested to be a high-risk threshold for this parameter when included in an algorithm for assessment of pulmonary reserve before surgery. The ERS/ESTS guidelines also state that a ppoDLCO value of 30% predicted is suggested to be a high-risk threshold for this parameter when included in an algorithm for assessment of pulmonary reserve before surgery.

Exercise Testing

Exercise testing has been used to assess a patient’s fitness for lung resection. Symptom-limited cycle ergometry, exercise oximetry, stair climbing and shuttle walking have all been reported to be able to predict complications.


Exercise capacity, measured as the VO2 max during symptom limited cycle ergometry, has been reported to be a predictor of postoperative complications, including postoperative and long-term mortality.[7,77–85] A sample of the available literature is outlined in Table 2. A meta-analysis of available trials demonstrated that patients without complications had significantly higher levels of VO2 max and percentage predicted (by a mean of 3 ml/kg/min and 8%, respectively).[86]

Table 2. Cardiopulmonary exercise testing in the assessment of the lung resection candidate.

Author (year) Findings VO2 max (ml/kg/min unless stated) Ref.
Olsen et al. (1989) Mean VO2 max 11.3 in those without complications and 7.8 in those with [80]
Bolliger et al. (1995) ppoVO2 max < 10 associated with 100% mortality; mean VO2 max 62.8% predicted in those with complications, 84.6% in those without; ppoVO2 max 44% predicted in those with complications, 68% in those without [81]
Bolliger et al. (1995) Mean VO2 max 84% predicted in those without complications and 61% in those with VO2 max < 60% predicted in nine patients – eight had complications, three died [82]
Larsen et al. (1997) High mortality rate if VO2 max < 50% predicted [83]
Brutsche et al. (2000) VO2 max and extent of resection were independent predictors of complications [84]
Smith et al. (1984) All with VO2 max < 15 had complications [157]
Bechard et al. (1987) 29% mortality with VO2 max < 10, no morbidity or mortality if >20 [158]
Loewen et al. (2007) VO2 max of 65% predicted a predictor of complications and poor outcome [7]
Win et al. (2005) VO2 max 91.7% predicted in those with a satisfactory outcome, 65.9% in those with a poor outcome [85]
Brunelli et al. (2009) No deaths if VO2 max >20, 13% mortality if VO2 max was < 12 [87]

ppo: Predictive postoperative; VO2 max: Maximal oxygen consumption.

Exercise capacity has been used to determine if individuals with unacceptable lung function by other measures might be able to tolerate resection. One study permitted otherwise inoperable patients to undergo resection if their VO2 max was greater than 15 ml/kg/min.[77] Of the eight individuals who qualified, there were two complications and no deaths. Another study permitting resection when the VO2 max was greater than 15 ml/kg/min found a 40% incidence of complications but no deaths in the 20 patients who qualified.[78] A total of five individuals had surgery but did not reach 15 ml/kg/min. Of these five, one death was observed. The median survival in those who qualified for surgery based on the exercise test result was 48 months, while the survival in 37 individuals who did not meet criteria was 17 months. Another study concluded the risks were acceptable with a VO2 max of 10 ml/kg/min or greater, three flights of stairs climbed for a lobectomy and five flights for a pneumonectomy.[79] A report of 204 patients who had cardiopulmonary exercise testing (CPEX) regardless of their standard lung function parameters and went on to a lobectomy or pneumonectomy was published. They found that CPEX did not add to risk stratification if the FEV1 and DLCO were over 80%. In the group with either FEV1 or DLCO under 80%, but both ppoFEV1 and ppoDLCO over 40%, there were five deaths, three of which occurred in patients with a peak VO2 under 12 ml/kg/min. Three patients in this group were found to have cardiac ischemia requiring intervention at the time of their CPEX. They found that patients with ppoFEV1, ppoDLCO or both under 40% predicted could tolerate major resection if their peak VO2 max was over 10 ml/kg/min. Even those with a ppoFEV1 under 30% or PPP under 1650 tolerated resection reasonably well if the VO2 peak was over 10 ml/kg/min.[87]

Results from CPEX testing other than VO2 max have also been assessed as predictors of outcome. Oxygen delivery was found to discriminate between fatal and nonfatal complications. Those with fatal complications had an oxygen delivery less than 500 ml/min/m2, while those with nonfatal complications or no complications had an oxygen delivery greater than 560 ml/min/m2.[88] The change in diffusing capacity with exercise has also been studied.[89] An increase of less than 10% of the predicted DLCO occurred in all who had complications, while only 10% of those with an increase greater than 10% developed a complication. An increase of less than 5% of predicted DLCO was associated with mortality.


The ACCP guidelines state that in patients with lung cancer who are being considered for surgery, either an FEV1 of under 40% ppo or a DLCO of under 40% ppo indicates an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. It is recommended that these patients undergo exercise testing preoperatively.

The ERS/ESTS guidelines state that exercise tests should be indicated in all patients undergoing surgery for lung cancer with FEV1 or DLCO under 80% of normal values. The ERS/ESTS guidelines also state that cardiopulmonary exercise testing is performed in a controlled environment, and is reproducible and safe. VO2 peak measured during an incremental exercise on treadmill or cycle should be regarded as the most important parameter to consider, as a measure of exercise capacity and as highly predictive of postoperative complications.

The ACCP guidelines state that in patients with lung cancer being considered for surgery, a VO2 max of under 10 ml/kg/min indicates an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. These patients should be counseled about nonstandard surgery and nonoperative treatment options for their lung cancer. The ACCP guidlines also state that patients with lung cancer being considered for surgery who have a VO2 max of under 15 ml/kg/min and both an FEV1 and a DLCO of under 40% ppo are at an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. It is recommended that these patients be counseled about nonstandard surgery and nonoperative treatment options for their lung cancer.

The ERS/ESTS guidelines state that the following basic cut-off values for VO2 peak should be considered: over 75% predicted or over 20 ml/kg/min qualifies for pneumonectomy; under 35% predicted or under 10 ml/kg/min indicates high risk for any resection. Evidence is not sufficient to recommend cut-off values for lobectomy.


Exercise Oximetry The predictive value of oxygen desaturation has varied in the literature. A 4% or greater desaturation during standardized exercise has performed better than measures of FEV1 and DLCO in predicting respiratory failure, major morbidity, intensive care unit admission, length of stay and home oxygen requirements in some studies.[90,91] Another study that looked at oxygen desaturation during a shuttle walk test did not find it to be predictive of outcome.[92]

Stair Climbing The number of steps climbed has shown a fair correlation with FEV1, DLCO, VO2 max and minute ventilation.[93,94] The ability to climb stairs has been used to estimate the risk of complications and mortality related to lung resection. A sample of the literature includes:

  • The ability to climb three flights of stairs (25 steps per flight) was associated with lower rates of postoperative intubation, fewer complications and a shorter hospital stay;[95]
  • A study of high-risk individuals showed a climb of 44 stairs (each 0.17 m high) could predict a good outcome;[96]
  • A study of 160 lung resection candidates found the altitude reached during the stair climb was the only independent predictor of complications (14.6 m in those with complications versus 20.6 m in those without complications). The authors suggested a cut off of 12 m be used to predict the tolerability of resection;[97]
  • A report of 640 patients who performed stair climbing prior to resection showed that the altitude reached was associated with cardiopulmonary complications, mortality and costs. A cut off of 12 m altitude had a positive predictive value of 40% for morbidity and 13% for mortality with a negative predictive value of 78% for morbidity and 97% for mortality;[98]
  • Those who are unable to perform a maximal stair climbing test due to underlying comorbidities have been found to have an increased risk of mortality after major lung resection.[99]

Other Measures of Exercise Capacity The distance obtained during a shuttle walk test, where an individual walks back and forth over a defined distance at an incremental and progressive rate, has correlated well with VO2 max obtained on a treadmill. Walking 25 shuttles (10 m each) approximated a VO2 max of 10 ml/kg/min.[100,101] Some have suggested that the shuttle walk distance may not predict surgical outcome.[102]

A 6-min walk test distance of 1000 feet or greater has been found to predict positive outcome.[96] It was the best predictor of postoperative respiratory failure in another.[76]


The ACCP guidelines state that patients with lung cancer being considered for surgery who walk under 25 shuttles on two shuttle walks or less than one flight of stairs are at increased risk for perioperative death and cardiopulmonary complications with standard lung resection. These patients should be counseled about nonstandard surgery and nonoperative treatment options for their lung cancer.

The ERS/ESTS guidelines state that shuttle walk test distance underestimates exercise capacity at the lower range and was not found to discriminate between patients with and without complications. Thus, it should not be used alone to select patients for operation. It could be used as a screening test: patients walking less than 400 m may have VO2 peak under 15 ml/kg/min. The ERS/ESTS guidelines also state that the standardized symptom-limited stair climbing test is a cost-effective test capable of predicting morbidity and mortality after lung resection better than traditional spirometry values. It should be used as a first-line functional screening test to select those patients that can undergo safely to operation (height of ascent >22 m) or those who need more sophisticated exercise tests in order to optimize their perioperative management.The ERS/ESTS guidelines then state that the 6-min walk test should not be used to select patients for operation.


Based on the above listed guidelines, both the ACCP and ERS/ESTS have produced algorithms for the preoperative pulmonary evaluation of lung cancer resection candidates (Figures 1 & 2).[25,26] The major differences in the algorithms are the recommendations for when to obtain a DLCO measure, and when to perform exercise testing. Minor differences in cut-off values for the various measures exist. The evidence used to support the content of these algorithms has been described in detail previously. Clearly, this evidence has been interpreted differently by the two groups. It is important to note that the two evaluation algorithms have not been validated, compared with each other, or compared with other existing algorithms.[45,46,102,103]

                                    Figure 1.                                                                         Preresection testing algorithm proposed by the American College of Chest Physicians.
CPET: Cardiopulmonary exercise testing; CT: Computed tomography; CXR: Chet x-ray; DLCO: Diffusing capacity for carbon monoxide; FEV1: Forced expiratory volume in 1 s; ppo: Predictive postoperative; VO2 max: Maximal oxygen consumption.
Reproduced with permission from [25].



                                    Figure 2.                                                                         Preresection testing algorithm proposed by the European Respiratory Society-European Society of Thoracic Surgeons.
DLCO: Diffusing capacity for carbon monoxide; FEV1: Forced expiratory volume in 1 s; ppo: Predictive postoperative.
Reproduced with permission from [26].



Alternative Surgeries


Lung Volume Reduction Surgery In select patients with severe emphysema, removal of the most emphysematous portion of their lung can lead to improvements in lung function.[104–106] Individuals with severe emphysema are at risk for lung cancer due to shared risk factors. Lung nodules are often found during the preoperative evaluation. Localized lung cancer has been found in approximately 5% of those undergoing lung volume reduction surgery.[107] Resection has been reported to be possible in individuals who do not meet standard criteria by using lung volume reduction surgery where appropriate. A lobectomy may be performed if a cancer is present in the lobe that will undergo lung volume reduction, whereas lesser resections are combined with volume reduction if cancer is found in a different lobe. A summary of some of the case series described is given in Table 3.[22,108–113] In addition to improvements in lung function, properly selected candidates have seen durable quality-of-life improvements, similar to those without lung cancer.[113]

Table 3. Outcomes of nodule resections during lung volume reduction surgery.

Author (year) Patients (n) Cancer (n) Preop FEV1 (% predicted) Postop FEV1 (% predicted) Mortality (%) Ref.
Choong et al. (2004) 21 21 29.0 40.0 0 [108]
Edwards et al. (2001) 14 14 40.7 41.5 14 [22]
DeRose et al. (1998) 14 9 27.0 35.0 7 [109]
DeMeester et al. (1998) 5 5 29.6 42.3 0 [110]
Ojo et al. (1997) 11 3 26.2 38.5 0 [111]
McKenna et al. (1996) 51 11 21.7 49.0 0 [112]
Pompeo et al. (2003) 16 16 0.92* 1.20* 0 [113]

*Actual value in liters as % predicted not available.
FEV1: Forced expiratory volume in 1 s; Postop: Postoperation; Preop: Preoperation.

Sublobar Resections For early-stage lung cancer, the resection of choice is a lobectomy. In general, those who undergo a lobectomy have a lower rate of locoregional recurrence than those who have a sublobar resection.[114] There is evidence that sublobar resections still play a role in lung cancer treatment, particularly in those at most risk from a standard resection. The FEV1 is a significant prognostic factor for death by nonlung cancer causes in individuals with stage I lung cancers.[115] Thus, individuals with a very low FEV1 may not survive long enough to enjoy the benefits of lobectomy for reasons unrelated to their lung cancer. The literature in this area is difficult to interpret, as many studies have reported contradictory findings. In general, the age of the patient and the size of the tumor have been reported to influence the potential risks and benefits of sublobar resections. Acceptable morbidity and mortality has been reported in series of patients with what would be considered prohibitively low pulmonary function measures by most guidelines. A sample of the literature follows:

  • A report of 14,555 patients from the Surveillance, Epidemiology and End Results (SEER)’s registry who had lung resection for stage I or II lung cancer found a benefit from lobectomy over a sublobar resection in younger individuals. The difference in survival disappeared after 71 years of age;[116]
  • One report found 5-year survivals of 92.4, 96.7 and 85.7% for lobectomy, segmentectomy and wedge resection, respectively, in tumors that were 20 mm in diameter or smaller.[117] For tumors larger than 20 mm, the survival gaps were wider at 87.4, 84.6 and 35.4% for lobectomy, segmentectomy and wedge resection, respectively. None with a tumor larger than 30 mm who had a wedge resection survived at 5 years;
  • No difference in oncologic outcome between anatomical segmentectomy and lobectomy was noted for tumors less than 2 cm in diameter;[118]
  • In 784 individuals resected for stage I lung cancer, including 207 who had sublobar resections, the hazard ratio for disease-free survival and overall survival in those who had a sublobar resection was 1.2 and 1.39, respectively.[119] When divided into stage IA and IB, the entire difference appeared to come from the stage IB group;
  • A report of 215 patients with T1N0M0 lung cancer, 147 treated with lobectomy, 47 with wedge resection and 19 with radiation therapy, found 1- and 5-year survival rates of 97 and 68% for lobectomy, 98 and 74% for wedge resection, and 80 and 39% for radiation therapy, respectively;[120]
  • Another group reported resection outcomes of 219 patients with stage IA lung cancer, with 117 treated with lobectomy, 60 with video-assisted thoracoscopic surgery (VATS) wedge resection, and 42 with open wedge resection.[121] The corresponding 1- and 5-year survivals were 91 and 70%, 95 and 65%, and 94 and 58%, respectively. The noncancer death rate was 38% in the wedge groups combined and 18% in the lobectomy group;
  • In some populations (e.g., adenocarcinoma in a Japanese study), limited resection has been reported to uniformly lead to cure;[122]
  • Some have shown that anatomical segmentectomies lead to similar outcomes when compared with lobectomies with less loss of lung function and better oncologic results when compared with wedge resections.[123] Others have suggested wedge resection leads to similar oncologic results when compared with lobectomy for stage I lesions.[124] Still, others have reported lobectomy to be superior to wedge resection mainly for smaller tumors;[125]
  • Sublobar resections have been reported to be safely performed in individuals with poor lung function. A report of 100 individuals with a preoperative FEV1 less than 35% predicted showed a 30-day postoperative mortality of 1% and a complication rate of 36%.[126] A total of 65% of resections were thoracoscopic wedge resections, and 8% included a lung volume reduction procedure;
  • Individuals with poor lung function who underwent resection were more likely to survive the perioperative period if they had a performance status of less than 2, less than two concomitant diseases and COPD as the cause of their low FEV1.[127]

Changes in Pulmonary Function with Sublobar Resection There is not much literature regarding the differences in loss of pulmonary function when a lobectomy is performed compared with when a sublobar resection is performed. One study reported the 12-month postoperative FEV1 to be 93.3% of the preoperative value in patients with normal lung function who underwent segmentectomy.[128] This was compared with a value of 87.3% of the preoperative value in those who had a lobectomy. Another report comparing changes in pulmonary function after lobectomy and segmentectomy for stage I lung cancer found that the FVC, FEV1, maximum voluntary ventilation and DLCO all decreased after lobectomy.[129] Only the DLCO was decreased in those who had a segmentectomy. A final report reviewed 40 patients who had undergone thoracotomy – 13 had a wedge resection, 14 a lobectomy and 13 a thoracotomy alone due to finding an inoperable tumor.[130] There was no decline in measures of pulmonary function or exercise capacity in the wedge resection group. Similar declines were seen in the lobectomy and thoracotomy alone groups (perhaps a result of progression of the tumor or the effect of radiation therapy in the thoracotomy alone group).

Difficulties with Sublobar Resections Accurate staging, obtaining clean resection margins, and conversion to larger surgeries are potential problems with sublobar resections. A sample of the literature follows:

  • One study investigated the feasibility of performing thoracoscopic wedge resections with radiation therapy for clinical T1 lesions in individuals with compromised cardiopulmonary status.[131] Clinical staging was often inaccurate, with 28% of patient upgraded and 17% found to have benign lesions at resection. Conversion to thoracotomy was required in 13% of T1 cancers and 31% of T2 cancers. Resection margins were positive in 6% of T1 cancers and 23% of T2 cancers. Operative failure rates were 22% for T1 cancers and 50% for T2 cancers. Pathologically staged T1 lesions were successfully resected in 75% of cases with narrow resection margins noted;
  • Another study reviewed the pathology of 31 T1N0M0 lesions that had been diagnosed by wedge resection, which then proceeded to completion lobectomy.[132] They found the average microscopic margin was 2.3 mm and noted microscopic growth beyond the gross perimeter of 7.4 mm. A total of 17 of the lobectomy specimens were free of cancer while cancer was found in the other 14;
  • One group reported 167 stage IB patients, 126 of whom received a lobectomy and 41 a sublobar resection with intraoperative brachytherapy. They reported similar local recurrence rates, disease-free and overall survivals in the two groups;[133]
  • Another group compared results from wedge resection with and without brachytherapy delivered by placement of a radioactive mesh at the resection margin. There was no difference in morbidity, mortality or survival but there was a decrease in local recurrence in the group that received the mesh (19 vs 2%);[134]
  • A different group reported the results of 48 patients who underwent wedge resection and brachytherapy delivered through three catheters placed at the resection margin at the time of surgery. Two patients had local recurrence over variable follow-up times. The authors felt the technique performed well from a safety standpoint;[135]
  • Location of the segmentectomy and resection margins were reported to influence the rate of local recurrence. Resection of segments within the S1–3 region had higher rates of recurrence.[136]


The ACCP guidelines state that in patients with very poor lung function and a lung cancer in an area of upper lobe emphysema, it is recommended that combined lung volume reduction surgery and lung cancer resection be considered if both the FEV1 and the DLCO are more than 20% predicted.

The ERS/ESTS guidelines state that anatomical lobectomy with or without complementary LVRS should be performed in well-selected COPD patients with lung cancer. The ERS/ESTS guidelines also state that anatomical segmentectomy could be recommended in the following situations:

  • Stage IA (tumor size 2–3 cm) that has margins of resection over 1 cm;
  • Stage I in patients with poor lung function;
  • Lung resection after prior lobectomy.

ERS/ESTS: wedge resection could be recommended in the following situations:

  • Stage IA (tumor size < 2 cm);
  • Small peripheral adenocarcinoma with an air-containing image (ground glass opacity) on high-resolution CT scan.

Perioperative Considerations


Level of Care Patients who undergo resection for lung cancer at hospitals performing large numbers of such procedures have fewer perioperative deaths and survive longer than those whose surgery is performed at hospitals with a low volume.[2,137] Patients who see physicians with a higher volume are more likely to have their cancers histologically confirmed and to receive active treatment for their cancer.[138] Patients who are diagnosed by or referred to a specialist within 6 months of diagnosis have been shown to have a lower risk of death.[139] In-hospital mortality postlung resection is lower at teaching hospitals than nonteaching hospitals, independent of patient volume.[9] The establishment of a multidisciplinary lung cancer team at a single center resulted in more patients with inoperable non-small cell carcinoma receiving active treatment and a prolonged survival when compared with results from immediately prior to the team being established.[140]


The ACCP guidelines recommended that patients with lung cancer be assessed for curative surgical resection by a multidisciplinary team, which includes a thoracic surgeon specializing in lung cancer, a medical oncologist, a radiation oncologist and a pulmonologist.

The ERS/ESTS guidelines state that the management of lung cancer patients must be performed by multidisciplinary teams (a thoracic surgeon specializing in lung cancer, a medical oncologist, a radiation oncologist and a pulmonologist). The ERS/ESTS guidelines also state that the surgical treatment of lung cancer patients must be performed in specialized centers by qualified thoracic surgeons, since specialization has been shown to have a positive impact on respectability, postoperative mortality and long-term survival. The ERS/ESTS guidelines then say that surgical volume has been shown to have a positive impact on respectability, postoperative mortality and long-term survival. Lung cancer surgery should be performed in centers with an adequate volume of cases (although volume thresholds reported in the literature varied in size and definition, a minimum surgical volume of 20–25 major lung resections per year, lobectomy or pneumonectomy, should be advised).


Smoking Cessation Current and former smoking has been shown to be a risk factor for postoperative pulmonary complications.[141,142] A paper from the cardiac surgery literature found that the surgical candidate needed to quit smoking 8 weeks prior to surgery to decrease the risk of pulmonary complications.[141] A second report of individuals undergoing a variety of surgeries found that a reduction of the amount smoked near the time of the surgery led to an increased risk of pulmonary complications.[142] A few reports are available from the thoracotomy literature. One study found that individuals who continue to smoke within 1 month of a pneumonectomy are at increased risk for developing major pulmonary events.[143] Another study was unable to find a paradoxical increase in pulmonary complications among those who quit smoking within 2 months of undergoing thoracotomy.[144] The sooner one is able to quit, the more likely it is that he or she will remain abstinent after surgery.[145]

Ancillary Care There is no direct evidence to support an additional role for bronchodilators and antibiotics in the lung resection candidate beyond what would be considered standard use for COPD or asthma. Little evidence exists to support the use of anti-inflammatory medications in the perioperative period. One report suggested that corticosteroid treatment suppresses cytokine production in resected lung specimens studied in vitro.[146] A second report suggested that administering clarithromycin prior to and after surgery leads to a reduction in clinical features of the systemic inflammatory response syndrome.[147] Traditional outcome measures, such as complications and mortality, could not be commented on.

Inspiratory muscle training and the use of incentive spirometry before and after resection have been reported to decrease the risk of postoperative pulmonary complications and to improve lung function outcomes.[148,149] A report of short-term noninvasive ventilation after lung resection showed improvement in oxygenation without worsening air leaks.[150] The effect of this intervention on other major complications was not reported. A separate group randomized 32 patients with a FEV1 less than 70% predicted who were scheduled for a lobectomy for lung cancer to noninvasive pressure support ventilation for 7 days prior to (1 h five-times daily) and 3 days after resection. They found improved FEV1, FVC, partial pressure of arterial oxygen (PaO2) and shorter hospital stays in the intervention group.[151] The use of thoracic epidural analgesia through the postoperative period has been associated with fewer respiratory complications (OR: 0.6) and a lower 30-day mortality.[42]

Perioperative Pulmonary Rehabilitation A report of eight patients who were denied resection based on poor lung function but then underwent 4 weeks of intensive inpatient pulmonary rehabilitation demonstrated that all eight were able to improve measures of lung function and exercise tolerance enough to permit the resection to occur. All survived resection, with only one requiring long-term oxygen therapy.[152] Another group identified lobectomy candidates with COPD who had a VO2 max less than 15 ml/kg/min. A total of 12 such subjects were enrolled in 4 weeks of preoperative rehabilitation. Standard measures of lung function did not change but the VO2 max increased by 2.8 ml/kg/min on average. The group had acceptable surgical morbidity and no deaths.[153] A study of ten patients with an FEV1 55% predicted, DLCO of 45% and significant limitation after resection found that 8 weeks of multidisciplinary inpatient rehabilitation led to improvement in the 6-min walk distance by 43.2% and exercise capacity by 34.4%, without a change in standard measures of pulmonary function.[154] Another group studied 618 individuals undergoing lung resection, 211 of whom were eligible for inpatient pulmonary rehabilitation.[155] A total of 25 patients agreed to participate in the 4-week program, and the other 186 were used as controls. Those who participated had poorer lung function at baseline. Rehabilitation took place 3 h per day, 5 days per week. Significant gains in the Borg dyspnea scale and 6-min walk distance were realized in the treated subjects. Their lung function was stable compared with baseline values. The control group deteriorated in all measures when taken 1 month postresection. The differences between the treated and control groups that existed at baseline were no longer present at the end of training.


The ACCP guidelines recommended that all patients with lung cancer be counseled regarding smoking cessation.

The ERS/ESTS guidelines state that smoking cessation of sufficient duration (2–4 weeks) before surgery should be recommended, since it may change the smoking behavior perioperatively and decrease postoperative complications. The ERS/ESTS guidelines also state that early pre- and postoperative rehabilitation should be recommended, since it may produce functional benefits in resectable lung cancer patients. Candidate selection, late outcomes (i.e., postoperative complications and death), and program content and duration need to be further investigated.


This article has detailed the rationale for pursuing a detailed pulmonary evaluation for potential lung resection candidates. There is an extensive amount of literature available to help guide us, as well as two recent sets of published guidelines.[25,26] As is highlighted by the differences within these guidelines, your approach to an individual patient should be based on your understanding of the available literature, your sense of your patient’s risk tolerance and knowledge of the strengths of your lung cancer team.

Expert Commentary

The decision to recommend lung resection as curative intent therapy for a patient with localized lung cancer can be a difficult one. There is a substantial body of literature available to help us predict someone’s risk of complications or mortality related to the cancer and/or the treatment. Two recent sets of guidelines help to summarize the available literature and put it into context. Despite this, there are very few absolute indicators of safety or excessive risk. Thus, many factors need to be considered when making a decision with an individual patient whose lung function is borderline, based on the previous literature and guidelines. I consider some of the following. Are there other options with more acceptable risk to benefit profiles? What type of risk tolerance does my patient have? What testing and treatment options are available in your area, and what are the strengths of my lung cancer team?

At present, in my clinic, I use the ACCP guidelines as a framework for my evaluation then individualize decisions with my patient’s characteristics and wishes in mind. I often do get both an FEV1 and DLCO as the initial testing both because I feel they are important and it is most practical to test them together. I believe the evidence is not strong enough to support the position of cardiopulmonary exercise testing within the ERS/ESTS guidelines. To simplify matters even further, one can focus on three numbers. First is 80% – if the FEV1 and DLCO are above 80% predicted then additional testing is not required. Second is 40% – if the ppoFEV1 or ppoDLCO is below 40%, then exercise testing should be performed. Third is 10 – if the VO2 max or its equivalent is below 10 ml/kg/min then alternative strategies for treatment should be discussed.

Recent advances have provided us with other options. Advances in perioperative support, sublobar resections, stereotactic body radiotherapy and radiofrequency ablation have provided us with options to discuss with our patients. Although the exact risks and benefits of these treatment modalities require clarification, they provide an opportunity to remain curative in our therapeutic intent in situations where we previously had only poor alternatives to surgery. Individual patients will have different tolerances to the risks and benefits of any approach that is outlined to them. One patient may consider a slightly higher cure rate worth the risk of a potentially lower postoperative activity tolerance, while another may not.

Advances that occur in our ability to predict functional outcomes, in surgical techniques, perioperative care, as well as pre- and postoperative medical and wellness management will continue to shift the thresholds that are used to assess the risks related to resection. Advances in testing related to early diagnosis, molecular prognosis and prediction of response to therapies will allow us to better predict the benefits of our chosen treatment plan. The final decision will always be made at the level of the individual patient.

Five-year View

In the next 5 years, several advances will occur that could influence our ability to judge the risks and benefits of lung resection. Additional tests of cardiopulmonary fitness whose predictive abilities could be validated include steady-state cardiopulmonary exercise testing, the impact of hyperinflation and air trapping on outcomes, the evaluation of daily physical activity, and DLCO changes with exertion. Preoperative sputum and exhaled gas analysis may influence perioperative treatment decisions in an attempt to mitigate risks. Imaging advances may allow us to more accurately predict postoperative lung function. Usable indices will be developed to help us predict immediate and delayed lung function changes as well as complications. The risks of resection will slowly decline as minimally invasive resections become more common and perioperative management advances become more generalized. We will gain knowledge about the true risks and benefits of alternatives to anatomical resections, such as sublobar resections (with and without locally delivered radiotherapy), stereotactic body radiotherapy and radiofrequency ablation. We will learn how to assess the nature of each individual’s lung cancer, allowing us to apply the most aggressive therapies more selectively. We will have more tools to allow us to have personalized discussions about the appropriate selection of treatment for each of our patients.


Key Issues

  • There is a poor prognosis for lung cancer when surgery is not an option, a reasonable morbidity and mortality related to standard resection despite an ill population, and a modest decline in lung function and exercise capacity from resection.
  • Lung resection should not be denied on the basis of age alone.
  • The forced expiratory volume in 1 s and diffusing capacity for carbon monoxide are measures of pulmonary function most commonly used to assess someone’s ability to tolerate resection.
  • There are several methods available to predict postoperative lung function. Most tend to underestimate actual postoperative lung function.
  • Exercise testing can be used to help determine who may tolerate lung resection.
  • Guidelines and testing algorithms are available to help you incorporate pulmonary function and exercise testing into decisions regarding patient’s ability to tolerate standard lung resection.
  • Alternatives to standard lung resection, including lung volume reduction surgery, sublobar resections, stereotactic body radiotherapy and radiofrequency ablation, are available. Our understanding of the outcomes, risks and benefits of these standard resection alternatives is evolving.


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    Papers of special note have been highlighted as:
    • of interest
    •• of considerable interest

Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.

Expert Rev Resp Med. 2010;4(1):97-113. © 2010 Expert Reviews Ltd.

Mazzone, P. J. (2010).  Preoperative Evaluation of the Lung Cancer Resection Candidate. Expert Rev Resp Med. 2010;4(1):97-113. © 2010 Expert Reviews Ltd

Dental hygeine and post-operative pneumonia in esophageal cancer patients

In an investigational study, Akutsu et. al. (2010) demonstrated a significant reduction in post-operative pneumonia through the implementation of a dental hygiene program.

A Japanese study suggests that one of the most important ways to reduce post-operative risk is also the easiest – by practicing good dental hygiene.  While research has previously linked coronary artery disease (CAD) with dental plaque and chronic gum inflammation – two articles by Akutsu et. al (2010) in Japan have shown a reduction in post-operative pneumonia in esophageal cancer patients through the use of dental hygiene regimens.

The first of these articles in an overview of several factors to reduce post-operative risk, and was previously mentioned in another post:

Akutsu, Y. & Matsubara, H. (2009) Perioperative Management for the Prevention of Postoperative Pneumonia with Esophageal SurgeryAnn Thorac Cardiovasc Surg. 2009 Oct;15(5):280-5. (free full text).  This is a well written report by Japanese surgeons on several techniques to reduce post-operative pneumonia.  Several of these items can be directly implemented by patients – such as pre-operative smoking cessation, pulmonary rehabilitation and good dental hygiene.

The second article, “Pre-operative dental brushing can reduce the risk of post-operative pneumonia in esophageal cancer patients” was published in Surgery (2010, Apr; 147(4) 497-502.)  The authors conducted an investigational study using 86 thoracic surgery patients scheduled to undergo esophagectomy.  A control group of 41 patients and the dental hygiene (treatment) group consisting of 45 patients.

The dental hygiene group underwent no special dental procedures or cleanings but were instructed to brush their teeth five times a day.

The results showed a dramatic decrease in the incidence of post-operative pneumonia in the treatment group.  32% of the control group developed pneumonia post-operatively compared to only 9% of the toothbrushing group.  12% of the patients in the control group required tracheostomy due to the development of pneumonia (and prolonged respiratory support).  No members of the treatment group required tracheostomy.

While the study size is relatively small – the results show an impressive reduction in post-operative pneumonia for a fairly small investment (increased tooth brushing/ dental hygiene.)

Pre-operative Incentive Spirometry for Pneumonia Prevention

Another study confirming the importance of pre-operative respiratory exercises for surgical patients – this one looking at cardiac surgery patients and the incidence of post-operative pneumonia.

Shared content from sister site.

Another study confirms the utility of using an incentive spirometer (IS) and performing ‘pulmonary toileting’ prior to surgery.  The study, re-posted below looks at the rate of post-operative pneumonia in cardiac surgery patients.

Patients were stratified into two groups; one group received pre-operative IS teaching several weeks before surgery and the other didn’t.  Results: a dramatic reduction in post-operative respiratory complications – confirming what we know (and taught our patients about).

If you don’t have your incentive spirometer – take the deepest breath you can (inhale slowly.. over 2-3 seconds), hold for ten seconds, slowly exhale.  Repeat ten times, then rest..  Do this several times a day – along with coughing exercises..(and get your incentive spirometer)

Article Re-post:

Preop Deep-Breathing Exercises Cut Pneumonia Risk After Cardiac Surgery

By Anne Harding

NEW YORK (Reuters Health) Jun 03 – Using an incentive inspirometer for a few weeks before cardiac surgery can help high-risk patients avoid pneumonia, new research confirms.

“The idea of the inspiratory muscle training before surgery is that if you increase your inspiratory muscle function before surgery, you can do your deep breathing exercises after surgery better and therefore the pulmonary complications can decrease after surgery,” researcher Karin Valkenet of the University Medical Centre Utrecht in the Netherlands told Reuters Health.

On Wednesday at the American College of Sports Medicine’s annual meeting in Denver, she reported that cardiac surgery patients in her study who did not receive at least two weeks of preop inspiratory muscle training (IMT) were three times as likely to develop pneumonia.

Valkenet’s study follows a 2006 paper in the Journal of the American Medical Association by another team from her center, which reported on 279 high-risk patients undergoing coronary artery bypass grafting (CABG) In that study, 6.5% of the IMT group developed pneumonia, compared to 16.1% of controls. Overall, 18% of the IMT group had postoperative pulmonary complications, compared to 35% of controls.

In the new study, Valkenet and her colleagues enrolled patients with diabetes, productive coughing in the previous five days, or impaired pulmonary function. Ninety-four such high-risk patients were given incentive inspirometers, trained to use them, and told to practice for 20 minutes a day at home. Their starting load was 30% of maximal inspiratory pressure, which they increased based on their perceived exertion.

Another 252 high-risk patients served as controls.

One patient in the IMT group developed pneumonia, compared to eight patients in the control group. While the difference was not statistically significant given the low number of events, Valkenet and her colleagues were able to show a relative risk of 2.9 for the patients who didn’t undergo the training, based on a propensity score analysis.

“The data confirms the randomized, controlled data that was published earlier so that’s very good news for us,” Valkenet said”.  [end of re-post]

Remember – this advice goes for all surgical patients – especially lung surgery patients, in addition to heart (cardiac surgery) patients.

The Benefits of Exercise in Thoracic Patients

A look at the literature, including a recent systemic review: exercise is not only safe for lung cancer patients – but improves quality of life, and may (according to Jones) improve post-operative outcomes..

There’s an article ( Jones et. al 2010) on the benefits of pre-operative and post-operative exercise regimens for patients with lung cancer, that was conducted down at Duke. They use a lot of abbreviations in the article, but the gist is that a patient’s post-operative risk can be determined by their peak oxygen consumption (which is measurable), and that this can be modified (improved) prior to surgery with a targeted fitness program. This program notably included weight training in addition to aerobic exercise.

A systematic review was recently published (Feb 2011) looking at a compilation of these types of studies to give an overview of the preponderance of evidence by Granger et. al. This isn’t an open access article so I can’t post the link here – but I can link the abstract which is a short summary of his findings..

So basically Granger looked at the above mentioned study, and fifteen others – and drew limited conclusions.. He limited his conclusions to saying exercise was safe, and helpful in lung cancer patients and improved the ‘health related quality of life’. It’s a bit different from what Jones had to say – but the message is the same; exercise is not only safe for lung cancer patients – but improves quality of life, and may (according to Jones) improve post-operative outcomes..

Nagarajan et al. (2011) reviewed several published papers on the topic of pulmonary rehabilitation in an effort to answer the questions of whether pre-operative pulmonary rehabilitation reduced post-operative complications & overall length of stay.  While they were unable to conclusively answer these questions – they did find that pre-operative pulmonary rehabilitation increased exercise capacity, and preserved pulmonary function in patients with COPD.  This may not sound important – until you realize that these are critical measures of quality of life. (for example – what if “increased exercise capacity” means a person can now walk to around their home, and perform daily activities of living such as showering and getting dressed without becoming short of breath?)

Here’s your helmet

If you knew now that you were going to be in a horrible but completely unavoidable car accident in a few weeks -you’d do things differently, wouldn’t you? You’d make sure to be in a car with the maximum amount of safety features (we’d all be in Volvos) with 6 air bags, automatic assisted braking, five point seatbelts and helmets. You’d do all of this, to ensure your survival. You wouldn’t just hop into a pinto and drive off to work..

I’ve always considered esophagectomies (surgical treatment for esophageal cancer) to be the ‘open heart’ procedure of Thoracic Surgery. It’s a big surgery on precariously positioned patients, which often represents the only hope for definitive treatment or potential cure.

Due to the nature of the disease and it’s presentation, these patients are usually quite fragile pre-operatively. Early in my career, I was fortunate enough to work with Dr. Ronald Hill and Dr. Geoffrey Graeber, who stressed the absolute importance of early and aggressive pre-operative optimization and nutritional rehabilitation in these patients. I learned that albumin and pre-albumin (nutritional labs) were just as important that almost any other factor in predicting outcomes (independent of catastrophic bleeding or other surgical events).

This training, more than anything else, changed the way I practice – and changed the way I view surgery. Before working with esophageal cancer patients – I viewed surgery the way many people see surgery – as a treatment for a condition, a means to a desired outcome.

I understood physiological stress, and the stress response and all of these concepts – but I still viewed surgery as a treatment. Now I see surgery, particularly large surgeries such as this for what it really is – a profound, manmade injury. The benefits only come later – if your patient survives the initial injury and recovery phase.
This paradigm shift was absolutely essential for the continued health and well-being of my patients – and it’s something I really try to impart to my patients (without terrifying them). This paradigm makes us truly understand why all the advance planning is necessary, vital and absolutely essential.

If you knew now that you were going to be in a horrible but completely unavoidable car accident in a few weeks -you’d do things differently, wouldn’t you? You’d make sure to be in a car with the maximum amount of safety features (we’d all be in Volvos) with 6 air bags, automatic assisted braking, five point seatbelts and helmets. You’d do all of this, to ensure your survival. You wouldn’t just hop into a pinto and drive off to work..

Pre-optimization is giving your patient a helmet, a seatbelt, and array of airbags, and understanding that they are about to be in a severe roll-over crash.

When you do these things for your esophagectomy patients – you do this for all your patients – and take the time to explain and impart this knowledge to the patients, so they can be active participants in this process. This pre-operative training/ planning, in my experience is the one crucial factor; (more than surgical technique, surgeon* or hospital facility) in ultimately determining outcomes.

K. Eckland, ACNP

Abstract (in advance of publication) on preoperative prevention of pulmonary complications

* All of the factors listed above have been postulated to predict post-operative outcomes. In particular, data shows that thoracic surgeons with greater than 12 – 25 cases (esophagectomies) per year have better outcomes than nonthoracic surgeons. Some argue that these successes are due to the widespread use of aggressive pre-operative strategies within the thoracic surgery specialty, and a better understanding of intra-operative factors; such as anatomy of the chest, leading to better understanding of tumors eligible for resection, and less intra-operative blood loss. For more information on the impact of thoracic surgery training on thoracic surgery outcomes, please see the post: Who is performing your thoracic surgery?

Additional Resources: Pre-operative management/ prevention of post-operative complications in patients undergoing esophagectomy

 Akutsu, Y. & Matsubara, H. (2009) Perioperative Management for the Prevention of Postoperative Pneumonia with Esophageal SurgeryAnn Thorac Cardiovasc Surg. 2009 Oct;15(5):280-5. (free full text).  This is a well written report by Japanese surgeons on several techniques to reduce post-operative pneumonia.  Several of these items can be directly implemented by patients – such as pre-operative smoking cessation, pulmonary rehabilitation and good dental hygeine.

What is Fast Track Thoracic Surgery?

walk as if your life depended on it..

Today we are taking about one of my favorite topics, Fast Track Thoracic Surgery –  which is a fancy name for trying to streamline the surgical experience to prevent complications and shorten the time to discharge.  It’s an on-going process, and many of the things that were once just ideas “What if we extubated people in the operating room?” are now standard practice.   But ten years ago, most people stayed intubated and on the ventilator overnight after surgery..

A lot of the techniques mentioned in the literature that we’ve included (links) here is now the current standard of treatment,(and these articles are just a few years old – which shows how quickly things can change) such as:
– VATS procedures versus open surgery,
– early extubation in the operating room,
and the one we are going to focus on,
early mobilization (that’s walking, in plain English) but since all of this ‘early mobilization’ (or getting out of bed and walking right as early after surgery as possible) falls on you, the patient – it’s important that we explain why we are asking you to do all these things that are the absolutely the last thing you want to do after you’ve been operated on..

We’ve already discussed this another article, but since ‘early mobilization’ is one of those things that absolutely, truly makes a huge difference, but so often get missed; because the patient doesn’t feel receptive to the idea after surgery, the surgeon doesn’t mention it during his visits, and the nurses are too busy to encourage you (because it means more work for them anyway) – so we are going to revisit the concept.

So, you want me to get out of bed and walk around, just after surgery?  But I am tired, sore, and I have all this stuff (IVs, chest tubes, urinary catheter) attached to me..

I know, I know – I wouldn’t want to do it either – but wanting to – and finding the strength and motivation to do it even when you really don’t want to – are two different things..  And you should know by now, I absolutely wouldn’t ask you to do it, if it wasn’t critically important.

But these low-tech things*, such as walking, and using an incentive spirometry really do make a huge difference – and yes, in some cases, a difference between life and death (from respiratory complications, etc.).  So not only do I want you to walk – I want to you do it a couple times a day – at least three, and I want you to enlist your friends and family to help.  (If I were there, I would be coming by to help you untangle all the equipment, make sure your behind is covered in your robe, and push your IV pole, while we chatted about other stuff – but in all likelihood – I’m not going to be there, so we better just get you moving anyway.)

And I want you to keep going – keep walking, even after discharge, when you get home.  Don’t plop down on the couch or bed with the remote – keep doing all the walking, coughing/ deep breathing exercises, and using your incentive spirometer..  Keep it up until you see your doctor at your follow up appointment..

At that appointment – particularly if you had a lobectomy, or a large piece of lung taken out – be sure to ask him about a prescription of pulmonary rehabilitation, if you didn’t get one a few weeks before surgery, or when you were discharged from the hospital.

* I had a couple of patients in the past who expressed surprise that things like walking, not computer-based technology were the main driving force between rapid recovery and the development of complications.  “There’s not some machine to do this?”
“Nope, just those legs you were born with..”

I’m not making fun, it’s just that it sounds far too simple for people to believe..which is why even though it sounds so obvious to you here, it’s one of the things I have to go over with people several times before and after surgery.
But, really, it is that simple.. Get up and walk like your life depended on it.  It does.

Now in some of these articles, ambulation and pre-operative management get just a passing mention;- but remember, these articles are written by surgeons, not nurses.. They’d rather talk about surgery, not ‘physiotherapy’.  But even so, they do take time to mention it – because it is important..

I’ll be updating this article with new references every so often.

Pre & Post-operative Surgical Optimization for Lung Surgery

How to maximize your chances before lung surgery to speed healing, post-operative recovery and reduce the incidence of complications.

As most of my patients from my native Virginia can attest; pre and post-operative surgical optimization is a critical component to a successful lung surgery. In most cases, lung surgery is performed on the very patients who are more likely to encounter pulmonary (lung) problems; either from underlying chronic diseases such as emphysema, or asthma or from the nature of the surgery itself.

Plainly speaking: the people who need lung surgery the most, are the people with bad lungs which makes surgery itself more risky.

During surgery, the surgeon has to operate using something called ‘unilung ventilation’. This means that while the surgeon is trying to get the tumor out – you, the patient, have to be able to tolerate using only one lung (so he can operate on the other.)

Pre-surgical optimization is akin to training for a marathon; it’s the process of enhancing a patient’s wellness prior to undergoing a surgical procedure. For diabetics, this means controlling blood sugars prior to surgery to prevent and reduce the risk of infection, and obtaining current vaccinations (flu and pneumonia) six weeks prior to surgery. For smokers, ideally it means stopping smoking 4 to 6 weeks prior to surgery.(1) It also means Pulmonary Rehabilitation.

Pulmonary Rehabilitation is a training program, available at most hospitals and rehabilitation centers that maximizes and builds lung capacity. Numerous studies have show the benefits of pre-surgical pulmonary rehabilitation programs for lung patients. Not only does pulmonary rehabilitation speed recovery, reduce the incidence of post-operative pneumonia,(2) and reduce the need for supplemental oxygen, it also may determine the aggressiveness of your treatment altogether.

In very simple terms, when talking about lung cancer; remember: “Better out than in.” This means patients that are able to have surgical resection (surgical removal) of their lung cancers do better, and live longer than patients who receive other forms of treatment such as chemotherapy or radiation.

If you are fortunate enough to have your lung cancer discovered at a point where it is possible to consider surgical excision – then we need you to take the next step, so you are eligible for the best surgery possible.

We need you to enhance your lung function through a supervised walking and lung exercise program so the surgeon can take as much lung as needed. In patients with marginal lung function,(3) the only option is for wedge resection of the tumor itself. This is a little pie slice taken out of the lung, with the tumor in it. This is better than chemotherapy or radiation, and is sometimes used with both – but it’s not the best cancer operation because there are often little, tiny, microscopic tumor cells left behind in the remaining lung tissue.

The best cancer operation is called a lobectomy, where the entire lobe containing the tumor is removed. (People have five lobes, so your lung function needs to be good enough for you to survive with only four.(4) This is the best chance to prevent a recurrence, because all of the surrounding tissue where tumors spread by direct extension is removed as well. Doctors also take all the surrounding lymph nodes, where cancer usually spreads to first. This is the best chance for five year survival, and by definition, cure. But since doctors are taking more lung, patients need to have better lung function , and this is where Pulmonary Rehab. comes in. In six weeks of dedicated pulmonary rehab – many patients who initially would not qualify for lobectomy, or for surgery at all – can improve their lung function to the point that surgery is possible.

Post-operatively, it is important to continue the principles of Pulmonary rehab with rapid extubation (from the ventilator), early ambulation (walking the hallways of the hospitals (5) and frequent ‘pulmonary toileting’ ie. coughing, deep breathing and incentive spirometry.

All of these things are important, where ever you have your surgery, but it’s particularly important here in Bogota due to the increased altitude.

One last thing for today:
a. Make sure to have post-pulmonary rehab Pulmonary Function Testing (PFTs, or spirometry) to measure your improvement to bring to your surgeon,
b. walk daily before surgery (training for a marathon, remember)

c. bring home (and use religiously!) the incentive spirometer provided by rehab.

ALL of the things mentioned here today, are things YOU can do to help yourself.

1. Even after a diagnosis of lung cancer, stopping smoking 4 to 6 weeks before surgery will promote healing and speed recovery. Long term, it reduces the risk of developing new cancers.

2. Which can be fatal.

3. Lung function that permits only a small portion (or wedge section) to be removed

4. A gross measure of lung function is stair climbing; if you can climb three flights of stairs without stopping, you can probably tolerate a lobectomy.

5. This is why chest tube drainage systems have handles. (so get up and walk!)

Additional References:

Smoking and post-operative complications

Preventing Atrial Fibrillation after Lung Surgery

and the snowball effect of atrial fibrillation after surgery. Discussion includes beta blockers and vitamin C as methods to reduce the incidence of post-operative atrial fibrillation with discussion of the literature supporting its use.

In previous posts, we’ve talked about prevention and management of respiratory complications of lung surgery. However, one of the more common complications of lung surgery, is atrial fibrillation, or an abnormal heart rate and rhythm.  Most of the time, atrial fibrillation after surgery is temporary – but that does not make it a benign problem.

Developing atrial fibrillation is problematic for patients because increases length of stay (while we attempt to treat it) and increases the risk of other problems (such as stroke – particularly if we can’t get the heart rhythm to return to normal).

‘The Cootie Factor’
Length of stay is important for more than cost and convenience. One of the things I try to explain to my patients – is that hospitals are full of sick people, and in general, my surgery patients are not sick– they’ve had surgery..
But surgery increases their chance and susceptibility to contracting infections from other patients, and visitors. I call this ‘the cootie factor’. (Everyone laughs when you say cooties – but everyone knows exactly what you mean.) So the reason I am rushing my patients out the door is more than just for patient convenience and the comforts of home – it’s to prevent infection, and other serious complications that come from being hospitalized, in close quarters, with people who have may have some very bad cooties indeed (MRSA, resistant Klebsiella, VRE, Tuberculosis and other nasties.)

But besides, length of stay – atrial fibrillation, or a very rapid quivering of the atrial of the heart (250+ times per minute) increases the chance of clots forming within the atrial of the heart, and then being ejected by the ventricles straight up into central circulation – towards the brain – causing an embolic stroke.. Now that’s pretty nasty too..

Atrial fibrillation risk reduction

But there are some easy things we can do to reduce the chance of this happening..
One of the easiest ways to prevent / reduce the incidence of post-operative atrial fibrillation – to slow down the heart rate. We KNOW that just by slowing down the heart by 10 – 15 beats per minute, we can often prevent abnormal heart rhythms.

Most of the time we do this by pre-operative beta blockade, which is a fancy term for using a certain class of drugs, beta blockers (such as metoprolol, carvedilol, atenolol) to slow the heart rate, just a little bit before, during and after surgery.

In fact, this is so important – national/ and international criteria uses heart rate (and whether patients received these medications prior to surgery) as part of the ‘grading’ criteria for rating surgery/ surgeons/ and surgery programs. It’s part of both NSQIPs and the Surgical Apgar Scale – both of which are important tools for preventing intra-operative and post-operative problems..

The good thing is, most of these drugs are cheap (on the $4 plan), very safe, and easily tolerated by patients. Also, most patients only need to be on these medications for a few days before and after surgery – not forever.

Now, if you do develop atrial fibrillation (a. fib) after surgery – we will have to give you stronger (more expensive, more side effects) drugs such as amiodarone, or even digoxin (old, but effective) to try to control or convert your heart rhythm back to normal.

If you heart rhythm does not go back to normal in a day or two – we will have to start you on a blood thinner like warfarin to prevent the blood clots we talked about previously. (Then you may have to have another procedure – cardioversion, and more medicines, if it continues, so you can start to see why it’s so important to try to prevent it in the first place).

Research has also looked at statin drugs to prevent atrial fibrillation after surgery – results haven’t been encouraging, but if you are already on cholesterol medications prior to surgery, there are plenty of other reasons for us to continue statins during and after surgery.. (Now, since the literature is mixed on whether statins help prevent a. fib – I wouldn’t start them on patients having lung surgery, but that’s a different matter.)

Now Dr. Shu S. Lin, and some of the other cardiac surgeons did some studies down at Duke looking at pre-operative vitamin C (along with quite a few others) and the results have been interesting.. That doesn’t mean patients should go crazy with the supplements.. anything, even Vitamin C can harm you, if taken willy-nilly (though the risk with vitamin C is usually minimal).

In fact, the evidence was strong enough (and risk of adverse effects was low enough) that we always prescribed it to our pre-operative patients for both heart and lung surgery.  (Heart patients are at high risk of atrial fibrillation too.)  We prescribed 500mg twice a day for a week before surgery, until discharge – which is similar to several studies. I’ve included some of these studies before – please note most of them focus on atrial fibrillation after heart surgery.

Vitamin C
Vitamin C with beta blockers to prevent A. Fib. This is probably my favorite free text about Vitamin C and Atrial fib – it’s my sort of writing style..

Contrary to popular belief, performing a VATS procedure (versus open surgery) does not eliminate the risk of post-operative atrial fibrillation.

Now Dr. Onaitis, D’Amico and Harpole published some interesting results last year (and of course, as Duke Thoracic surgeons, I am partial) – but I can’t repost here since it’s limited access articles..