Hello, I'm Phil Carrott, one of the thoracic surgeons in the University of Michigan. And I'm here to discuss perioperative evaluation and fitness in thoracic oncology patients. This will mainly focus on lung cancer but we'll have the application to any sort of patient in thoracic oncology that is to be prepared for surgery. So fitness for surgery, the PFTs and VO2Max, cardiac evaluation, and pre-operative preparation for better fitness are objectives today. So what pulmonary function parameter most actually predicts operative fitness? Is it the FEV1? Is it the FVC? DLCO? Or the FEV1/FVC ratio? I'll be thinking about this during the lecture. So for lung resection, general guidelines use 40% of predicted for FEV1 and DLCO as cut-offs for surgery. The absolute FEV1 remaining after resection should be above 800 milliliters on average, in order to have adequate lung function post-operatively. For PFTs, the general guidelines for surgery, in general, for LVRS should be greater than 20% of predicted. For lobectomy, greater that 40% of predicted. And for pneumonectomy, greater than 60% of predicted. Although other factors can predict fitness better than just these numbers. FEV1 is dependent on airway health and the physical strength of the patient. If they're not trying hard enough, that could give you a sort of false low FEV1. The DLCO shows the alveolar health, so how good the tissue is. And further testing should be done on values below 60% of predicted to ensure good patient fitness for surgery. So V/Q scans can help predict the contribution of the planned resection area. Specifically if the lobe is collapsed, that is not really contributing to the PFTs in the first place. Cardiopulmonary exercise testing is also useful, particularly in borderline patients. The V/Q scan will show contribution of each lobe but should be carefully evaluated as zones on the scan are not per lobe. So this is an example of a relatively borderline V/Q scan. You can see the left lung is only approximately 22% of the total perfusion and ventilation. And if a left pneumonectomy were considered in this patient, they would probably do fairly well, as long as their PFTs for the right lung are adequate. So in marginal patients, VO2Max should be above 15 milliliters per kilogram per minute, or 40% of predicted. And this can trump marginal PFTs if somebody has a good functional status but for some reason, did not do well on their pulmonary function test. So general operative fitness can also be assessed in the office and improved by the patient pre-operatively. Stair walking is a good test of both coordination and fitness that a patient that is uncoordinated may have more trouble post-operatively if they're very old or in poor shape. A six minute walk test is a good test routinely done in a pulmonologist's office. You'll spend a couple of minutes on pre-habilitation which is the exercise improvement before surgery. A relatively new idea that we've been doing for some time at the University of Michigan. And incentive spirometer training should be carried out pre-operatively rather than post-operatively, so the patients know how to use the incentive spirometer. In pre-operative preparations, so our routine is for pre-habilitation, is increasing physical activity. And patients can do this just by walking one to three miles every day. Using the incentive spirometer every day. And making this routine, so that they are in better shape, especially if they're sedentary to some extent. Reviews showed that there are trends to better outcomes, better quality of life, and better aerobic capacity in patients that undergo this simple pre-operative preparation. And I have just a couple slides on cardiac clearance. So the Journal of JACC guidelines. Basically, if the patients are high risk for some reason or a have a poor functional capacity, they should be assessed further. As the risk factors, history of myocardial infarction, history of heart failure, history of a stroke, diabetes, or renal failure with a creatinine over two. Should all have further workup as a stress test of some sort before surgery. They prefer the exercise stress if possible. Alternatives in patients that may not be able to undergo an exercise stress test are radionuclear stress or stress echo or if the EKG is uninterpretable. In asymptomatic patients, it can be indicated to do exercise stress if it's a high risk surgery. Most complex surgery and thoracic oncology, such as a pneumonectomy or esophageal cancer, should probably undergo cardiac testing for almost any patient. Other testing in asymptomatic patients may be appropriate, if they're unable to walk or there's some other complicating factor. So in pulmonary function testing, what parameter most accurately predicts for operative fitness? Is it FEVI, FVC, DLCO or the ratio? It is in fact, DLCO predicting more accurately than FEV1. But all of these parameters should be taken into account when you're assessing patients pre-operatively. So for fitness, for surgery, PFTs and exercise stress testing are good starting points in patients to undergo in complex surgery. Pre-habilitation can minimize pulmonary complications especially pneumonia and stopping smoking. And marginal operative candidates should have further tests to more accurately assess fitness. Thank you.
