This video features Gerard J. Criner, MD, FACP, FACCP presenting on Evaluation of a Surgical Patient. This presentation was given at our October 20th Management of Early Stage Non-Small Cell Lung Cancer event in 2022.
Which global international studies has been revolutionary and showing that we can diagnose patients at an earlier stage and we can have a significant impact on their mortality. However, there are some challenges that come to us the ups TSF recent guidelines state that patients can be screened for low dose ct for lung cancer screening that starts at the age of 50 up to the age of 80 unless they've stopped smoking within the last 15 years or they're incapacitated and screening won't have a value for them. So this means that more patients are being screened at an older age. And the patients that receive lung cancer screening has shown from the nelson study show that these lesions are small and they're in multiple locations and hard to get lesions so that early stage lung cancers are small and sometimes difficult to reach. So what does that mean to us when we're in the patient? Well in this data, it looks at patients for diagnostic imaging who have COPD. You look to the left with ct biopsy. Those patients that have COPD are more likely to have complications, both hemorrhage and have need for pneumothorax with chest to management. And those patients that undergo surgical resection who have COPD have a substantially higher mortality. So it matters when you evaluate the patient, not only for surgery, but how we approach them for diagnostic vibes is whether it's C. T. For which the state is or navigational bronchoscopy or other means of trying to diagnose the small peripheral lesions. Think holistically of where these lesions occur and with the kind of biological substrate that exists in these. So, if we look at these patients overall for comorbidities. If a patient with COPD doesn't have a co morbid condition, you're not looking hard enough because 99.7% of patients with COPD have one co morbid conditions. 50% of patients have more than four co co morbid conditions. And if you look at this bottom left there called middle drome shown by devo and Shelly, the circle of death is in the dash circle. Those patients that are closer to that circle have a higher mortality. And if you look at the most common co morbid condition that COPD patients have its coronary artery disease, congestive heart failure? That's 24% of the patient population. It's a significant contributor to not only their morbidity but their mortality. So here's our current dilemma lung cancer screening and early treatment improves outcomes. No question. We have a little bit debate from our X. Outside us colleagues, but they don't argue with us anymore. Nelson study proved that however, these patients, they're older, they're more likely to have severe underlying lung diseases and there are more likely have multiple co morbid conditions. So in that context, what can we do to assess the fitness of high risk patients to the diagnosis and therapeutic treatment, well, here are some things that exist that has existed for years. Global risk stratification scores and they are recommended to stratify risk and calculate morbidity and mortality. They're somewhat helpful if you're older. You do worse. But most of our patients are older now. So you can't do much about age if you could I would do something right now. Um You can predict your preoperative FTp one that's helpful male sex mainly because it drags more more co morbid conditions if there and thin and depending on the size and stage of the invasiveness of the procedure they're going to have. So those are facts. So the right looks at the cardiac thoracic risk index and that's helpful. And it elevates also might need to see pet to assess their overall cardiopulmonary fitness. So do you really do postoperative pulmonary function tests? Do they serve a purpose? Are they really good? Well if you look at the bottom left, this is a pre operative function shown on the first box and whiskers to the left. This is what the second is what the predicted postoperative pulmonary function is. And the last is what it is. It's seven days. You can see overall in this study it performs pretty well that what you predicted before ends up being what the patient has seven days later. There's multiple ways you can do this to predict predicted D. L. C. O. Or the FB. One. Both of those are the time health pulmonary function predictors that dictate outcomes in patients is basically by taking the FB one presenter predicted and multiplying that or the dl by the One minus the number of segments divided by the number that resected by 19 overall number of segments. You can do that by an atomic ways. You can do it by profusion assessment. They both end up with the same results. If you look to the right of this, if you look at A. D. L. That's less than 60% your post operative risk of pulmonary dysfunction is going to be higher as well as your mortality. So do these really work. This is the best study done by a group of swiss colleagues about 25 years ago by Wiser and colleagues and what they did prospectively take 100 and 37 patients and they looked at their heart history and E. C. E. C. G. And if they found that those patients were at risk it was found in six patients they underwent a cardiac workout. Those six patients two of those were found to be inoperable the bottom left, which is the numbers of inoperable patients that were determined if the patients ended up having no evidence of cardiac risk, Those patients underwent lung function testing and if the D. L. And M. P. B. One were greater than 80% of predicted those patients underwent and Newman ectomy. If the patients ended up having an F. D. One or D. L. Less than 80% those patients underwent cardiopulmonary exercise test and if their oxygen consumption or auction uptake was greater than 10 20 mls per kilogram or greater than 80% of predicted. Those patients also underwent a human. So you can see that overall half of the patients met that criteria out of 131. But if the patients did not meet those performances on everyone in the L. C. O. In the auction update, um they were less than 40%. Those patients were declared to be inoperable but that didn't define any of the patients in the study. If they were in this intermediate zone of 40 to 75% of a cardiopulmonary exercise test, those patients underwent the split lung function using what we did, the postoperative predictive, F. B. B one and B. L. C. O. And if those were both of those were less than 40% those patients were declared to be inoperable again in this study none of those ended up leading that category. If they did have a P P O. F. E. D. One or D. L greater than 40% then the deciding factor was the auction uptake on cardiopulmonary exercise test. If it was less than 10 mls per kilogram, those patients were declared inoperable, that was three out of five patients. If it was either of those, if the cardiopulmonary exercise test is greater than 10 ml with an F. U. B. One for the L. C. O. Greater than 40% of predicted that the patients were respected up to the number of sub segments. So there are three categories of patients in the end. People that were high risk. five out of 137 patients that were respected based on a limited sub low bar or sub pulmonary sub longer section which was 14 or patients that had 118 out of the group. So how well did it did it work well in this prospective study collection of data compared to what they had done historically at the same center in Switzerland. They found that they decreased post operative morbidity by 50%. Post operative mortality by 50%. And if they looked at the people that they deemed high risk and follow those patients over a year all those patients died from acute respiratory failure, cardiac failure. So they have 50% lower morbidity and mortality by using P. P. O. Of F. D. One and D. L. C. O. Cardiac risk assessment. And basically using a cardiopulmonary exercise test to define your limits of cardiopulmonary exercise testing. There's some caveats to this. Patients with pulmonary fibrosis do worse. That the cutoffs and designation of risk factors for patients with interstitial lung disease are higher. If the D. L. Is less than 60% of predicted and the FTC is less than 80% of predicted. As shown in this study, patients with I. P. F. With one cancer receptions uh procedures have much higher morbidity much higher mortality. The opposite is true for patients with COPD emphysema predominant type. That if the cancer reception can be coupled with one-born reduction surgery patients can be operated with less than 30% and have a good outcome in terms of both cancer resection surgery and not a worsening of their lung function but actually an improvement of their one function overall. So with this our guidelines recommend this is the last guidelines from american quality, chest physicians are just that pretty much uses the same criteria that wiser and colleagues used the swiss study but changes the criteria little bit rule out cardiac disease first. And if you look at patients that have a F. A. B. One predicted, that's greater than 60% or D. L. That's greater than 60%. Those patients are considered low risk go to surgery if it's less than that. However, if it's 60 the 30% of predicted, they recommend doing stair climbing or a shuttle walk test and it meets various thresholds, they still could be low risk patients. However, if these patients have an F. D. One or D. L. C. O, less than 30 percent of predicted. They reckon they recommend a cardiopulmonary exercise test with near similar values to which I just described to you in detail, less than 10 ml or high risk. If it's 10 to 20 ml or moderate risk and if they're greater than 20 ml, they're low risk patients overall. So how good are these recommended? Maybe not as good as we think. You look at this recent meta analysis. Looking at exercise testing. The only robust testing that we have results are on the cardiopulmonary exercise test. Looking across the spectrum of outcomes, your preoperative evaluation, your post operative treatment, your prognosis and your efficacy assessment. Clearly see pets have been the most studied and have the most robust data to predict your outcome of patients. Six minute walk test comes in a second somewhat close second overall to address all those categories. But endurance shuttle walk test, an incremental shuttle shuttle walk test and hysteric climbing test, stair climbing might sound cool but it doesn't have the data to really bring home to assess the patient overall. So see pet or a six minute walk test really want to look at. And these investigators also from UFT, came up with having a six minute walk test that was 300-500 m, assess the patient's of um of a low risk. One of the newer assessments for pulmonary function testing looks at using the ventilatory efficiency index or inefficiency index with a ve over V. C. 02 greater than 35 leaders for per minute. And if you look at that over all those patients that have ventilatory efficiency greater than that level or more likely have a pulmonary complications are more likely going to stay in the hospital longer and have a seven fold greater tenfold greater mortality. So ventilatory inefficiency maybe something else you can add on to the video to max to help the refined assessment. So those are the bad things. But what can we do pre operatively to modify the risk of these patients who we know are older and they have other lung conditions. Overall. This retrospective analysis that was done I think somewhere in the U. K. Looked at body mass index activity whether they were using aspirin as a surrogate of basically vascular or cardiovascular disease. If they were current smokers, if they had COPD and looked at unique variant analysis and found that those people that had those factors were more likely have a postoperative pulmonary condition complication with race intersectional surgery. If they looked at the odds, risk of those factors. If they were older, your odds risk for greater almost four that they would have a postoperative complication. Used aspirin almost four times greater current smoking seven fold greater. If they had a B. M. I. That was greater than 33 fold greater. If they had COPD three fold greater. And if you look at the postoperative complications in that group and mortality it was substantially higher in those pages that made these risks. So taking a patient telling them that they have time, maybe they could lose weight. If they basically could have their COPD better managed if they could stop smoking. Those are maybe modifiable risk factors that those patients. One thing that isn't mentioned in any of these guidelines is the impact of reality is the paper from Jama surgery that looks at the importance of morality on surgical outcome and as you can see to the bottom right of the curve, if you are more frail, your mortality can be 30-40%. If you look at the top left, if you're frail and have a surgical procedure for malignancy, your likelihood of a bad outcome is higher and it's not only if you die, but if you survive, you're more likely to be in a nursing home and you're more likely to stay in the hospital for a longer period of time. So frugality is an important factor that we can rapidly assess in clinic by history by simple things you can do on physical examination to dictate out that program, routine and frugality and COPD isn't uncommon study that looked at this at 12 studies and does a minute analysis on it. If you look at the top right by 25% of patients with COPD are frail, 75% of them are pre filled. So almost all the patients have some degree of reality that you should be able to assess before you look at the likelihood of surgical outcome. Is there anything you can do about that? Well this study looked at prospective rehabilitation in patients undergoing resection for non small cell surgery. Found that you could you could have about a 30 to 40% reduction and complications if you did intensive rehab for 7 to 14 days before you did your surgery. So if you assess the patients, find them trail, you might be able to do something to recondition them. They undergo the surgical procedure and this isn't just a one and done get them through the surgery. If you look at patients that are more fit their long term survival after resection for lung cancer is substantially high, so it may have long term benefits for the people do that. Besides those factors is the type of procedure and surgical technique that you use. If you look at that and you look at rats and people that have less than 30% predicted FBI. one less invasive receptions for lung cancer have a substantial improvement in patient survival. So that's where the surgeons end up being the ones who decide what's the best approach for patients. But if you can go to a place that has the skill experience and expertise and sub total receptions for patients who have significant underlying lung disease, especially COPD, your outcome can be better. So this is a summary of our risk stratification shown in the center from the guidelines which have just gone through with you. But these other factors around it, you need to consider reality obesity, smoking, status anxiety, depression, malnutrition, de conditioned state. And if they have underlying current from a lung disease, COPD interstitial lung disease to optimize the outcome of your patient. Thanks