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ESTIMATE OF COMPLICATION IN THORACIC SURGERY

ESTIMATE OF COMPLICATION IN THORACIC SURGERY. 11-15 APRIL 2012 TURKISH THORACIC SOCİETY 15. ANNUAL CONGRESS ANTALYA/SİDE PROF. DR. TAHİR ŞEVVAL EREN DICLE UNIVERSITY MEDICAL SCHOOL DEPRT. THORACİC SURGERY. THERE IS NO CONFLICT OF INTEREST.

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ESTIMATE OF COMPLICATION IN THORACIC SURGERY

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  1. ESTIMATE OF COMPLICATION IN THORACIC SURGERY 11-15 APRIL 2012 TURKISH THORACIC SOCİETY 15. ANNUAL CONGRESS ANTALYA/SİDE PROF. DR. TAHİR ŞEVVAL EREN DICLE UNIVERSITY MEDICAL SCHOOL DEPRT. THORACİC SURGERY

  2. THERE IS NO CONFLICT OF INTEREST

  3. PLAN PRESENTATION • GENERAL INFORMATION • RISK FACTORS • Patientrelated • Operationrelated • PREOPERATIVE RISK ASSESSMENT • RISK MODELS AND RISK SCORES • PULMONARY FUNCTION TESTS andDLco • TESTS TO EVALUATE PULMONARY CAPACITY • Simpleexercisetests • Complexexercisetests • ESTIMATE OF POSTOPERATIVE PULMONARY FUNCTION • ALGORITHM • CONCLUSION

  4. Wehaveto define thebenefitsandrisks of anyprocedurebeforethetreatment. Low risk No stres High risk High stres

  5. Regardingresectionsandpulmonarycomplicationsin thoracicsurgery; Mortality 1-14 % Morbidity 7-70 % Surgicalprocedureand general anesthesialeadpulmonarycomplicationsthroughseveralmechanisms. Smetana GW. Evaluation of preoperativepulmonary risk, 2012 UptoDate. Keoogh BF, et al. AnaesthesiaandIntensiveCareMedicine 2011. Bapoje SR, et al. Chest 2007. Bernstein WK, Semin CardiothoracVascAnesth 2008.

  6. New surgicaltechniquesand VATS havedecreasedpostoperativecomplicationsduetodiminishedlungfunctions. • Inaddition, morbidityandmortalityrelatedtolobectomyandpneumonectomyhavebeenevenchallenging. Colice GL, et al. ACCP evidencedbasedclinicalpracticeguidelines (2nd Edition) Chest 2007

  7. Themaincardiopulmonarycomplications: • Atelectasis • Bronchitis • Pneumonia • Pulmonaryedema • Pulmonaryemboli • Respiratoryfailure • Myokardinfarction • Rythimdisorder • Hypotension/schock • Mechanicventilatoryneed > 48 hours • Hypercapnia • Death Bapoje SR, et al. Chest 2007

  8. Respiratoryfunctionsareaffectedbythoracotomytogetherlungresectionregardingtheextent of removal. Withinlobectomy 10-20 %, Withinpneumonectomy 40-50 % loss . Ali KM, et al. Chest 1980 Wynne R et al. AJCC 2004.

  9. Preoperative Risk Assesment Toevaluatepostoperativemortalityandmorbidity. Tocalculatepostoperativerespiratoryfunctions. Tochoosethesurgicalprocedureandto define therisks.

  10. RISK FACTORS Smetana GW. Evaluation of preoperativepulmonary risk, 2012 UptoDate. BTS/SCTS guidelines , Thorax 2001, update2010

  11. PREOPERATIVE RISK ASSESSMENT • HISTORY, PHYSICAL EXAMINATION • CHEST X-RAY • CARDIAC EVALUATION • RISK MODELS AND RISK SKORS • RESPIRATORY FUNCTION TESTS • REVERSIBILITY TEST • ARTERIAL BLOOD GASES • PULMONARY ARTER Y OCCLUSION PRESSURE (PNEUMONECTOMY) • CARDIOPULMONARY EXERCISE TESTS • VENTILATION PERFUSION SCREENING (RESECTION)

  12. PREOPERATIVE RISK EVALUATION HISTORY & PHYSICAL EXAMINATION • Inadequateexercisecapacity (estimate of complication) • At leastabilitytowalk 500 meters • Copioussecretionandpurulentsputumincreasepostoperativeproblems.

  13. PREOPERATIVE RISK EVALUATION HISTORY • Dyspnoea on lightexertion • MI withinthelast 3 months • AnginaPectoris, Hypertension, valvediseaseandconductiondisorders

  14. PREOPERATIVE RISK EVALUATION PHYSICAL EXAMINATION • Decrease in breathingsounds • Increase in expiration • Wheezing • Rale ve ronchi • Barrelchest • Cyanosis • Flapping tremor • Respiratory rate RISK

  15. PREOPERATIVE RISK EVALUATION • Abilitytocougheffectively be controlled • Coughingexercisesmustmake • Deeprespiratoryexercises • Incentivespirometry • Blowingbaloon

  16. CHEST X-RAY • Complication risk wasrepeorted 22% in thosewithpreoperativepathological x-ray • as 7% in patientswith normal x-ray. Doyle RL. et al. Chest 1999. Smetana GW. Evaluation of preoperativepulmonary risk, 2012 UptoDate

  17. CARDIAC ASSESSMENT • Changedby ACC (AmericanCollege of Cardiologyand AHA (AmericanHeartAssocciation) . • Focusing on thesurgicalprocedureinstead of general cardiacevaluation. ACC/AHAguidelines 2007

  18. CARDIAC ASSESSMENT • ACC/AHA Guidelinesclassifythoracicsurgery as an intermediate risk procedurewith a cardiac risk of 1%- 5%. • Risk of perioperative MI is 0.13% in patientswith no priorcardiachistoryversus2.8% to 17% in patientswith a priorhistory of MI. ACC/AHA guidelines 2002/2006. Ferguson MK. PreoperativeevaluationThoracicSurgeryPatients 2010.

  19. CARDIAC ASSESSMENT • Familyhistory • Smokinghistory • Hypercholesterolemi • DM • HBP • Previouscardiacdisorder

  20. CARDIAC ASSESSMENT • Functionalstatus • Physicalexamination • ECG • Activecardiacconditionsmust be identified • CardiacmurmurorunexpecteddyspneaECHO ACC/AHA 2007 guidelines

  21. CARDIAC ASSESSMENT • Inpatientswithoutactivecardiacconditions, a revisedcardiacindexmay be applied. • Patientswithgoodcardiacfunctionalcapacity (such as theabilitytowalkuptwoflights of stairswithoutstopping) andtwo risk factorsorfewermayproceedtosurgerywithoutfurthercardiacassessment. BTS/SCTS guidelines 2010

  22. CARDIAC ASSESSMENT • Patientswithpoorcardiacfunctionalcapacityorthreeormore risk factorsorwith severe activecardiacconditionsrequirefurthercardiologyinvestigationandreview. BTS/SCTS guidelines 2010

  23. CARDIAC ASSESSMENT • Patientswhohavesufferedmyocardialinfarctionwithintheprevious 6 monthsrequirecardiologyassessment, and in recentinfarction, shouldwait at least 30 daysbeforesurgeryforlungresection. BTS/SCTS guidelines 2010

  24. CARDIAC ASSESSMENT • CABG withinthelast5 yearsandfollowedbywithoutanysymptomor • No major risk afterwithin 2 years of cardiaccardiacevaluationand normal findings on physicalexamination No needforfurthercardiacassessment. ACC/AHA guidelines 2007

  25. CARDIAC ASSESSMENT • Moderate Risk: • ModerateAngina • Story of MI orfinding of MI on ECG • Compensatedheartfailure • DM • Renalfailure • Low Risk: • Olderage • Abnormal ECG • Lowfunctionalcapasity • Strokehistory • Uncontrolled HBP High Risk: • Unstablecoronarysyndrome • MI within 30 days • Unstableor severe coronaryangina • Decompanstingheartfailure • Severe valvedisease • Highlevelatrioventricularblock • Ventriculararrythmia • Uncontrolledsupraventriculararrythmiaswithventricularresponse ACC/AHA guidelines 2007.

  26. CARDIAC ASSESSMENT • Topostponethesurgery in thehigh risk groupunlessemergency. • Toconsiderthemedicaltreatmentfollowedbycoronaryangiography in thesepatients. ACC/AHA guidelines 2007

  27. CARDIAC ASSESSMENT • Morerecent data indicatethatcommonlyusedregimens of perioperativebeta-blockersincreasethe risk of strokeandoverallmortality. • Threfore, theinstitution of a beta-blockertherapy is not recommendedin heartischemicdiseasepatientswhoare not alreadytakingthem. Devereaux PJ, et al. POISE trial, Lancet 2008.

  28. RISK MODELS AND RISK SCORES

  29. RISK MODELS AND RISK SCORES • Severallogisticmodelsandscoringhavebeendeveloped, testedandissued. • Surgicalriskswerestudiedto define formorbidityandmortalitypreoperatively in populationbasedresearches . Brunelli A, et al. AnnThoracSurg 1999. Birim O, et al. Eur J CardiothoracSurg 2003. Ferguson MK, et al. Eur J CardiothoracSurg 2003. Berrisford R, et al. Eur J CardiothoracSurg 2005.

  30. RISK MODELS AND RISK SCORES • EuropeanSocietyObjectiveScore (ESOS) • Thoracoscore (TheThoracicSurgeryScoringSystem) • Canet risk index • POSSUM (Physiologicandoperativeseverityscorefortheenumeration of mortalityandmortality • Cardiopulmonary risk index (Epstein-CPRI) • EVAD (Expiratoryvolume, age, diffusingcapacity) • Charlsonindex • PRQ (Predictiverespiratoryquotient) • PPP (Predictedpostoperativeproduct) • E-PASS (Estimation of physiologicabilityandsurgicalstress) • Kaplan-Feinsteinindex • ASA • ECOG • Arozullahmultifactorial risk index Berrisford R., et al. Eur J CardiothoracSurg, 2005. Canet J, et al. Anesthesiology, 2010. Brunelli A, et al. (ESOS) Eur J CardiothoracSurg, 2008 Arozullah AM, et al. AnnSurg 2000. Falcoz PE. Et al. J ThoracCardiovasSurg, 2007.Epstein SK, et al. Chest 1993.

  31. RISK MODELS AND RISK SCORES • ESOS, developedfromthelungresectiongroup of 3400 patients (ESTS databaseversion 1). (ERS/ESTS). • Developedtoestimatehospitalmortality . • Composed of 2 specificobjectivepredictors : ageand ppoFEV1 • Used in thoracicsurgicalunits in Europe. Berrisford R. Eur J CardiothoracSurg 28, 2005 Brunelli A. Eur J CardiothoracSurg 33, 2008

  32. RISK MODELS AND RISK SCORES • ThoracoscorewasdevelopedbyFrancemultiinstutionaldatabase (Epithor) . • Has includedmorethan 15.000 patientsundergonedifferentprocedures. • Usedtoguessforhospitalmortalityand has 9 factors. • BTS reccommends (2010), Thoracoscore, thelastone (Global risk model). Falcoz PE. J ThoracCardiovasSurg 133, 2007. Lim E, et al. Guidlines on theradicalmanagement of patientswithlungcancer. BritishThoracicSocietyandtheforCardiothoracicSurgery in GreatBritainandIreland. Thorax 2010.

  33. RISK MODELS and RISK SCORES Falcoz PE, et al. J ThoracCardiovascSurg 2007

  34. RISK MODELS AND RISK SCORES • Thesescoringsystems do not needin theroutineassessment of patientsundergoinglungsurgerytoday. • Thisscoringsystems can be usedfor risk classificationandcomparisonamongsurgicalcandidates (formortalityandmortality). Brunelli A, et al, ERS/ESTSclinicalguidlines . EurRespir J 34:17-41, 2009. Lim E, et al. Guidlines on theradicalmanagement of patientswithlungcancer. BritishThoracicSocietyandtheforCardiothoracicSurgery in GreatBritainandIreland. Thorax 2010.

  35. PULMONARY FUNCTION TESTS

  36. PULMONARY FUNCTION TESTS Indications • Smokinghistoryoractivesmoker • Symptoms of respiratorysystems (cough, dyspneoa) • Abnormalfinding on physicalexamination • COPD history • Morbidobesity • Olderage • Debilityandmalnutrition • Thoseforlungresection Delisser HM, et al. In:Fishman’sPulmonarydiseasesanddisordersMcGrawHill 1998. Zibrak JD, et al. ClinChestMed 1993

  37. PFT-II • Cheapandavailableeverywhere. • Inrecentstudies,RFT has not beenpropersolelyto define postoperativemorbidityandmortality. Smetana GW. N Engl J Med . 1999. Lim E,et al. Thorax 2010 (BTS /SCTS guidlines)

  38. PFT-III • Preoperative PFT does not alwayscorrelatewithpostoperativecomplications. • Preoperative normal RFT may not indicatepostoperativecomplication risk to be low. Smetana GW. N Engl J Med . 1999. Falcoz PE, et al. J ThoracCardiovascSurg 2007. Lim E,et al. Thorax 2010 (BTS guidlines)

  39. PFT-IV • FEV1 and(Forcedexpiratoryvolume in onesecond) DLco(Carbonmonoxidediffusingcapacity)testsaremoreimportantfortheassessment of postoperativemorbidityandmortalityrisks. BTS guidelines. Thorax 2001. Brunelli A,et al. ERS/ESTES clinicalguidelines. 2009. Colice GL, et al. ACCP guidelines. Chest 2007.

  40. PFT-V At thesame time • Usedforcalculation of predictedpostoperative FEV1 (ppo FEV1) andpredictedpostoperativeDLco (ppoDLco). Ppo:Predictedpostoperative BTS guidelines. Thorax 2001. AmericanThoracicsociety, standardization of spirometry, 1994. EuropeanRespiratorySociety, lungvolumesandforcedventilatoryflows, EurRespir J 1993

  41. PFT-VI First, andespecially • FEV1, FVC and • FEV1/FVC rate is checked.

  42. PFT-VII FEV1: Forcedexpiratoryvolume in onesecond • Normal healthypeople can exhale80% of theirvitalcapasitywithinfirstsecond, allwithin 3 seconds. • So, theamountout in thefirstsecond is evaulated as a distinctiveparameterandstated in litresor %predicted. • FEV1 is decreased inobstructivelungdiseases. AmericanThoracicsociety, standardization of spirometry, 1994. EuropeanRespiratorySociety, lungvolumesandforcedventilatoryflows, EurRespir J 1993

  43. PFT-VIII FVC : Forcedvitalcapacity • Theamount of theairexhaledfollowingforcedinspiration. • Expressed as litre or % predicted . • It is decreased in restrictivelungdiseases. AmericanThoracicsociety, standardization of spirometry, 1994. EuropeanRespiratorySociety, lungvolumesandforcedventilatoryflows, EurRespir J 1993

  44. FEV1/FVC rate • Importantcriteriafordifferentation of restrictiveandobstructivelungdiseases. • Both FEV1and FVC togetherdecreasesotheyremain normal in restrictivediseases. • FEV1 significantlydecreases in obstructivediseasesandthis rate becomeslow. AmericanThoracicsociety, standardization of spirometry, 1994. EuropeanRespiratorySociety, lungvolumesandforcedventilatoryflows, EurRespir J 1993.

  45. REVERSIBILITY TESTING-I • It is proper in COPD. • Theprocedure is repeatedafter 15-20 minutes of bronchodilatationfollowingbasal FEV1 measurement. • An increase of 15 % ormorethan 200 ml in FEV1orFVCshows ‘meaningfulreversibility’ . Ruppel GL, Manuel of pulmonaryfunctiontesting, 7th edt. Mosby-yearBook, 1998. AmericanThoracicsociety, standardization of spirometry, 1994. EuropeanRespiratorySociety, lungvolumesandforcedventilatoryflows, EurRespir J 1993.

  46. REVERSIBILITY TESTING-II • Generally, both FEV1 and FVC increasesand FEV1/FVC rate is not changed . • FEV1/FVC rate is not to be usedforevaluation of theresponsetobronchodilatators. • Reversibility test (+) patientsundertakepreoperativelybronchodilatortheraphyandcorticosteroids . • Respiratoryfunctionsareimprovedandcomplicationrisksaredecreased. Ruppel GL, Manuel of pulmonaryfunctiontesting, 7th edt. Mosby-yearBook, 1998. AmericanThoracicsociety, standardization of spirometry, 1994. EuropeanRespiratorySociety, lungvolumesandforcedventilatoryflows, EurRespir J 1993.

  47. DLco (Carbonmonoxidediffusingcapacity) calculation-I • Themostvaluable test showingalvealargasexchange in patientsundergoinglungresections. • It is alsoexpressed as TLco (Carbonmonoxide transfer factor) . • Shown as Mmol/Kpa/min . • indicatesalveolarmembransufficiency. Ruppel GL, Manuel of pulmonaryfunctiontesting, 7th edt. Mosby-yearBook, 1998. Aubrey WR. AnesthesiaandIntensiveCareMedicine 2011.

  48. DLcocalculation-II • Considered as an independentpredictorin theassessment of postoperativemorbidityandmortality in resectionsurgery. • Publicationshaveincreased in recentyears, indicatingthat it has a highlydeterminative role in resectionsurgery. Brunelli A. Semin ThoracicSurg 2010.

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