Chapter 4

The decision to proceed with any surgical procedure involves a careful consideration of the anticipated benefits of surgery and an assessment of the risks associated with the operation. An important component of estimating the benefit of surgery is knowledge of the natural history of the condition in question. It is a popular, though inaccurate, conception of the preoperative evaluation that the evaluating physician “clears” the patient for surgery. This implies a binary clinical scenario: Either the patient is at low risk and is “cleared,” or the risk is excessive and the patient is “turned down” for surgery. The reality, of course, is more complex and often more gray than black and white. A more accurate view of preoperative evaluation fulfills two goals: first, to accurately define the morbidity and risks of surgery, both short and long term, and second, to identify specific factors or conditions that can be addressed preoperatively to modify the patient's risk of morbidity. The formulation of an approach to accomplish these goals requires knowledge of both the specific characteristics of the patient population and the general effects of thoracic surgery on patients.

Many patients undergoing a noncardiac thoracic surgical procedure do so as a consequence of known or suspected lung or esophageal cancer. These diseases share the common risk factor of a significant and prolonged exposure to cigarette smoking. The combination of age and prolonged cigarette smoking yields a population with a significant incidence of comorbid factors beyond the primary diagnosis. A major source of comorbidity in the population of patients with lung cancer is the presence of chronic obstructive pulmonary disease (COPD). The diagnosis of COPD is an independent risk factor for the development of lung cancer, after controlling for cigarette smoke exposure.1,2

Several reports use the Charlson Comorbidity Index as an indicator of comorbid conditions and predictor of postoperative complications. This index generates a score based on the presence of comorbid conditions and has been demonstrated to stratify the risk of postoperative complications in thoracic surgery patients.3,4 In a recent study, the mean age of patients undergoing esophagectomy was 58.1 years, with 45% of patients over age 60.5 In another study from Japan, the median age was 62.3 years, and 88% were male.6 A recent study comparing transhiatal esophagectomy with transthoracic esophagectomy reported mean ages of 69 and 64 years, with patients up to age 79 included in the study.7 In a recent review, 28–32% of patients undergoing esophagectomy in the United States were over age 75, and 40% had a Charlson score greater than 3.8

Similarly, patients with lung cancer tend to be older and to have multiple comorbid conditions. In a series of 344 patients, 36% were over age 70, and 95% had a significant smoking history.9 A recent review of Medicare patients undergoing thoracic surgery in the United States showed that in patients undergoing lobectomy, 32–35% were over ...

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