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Key Concepts

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  • Role of preoperative evaluation

    • The role of the preoperative evaluation is to (1) determine the risk and morbidity associated with the proposed operation and (2) identify any patient conditions or factors that can be treated to mitigate the risk of morbidity and mortality.

  • History and physical examination

    • The examination should focus on pulmonary and cardiac conditions, as these represent the most common complications after thoracic surgery.

  • Functional and performance status

    • The patient’s ability to withstand and recover from a major thoracic operation should be assessed prior to surgery. Standard tests such as the Karnofsky score, Zubrod score, DASI questionnaire, stair climbing, and shuttle walk are all useful metrics.

  • Pulmonary and cardiac testing

    • Pulmonary function testing remains the cornerstone of preoperative evaluation. FEV1, DLCO, and postoperative predicted values are important predictors of outcomes. Assessment of cardiovascular risk should include noninvasive testing in patients with a history of cardiac disease and more invasive testing as indicated.

  • Risk stratification models

    • Mathematical models using the Epithor and Society of Thoracic Surgeons General Thoracic Database can provide reasonably accurate risk stratification for patients undergoing major thoracic surgery.

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Introduction

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Preoperative evaluation of the prospective thoracic surgical patient is a complex process, as patients presenting for major noncardiac thoracic surgery today tend to be older, have underlying chronic obstructive lung disease, and often have multiple comorbidities. Pulmonary and cardiovascular complications occur frequently in the postoperative period and should be aggressively identified and mitigated where possible. The ability to predict and stratify which patients are at a higher risk of complications allows appropriate patient selection and helps guide operative approaches. Preoperative evaluation, therefore, serves two purposes: (a) determining the risk and morbidity associated with the proposed surgical procedure and (b) identifying any patient conditions or factors that could be addressed in the preoperative period to decrease the risk of morbidity and mortality.1

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History and Physical Examination

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There is no substitute for a thorough history and physical examination combined with the sound clinical judgment of an experienced physician. There are several specific components in the history of a potential thoracic surgical patient that should be investigated. These important components include presenting symptoms, previous diagnosis of cardiopulmonary disease, comorbid conditions such as diabetes mellitus, renal and liver dysfunction, current medications and allergies, tobacco use, and alcohol use.1 As the most frequent complications are pulmonary and cardiovascular, the history should focus on these areas.

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The physical examination should likewise focus on several signs that indicate important comorbidities. Examination begins with an assessment of overall appearance, looking especially for evidence of cachexia and generalized wasting. Cervical and supraclavicular lymphadenopathy can indicate metastatic disease. Cardiovascular examination should note murmurs (valvular disease), arrhythmias (atrial fibrillation), and presence of peripheral edema (congestive heart failure). Pulmonary examination should note respiratory rate, use of accessory respiratory muscles, and presence of wheezing or rales. Abdominal examination ...

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