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Ann Thorac Surg 1997;63:1409-1410
© 1997 The Society of Thoracic Surgeons
DR KAMAL A. MANSOUR (Atlanta, GA): I congratulate Dr Knott-Craig and his group for tackling a group of 173 patients who were considered inoperable on the basis of insufficient cardiopulmonary reserve or advanced age. Excluding the 2 nonresectable patients, the remaining 171 patients were operated on after meticulous preoperative, intraoperative, and postoperative management with acceptable mortality of 2.8% to 4.8% in those patients who are more than 70 years of age.
I have a comment and one question. In patients with poor pulmonary reserve, we obtain ventilation/perfusion scans with lobar count for predicted FEV1 and postoperative diffusing capacity of carbon monoxide and may measure maximal oxygen uptake with exercise. In patients who are older than 65 years, or those patients with a history of heart disease regardless of age, we obtain a treadmill exercise test, dobutamine stress echocardiogram, or cardiac catheterization depending on the situation. We had several patients who underwent lung resections either concomitantly with or after coronary bypass operations. We, like you, digitalize all lobectomies in patients older than 60 years and all pneumonectomies regardless of age.
I have one question. What is the lowest predicted FEV1 or any other test you consider acceptable for pulmonary resection?
DR KNOTT-CRAIG: Thank you, Dr Mansour, for your kind comments. Emory University is associated with excellent results in lung resections, and we are all familiar with them. We also employ split-function tests, electrocardiograms, cardiac evaluations, and other tests. They form part of the very necessary preoperative evaluation of patients. There is confusion, though, in the literature about which preoperative lung function test is the most predictive of morbidity and mortality after resections.
In terms of the lowest FEV1 consistent with a good outcome, I am not sure that we know the answer to that. Certainly 15 or 20 years ago it used to be an FEV1 of 2 L. Ten years ago it used to be an FEV1 of 1.5 L. Currently we have a series of patients similar to that reported recently from the Mayo Clinic with FEV1s of the entire series less than 1.2 L. These patients do not have an outcome very different from that of the rest of the group.
I do think there are different groups of patients though: in those patients who are heavy smokers and are poorly prepared preoperatively, a lower FEV1 can be consistent with a good outcome; however, patients who are receiving steroids, three or four bronchodilators, and home oxygen and who have physiotherapy at home as a routine are different. It is unlikely that one can improve their pulmonary function after the operation.
DR JONATHAN C. NESBITT (Houston, TX): Doctor Knott-Craig, I appreciate your comments and congratulate you on your results. At the M. D. Anderson Cancer Center over the last few years, more than 500 patients have undergone anatomic resections with less than a 2% mortality. This includes high-risk patients. As you noted, we adhere to a standard practice of preoperative smoking cessation and an exercise program to improve perioperative morbidity and mortality.
In your discussion, you mentioned that you did not use epidural catheters for pain control. Your reasons for not using a well-accepted standard of care were a bit unclear. At my institution, an epidural catheter is used for virtually every patient because we believe it provides the best method for postoperative pain control and adds significantly to the reduction of postoperative pulmonary complications. My first question is, what are your specific reasons for not using an epidural catheter?
My second question addresses the issue of digitalization. We do not routinely use digitalis, even for those patients undergoing pneumonectomy. We have not found a difference in the prevention of postoperative atrial dysarrhythmias. In your group of patients, was digitalis routinely used, and did it make a difference?
DR KNOTT-CRAIG: As you know, both issues are controversial. We had, from historical papers, expected the incidence of arrhythmias to be around 12% to 15% in our patient group. We experienced arrhythmias in 4%. All I can say is that the incidence of arrhythmias was about a third of what we had expected, so we have continued digitalizing the patients.
In terms of the epidural anesthesia, it is a personal bias for which I do not make any apologies. In our institution, the epidural anesthesia is managed by anesthesiologists whose availability to the patient is very different from that of thoracic surgeons. I think if you limit the amount that you spread the muscles, avoid transecting the muscles, spread the ribs just enough to do the operation carefully, infiltrate the pleural spaces with long-acting local anesthetics, and start administration of intravenous nonsteroidal analgesics before you cause edema and inflammation in the muscles, I think that you can have very acceptable pain management without an epidural catheter. We found early on in our experience that in elderly patients with epidural catheters, decreased bowel sounds developed and the patients had difficulty passing gas and stools. As this occurs, the abdomen distends and the diaphragms do not work well. If they have poor pulmonary reserve too, this seems to precipitate a number of complications. So my personal bias is against epidural anesthesia.
DR KENWYN G. NELSON (Tyler, TX): I have two comments to make. I appreciate your paper very much, Dr Knott-Craig, but my first comment is that I think that not only physiotherapy but the exercise program is essential in the patients you are talking about who are at serious risk. Those who are more than 80 years old, even if they cannot walk, can go through an exercise program with their arms. It is mostly a program of self-health: they feel so much better and they look forward. If they do not do that, and you have a patient who is not feeling like he or she can accomplish anything, you might as well not do the operation.
Finally, I think it is time that we relate more to our percent predicted FEV1s rather than the FEV1 value. The body surface area is so significant here that just to relate to a patient as having 750 mL is not enough. It has to be related to the body size as well.
DR KNOTT-CRAIG: Those comments are absolutely accurate, and I agree with all of them. I guess it is difficult to present all these data in a 10-minute presentation.
Related Article
Ann. Thorac. Surg. 1997 63: 1405-1409.
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