Cardio-Pulmonary Exercise Testing Prior to Major Surgery
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EDITORIAL – THORACIC ONCOLOGY
Cardio-Pulmonary Exercise Testing Prior to Major Surgery Michael R. Gooseman, MD, and Alessandro Brunelli, MD Department of Thoracic Surgery, St. James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
The current issue of the Annals of Surgical Oncology publishes the excellent systematic review and meta-analysis of Sivakumar et al.1 which contributes to an increasing body of evidence supporting the role of cardio-pulmonary exercise testing (CPET) in the pre-operative assessment of patients undergoing major surgery. This work has demonstrated the value of incorporating CPET into the work-up for patients being submitted to oesphagectomy. The production of guidance relating to acceptable parameters deeming a patient safe to proceed with this operation may benefit from the growing experience in other aspects of chest surgery. CPET is now accepted as the gold standard in functional assessment and risk stratification for patients being considered for major lung resection surgery. As Sivakumar et al. point out, the role of CPET in thoracic surgery has been studied for several decades. In the 1980s and 1990s there was a number of small studies that showed VO2max was inversely associated with mortality after lung resection. Bolliger et al. demonstrated that the percentage of predicted VO2max was inversely associated with developing complications. There has also been extensive work comparing CPET with low technology testing such as stair climbing and shuttle walk testing. Despite the increasing data supporting CPET, it was initially limited in its utilisation. A 2009 European Respiratory Society/European Society of Thoracic Surgeons web-based survey showed that CPET technology was available in 75% of hospitals but only 10–30% of patients had CPET prior to lung
Ó Society of Surgical Oncology 2020 First Received: 8 May 2020 A. Brunelli, MD e-mail: [email protected]
resection. The problems facing CPET prior to oesphagectomy are therefore similar to what was faced in lung resection surgery. The role of CPET prior to lung resection surgery became clearly defined in the American College of Chest Physicians (ACCP) guidance. Broadly speaking, patients are considered for CPET when they either have poor lung function, perform poorly on low technology exercise testing such as stair climbing, or have a significant cardiac risk assessment. Brunelli et al.2 contributed work that helped in defining thresholds for work regarding risk stratification. This group showed that patients with a VO2max [ 20 ml/ kg/min undergoing lung resection had no mortality while the mortality rate was 13% in patients with a VO2max \ 12 ml/kg/min. The guidance recommends that a patient with VO2max [ 20 ml/kg/min can safely proceed with any form of surgical lung resection. It might be sensibly argued that the same can be considered for oesphagectomy patients. Licker et al. demonstrated that patients undergoing lung resection with a VO2max \ 10 ml/kg/min had a morbidity of 65%. This work and others informed t
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