Surgery is the treatment of choice for patients with early-stage non-small cell lung cancer (NSCLC).
Because each patient’s condition and physical status is different, the surgeon will determine the surgical plan by forming a multidisciplinary team of specialists (including pulmonary surgery, medical oncology, radiation therapy, imaging, pathology, cardiology, respiratory, rehabilitation, etc.) to perform a comprehensive evaluation of you.
The evaluation includes a variety of potential factors that may affect the entire course of the disease, such as cardiac, pulmonary, hepatic, renal, endocrine, hematologic, and immune system function, as well as nutritional and psychological status, to reduce and minimize the risk of perioperative complications and long-term pulmonary dysfunction.
This article provides an overview of what you and your surgeon each need to do before surgery, what factors your surgeon needs to consider, and more.
Surgery can cause anxiety, fear, etc. for you and your family, especially in older adults.
So, the surgeon will usually explain your condition, the need for the procedure, the surgical approach, the possible outcomes, the risks of the procedure, the possible complications, the postoperative recovery process and outcomes, and the possible complications and adverse effects of intraoperative blood transfusion in appropriate detail to your family, and sign the consent form for surgery, the consent form for blood transfusion, and the consent form for anesthesia, respectively.
With good psychological preparation, you will be able to accept the surgery in a positive frame of mind, and both you and your family will be able to cooperate with the whole treatment process.
Depending on your physical state and how the proposed surgery may affect you, your doctor will advise you to prepare for the following:
After thoracic surgery, you are prone to complications such as acute respiratory failure, pulmonary atelectasis, pneumonia, lung infection, and pleural effusion.
Preoperative respiratory function training can improve surgical tolerance, improve postoperative lung function, and prevent postoperative respiratory complications.
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(2) Pre-operative smoking cessation
Preoperative smoking cessation can reduce the incidence of perioperative respiratory complications. You should quit smoking for 2 weeks prior to surgery.
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(3) Gastrointestinal preparation:
Fast from 12 hours prior to surgery. Drinking is prohibited 4 hours before surgery to prevent asphyxia or aspiration pneumonia due to anesthesia or vomiting during the procedure.
What will the surgeon do to prepare you?
(1) Preventing infection:
Preoperatively, your doctor will improve your fitness, promptly treat identified foci of infection, and protect you from exposure to infected people. You will also be given prophylactic antibiotics.
(2) Blood and fluid transfusions:
Before surgery, your surgeon will do a blood type and cross-match test and have a quantity of blood products on hand and ready for use during surgery.
If you have water, electrolyte and acid-base balance imbalance or anemia, the surgeon will try to correct it before surgery.
Special preoperative preparations
In addition to the general preparation described above, your surgeon will make special preparations depending on your specific situation.
Correcting malnutrition
Malnutrition can cause hypoproteinemia and negative nitrogen balance, which can have a serious impact on cardiopulmonary function, can cause tissue edema, affect wound healing, and can reduce resistance and predispose you to co-infection.
Preoperatively, the surgeon will correct this if possible. Elective surgery is usually started about 1 week before surgery so that you are provided with adequate calories, protein, and vitamins orally or intravenously to facilitate postoperative tissue repair and wound healing and to improve resistance to infection.
Correcting anemia
Blood transfusions are effective in improving microcirculation and maintaining tissue supply. However, blood transfusion can also lead to an increased rate of postoperative infection. Large amounts of blood transfusion in tumor patients can induce immune tolerance and increase the rate of postoperative tumor recurrence. Therefore, when correcting anemia, physicians will strictly follow transfusion indications.
In general, hemoglobin Hb >100 g/L can be transfused without blood;
Hb <70 g/L or hematocrit Hct <22% should be considered for transfusion;
Hb between 70 and 100 g/L, your doctor will decide whether to transfuse based on your age, cardiopulmonary function, and assessing the likelihood of continued bleeding after surgery.
What other factors does the surgeon consider before surgery?
Heart disease
Most patients with comorbid heart disease still tolerate surgery well. The risk is significantly higher only when the heart disease is progressive, unstable, or decompensated, such as a recent myocardial infarction, unstable or progressive angina, heart failure, severe aortic or mitral stenosis, and severe hypertensive heart disease. In the presence of these conditions, lung cancer surgery cannot be performed.
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Pulmonary dysfunction
Pulmonary function should be evaluated before doing pneumonectomy and mediastinal tumor resection.
You are at increased risk for postoperative pulmonary complications if you have a long history of smoking, a history of heavy cough, obesity, age over 60 years, chronic obstructive pulmonary disease, bronchiectasis, and anesthesia lasting longer than 3 hours.
If pulmonary insufficiency is present, preoperative blood gas analysis, pulmonary function tests, chest x-ray, and electrocardiogram should be performed.
Blood gas analysis with arterial partial pressure of oxygen PaO2 <60 mm Hg and arterial partial pressure of carbon dioxide PaCO2 >45 mm Hg is associated with a significant increase in perioperative pulmonary complications.
Exertional expiratory volume in one second (FEV1) testing is extremely valuable in the assessment of pulmonary function. In combination with age and size, a value below 50% indicates the presence of severe pulmonary disease and a significant increase in postoperative complications that may require postoperative mechanical ventilation and special monitoring.
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Liver disease
Hepatitis and cirrhosis are the most common liver diseases.
Patients with liver disease can have no clear history of liver disease and no obvious clinical manifestations, so preoperative hepatitis marker testing and liver function tests should be done in all cases.
In general, mild impairment of liver function does not affect surgical tolerance; more severe impairment of liver function or on the verge of decompensation significantly reduces surgical tolerance and requires longer and more rigorous preparation before elective surgery; severe impairment of liver function, such as significant malnutrition, ascites, jaundice, or acute hepatitis, makes surgery inadvisable.
Nephropathy
Anesthesia, surgical trauma, and certain medications can increase the burden on the kidneys, and preoperative renal function should be routinely tested.
Mild to moderate renal impairment, with appropriate medical management, generally tolerates surgery well; severe impairment can also be tolerated fairly safely with the protection of effective dialysis therapy, but the surgeon will maximize renal function prior to surgery.
High blood pressure
If your blood pressure is under 160/100 mm Hg, no special preparation may be required.
If blood pressure is too high, anesthesia induction and surgical stress can increase the risk of cerebrovascular accidents and congestive heart failure. Before surgery, your surgeon will recommend appropriate antihypertensive medications to control blood pressure, but does not require blood pressure to be reduced to normal levels before surgery.
If you have had hypertension for a long time, your doctor will also look for secondary organ damage (heart, brain, kidney, etc.) and associated concomitant conditions (e.g., hyperlipidemia, diabetes, etc.) in the context of your specific situation, and may test and treat accordingly.
Diabetes mellitus
Patients with diabetes are in a stressful state throughout the perioperative period, with a 50% increase in complication rates and mortality compared with those without diabetes.
Diabetes affects wound healing, increases infectious complications, and is often associated with asymptomatic coronary artery disease. The preoperative evaluation includes chronic complications of diabetes (e.g., cardiovascular and renal disease) and glycemic control, and the surgeon will manage the results accordingly.
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Coagulation disorders
Routine coagulation tests, the rate of positive detection of severe coagulation disorders is very low, so your doctor will also take a careful history, do a physical examination for you and try to avoid missing it.
If you take your usual medications, you generally stop taking aspirin 7 days before surgery, Nonsteroidal Antiinflammatory Drugs (NSAIDs) such as ibuprofen 2-3 days before surgery, and antiplatelet agents (such as clopidogrel) 10 days before surgery.
If clinically determined to have a coagulation disorder, the physician will treat it accordingly before elective surgery.
Age
Due to modern advances in surgical science and geriatrics, age alone is no longer a contraindication to surgery. In the absence of serious cardiovascular, renal, or other systemic disease, the risk of major surgery in general is only mildly increased in the elderly.
However, the ability to tolerate surgery in the elderly is significantly less than in younger people because of the diminished physiological function of various organs. In addition, common diseases that accompany the elderly, such as coronary artery disease, hypertension, pulmonary infections, and diabetes, can adversely affect surgery, and surgery itself can cause worsening of these concomitant diseases.
For this reason, in older adults, physicians consider factors such as tumor stage, surgical resection modality, life expectancy, and potential surgical comorbidities in the surgical decision-making process.
Summary
A thorough, systematic, and comprehensive preoperative evaluation plays a critical role in postoperative outcomes and quality of life. You should actively cooperate with your surgeon during your visit and prepare for surgery to achieve a better outcome.
Co-authors: Dr. Jing-Hua Chen, Guangdong Provincial People’s Hospital, Guangdong Lung Cancer Institute