Patients with severe medical comorbidities have often been rejected for open pulmonary resections and subjected to alternative treatment modalities, unfavourable of final outcome. Video-assisted Surgery (VATS) with reduced postoperative morbidity, offers opportunity for surgical treatment also for patients with high risk.
Key words: ASA, ppoFEV1, ppoDLCO, VO2max, VO2at
In UMC Ljubljana first VATS lobectomy was performed in 2008 and reach the number of 300 VATS lobectomies in February, 2016. According to preoperative tests 25 of total 278 (9 %) patients were classified as high risk patients (ASA 4). The intraoperative courses were uneventful in most cases. Most of high risk patients (84 %) survived and were discharged from hospital, although more than half of them (14/25; 56%) suffered from postoperative complications, like prolonged air leak (> 5 days), subcutaneous emphysema and respiratory compromise. The postoperative recovery was 3-52 days (average 15,3 days). 4/25 (16%) patients died of pneumonia and respiratory failure after resection. A quarter of high risk patients (7/25 or 28%) recovered with no complications and were discharged earlier.
Patients with compromised pulmonary or cardiac function are considered high risk for peri-operative complications. Poor functional capacity (< 4 MET), low values of predicted postoperative forced expiratory volume in one second ( ppoFEV1 < 40%), low predicted postoperative diffusing capacity for carbon monoxide ( ppoDLCO< 40%), low peak oxygen consumption during exercise (VO2max< 12 mlkgmin), low anaerobic threshold (VO2at < 10 mlkgmin) are warning exams for every anaesthesiologists. In spite of minimal invasive surgery, in those patients advanced anaesthetic approach is inevitable.
During VATS contra-lateral lobectomy in a patient with prior lung resection, modified oxygen supplementation to operated lung is needed. In predetermined pulmonary hypertension pulmonary vasodilators (iNO, Iloprost ) are used during one lung ventilation and after pulmonary resection. Selective lobar blockade is another option to decrease the incidence of hypoxemia and aggravation of pulmonary hypertension. Advanced hemodynamic monitoring and usage of TEE make VATS procedures feasible in severe cardiac disability. Invos cerebral oximetry is indispensable in case with low cardiac output and possible hypoxemia during one lung ventilation.
In high risk patient advanced and invasive anaesthetic approach is mandatory regardless minimal invasive surgery.
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