Lung resection is major surgery akin to aortic aneurysm repair, craniotomy or major GIT resection. It is performed on patients who not only have bad lungs but have other smoking related co-morbidity. In addition, when achieving good oncological margins, we are taking away good lung in patients which these patients need.

Successful lung surgery involves:

1. •careful selection and preoperative assessment of patients,
   

2. •anticipation of complications and
   

3. •careful management of
   

1. 1.oxygenation
   

2. 2.pain relief
   

3. 3.secretions and
   

4. 4.chest drains
   

4. 
   

Preoperative treatment

All patients will need to have treatment altered or new treatments started on admission. Some will need to be admitted early for pre-treatment.

1. •Physiotherapy
   

2. •Bronchodilators
   

3. •DVT prophylaxis
   

4. •Smoking cessation
   

5. •Cardiovascular
   

Routine tests

1. •FBP - within last month unless intervening illness
   

2. •U&E - within last month unless intervening illness. Specifically request serum creatinine as it is not on the routine U&E block of tests.
   

3. •Crossmatch blood products (guidelines)
   

4. •CXR - should generally be within last 24 hours. Common sense can be used if there has been no change in condition over recent days. If there is no RVH film get one done for our records.
   

5. •ECG - within last month
   

Pre-thoracotomy tests

1. •Arterial blood gases - must be done on current admission. It is recommended that you use radial artery on same side as surgical incision as the anaesthetist will want to use the contralateral artery for intraoperative arterial BP and ABG monitoring.
   

2. •Pulmonary function tests - during last month. All should have FEV1 and FVC. Those with FEV1 < 60% of normal should have reversibility and Carbon Monoxide Transfer Factor.
   

Pre lung resection tests

1. •Sputum Cytology - if there is no histology or cytology take early morning sputum specimen for cytology. Also take sputum for bacterial and AAFB culture.
   

2. •Bronchoscopy - should have been performed either at RVH or elsewhere. The report must be available. For central lesions the surgeon will usually require rigid bronchoscopy to be done during assessment or just prior to lung resection.
   

3. •CT scan - all lung cancer patients will require CT scan to determine the central extension of the tumour and to identify mediastinal lymphadenopathy and to identify lung, liver and adrenal metastases. Films and report are to be available at the time of surgery. Any disks from other hospitals should be uploaded on to the RVH PACS, preferably on receipt by the secretaries.
   

4. •PET scan - all lung cancer patients will have had a PET scan to rule out distant metastases. This is usually more recent than the CT. It should be available on the RVH PACS.
   

5. •Fine needle aspirate - if the above methods have failed to obtain histology and the lesion is peripheral, fine needle aspirate performed by the radiologists may be successful. In general histology is desirable before lung resection and mandatory before pneumonectomy. Therefore when pneumonectomy is likely and there has not been a histological diagnosis arrange for frozen section in theatre.
   

6. •Differential ventilation lung scan with quantification is only needed for patients with borderline FEV1 (< 40% for planned lobectomy, 50% for planned or probable pneumonectomy)
   

7. •All patients with a previous coronary artery history and other borderline patients should have preoperative cardiopulmonary treadmill test (VO2 max). An echocardiogram should also be performed to assess left ventricular function.
   

All CXR and CT films, bronchoscopy report, PFT’s and histology must go to theatre with the patient.

Further discussion of the assessment of a lung cancer patient for surgery including British Thoracic Society guidelines is available on this link.