Pre & Post-operative Surgical Optimization for Lung Surgery


Update: 18 April 2011 – USAtoday published a nice new article on Shannon Miller (former Olympic gymnast) and how she’s using exercise to help recover from cancer.  The article really highlights some of the things we’ve been talking about here.

As most of my patients from my native Virginia can attest; pre & post-operative surgical optimization is a critical component to a successful lung surgery. In most cases, lung surgery is performed on the very patients who are more likely to encounter pulmonary (lung) problems; either from underlying chronic diseases such as emphysema, or asthma or from the nature of the surgery itself.

Plainly speaking: the people who need lung surgery the most, are the people with bad lungs which makes surgery itself more risky.

During surgery, the surgeon has to operate using something called ‘unilung ventilation’. This means that while the surgeon is trying to get the tumor out – you, the patient, have to be able to tolerate using only one lung (so he can operate on the other.)

Pre-surgical optimization is akin to training for a marathon; it’s the process of enhancing a patient’s wellness prior to undergoing a surgical procedure. For diabetics, this means controlling blood sugars prior to surgery to prevent and reduce the risk of infection, and obtaining current vaccinations (flu and pneumonia) six weeks prior to surgery. For smokers, ideally it means stopping smoking 4 to 6 weeks prior to surgery.(1) It also means Pulmonary Rehabilitation.

Pulmonary Rehabilitation is a training program, available at most hospitals and rehabilitation centers that maximizes and builds lung capacity. Numerous studies have show the benefits of pre-surgical pulmonary rehabilitation programs for lung patients. Not only does pulmonary rehabilitation speed recovery, reduce the incidence of post-operative pneumonia,(2) and reduce the need for supplemental oxygen, it also may determine the aggressiveness of your treatment altogether.

In very simple terms, when talking about lung cancer; remember: “Better out than in.” This means patients that are able to have surgical resection (surgical removal) of their lung cancers do better, and live longer than patients who receive other forms of treatment such as chemotherapy or radiation. If you are fortunate enough to have your lung cancer discovered at a point where it is possible to consider surgical excision – then we need you to take the next step, so you are eligible for the best surgery possible.

We need you to enhance your lung function through a supervised walking and lung exercise program so the surgeon can take as much lung as needed. In patients with marginal lung function,(3) the only option is for wedge resection of the tumor itself. This is a little pie slice taken out of the lung, with the tumor in it. This is better than chemotherapy or radiation, and is sometimes used with both – but it’s not the best cancer operation because there are often little, tiny, microscopic tumor cells left behind in the remaining lung tissue.

The best cancer operation is called a lobectomy, where the entire lobe containing the tumor is removed. (People have five lobes, so your lung function needs to be good enough for you to survive with only four.(4) This is the best chance to prevent a recurrence, because all of the surrounding tissue where tumors spread by direct extension is removed as well. Doctors also take all the surrounding lymph nodes, where cancer usually spreads to first. This is the best chance for five year survival, and by definition, cure. But since doctors are taking more lung, patients need to have better lung function , and this is where Pulmonary Rehab. comes in. In six weeks of dedicated pulmonary rehab – many patients who initially would not qualify for lobectomy, or for surgery at all – can improve their lung function to the point that surgery is possible.

Post-operatively, it is important to continue the principles of Pulmonary rehab with rapid extubation (from the ventilator), early ambulation (walking the hallways of the hospitals (5) and frequent ‘pulmonary toileting’ ie. coughing, deep breathing and incentive spirometry.

All of these things are important, where ever you have your surgery, but it’s particularly important here in Bogota due to the increased altitude.

One last thing for today:
a. Make sure to have post-pulmonary rehab Pulmonary Function Testing (PFTs, or spirometry) to measure your improvement to bring to your surgeon,
b. walk daily before surgery (training for a marathon, remember)

c. bring home (and use religiously!) the incentive spirometer provided by rehab.

ALL of the things mentioned here today, are things YOU can do to help yourself.

Footnotes:
1. Even after a diagnosis of lung cancer, stopping smoking 4 to 6 weeks before surgery will promote healing and speed recovery. Long term, it reduces the risk of developing new cancers.

2. Which can be fatal.

3. Lung function that permits only a small portion (or wedge section) to be removed

4. A gross measure of lung function is stair climbing; if you can climb three flights of stairs without stopping, you can probably tolerate a lobectomy.

5. This is why chest tube drainage systems have handles. (so get up and walk!)

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