Optimisation of the high-risk thoracic surgical patient: a narrative review

Background and Objective: High-risk patient cohorts have significant rates of morbidity and mortality following thoracic surgery, these outcomes can be modulated with preoperative intervention. This review article examines the existing literature pertaining to specific high-risk groups of patients and the impact of preoperative optimisation. Methods: We performed literature searches using the PubMed and BMJ search engine for English-language articles published from 1966 to 2022. A separate literature search was performed for each individual topic area to identify existing evidence of optimisation and the magnitude of effect. Key recommendations were compiled for each topic area. Key Content and Findings: We identified a number of high-risk patient cohorts, with disease states that could be modified. The key recommendations for the optimisation of these high-risk patients are as follows. Nicotine replacement therapy and a supervised pulmonary rehabilitation programme should be prescribed for current smokers. Surgery should be delayed four weeks after cessation where tumour characteristics allow. Vaping should be discouraged in the preoperative period. Oral nutritional supplements should be prescribed for patients identified as malnourished. Patients should be encouraged to follow a high-protein diet. Thoracic surgical units should have an established exercise/prehabilitation programme tailored to high-risk patients, specifically those with advanced respiratory disease and poor preoperative lung function. Patients with an ‘active’ cardiac condition should be assessed and optimised by a cardiologist. Severe mitral and aortic stenosis should be treated prior to lung resection. Ischaemic heart disease should be managed as per national guidance (irrespective of surgical status). A preoperative haemoglobin of ≥130 g/L in both sexes should be targeted, iron deficiency should be treated with oral supplementation or IV infusion. Patients with chronic obstructive pulmonary disease should be optimised preoperatively on dual bronchodilator therapy and nebulised budesonide. Abstinence from alcohol should be supported with a combination of pharmacological and psychotherapy techniques in those with a history of alcohol abuse, for at least 4 weeks prior to surgery. Conclusions: The optimisation of the high-risk surgical patient is crucial, not only to reduce individual suffering but also to maximise resource utilization of healthcare systems. Multiple methods of optimisation have demonstrated significant reduction in postoperative morbidity and mortality. These interventions are typically both low cost and relatively easy to provide. As resection rates increase and lung cancer screening roles out, now, more than ever, the thoracic surgical community must become experts in the optimisation of high-risk patients in order to best utilise available resources and meet increasing demand.